[Senate Hearing 108-]
[From the U.S. Government Publishing Office]



 
       DEPARTMENT OF DEFENSE APPROPRIATIONS FOR FISCAL YEAR 2005

                              ----------                              


                       WEDNESDAY, APRIL 28, 2004

                                       U.S. Senate,
           Subcommittee of the Committee on Appropriations,
                                                    Washington, DC.
    The subcommittee met at 10:05 a.m., in room SD-192, Dirksen 
Senate Office Building, Hon. Ted Stevens (chairman) presiding.
    Present: Senators Stevens, Inouye, and Leahy.

                         DEPARTMENT OF DEFENSE

                            Medical Programs

STATEMENT OF LIEUTENANT GENERAL JAMES B. PEAKE, SURGEON 
            GENERAL, UNITED STATES ARMY

                OPENING STATEMENT OF SENATOR TED STEVENS

    Senator Stevens. Good morning. We are pleased to see you 
here this morning.
    We are going to have a hearing on the medical programs. Two 
panels are scheduled. First, we will hear from the Surgeon 
Generals, followed by the Chiefs of the Nursing Corps. We have 
joining us today from the Army Surgeon General, Jim Peake; from 
the Navy, Admiral Michael Cowan; from the Air Force, General 
George Taylor. We welcome you all back again.
    I understand this is your last appearance before the 
committee, General Peake.
    General Peake. Yes, sir.
    Senator Stevens. And Admiral Cowan.
    Admiral Cowan. Yes, sir.
    Senator Stevens. We do thank you for your service and 
assistance to this committee and value your views.
    This is a very difficult period for defense health 
programs, as we all know. The President's fiscal year 2005 
request for the defense health program is $17.6 billion, a 15 
percent increase over the fiscal year 2004 request. The request 
provides for the health care of 8.8 million beneficiaries and 
for the operation of 75 military hospitals, 461 military 
clinics.
    Despite the increase that is requested this year, this 
committee remains concerned that the funding may not be 
sufficient to meet all our requirements. We recognize that the 
continuing conflict in Iraq and the global war on terrorism, 
along with rising costs for prescription drugs and related 
medical services, will continue to strain the financial 
resources that are requested in this budget and place increased 
demands on our medical service programs and providers.
    Now, Senator Inouye and I are both personally familiar with 
the value of military medicine and have worked with your 
organizations for many years. We committed to work with you and 
to address the many challenges that you face.
    Let me take a moment to commend the Department's medical 
service personnel for their work in the global war on 
terrorism. Their performance has been nothing short of 
extraordinary. From the moment our soldiers, sailors, airmen, 
and marines go into harm's way military medics are deployed as 
part of the fight. We applaud their efforts and your efforts in 
serving jointly to meet the medical needs of our warfighters 
and their families, and we commend all of our witnesses here 
today for your leadership and compassion for those who serve.
    We have taken visits, as you know, to Walter Reed and to 
Bethesda and have been really honored to meet some of the young 
men and women that are there. I have got to tell you that 
almost every person said, ``Senator, can you help us go back to 
our unit.'' The morale of these people is just overwhelming and 
we are proud of them all.
    I want to yield to my co-chairman for his comments.

                 STATEMENT OF SENATOR DANIEL K. INOUYE

    Senator Inouye. I thank you very much, Mr. Chairman.
    I want to join you in welcoming our witnesses this morning 
as we review our Department of Defense (DOD) medical programs. 
Since this will be General Peake's and Admiral Cowan's last 
appearance before this committee, I would like to take this 
opportunity to thank them for their dedicated service to the 
military.
    Lieutenant General James Peake assumed command of the 
United States (U.S.) Army Medical Command in September 2000. In 
the years following, he oversaw 24,000 medical personnel 
deployed for overseas operations and an increased demand on 
military treatment facilities back home. He is the son of a 
medical service corps officer and a nurse, and your entire life 
has been in service to this Nation. Your time as an infantry 
officer gave you a unique warrior's perspective on how our 
wounded should be cared for, and it has helped to shape your 
vision for the Army medical department.
    Vice Admiral Cowan has served in the U.S. Navy for 32 years 
and as Surgeon General of the Navy and Chief, Bureau of 
Medicine and Surgery since August 2001. One could not have 
expected that just 1 month after taking that new 
responsibility, the military would be deployed at unprecedented 
levels and you would oversee the deployment of over 4,300 naval 
medical personnel. In addition to the extensive overseas 
operation, the Navy was also on the forefront of domestic 
events such as the lead laboratory for the recent ricin 
incident in the Senate.
    Admiral Cowan and General Peake, I commend and thank you 
for the service you have rendered to this country, and I am 
certain my colleagues all join me in this.
    Since the beginning of Operation Iraqi Freedom, I have 
heard numerous personal accounts and read dozens of articles 
indicating lifesaving changes made in medical deployments, 
technology, equipment, body armor, and unit configuration. From 
positioning surgeons closer to the front line than ever before 
and using new hemorrhage control dressings and embedding 
physical therapists in deployed units, decreasing the size of 
equipment, and aeromedical evacuation teams, they have 
drastically altered the fate of hundreds of lives. We will 
continue to support the personnel and programs that improve 
your capability to save lives.
    We will also look forward to an open discussion today with 
our panels. In particular, we will want to look into the status 
of the next generation contracts for TRICARE, our force health 
protection system, deployments of medical personnel, recruiting 
and retention, among others.
    Once again, I would like to thank the chairman for 
continuing to hold hearings on these issues which are so 
important to our military and their families.
    Mr. Chairman, you should forgive me. I think I need some 
help here. I have got a cold. Any cold medicine here?
    Senator Stevens. Is there a doctor in the house?
    Senator, do you have an opening statement?

                 STATEMENT OF SENATOR PATRICK J. LEAHY

    Senator Leahy. Just very briefly, Mr. Chairman. I thank you 
for having the hearing. I would suggest to Senator Inouye what 
he needs is time in the sun and maybe a few days in--oh, I do 
not know--Hawaii?
    Senator Inouye. It is a good place.
    Senator Leahy. I wanted to come to this hearing because I 
am concerned about the adequate health care for our armed 
services, whether it is active duty or Reserves. I know 
everybody here is concerned.
    I have gone out and visited some of our wounded soldiers 
out at Walter Reed. It is one of the most moving and impressive 
things. My wife is a registered nurse and she probably 
understood better than I did some of the injuries of some of 
the people that she has talked with at greater length.
    One of the most impressive things, Senator Stevens and 
Senator Inouye, I remember one young man who was trying on a 
new prosthetic leg. He had lost his leg. He was trying on a 
prosthetic, high-tech leg, microchips. General, I see you 
shaking your head. You know exactly what I am talking about. 
Microchips check to see how best to design it. The two of us 
asked him, what are you going to do now? And he looked at us 
like, well, I just want to get the training with the leg done 
so I can go back to the service. And I thought what a 
wonderful, wonderful answer.
    Yesterday's Washington Post had a front page article, and 
if you have not read it, please do. It is a heartbreaking story 
about the devastating wounds our soldiers are suffering, and 
they are devastating. The good news is we can save more lives 
that I guess in other past combats we might not have been able 
to save them. The bad news, of course, is that they are 
horribly wounded, maimed, blinded, and things like this. I 
think what we have is a real responsibility because of that to 
do our best.
    That is all I have to say, Mr. Chairman. I do appreciate 
your having this hearing. I think it is an extremely important 
one.
    Senator Stevens. Well, we all know General Shinseki who was 
entitled to a full military discharge based upon his injuries 
and he continued in the service to become the Chief of Staff of 
the Army. So they have great examples from our past and we are 
pleased to be part of the process to help encourage them.
    Our first panel is General Peake. We call on you first.
    General Peake. Mr. Chairman, Senator Inouye, distinguished 
members, it really is an honor to represent Army medicine 
before you.
    Senator Stevens. We will put all your statements in full in 
the record.
    General Peake. Thank you, sir.
    It really is a unique time in our history. I reviewed the 
first testimony I gave before this committee in April 2001 I 
think it was, and we talked then about the new set of benefits 
that came out of NDA01, TRICARE for life, pharmacy benefit for 
over 65 retirees, reduction of catastrophic caps, school-age 
physicals, many other things, and we spoke about the need to 
adequately fund that benefit.
    But I also made mention then of the fundamental importance 
from a readiness base of medical support to soldiers that comes 
from our direct care system then, and I commented on the U.S.S. 
Cole response of wounded sailors passing through our joint 
system on their way back to Portsmouth back then. I also said 
that it was an exciting time to have this job. I had no idea.
    That hearing seems like a long time ago. Since then, your 
military medical system has responded to 9/11, was a key part 
of the response to the anthrax letters, played a major role of 
the cleanup right here on Capitol Hill. Our medics supported 
the take-down of the Taliban in Afghanistan. Forward surgical 
teams, linked with the special operations forces, combat 
support hospitals providing the only sophisticated level of 
care in that war-ravaged country, medics fighting uphill on 
treacherous terrain to save lives. Even the march to Baghdad 
now seems like a long time ago, a march where medical assets 
leap-frogged forward with the combat troops. One of our forward 
surgical teams set up nine different times in that march to 
Baghdad, integral to the fighting formations and operating on 
our own soldiers and Iraqi civilians and enemy prisoner of war 
(EPW's) as well.
    Army medical evacuation helicopter crews have sustained 
their legacy as heroes, serving Army and cross-attached to the 
marines. Our combat support hospitals operated in split-based 
modes, covering each sequential setup of the log bases as we 
moved forward. The front ends of that system linked back 
through Europe where our jointly staffed facility at Landstuhl 
in Germany has continued to be the primary hub for patients 
who, under our construct of essential care in theater, could 
find themselves there within 24 to 48 hours of wounding, linked 
back to centers of excellence like the amputee center that you 
mentioned here at Walter Reed or our burn center at Brook in 
San Antonio. All of these efforts supported by a base of an 
integrated health care system that trains to the highest 
standards, that inculturates our physicians and our nurses to 
the men and women that they support by a base of research that 
focuses on things relevant to the soldier so that we could 
field things like new skin protectants, hemostatic dressings, 
one-handed tourniquets. It is a base that can provide teams of 
world-class experts that go into country to look at things like 
Leishmaniasis or investigate pneumonia deaths or to study the 
mental health aspects of combat in an active combat zone.
    We are about to complete the largest troop movement since 
World War II. Across this country, each of our power projection 
platforms and power support platforms, our soldiers have had 
medical screening, have been medically protected with 
immunizations, received care when required as they martialed 
for deployment, have received post-deployment screening and 
reintegration training and care and counseling, a tremendous 
medical effort focused on our balance scorecard objective, a 
healthy and medically protected force.
    As a health system, our business has increased during this 
time not only with the soldiers I have described, but with 
family members of the deployed reservists and with the 
remarkable increase in our retirees who appreciate the quality 
of the benefit that has been legislated. I do believe the next 
generation of TRICARE contracts creates the correct incentives 
to maximize the use of our direct care system and ensure our 
contract partners meet the same high standards for those not 
around our military treatment facilities.
    But it is not a magic bullet to contain the cost growth of 
medicine, of which we are really a microcosm, especially with 
the increase in those using our system. It is a cost growth 
that is faster than the overall DOD budget growth, as you have 
recognized in the past with a history of supplementals.
    All of this at the same time that General Shinseki's legacy 
of transformation is being carried forward aggressively to make 
us more modular, agile, ready, and relevant to the challenges 
militarily of today and tomorrow.
    We are fortunate to have really great leaders in our Army 
from our Secretary, Mr. Brownlee, who is a soldier himself, to 
our Chief, General Schoomaker, whose focus on the soldier is 
extraordinary.
    But equally extraordinary are those soldiers. They inspire 
me and they inspire all of us who lead them at all levels. I am 
going to close with a couple of quotes from this last week in 
Iraq. I got this e-mail.
    Since Sunday evening, a little more than 72 hours ago, we 
have done almost 60 cases with essentially nonstop surgery. I 
am awed at the excellence and dedication of the soldiers in my 
command. They have truly done an incredible job, and I am proud 
to be associated with them. That is from Steve Hetz, who is the 
commander of the 31st Combat Support Hospital in Ballad, a 
soldier, a surgeon who ran our teaching program at William 
Beaumont Army Medical Center for many years.
    From Michael Oddie, a cardiac surgeon from Akron, Ohio, a 
reservist, a commander of the 848 Forward Surgical Team who is 
commanding the medical facility at the prison near Baghdad. He 
sent me a note after an attack that gave them 78 casualties, of 
which they air evacked 13, admitted 26, operated on 10 that 
night and the next day. He says, it was awesome and inspiring 
to see this group of soldiers perform so well and so cohesively 
in a dire situation. We really do have a great group of 
soldiers. This hospital commander stuff is as headache, but it 
is rewarding to see such an effort. It would have made you 
proud.

                           PREPARED STATEMENT

    Well, sir, I am proud and I am proud of them and I am proud 
to have been a part of this team at this table. On behalf of 
all of our soldiers and their families and the medics, I deeply 
appreciate the unwavering support that you and this committee 
have given us all. Thank you very much.
    Senator Stevens. Part of our group visited Ballad. It is a 
very interesting operation, an enormous base. Those facilities 
are well operated and obviously very modern.
    [The statement follows:]
        Prepared Statement of Lieutenant General James B. Peake
    Mr. Chairman and Members of the Subcommittee, thank you for this 
opportunity to appear before you today. This will likely be the last 
time I appear before your committee as the Army Surgeon General, and I 
wish to express my gratitude for your unwavering support for our 
military and especially for our medical personnel.
                           core competencies
    Our Nation is at War, and there is nothing that brings the missions 
of military medicine into focus like war. Healthy and medically 
protected Soldiers; a trained and equipped Medical Force that deploys 
with the Soldiers, providing state-of-the-art medical care; and 
managing the health of all Soldiers and their families back home while 
keeping the covenant with our retirees--this is the mission of the 
United States Army Medical Department (AMEDD). We are keeping our 
promise to all of our beneficiaries by providing quality and timely 
healthcare.
                healthy and medically protected soldiers
    This is a part of ongoing health maintenance informed by research 
in military relevant areas and about which few outside the military 
have much interest. From the development of vaccines for diseases 
seldom seen in the United States to formulating an insect repellent 
that can serve as a sunscreen and camouflage paint all at the same 
time, to working with the Food and Drug Administration to establish 
workable protocols for new drugs in remote locations, we meet our 
obligations to medically protect soldiers. It requires an integrated 
approach to educate soldiers about their health and about the things 
they can do to protect themselves day to day and in whatever region of 
the world they may find themselves deployed.
                          current deployments
    There have been many improvements in military medicine since I last 
appeared before this committee. These improvements are making a 
difference in how well we are taking care of our Soldiers on the 
battlefield.
    To spearhead the Army Medical Department Transformation initiative, 
we have implemented the Medical Reengineering Initiative or MRI. MRI 
was approved by the Vice Chief of Staff of the Army in 1996 as an Army 
medical force design update (FDU), which reorganizes Echelon Above 
Division and Echelon Above Corps deployable medical units. These are 
the medical units that provide levels of battlefield medical care above 
the Battalion Aid Station and Division level medical companies. MRI 
will provide the Army with the modular organizational structure that 
supports the Current Force and will provide a bridge to the Future 
Force. MRI is versatile as exemplified by unit designs that are 
modular, scalable and possess standardized medical capabilities that 
can be deployed around the globe. The Army Plan (TAP) and the Army 
Strategic Planning Guidance (ASPG) 2006-2023, recognizes MRI as an 
example of modularity. MRI promotes scalability through easily 
tailored, capabilities-based packages that result in improved tactical 
mobility, reduced footprint, and increased modularity for flexible task 
organization. This design enables the Joint Forces Commander to choose 
among augmentation packages, thus enabling rapid synchronization of 
desired medical capabilities. MRI is enabling us to provide better care 
further forward on the battlefield and faster than ever before.
    With your help we are also saving lives through the deployment of 
the hemostatic dressings and the chitosen bandage. These are two new 
lifesaving wound dressings that are being used in Operation Enduring 
Freedom (OEF) and Operation Iraqi Freedom (OIF). Approximately 1,200 
hemostatic dressings were deployed under an Investigational New Drug 
battlefield clinical protocol. A team medic successfully applied a 
hemostatic dressing to a left thigh wound after he was unable to 
completely control femoral arterial bleeding with a pressure dressing 
and tourniquet. Similar success was achieved in two documented reports 
of Special Forces Medics using these bandages to treat severe bleeding 
caused by gunshot wounds to the extremities. Approximately 5,800 of 
these bandages have been deployed to the theater of operations. Our 
researchers continue to look for solutions for non-compressible 
hemorrhage wounds to the chest or abdomen. A hemostatic foam that can 
be injected into the body cavity is currently under research as well as 
a hand held high intensity focused ultrasound (HIFU) device. Our 
researchers at Medical Research and Materiel Command (MRMC) are working 
on a number of projects which will improve health care on the 
battlefield and in our treatment facilities. Some examples include the 
Hemoglobin-Based Oxygen Carrier (HBOC) a temperature stable, oxygen 
carrying solution that can be readily available to treat combat 
casualties with life threatening hemorrhage. MRMC is working with 
several companies to design Phase 2 and Phase 3 clinical trials with 
the goal of attaining FDA approval and licensure. MRMC is also 
sponsoring research on developing a better insect repellent, especially 
to protect our Soldiers from sand flies. In OIF over 400 of our 
Soldiers have been diagnosed with Leishmaniasis, which is a disease 
caused by parasites transmitted by sand flies. Leishmaniasis includes a 
wide spectrum of diseases ranging from the cutaneous form to the 
potentially fatal visceral disease. No prophylactic drugs or vaccines 
exist to combat this disease, hence personal protective measures are 
currently being used in theater. Each infected Soldier must be 
evacuated to Walter Reed Army Medical Center or Brook Army Medical 
Center of a 10-28 day therapy. Our researchers are looking for ways to 
identify and treat this disease in theater to avoid evacuation and 
reduce long-term scarring.
    We are progressing in transforming the combat medic to the new 91W 
Military Occupational Specialty (MOS). These medics train for 16 weeks 
versus the previous 10 week course and gain National Registered EMT-
Basic certification. The 91W combat medic training is conducted at the 
Army Medical Department Center and School. Active duty medical 
specialists and clinical specialists who have not converted to the 91W 
MOS are required to complete the training in their units that include 
not only EMT certification, but pre-hospital trauma training and 
advanced airway and IV management.
    Not only are we improving our training for personnel, but we are 
also improving our capability to transport patients on the battlefield. 
In order to treat Soldiers on the battlefield we have to be where they 
are. The 507th Medical Company (Air Ambulance) and the 126th Company 
(Air Ambulance) took our most advanced casualty evacuation helicopter, 
the HH-60L Black Hawk, to support operations in Southwest Asia and 
Afghanistan. These aircraft include a digital cockpit, on-board oxygen 
generation system, external electric hoist, advanced communications, 
improved litter support system, medical suction and electrical power 
for medical equipment. We currently have nine HH-60Ls and are working 
on upgrading the entire medical evacuation fleet. On the ground, we 
have the medical evacuation vehicle variant (MEV) of the Stryker. This 
vehicle is integrated into the fighting formation of the 3rd Brigade, 
2nd Infantry Division that deployed to Iraq last November. The new 
ground ambulance can carry four litter patients or six ambulatory 
patients while its crew of three medics provides basic medical care. It 
can be delivered to the battlefield in a C-130 aircraft, has the speed 
and mobility to keep up with fighting forces and can communicate with 
the most advanced combat formations.
            reserve component and national guard integration
    This war has reinforced a lesson we learned long ago: the AMEDD 
could not do its wartime mission without the Army National Guard and 
Army Reserve. Guard and Reserve medical units play key roles in Iraq, 
Afghanistan, and also in replacing active-duty personnel deployed from 
our stateside and European hospitals. We rely on Reserve Medical 
Support Units to process deploying Soldiers. Without them, active duty 
medical forces at mobilization sites would not be able to continue 
normal care for Soldiers and families.
Professional Filler System
    The Army Medical Department has been very successful in supporting 
contingency operations and the Global War on Terrorism (GWOT) by using 
a Professional Filler System or PROFIS to man early deploying units. 
Our PROFIS system takes AMEDD personnel from our fixed facilities and 
assigns them to deploying units who do not have their full complement 
of medical personnel. Medical Command (MEDCOM) is currently prepare to 
5,787 PROFIS personnel to deploying units. Of the 5,787: 1,177 are 
Active Component personnel slated against spaces in Reserve units and 
the remaining 4,610 personnel are PROFIS to active component units or 
multi-component units. We currently have 839 PROFIS deployed to support 
OIF and OEF and all the while, our Regional Medical Commands are still 
maintaining their baseline medical care workload despite personnel 
being deployed.
Medical Holdover
    A small percentage of Reserve Component Soldiers who mobilized in 
support of Operation Iraqi Freedom were not medically fit to deploy. 
Personnel guidance prior to October 25, 2003 stated Soldiers who were 
not medically fit to deploy would remain on active duty until maximum 
therapeutic benefit had been accomplished. If the Soldier's condition 
was still not at the point where he or she could deploy, then a Medical 
Evaluation Board would ensue and the Soldier would be released from 
active duty. By the end of October 2003 there were 4,452 Soldiers in 
the Medical Holdover (MHO) population and the numbers were growing. 
Personnel guidance changed on October 25, 2003 and the Army now returns 
Soldiers to their units and their homes if they are found medically 
unfit during the first 25 days of mobilization. The number of Soldiers 
who enter MHO during mobilization is now less than 1 percent. In 
October 2003 the Army also instituted enhanced access standards for MHO 
Soldiers, realizing these Soldiers were not near their homes and 
family, were living in quarters that were intended for short-term 
housing, and that the process of providing maximum therapeutic benefit 
was taking too long. The enhanced standards include 72 hours for 
specialty referrals, one week for magnetic resonance imaging and other 
diagnostic studies, two weeks for surgery, 30 days for the medical 
portions of the medical evaluation board processing, and one case 
manager for every 50 MHO Soldiers. Currently the AMEDD is meeting or 
exceeding those standards more than 90 percent of the time. Of the 
Soldiers in MHO on November 1, 2003, 871 remain on active duty. The 
total number of MHO Soldiers is 4,393 which is what our modeling 
predicted given the number of Soldiers mobilizing for OIF2 and the 
number of Soldiers demobilizing from OIF1. It is important to note the 
military is in the middle of the one of the largest troop movement 
operations since World War II.
Soldier Readiness Processing
    As indicated above, a very small percent of Reserve Component 
Soldiers are mobilized, but are not medically ready to deploy. Soldier 
Readiness Processing (SRP) evaluates Soldiers to ensure they are 
medically and dentally ready to deploy. This means the Soldier has the 
required immunizations, is medically healthy, has a dental readiness 
classification of 1 or 2, and has his personal medical equipment such 
as ear plugs, eye glasses and protective mask inserts. Active Component 
units participate in the SRP process on a routine basis and are 
constantly maintained in a deployable status. RC Soldiers have a 
limited amount of time to participate in SRP's hence their medical 
status sometimes is not up to par to deploy with the rest of their 
unit. An integral part to the successful mobilization of our Army 
Reserve (USAR) and National Guard (ARNG) troops is providing medical 
and dental services by using the Federal Strategic Health Alliance 
(FEDS-HEAL) Program. The FEDS-HEAL program brings together resources of 
the DOD, Department of Health and Human Services and Veterans Health 
Administration to create a robust provider network. FEDS-HEAL delivers 
readiness services to USAR, ARNG, and United States Air Force Reserve 
service members in all 50 states and territories. The FEDS-HEAL 
provider network performs medical examinations, dental examinations and 
treatment, immunizations, and other medical readiness services through 
Veterans Administration medical centers, Federal Occupational Health 
clinics, and a network of over 1,100 physicians and nearly 2,250 
dentists. In addition to exams and treatment, FEDS-HEAL provides a data 
management service and inputs patient care data into the Army's Medical 
Protection System (MEDPROS). The FEDS-HEAL Program Office provides 100 
percent Quality Assurance Reviews prior to MEDPROS reporting. In 
Calendar Year 2003, Reserve and Guard forces received 42,624 dental 
exams, 44,730 dental treatments, 29,971 physical exams, 54,108 
immunizations, and 2,427 vision exams.
90 Day Rotation Policy
    From late 1995 to early 1998, one-third of RC physicians who 
deployed to the Balkans left the USAR due to the 270 day length of 
rotations. Recruitment and replacement of these physicians was 
difficult. The loss resulted in personnel shortfalls of physicians, 
dentists, and nurse anesthetists. A 1996 survey of 835 RC physicians 
found that 81 percent could be mobilized up to 90 days without serious 
impact to their civilian practice, however, extended deployments beyond 
90 days had a severe negative impact. In late 1999 the Army conducted a 
pilot program deploying RC physicians, dentists, and nurse anesthetists 
for 90 day rotations. In 2001 a follow-on survey was conducted which 
validated the finding that RC physicians, dentists, and nurse 
anesthetists could deploy for that period of time without adversely 
affecting their private practice. The Army rotation policy was modified 
in early 2003 to provide for 90 day ``Boots on the Ground'' or BOG 
rotations either in the continental United States or outside of the 
continental United States for these specialties. Many medical 
professionals want the opportunity to serve their country. This policy 
enables them to stay with us in the Reserves and contribute to the 
mission.
                    pre and post health assessments
    We place a high priority on maintaining the health of Soldiers 
before, during, and after deployment. Before Soldiers deploy we closely 
monitor their Individual Medical Readiness (IMR). That means up-to-date 
immunizations, periodic health assessments, screening tests and medical 
equipment (ear plugs, eyeglasses, etc.). We are working on uniform 
metrics to inform commanders on the state of medical readiness of their 
troops.
    For the first time in military history, we are implementing a 
systematic process of capturing this information. All of this data is 
part of the pre-deployment health assessment, which provides baseline 
information on the Soldier's health status before deploying. Upon 
redeployment all Soldiers are required to fill out a post-deployment 
health assessment form. We are working on ways to improve the 
collection of this data, to include using hand-held devices that can 
electronically download the information into the central record-keeping 
repository. Once the information is captured electronically, the 
TRICARE online web portal can be used by the Soldier's medical provider 
to access the record. Department of Veterans Affairs can also access 
the information from the individual's medical record, which is 
available to the VA upon the Soldier's separation from the military.
    Despite these advances in management and use of our databases, we 
in the Army recognized the need for improvement. First and foremost, we 
realized the limitations of paper forms for pre- and post-deployment 
health assessment. Completing, copying and shipping paper forms from a 
worldwide deployed and busy Army was a process that was difficult to 
comply with, and almost impossible to oversee. In September 2002, we 
launched an initiative to improve our assessment process by automating 
the collection, distribution, and archiving of the data. The first 
automated assessment form on the internet was activated on April 1, 
2003. A hand-held computer variant of the enhanced (four-page) post-
deployment program was deployed to the Central Command Area of 
Operations (CENTCOM AOR) and to Europe beginning in August 2003. From 
June 1, 2003 through February 27, 2004, we have received 127,696 
automated health assessment forms, which comprise about one-third of 
all forms received during that period. Automated pre-deployment health 
screening was accomplished for the entire Stryker Brigade Task Force 
before it deployed in November 2003, and is approaching 100 percent for 
the 39th and 81st enhanced Separate Brigades. In Kuwait, all post-
deployment health assessments are automated; in Iraq, about half of all 
screening is performed using the automated form.
    In November 2003, the Army initiated a formal deployment health 
quality assurance program. This program includes audits of the 
deployment health assessment program on Army installations. Audits have 
been conducted at six Army installations (Forts McCoy, Drum, Lewis, 
Hood, Stewart, and Bragg). These audits reveal that compliance with the 
Army pre- and post-deployment health assessment program is generally 
higher than indicated by comparison with Army personnel databases, and 
is likely to rise further with automation support and standardization 
and centralization of Soldier readiness processing on installations and 
across the Army.
                         lowest kia/wia ratios
    Our died of wounds rate after receiving some level of care in OIF 
is 1.5 percent, the lowest in recorded warfare. A variety of factors 
have contributed to this, to include body armor and Forward Surgical 
Teams (FST). FSTs bring resuscitative surgical skills far forward on 
the battlefield and apply life-saving techniques that preserve the A-B-
Cs of life: airway, breathing, and circulation. They target the 15-20 
percent of wounded who, without care within the first hour after 
wounding, would die while being evacuated to the combat support 
hospital. Uncontrollable hemorrhage has been the major cause of death 
in this group in previous wars. The FST is well equipped to identify 
and stop bleeding by using a hand held ultrasound machine which can 
identify internal bleeding.
            transition to the department of veterans affairs
    Our goal for injured and ill Soldiers is to effect a seamless 
transition of care from DOD to the VA health care system. In September 
2003, Secretary Brownlee put together a Disabled Soldier Liaison Team 
(DSLT) specifically to look at the transition process for our most 
severely disabled Soldiers and make recommendations to improve that 
process. The mission of the DSLT was to assist Soldiers in their 
transition from the Army to the Department of Veterans Affairs Health 
Care system. The team was chartered to help Soldiers understand the VA 
system and their benefits. Our efforts in the medical department 
focused on identifying and appointing case managers/discharge planners 
who served as the primary point of contact with the VA. The VA also 
designated OIF/OEF coordinators in each of their regional offices and 
provided staff at our busiest medical centers to facilitate a Soldier's 
transition into their system. We currently have five VA coordinators 
physically located at Walter Reed Army Medical Center who provide 
personal liaison support between Soldiers and the VA.
                               readiness
    One of the key successes in fighting the war on terrorism has been 
our use of special medical augmentation teams (SMART). The Army Medical 
Department has used this reach back capability to our sustaining base 
to provide world-class expertise on the ground to support the 
Warfighter. We have rapidly deployed subject matter experts in 
leishmaniasis, pneumonia, mental health and environmental surveillance, 
to name a few, into Iraq or Afghanistan to provide assessments and 
recommendations to the command. A prime example of this capability is 
the environmental surveillance team from the U.S. Army Center of Health 
Promotion and Preventive Medicine (CHPPM) that was deployed to Iraq to 
assess an evolving concern near a nuclear research facility. An 
infantry regiment was operating within a few kilometers of the Tuwaitha 
Nuclear Research Facility. Concerns were raised about possible 
radiation and chemical exposures to U.S. service members and local 
civilians due to looting. A SMART Preventive Medicine Team from CHPPM 
deployed into the area to assess the Tuwaitha facility, which included 
a site inspection and environmental sampling. All of the field data, 
reports, and potential health risks were communicated to field 
commanders and Soldiers. Due to weather conditions, short exposure 
time, conditions of exposure, and location of troops relative to the 
site, the resultant health risk was low based on U.S. peacetime 
standards.
    In July 2003 the Army Medical Department chartered a team of mental 
health experts from CONUS treatment facilities around the nation to 
assess mental health issues in Iraq. Specifically, the mental health 
team was organized to assess the July increase in suicides in OIF, 
evaluate the patient flow of mental health patients from Theater, and 
assess the stress-related issues Soldiers were experiencing in a combat 
operation. This was the first time a mental health assessment team has 
ever come together and conducted a mental health survey with Soldiers 
in an active combat environment. The team remained in Iraq for six 
weeks and with the support of the combatant commanders, traveled to 
several base camps conducting their assessment.
    The AMEDD also has nationally recognized experts in the chemical, 
biological, radiological, and nuclear (CBRN) field, which can be formed 
into SMART teams to rapidly respond to a CBRN threat either CONUS or 
OCONUS. These experts come from our medical centers, the U.S. Army 
Medical Research and Materiel Command, CHPPM, and the Army Medical 
Department Center and School. Their expertise ranges from medical 
surveillance and epidemiology to casualty management. The AMEDD Center 
and School also has developed a number of short and long courses 
addressing CBRN topics which can be taught in house or exported to our 
treatment facilities. CBRN training has been incorporated into the 
Soldiers' common skills training, advanced individual training, 
leadership courses, primary care courses, and a number of other 
avenues.
    Our partnerships and collaboration with civilian counterparts is 
crucial in training our medical force. The U.S. Army Medical Research 
Institute of Infectious Diseases (USAMRIID) at Fort Detrick, MD, is a 
great national resource of expertise on testing methods to eradicate 
dangerous diseases. USAMRIID is partnering with the National Institutes 
of Allergy and Infectious Diseases (NIAID) and the U.S. Department of 
Agriculture (USDA) towards building a synergistic biodefense campus. 
The goal is to leverage the knowledge and capabilities of these 
research institutions by co-locating them on a single campus to fight 
the Global War on Terrorism.
                             garrison care
    The AMEDD is a $9 billion per year enterprise whose business is to 
take care of the Soldier, the family member and the retiree. Managing 
this complex organization with its many missions requires a structured 
system that directs the members towards a common goal. The system in 
place today is the balanced scorecard, which uses a building block 
approach to guide the organization in making the right decisions at the 
right time. The AMEDD is continually measuring itself and using 
assessment tools to ensure best business practices are in place and 
being used. The Decision Support Center sends out patient satisfaction 
surveys to measure a patient's satisfaction with a provider at a 
particular treatment facility. This type of feedback is invaluable in 
identifying where the organization is doing well or where the 
organization needs to improve.
    The AMEDD has used funds to establish venture capital projects and 
advanced medical practices initiatives to help military treatment 
facilities improve delivery of health care. Such projects include 
hiring certain specialties in a particular field to bring in more 
patients, renovating clinic space or purchasing new equipment to 
capture a particular market niche. Each project is required to have a 
business case analysis that must demonstrate the project will pay for 
itself within three years. This type of program helps commanders make 
better business decisions and saves money for the AMEDD in the future.
    Our health care delivery system is poised to move into the next 
generation of TRICARE contracts. The new contracts are performance 
based and have been designed to control costs through incentives for 
the direct care system and for the contractors. Its goals are to 
increase beneficiary satisfaction and improve portability. Transition 
activities at every level of the military health care system and within 
contractor organizations demonstrates a full commitment to a successful 
transition. For the AMEDD specifically, there is a TNEX Transition Task 
Force that has developed a transition task list that identifies 
critical, time sensitive tasks that must be accomplished in sequence 
for the transition to be successful at the MTF level. Transition 
activities include training and educating staff on market management 
and revised financing. The Transition Task Force trains and develops 
personnel in key positions such as future commanders, data analysts, 
and health care administrators in executive level positions. We look 
forward to this exciting era of change, which will begin in June of 
this year.
    Complimenting our delivery of health care is the availability of 
housing for visiting family members. Through the philanthropic efforts 
of the Fisher Foundation, there are 14 Fisher Houses operating at 9 
locations. In fiscal year 2003 the Army Fisher Houses served 2,560 
families, providing 39,680 family-nights of lodging. We estimate that 
staying in a Fisher House saved these families over $1.5 million in out 
of pocket lodging costs. The average length of stay per family was 15.5 
days. The contributions that the Army Fisher Houses have made in 
supporting the families of our combat casualties from Afghanistan and 
Iraq have been uniquely valuable. Since March 2003, Army Fisher Houses 
have accommodated 851 families attending to service members who were 
injured in combat operations or in support of combat operations. The 
occupancy rate for the Fisher Houses at Landstuhl Regional Medical 
Command in Germany, Walter Reed Army Medical Center in the National 
Capitol Region and at Fort Sam Houston, San Antonio has averaged over 
97 percent. Its obvious that the Army Fisher Houses provide a valuable 
benefit for military families.
    In an effort to protect direct care funds, the Congress passed 
legislation restricting the flow of funds from the direct care system 
to the private sector care system and vice versa. With the new health 
care contracts using the best business practices, there are incentives 
built into the system to use the direct care side as much as possible. 
Restricting movement of Defense Health Program funds will not allow the 
military treatment facilities the flexibility to manage their resources 
efficiently. In the new management environment, military treatment 
facilities are incentivized to increase productivity by pulling more 
beneficiaries into their facilities. The Army appreciates the 
congressional intent to protect direct care funding, but we recommend 
that the fiscal year 2005 Defense Appropriations Act language remove 
this restriction and allow flexibility to move funds to wherever care 
is delivered without a prior approval reprogramming.
                                summary
    Health care is a key quality of life issue for our military. I am 
committed to providing that quality care throughout the spectrum of 
operations, from the foxhole to the regional medical center. The Army 
Medical Department recognizes its responsibility to the men and women 
who defend our nation, to their families who support them, and to the 
retirees who have contributed so much to our country. We are committed 
to providing all of them exceptional healthcare. Army medicine is more 
than an HMO. Our system of integrated care includes teaching centers, 
research and development organizations, health clinics, field 
hospitals, and much more. The direct care system is truly the medical 
force projection platform for our Army; the Army we support across the 
world and across the spectrum of conflict. We do this quietly and on a 
daily basis all the while integrating active, guard and reserve units 
in support of the Chief of Staff's vision of THE Army.
    I would like to thank my fellow Surgeons General. Their support, 
teamwork, and camaraderie are much appreciated. I would also like to 
thank the Committee for its continued commitment to our men and women 
in uniform, the civilian workforce, and our beneficiaries.

    Senator Stevens. Admiral Cowan.
STATEMENT OF VICE ADMIRAL MICHAEL L. COWAN, SURGEON 
            GENERAL, UNITED STATES NAVY
    Admiral Cowan. Thank you, Chairman Stevens, Senator Inouye, 
and distinguished members of the subcommittee for inviting me 
here today.
    We frequently hear it said that post-9/11 everything 
changed, but for us in Navy medicine much remains the same. In 
fact, the events that have occurred since September 2001 have 
continually reemphasized the importance of our total mission of 
force health protection.
    The four pillars of force health protection are: first, to 
prepare a healthy and fit force that can go anywhere and 
accomplish any mission that the defense of this Nation requires 
of them; second, for our medical personnel to go with them to 
protect them from the hazards of the battlefield and 
deployment; third, to restore their health wherever protection 
fails while also providing outstanding and seamless health care 
for their families back home; and finally, to help a grateful 
Nation thank our retired warriors by providing them health care 
for life through TRICARE for Life.
    We strive to create a healthy and fit force by supporting 
healthy lifestyles not just for our sailors and marines but for 
their families as well. Our long-term goal is to form 
partnerships with families to adopt healthy lifestyles that 
have positive effects through their lifetimes. Healthier 
behaviors result in a fit and healthy force and also reduce the 
need for restorative medicine later in life. We work closely 
with our people so they are less likely to become our patients.
    Nearly one in six of naval medicine's deployable personnel 
are deployed today in support of operations on the global war 
on terrorism and in Iraq, and we will continue to operate at 
that rate for the foreseeable future. Forward medical personnel 
provide first responder, stabilization and forward 
resuscitative care at modular theater facilities, both ashore 
and afloat. Our theater hospitals are deployed independently or 
combined with other modules in a Lego-like fashion, a building 
block fashion, to provide essential care in theater. Definitive 
care is through a medevac process in fixed overseas and 
continental United States (CONUS) medical treatment facilities 
(MTF).
    Naval medicine's most vital asset is our people. Attracting 
skilled professionals and, equally importantly, retaining them 
to take advantage of their experience and enhanced skills 
represents one of our more significant challenges.
    We continue to support ongoing efforts implementing the 
Presidential task force recommendation to pursue sharing 
collaboration with the Department of Veterans Affairs, 
specifically to optimize the use of Federal health care 
resources. I believe that our progress in these collaborations 
is one of our great success stories.
    We worked hard to get the best value from every dollar that 
Congress has provided, and your assistance is needed to help 
restore the flexibility to manage funds across activity groups. 
Fenced private sector funds prevent transfer from the MTFs to 
private sector and prevent transfer from private sector to the 
MTF's. This does not allow us to increase productivity in the 
MTF's without the burden of prior approval reprogramming. This 
is very important in the upcoming year because the new T-NEX 
contracts with their incentives to move care into the MTF's 
make restoration of the flexibility all the more vital.
    We continue to work on the forefront of technology, and I 
would specifically highlight information technologies to 
include the development of naval medicine online. This 
communication tool will be the key to knowledge sharing 
throughout naval medicine as an enterprise, allowing the right 
information to flow to the right people at the right time 
whenever and wherever it is needed. Naval medicine is also 
committed to transforming the naval/Marine Corps infrastructure 
and services.
    We are further committed to the Chief of Naval Operations 
(CNO) transformational vision for projecting decisive joint 
capabilities from the sea, SeaPower 21. Examples of that 
transformation abound throughout naval medicine where hard work 
in identifying deficiencies and cutting costs have resulted in 
multiple opportunities to support the recapitalization of the 
Navy. This transformation is not limited to shore facilities. 
It includes remaking our fleet assets to include the 
reconfiguration of forward medical assets from cold war era 
platforms to the smaller and more agile task-oriented units 
that we deploy today.
    Finally, we are right-sizing our active forces to the best 
mix of active, civilian, and contract personnel to bring the 
right capability to bear and in alignment with the CNO's 
vision. We have reconfigured and integrated naval reserve 
components in very different ways to shape missions, along with 
the active component, creating a single unified force and 
assuring the very best use of the skills and talent of all of 
our medical personnel.
    We are effecting positive change throughout naval medicine, 
embracing the CNO's vision, and I am confident that we are on 
the right course for the challenges ahead.

                           PREPARED STATEMENT

    I share General Peake's gratitude and sense of having been 
honored by the work and the interest of this committee, and I 
thank you for everything that you have done with us and for us 
during my time as the Navy Surgeon General. It has been a 
privilege to serve.
    [The statement follows:]
          Prepared Statement of Vice Admiral Michael L. Cowan
    Chairman Stevens, Senator Inouye, distinguished members of the 
subcommittee, thank you for inviting me here today. Each year, the Navy 
Surgeon General has the privilege of appearing before the Senate 
Appropriations Committee Subcommittee on Defense to provide an update 
on the state of Naval Medicine. It has been a year of challenges met 
and rewards reaped, and of maturing of programs that we undertook in 
the wake of September 11, the anthrax attacks by terrorists unknown, 
and the prosecution of the Global War on Terrorism.
    Force Health Protection is the primary focus of Naval Medicine. 
Force Health Protection is comprised of four mission objectives: (1) 
Preparing a healthy and fit force that can go anywhere and accomplish 
any mission that the defense of the nation requires of them; (2) go 
with our men and women in uniform to protect them from the hazards of 
the battlefield; (3) restore health, whenever protection fails, while 
also providing outstanding, seamless health care for their families 
back home; and (4) help a grateful nation thank our retired warriors 
with TRICARE for Life.
    Naval Medicine balances all these actions to make force health 
protection work and see that all our beneficiaries get the outstanding 
healthcare they deserve. Wherever our Marines and Sailors at the tip of 
the spear deploy, we are along side them as we provide operational 
support in the Global War on Terrorism, achieving very low disease and 
combat casualty rates on the battlefield. The lessons we've learned 
from previous wars have led us to innovations toward a new level of 
agility and capability. Today, Expeditionary Medical Units are being 
built and fielded. These are complete lightweight tent hospitals that 
can be airlifted on site within days, and smaller units, Forward 
Resuscitative Surgery Systems, can be deployed to the action and made 
ready for patient care within hours. They, staffed with their ``Devil 
Docs,'' have proven to be lifesavers for wounded Marines.
    In defense of bio-terror attacks against our Nation, including the 
recent ricin attack at the Dirksen Senate Office Building, the Naval 
Medical Research Center, has made great advances in developing 
enhanced, rapid analysis and confirmation processes. These innovations 
have directly supported the nation's security and are a vital component 
in protecting our military fighting a war both abroad and here in the 
homeland.
    Naval Medicine provides the most visually recognizable healthcare 
facility in the world--the military treatment facilities aboard the 
distinctive white with red-crossed hospital ships USNS COMFORT and USNS 
MERCY. These ships are symbols of life saving and caring that also send 
a clear message to our enemies: We are committed to our mission, and 
are prepared to take care of the casualties we may suffer to accomplish 
it.
    Naval Medicine is an effective defensive weapon system for the Navy 
and Marine Corps Team. Naval Medicine treated every combat casualty 
within the critical ``Golden Hour'' through the use of new and 
innovative surgical units, such as the Forward Resuscitative Surgery 
System (FRSS). We reconfigured our Cold War era Fleet Hospitals to 
become more agile, mobile 116 bed Expeditionary Medical Facilities that 
are being used to support operations around the world. Sailors and 
Marines can be confident that they will have world class health care 
professionals at their side at all times--at sea or ashore.
    Force Health Protection remains our primary mission. We strive to 
create a healthy and fit force through encouraging and supporting 
healthy lifestyles not only for our Sailors and Marines, but for their 
families as well. Our goal is to form a partnership with our families 
to help them adopt healthier lifestyles that will have a positive 
effect throughout their lifetimes. These healthier behaviors will not 
only result in a fit and healthy force, but will reduce the need for 
restorative medicine later in life. We work with our people so that 
they will be less likely to become our patients.
    We recognize that health care is a major retention and recruitment 
issue as well as a readiness issue, and strive to provide world-class 
care not only to the families of our Sailors and Marines, but to 
retired service members and their families as well. Naval Medicine is 
implementing Family Centered Care initiatives to increase patient 
satisfaction and continuously improve on our delivery of patient care. 
If we can retain our families within the direct health care system, 
Naval Medicine can continue to assist them with the tools to form 
healthy habits throughout their lives.
                        force health protection
    Force Health Protection is a continuum of services designed to 
create and maintain a healthy and fit force. This continuum begins with 
medical and dental screening during induction into the service, 
followed by annual preventive health assessments, regularly scheduled 
physical examinations, pre and post deployment assessments and ending 
with separation or retirement physicals. Health care professionals 
participate and review every assessment along the continuum. The same 
schedule of physical assessments is followed for both active duty and 
reserve service members.
    Over 100,000 Navy and Marine Corps personnel completed post 
deployment health assessment forms since April 2003. Primary care 
providers then interview service members if there are any indications 
of deployment related illnesses or injuries, or changes in their health 
concerns. Service members may be referred for additional specialty care 
if indicated. As of March 2004, 7 percent of active-duty and 15 percent 
of reservists required post deployment medical referrals.
                          deployment medicine
    In support of Operation Iraqi Freedom (OIF), over 7,300 active and 
reserve Naval medical personnel were deployed or mobilized, at sea or 
shore. From the battlefield Hospital Corpsmen to the Forward 
Resuscitative Surgery System (FRSS), the Fleet Hospitals (FH) and the 
hospital ship USNS COMFORT, and to the National Naval Medical Center 
(NNMC), Bethesda, wounded, injured, and sick Coalition Force warriors, 
Iraqi prisoners of war, Iraqi civilians (displaced persons) received 
the highest quality medical care possible.
    Our readiness platforms include two 1,000 bed hospital ships, 6 
active duty and 2 Reserve Fleet Hospitals as well as special medical 
units supporting Casualty Receiving and Treatment Ships (CRTS) and 
smaller, organic units assigned to augment the Marine Corps and 
overseas hospitals.
    Nearly one in six of Naval Medicine's deployable personnel are 
deployed today in support of operations fighting the Global War on 
Terrorism and will continue to operate at that rate for the foreseeable 
future. Forward medical personnel provide first responder, 
stabilization and forward resuscitative care at modular theater 
hospitals, both ashore and afloat in theater. Our modular theater 
hospitals can be employed independently or combined with other modules 
to provide essential care in theater. Definitive care is provided in 
fixed overseas and CONUS military medical treatment facilities.
    During Operation Iraqi Freedom, Naval Medicine employed a new type 
of unit to provide far forward surgery. The Forward Resuscitative 
Surgery System (FRSS) was developed to provide forward surgical 
capability to support the Marine Corps' Regimental Combat Teams. The 
FRSS is staffed with a team of two general surgeons, one 
anesthesiologist, one critical care nurse and four Hospital Corpsmen. 
The FRSS can accommodate 18 casualties in 48 hours without re-supply. 
During OIF, six FRSS teams treated 96 casualties and performed 153 
surgical procedures during combat operations.
    This year has also seen the introduction of the Forward Deployable 
Preventive Medical Unit (FDPMU) designed to assess, prevent, and reduce 
health threats in support of deployed operating forces. Other missions 
for the FDPMU include humanitarian assistance, consequence management, 
and disaster relief operations. Capabilities can include chemical, 
biological, and radiological agent detection and identification, as 
well as toxic environmental chemical detection and identification.
    The Forward Deployable Preventive Medical Units are capable of 
deploying within 96 hours, can serve as a joint force asset to provide 
specialized preventive medicine, and CBRN response services in support 
of force health protection to combatant commanders and Joint Task Force 
Commanders. Naval Medicine has elements of two FDPMUs currently 
deployed to Iraq and elements of another FDPMU currently deployed to 
Haiti.
    Our mobile platforms continue to be refined, making them more agile 
and adaptable to specific missions. Transformation efforts continue by 
the Fleet Hospital Program with the continued development and 
refinement of the Expeditionary Medical Unit (EMU). The EMU provides 
both forward stationed and CONUS-based forces the ability to rapidly 
deploy, employ, sustain and redeploy scalable medical capabilities to 
austere regions of the globe. The transformation process from Fleet 
Hospitals to EMUs is planned to continue over the next several years as 
we reshape our forward presence to a lighter, smaller and more agile 
force.
    EMU Alpha was deployed to Djibouti in September 2003 and is still 
receiving patients. NH Jacksonville is providing the staff for EMU 
Alpha.
    As part of the post Operation Desert Storm lessons learned 
analysis, Naval Medicine embarked on an extensive effort to better 
organize and train our wartime-required active and reserve medical 
force, while at the same time optimizing our peacetime healthcare 
benefit mission. Naval Medicine developed and implemented a CONUS 
readiness infrastructure strategy that aligned specific operational 
platforms to a single Military Treatment Facility (MTF), along with the 
active duty and reserve manpower required to perform both wartime and 
peacetime missions. This readiness alignment strategy provides the MTF 
commander with the authority and the resources to balance wartime 
readiness and peacetime benefit missions.
    As a result of this new structure, Naval Medicine can employ 
``Tiered Readiness.'' This strategy allows platform rotation to support 
ready surge requirements. Each platform and their parent Medical 
Treatment Facility (MTF) will be on a scheduled rotation: for six 
months, two MTFs and their supporting Fleet Hospital personnel will 
have to be ready to deploy within 10 days. Three additional Fleet 
Hospitals and their parent MTFs have sixty days to prepare for a 
possible deployment. Finally, there is a sixth Fleet Hospital, in 
reserve, which must be ready to deploy within 120 days. Tiered 
Readiness enables Naval Medicine to plan, prepare and meet our 
operational commitments and is in synch with the Chief of Naval 
Operations' transformational vision for the United States Navy.
               naval medicine office of homeland security
    Winning the Global War on Terrorism is job #1 and Naval Medicine 
brings many assets to bear in this fight. As its Surgeon General, I 
think of Naval Medicine as a ``Defensive Weapon System'', which, in 
addition to providing the highest quality medical care to our 
warfighters, also can take action to deter threats through such 
mechanisms as delivering vaccines that eliminate specific disease 
threats. We have sophisticated technologies designed to detect 
biological, chemical and radiological threats before they cause harm, 
and we have highly trained medical personnel who can identify early 
signs of an intentional or natural disease outbreak that could degrade 
our military effectiveness if unrecognized. Naval Hospitals and clinics 
are vital national security assets that are a cornerstone of both force 
health protection and the National Disaster Medical System.
    The Naval Medicine Office of Homeland Security, only in its second 
year, continues to make great contributions to our Force Protection, 
disaster preparedness, and homeland security missions, both here and 
abroad. Naval Medicine continues to execute cutting edge initiatives to 
ensure our hospitals and clinics around the world can continue to 
provide care for all who depend upon us--even in the event of an attack 
or disaster. Presently, we are executing an enterprise-wide program to 
strengthen our effectiveness in responding to disaster. The Disaster 
Preparedness, Vulnerability Analysis, Training and Exercise (DVATEX) 
Program has been conducted at 24 of our 30 military treatment 
facilities. It employs a comprehensive vulnerability analysis of all 
hospital operations in a disaster or terrorist attack. DVATEX provides 
emergency preparedness education thus far to over 5,000 Naval Medicine 
personnel, and it has exercised hundreds of our people, alongside their 
loyal civilian counterparts, to improve integration during an 
emergency.
    DOD is about to deploy a web-based training program that will be 
used to educate physicians, nurses and other health care providers on 
response to chemical and biological emergencies. Originally developed 
for Navy use, the program has been adopted by the MHS and the Defense 
Medical Readiness Training Institute is preparing it now for educating 
personnel in all three Services.
               naval medicine's people: a manpower status
    Naval Medicine's most vital asset is its people. Attracting skilled 
professionals and, perhaps more important, retaining them to take 
advantage of their experience and enhanced skills, is one of Naval 
Medicine's greatest challenges.
    Naval Medicine strategies to recruit and retain the best people 
include a multi-faceted and highly coordinated approach: The 
professional and educational needs of our health care professionals 
must be met to ensure they, at a minimum, are equal to their civilian 
counterparts. Their work environment must be supportive of their 
contributions and accommodating to their special needs, missions and 
requirements, while continuously challenging them professionally. 
Finally, their financial compensation must be sufficiently competitive 
with their civilian counterparts for us to attract and retain the right 
people.
    We require our Naval Medicine professionals to have the same skills 
and qualifications as their civilian counterparts, and also require of 
them additional unique personal and professional challenges. A status 
of Naval Medicine's people is below:
Medical Corps
    At the beginning of fiscal year 2004, the Navy's Medical Corps was 
manned at approximately 101.8 percent. Navy Medicine is working on 
community management initiatives to ensure more of a balance between 
specialties. The attrition rate for fiscal year 2003 was 9.2 percent, 
with the three-year average rate at 8.9 percent. Attrition is expected 
to be higher in fiscal year 2004, due to the number of requests for 
resignation and retirement that have already been received. High 
operational tempo and longer deployment durations have been cited as 
major reasons for this increase.
    Despite success at manning and retaining skilled professionals at 
the Medical Corps' top line, several critical specialty areas remain 
undermanned. These specialties are: Anesthesia (85 percent), Cardiology 
(57 percent), Pulmonary/Critical Care (76 percent), Gastroenterology 
(79 percent), General Surgery (88 percent), Infectious Disease (89 
percent); Pathology (85 percent), Urology (85 percent), and Radiology 
(75 percent). Not surprisingly, surgical specialists, 
anesthesiologists, cardiologists, gastroenterologists, and radiologists 
continue to be the most difficult to recruit and retain because of the 
high salaries offered in civilian practices.
Medical Special Pays
    To be competitive in a marketplace with a limited number of 
qualified applicants and retain them once they have chosen Naval 
Medicine, adequate compensation is critical. The civilian-military pay 
gap has increased steadily, which makes it difficult to recruit and 
retain physicians in high demand specialties.
Dental Corps
    At the close of fiscal year 2003, the Navy Dental Corps was manned 
at 91 percent. Despite aggressive efforts to improve Dental Corps 
recruitment and retention, the annual loss rate between fiscal year 
1997 and fiscal year 2003 increased from 8.3 percent to 11.7 percent. 
In addition, declining junior officer retention rates has negatively 
impacted applications for residency training programs, which have 
dropped 18 percent over the last five years. The civilian-military pay 
gap and the high debt load of our junior officers are the primary 
reasons given by Dental Corps officers leaving the Navy.
Nurse Corps
    At the close of fiscal year 2003, the Navy Nurse Corps was manned 
at just under 98 percent. The nursing shortage nation-wide has made the 
Navy's competition for recruiting and retaining skilled nurses a 
challenge. It has been further challenged by the Nurse Reinvestment 
Act, which offered loan repayment and sign-on bonuses to nurses in the 
civilian sector. Naval Medicine continues to meet military and civilian 
recruiting goals and nursing requirements by using a broad range of 
accession sources, pay incentives, graduate education and training 
programs, and retention initiatives that include such quality of life 
and practice opportunities as leadership challenges, operational 
experiences, promotion opportunities, and diversity in assignments with 
job security. The Nurse Accession Bonus, Certified Nurse Anesthetist 
(CNRA) Incentive Pay, Board Certification Pay, and Special Hire 
Authority are all initiatives that are critical in supporting Naval 
Medicine's success in meeting its nursing wartime and peacetime 
missions.
Medical Service Corps
    Medical Service Corps manning at the beginning of fiscal year 2004 
was 95.6 percent. The loss rate increased from 6.8 percent in fiscal 
year 2002 to 7.2 percent in fiscal year 2003. Loss rates vary 
significantly between specialties and certain specialties continue to 
have either shortages or experience gaps caused by low continuation 
rates at the junior officer pay grades. The potential effects of 
successive military deployments and the military to civilian billet 
conversions on retention and recruiting are being monitored closely.
    The majority of Medical Service Corps officers enter military 
service directly from the private sector and have funded their own 
professional education. Many Medical Service Corps officers incur 
significant educational debt prior to commissioning and active Naval 
service. Additionally, there is an increasing number of doctoral and 
masters level educational requirements for certain healthcare 
professions with the increase in qualifying degree requirements, 
further exacerbating the educational debt load of our newest officers.
    Biochemists, microbiologists, entomologists, environmental health 
officers, radiation health officers and industrial hygiene officers are 
integral members of Chemical, Biological, Radiation, Nuclear & 
Environmental (CBRN&E), homeland security, and operational readiness 
requirements and initiatives. With their strong educational background, 
significant work experience and security clearances, these officers are 
prime recruiting targets for civilian enterprises working in parallel 
with Department of Defense and Department of Homeland Security 
missions.
Hospital Corps/Dental Technicians
    The Hospital Corps manning at the end of fiscal year 2003 was 94 
percent. Like the Medical and Dental Corps, some specialty areas, 
identified by their Navy Enlisted Classifications (NEC) struggle to 
remain manned above 75 percent. In the operational forces, the Marine 
Corps reconnaissance Hospital Corpsman specialty is currently manned at 
44 percent. In Naval Military Treatment Facilities, cardio-pulmonary 
technicians are manned at 72 percent, bio-medical repair technicians at 
72 percent, morticians at 56 percent, respiratory technicians at 73 
percent, and basic SEAL hospital corpsman at 70 percent of authorized 
levels. Manning for the Dental Technician rate is at 95 percent of 
authorized levels.
    Initiatives to ensure consistent manning levels, as well as to 
bolster undermanned NECs, include the Navy's Perform to Serve program, 
which allows sailors in other rates to transfer or ``cross-rate'' into 
the Navy Hospital Corps and acquire NECs in critically undermanned 
areas. A current initiative to merge the Hospital Corpsman and Dental 
Technician rates into a single rate may help bolster NECs with poor 
manning levels.
Rightsizing the Force
    Navy Medicine is converting 1,772 non-readiness military manpower 
positions (billets) to civilian/contract positions in fiscal year 2005. 
All of these positions are at CONUS MTFs or DTFs. OCONUS and 
operational commands are unaffected.
    The final determination of which billets will be converted has not 
occurred yet. The draft list of the 1,772 billets under consideration 
was identified from a larger list of approximately 5,400 over Total 
Health Care Support Readiness Requirement (THCSRR) billets that Naval 
Medicine has been studying. Our manpower and resource management 
experts are working closely with representatives from the Medical, 
Dental, Medical Service, Nurse and Hospital Corps Chiefs/Director's 
Offices, and the Center for Naval Analyses (CNA). Factors to determine 
the final 1,772 positions include readiness impact based on emerging 
threats, community manning levels, the cost of conversion, and skill 
availability in the market place.
    This initiative is very much in line with Navy's fiscal year 2004 
human resource philosophy, which includes maximizing civilian and 
contract personnel for non-military essential (non-readiness) 
positions. The conversion of these positions will help alleviate the 
stress on the operating forces and ensure that military personnel are 
used to perform tasks that are military essential.
              naval medical education and training command
    I am pleased to report to the Committee that the Naval Medicine 
Education and Training Command, or NMETC, has successfully progressed 
as the central source of learning for all Naval Medical personnel. The 
five learning centers comprising NMETC are co-located with the Fleet on 
the east, west and southern coasts along with basic recruit training in 
Great Lakes, Illinois and Naval Headquarters here in Washington.
    NMETC has established itself as the Learning Center for Force 
Health Protection and is in precise alignment with Navy's Sea Warrior 
program. It has demonstrated being on par with the line Navy in 
implementing the Chief of Naval Operations' Revolution in Training by 
way of the 5 Vector model which when fully operational, will show 
sailors what they need to learn, how to access that learning and 
provide a career road map, which tracks their learning and promotion 
potential. The Naval Medical Department has increasing numbers of 
subscribers to the new web-based Navy Knowledge Online or NKO, and is 
utilizing the growing number of NMETC developed courses to enhance 
their learning. They are also rapidly beginning to share and manage 
their knowledge in an environment of community practice--all in one 
place, in real-time, in NKO. By increasing our partnership with 
civilian academe, we've exploited its skills and knowledge to enhance 
the learning of our Sailors by exposing them to newer ways of thinking 
and state of the art technologies.
    NMETC has established a Naval Reserve medical liaison that provides 
input concerning the rapidly evolving requirements of the Naval Reserve 
and thus utilizes our Reserve partners in ONE Naval Medical education 
and training service.
    Our ``A'' School, the Naval Hospital Corps School, is in the lead 
to see that our young Sailors, both in Active and Reserve components, 
are economically and efficiently trained. This is demonstrated by an 
improved technology-based program to train Hospital Corpsmen in a 
blended learning environment available both in the classroom, and non-
traditional settings. Our instructors are highly trained and many come 
directly from the operational arena.
    The Naval Schools of Health Sciences in Portsmouth and San Diego 
integrate the precepts of Force Health Protection into every aspect of 
the training and educational curricula and programs. The Commanding 
Officers personally lead this effort through military training, 
leadership and physical fitness. Their mission, to support readiness 
through leadership in advanced medical training, is designed to meet 
the needs of military medicine in conflict and in peace. It is the 
cornerstone for all facets of each training program. All courses 
include learning modules directed towards the protection and self-
treatment of that sailor and other casualties resulting from weapons of 
mass destruction. Many of our instructors are fresh from the Fleet and 
the Fleet Marine Force, and bring enormous operational experience to 
new students in the classroom. We have incorporated experiences from 
Operation Enduring Freedom and Operation Iraqi Freedom into various 
training programs such as the Joint Special Operations Medical Training 
Center at Fort Bragg, which teaches trauma and emergency care skills to 
corpsmen attached to SEAL Teams and reconnaissance units.
    Projected training requirements for fiscal year 2005 through fiscal 
year 2010 show an increase in the total numbers of personnel to be 
trained as Independent Duty Corpsmen, Laboratory Technicians, Search 
and Rescue and Preventive Medicine Technicians to support operational 
readiness. We are committed to support and to participate with the 
medical activities of our sister services by continuing our 
relationships with other DOD training organizations that prepare 
medical personnel for delivering care to the Fleet as well as in 
integrated operational environments.
    As a primary deliverer of skills sets for Sea Warrior, our schools 
provide benchmark model training programs where students in 
cardiovascular technician, nurse anesthesia, physician assistants, 
preventive medicine technician, surgical technician, medical laboratory 
and nuclear medicine technician exceed professional national 
certification rates by as much as 30 percent thus, augmenting the Chief 
of Naval Operations' ``Revolution in Training.''
    The Naval Operational Medical Institute, or NOMI, with its 
specialty detachments, is our dedicated operational training arm. It is 
fully engaged in preparing line and medical personnel to learn and 
implement survival and medical skills in hostile environments on land, 
in the air and on the sea. Recently, NOMI developed a training program 
and standards for Enroute Medical Care to personnel assigned to Marine 
Corps units with field medical evacuation requirements.
    Naval Medicine at NOMI now has a Center for Medical Lessons Learned 
that provides feedback related to the operational environment. This 
helps to refine and improve requirements for training both at NOMI, as 
well as in our other training programs. The Medical Operational Lessons 
Learned Center is a web-enabled system that has captured 31 lessons 
learned to date from medical personnel who were forward deployed in 
support of operations. The Center is a single point for data collection 
and analysis of all Naval Medical observations and provides expeditious 
feedback related to the operational environment in areas such as 
readiness training, health services support delivery, logistics and 
field medicine.
    As our duty, and part of the continuum of care, the Mitchell Center 
for Repatriated Prisoners of War performs approximately 450 extensive 
evaluations per year on former POWs, their spouses and comparison 
groups. The results of these studies have facilitated the minimization 
of the development or worsening of post-traumatic stress disorder and 
other physical and mental conditions among former prisoners of war.
    NOMI is also is our service's lead on the Trauma Combat Casualty 
Care Committee. Civilian trauma experts participate in this Triservice 
Committee, which produces guidelines integrated into special operations 
curriculum. These guidelines have also been published as a chapter on 
military medicine in the most recent Pre-Hospital Trauma Life Support 
Manual. This manual is also being utilized by the civilian EMT-
paramedic community to enhance first responder training and 
capabilities within police, fire, and rescue services.
    In fiscal year 2003, our schoolhouses prepared 8,732 medical 
department enlisted and officers to join the Fleet and Marine Corps 
medical components and to staff our Military Treatment Facilities, 
research commands and other support communities. Naval Medical 
personnel are ready to deploy wherever and whenever the Naval Services 
deploy, and much of the time are the only direct care providers in the 
field and especially at sea.
    In addition to preparing for the operational arena, our educational 
programs include learning opportunities in healthcare management, 
fiscal responsibility and efficient direct healthcare delivery. We are 
ensuring Force Health Protection by producing highly qualified, 
technically competent personnel to directly support the Navy and Marine 
Corps in any mission the Commander in Chief calls upon them to carry 
out.
          uniformed services university of the health sciences
    As the Executive Agent for the Uniformed Services University of the 
Health Sciences (USUHS) and a member of the Board of Regents, I am 
pleased to announce that the University recently received a ten-year 
accreditation with commendation from the Middle States Commission on 
Higher Education. This is a noteworthy accomplishment and it reflects 
well on the successful, on-going commitment of the University to 
provide the highest levels of professional health care education for 
our Nation's Military Health System (MHS).
    The quality of the USUHS alumni ensures that the intent of the 
establishing legislation, The Uniformed Services Health Professions 
Revitalization Act of 1972, is being realized. The military unique 
curricula and programs of USUHS, successfully grounded in a multi-
Service environment, draw upon lessons learned during past and present 
day combat and casualty care. USUHS alumni, 3,421 physicians, 200-
advanced practice nurses and 798 scientists, have become an invaluable 
and cost-effective source of career-oriented, dedicated uniformed 
officers. Our University graduates volunteer in large numbers for 
deployment or humanitarian missions; they serve proficiently in desert 
tents, aboard The Hospital Ship COMFORT, and during air evacuations. 
USUHS graduates embody the University's mission-driven goal of Learning 
to Care for Those in Harm's Way; they are equal to their sacred mission 
of providing care to our Nation's most precious resource--the men and 
women who serve in the Armed Forces.
    I would also like to take a moment to recognize the USUHS 
President, James A. Zimble, M.D., VADM, USN (retired), and 30th Surgeon 
General of the Navy, who has successfully guided our University for the 
past thirteen years. Dr. Zimble served our Nation for over 40 years, 
will retire in August of 2004. Under his leadership, the University has 
become the Academic Center for the Military Health System; during his 
tenure, the University has achieved peer recognition, on-going 
accreditation with commendation from 14 accrediting entities, and the 
Joint Meritorious Unit Award from the Secretary of Defense. He is a 
public servant who has unselfishly dedicated the better part of his 
life to Caring for Those Who Serve in Harm's Way. I wish him the very 
best in his well-deserved retirement. He will be greatly missed.
                          health care delivery
    Naval Medicine continually examines our methods of delivering 
services to ensure that they are the best value for Naval Medicine, the 
MHS and our beneficiaries. We focus on increasing our efficiencies, but 
will never compromise clinical quality, access to care, customer 
satisfaction or staff quality of life to achieve that goal.
    This year the Bureau of Medicine and Surgery (BUMED) developed a 
business planning model that combined standard business planning 
methodology with an automated business planning tool. This new process 
requires all activities in Naval Medicine to develop, submit, and 
monitor a comprehensive annual business plan that is integrated with 
their existing financial plan. This methodology takes into account the 
changes in our financing due to the TRICARE for Life program, the 
prospective payment system and the TRICARE Next Generation contracts. 
The automated tool takes information from seven different data sources 
to help local commands and headquarters personnel identify variations 
in cost and productivity for the same services between MTFs. It also 
helps identify high cost, low productivity services provided at local 
MTFs. We are providing specialized training to the senior leaders in 
our MTFs, to ensure that their business plans optimally represent the 
size and diversity of services provided at their facilities. Our goal 
is to reduce the variation in cost and productivity between our MTFs, 
driving out inefficiencies that will result in increased cost savings, 
patient satisfaction and quality of medical care rendered.
    ``Family-Centered Care'' is one of the initiatives we have 
undertaken to provide best value for our beneficiaries. Family-Centered 
Care initiatives are intended not only to increase patient satisfaction 
and improve the delivery of care; they are intended to create 
partnerships between providers, patients, and their families by 
empowering patient's families to become active in the care plan. In the 
military, the definition of family must be expanded to include both 
immediate and extended family members as well as friends and the social 
support network of both single service members and spouses of deployed 
service members. Single service members create virtual families' 
through a social network within and outside their units. Family-
centered care must incorporate this non-traditional type of family 
support in the delivery of care. By partnering with patients and their 
families, we can retain them in the direct health care system. This 
will enable Naval Medicine to provide families with the tools to 
develop and maintain healthy habits throughout their lives.
    Our first Family-Centered Care initiative includes significant 
improvements to perinatal services in order to integrate our young 
Sailors and Marines into our health care system during the time in 
which they are starting their families. Our MTFs have implemented 
numerous initiatives to provide increased quality of service for 
expectant women and their families. These initiatives include: 
increased continuity with providers through prenatal visits with small 
care teams or individual providers; encouraging our providers to work 
with patients to create a birth plan for their deliveries; providing 
private post-partum rooms where possible; providing 24/7 breastfeeding 
support; DEERS enrollment by the bedside; and establishing a system to 
provide seamless transfer of care between MTFs during permanent change 
of station moves for expectant women. These initiatives have been 
successful in encouraging our patients to choose to deliver their 
babies in our MTFs despite the fact that they now have the choice to 
seek perinatal care in the civilian community.
    In fiscal year 2003, Naval Medicine embarked on a global Case 
Management Program (CMP) in Navy MTFs. This program provided contract 
registered nurses and social workers to assist in the coordination of 
care for patients with complex illnesses or serious injuries. These 
professionals work with all disciplines within a medical treatment 
facility and within the TRICARE network to ensure that patients have a 
seamless transition in healthcare services, receive the proper referral 
to needed services and reduce the incidence of duplicate or unnecessary 
services. This program reduced health care costs, increased patient 
satisfaction and ensured high quality care for our beneficiaries.
    Naval Medicine initiated a third Radiology Residency Program at the 
Naval Medical Center in Portsmouth, VA. This proactively addressed 
staffing issues in the most critically understaffed and expensive 
medical specialty in the Navy, immediately improving access to imaging 
services in the short-term while providing long-term specialty 
availability.
    We have also invested in Pharmacy Automation Equipment at selected 
treatment facilities. This program leverages technology by using bar 
code scanners and computers to continuously track and monitor 
medication administered to our inpatients. This equipment greatly 
improves the safety of our patients by reducing the probability of 
unintended medication errors.
    We continue to fund new pilot projects designed to increase our 
effectiveness in providing healthcare services. With our new business 
planning tool, we will be able to quickly identify those projects that 
successfully increase productivity and share those improvements in all 
of the MTFs throughout Naval Medicine. It is our intent to continuously 
improve our patient care delivery systems to ensure the best health 
care for our beneficiaries.
    Patient safety is a top priority for Naval Medicine. Every MTF has 
a minimum of one full time staff member dedicated to coordinating 
command-wide patient safety initiatives. All of our MTFs participate in 
the MEDMARX system for medication error reporting that groups 
medication error events and near misses into five process nodes, 
allowing MTF staff to evaluate process changes that will increase the 
safety of medication administration. Naval Medicine also uses a 
standardized root cause analysis methodology that is used by both local 
MTF and headquarters staff to track and analyze trends in patient care 
systems that affect patient safety. All of our MTFs are required to 
submit monthly patient safety scores and receive a monthly Safety 
Assessment Score. These scores are used to assess overall MTF 
performance and are monitored closely.
    We maintain our high standards through rigorous reviews. Our 
medical treatment facilities are reviewed by leading accreditation 
agencies including the Joint Commission of the Accreditation of 
Healthcare Organizations (JCAHO), Accreditation Council for Graduate 
Medical Education; the College of American Pathologists and the 
American Association of Blood Banks.
    Naval Medicine has implemented through the JCAHO a major paradigm 
shift in the accreditation process of our MTFs: ``Shared Vision-New 
Pathways''. Shared Visions-New Pathways shifts the focus from survey 
preparation to continuous improvement of operational systems that 
directly impact the quality and safety of patient care. It is intended 
to force standards based process integration across all functional 
lines by using actual patient experience as a lever.
DOD/VA Resource Sharing and Coordination: Status on Implementation of 
        Presidential Task Force Recommendation
    Naval Medicine continues to support ongoing efforts implementing 
the Presidential Task Force recommendations to pursue sharing 
collaboration with the Department of Veterans Affairs specifically to 
optimize the use of federal health care resources. I believe our 
progress is one of our success stories. Site-specific sharing 
initiatives, including in the key geographical areas as directed by the 
fiscal year 2002 and fiscal year 2003 Defense Authorization Acts, are 
occurring and continue to be developed.
    Naval Medicine currently has 54 medical agreements, 34 Reserve 
agreements, 24 Military Medical Support Office agreements, and 13 non-
medical agreements with the Department of Veterans Affairs. Naval 
Medicine has also partnered with the Department of Veterans Affairs on 
five medical facilities construction projects. These are:
  --1. Naval Hospital Pensacola FL.--This joint venture outpatient 
        facility will be built on Navy property, and the VA will fund 
        the project, and provide Naval Medicine with 32,000 square 
        feet. This will be a replacement facility for Naval Medicine's 
        aging Corry Station Clinic. Navy and VA have agreed on a site 
        and negotiations continue on the amount of land to be allocated 
        for construction and how services will be integrated to best 
        serve both DOD beneficiaries and Veterans.
  --2. Naval Hospital Great Lakes, IL.--A fiscal year 2007 construction 
        start has been proposed to build a separate Navy/VA Ambulatory 
        Care Clinic on the grounds of the North Chicago Veterans 
        Affairs Medical Center. Full integration planning has begun, 
        with facility and site analysis to follow. The North Chicago 
        VAMC is now providing emergency and inpatient services to Navy 
        beneficiaries. Additionally, the North Chicago Veterans Affairs 
        Medical Center will be available to the Navy for specified 
        services with the Department of Veterans Affairs funding 
        modifications of its surgical suites and urgent care 
        facilities.
  --3. Naval Hospital Beaufort, SC.--A tentative fiscal year 2011 
        construction start has been planned for a replacement hospital. 
        The Department of Veterans Affairs currently operates a small 
        clinic within the existing hospital, and is expected to be a 
        partner in developing the replacement facility.
  --4. Naval Ambulatory Care Clinic Charleston, SC.--A fiscal year 2005 
        construction start has been planned for a replacement clinic 
        aboard Naval Weapons Station (NWS) Charleston. Navy has offered 
        the Department of Veterans Affairs the options of an adjacent 
        site onboard NWS or the take-over of the existing NWS clinic. 
        The Department of Veterans Affairs is studying these options 
        with a final decision to be made in the future.
  --5. U.S. Naval Hospital Guam.--A fiscal year 2008 construction start 
        is planned for replacement of the current hospital. The Navy 
        has offered the Department of Veterans Affairs a site for 
        nearby freestanding community-based outpatient clinic. It's 
        proposed that the Department of Veterans Affairs will fund the 
        clinic, roads and parking, and will continue to utilize Navy 
        ancillary/specialty care.
    Other examples of partnerships that show the depth and variety of 
our collaboration include the development of uniform clinical practice 
guidelines for tobacco use and diabetes last year, and development of 
hypertension and low back pain guidelines scheduled for 2004. Asthma 
guidelines are projected for revision in 2005.
    In the works is a VA/DOD agreement that would permit the use of 
North Chicago VA Medical Center spaces to establish a center to 
manufacture blood products in exchange for the use of these blood 
products. This agreement would alleviate the necessity for Naval 
Medicine construction costs for a new center at Naval Hospital Great 
Lakes. An agreement between the Bureau of Medicine and Surgery and the 
Department of Veterans Affairs headquarters to share each other's 
``lessons learned'' databases is presently being developed.
    Aggressive investigation of other mutually advantageous resource 
sharing possibilities is on-going at all Naval Medicine facilities with 
the focus of providing of our beneficiary populations--military and 
veterans, the outstanding healthcare they deserve.
               defense health budget for fiscal year 2004
    One of Naval Medicine's greatest accomplishments is meeting the 
healthcare needs of all its beneficiaries--active duty, retiree, family 
members and eligible survivors. Nation-wide, healthcare costs are now 
increasing at the fastest rate in the last decade. Healthcare inflation 
continues to exceed inflation in other sectors of the economy. 
Utilization of healthcare services continues to increase as technology 
advances results in effective new--albeit sometimes costly--treatments 
and longer life spans.
    In addition, as the news of TRICARE's quality and effectiveness 
spreads, and as the costs of other insurance programs rises, more 
retirees under 65 are dropping other health insurance and relying on 
TRICARE. From the trends of the past few fiscal years, it's estimated 
that in fiscal year 2004 there will be a 5.2 percent increase in this 
population.
    DOD has ongoing programs that help control health care cost 
increases, such as building cost control incentives to managed care 
support contracts and competitively awarding these contracts for best 
value, and ensuring the pharmaceuticals delivered in our Military 
Treatment Facilities and through the TRICARE Mail Order Pharmacy 
Program are procured through using discounted federal government 
pricing. DOD and Naval Medicine management programs have also been 
utilized to ensure that healthcare provided to beneficiaries is 
reviewed for clinical necessity and appropriateness.
    Naval Medicine has worked hard to get the best value from every 
dollar Congress has provided, but your assistance is needed to restore 
the flexibility to manage funds across activity groups. Fencing sector 
funds prevents transfer of funds from MTFs to the private sector, but 
also prevents transfer of private sector funds to the MTFs. This 
fencing prevents funding MTFs to increase their productivity without 
the burden of prior approval reprogramming, which can take anywhere 
from three to six months. The T-NEX contract, with its incentive to 
move care into MTFs, makes having this flexibility all the more vital. 
Two-way flexibility between the private sector care and direct care 
accounts is necessary for revised financing to function successfully. 
The Navy appreciates the congressional intent to protect direct care 
funding, but we recommend that the fiscal year 2005 Defense 
Appropriations Act language remove the separate appropriation for 
Private Sector Care to allow the flexibility to move funds to wherever 
care is delivered without a Prior Approval reprogramming.
         transition to the next generation of tricare contracts
    TRICARE Next Generation has provided sweeping improvements in its 
provision of TRICARE Benefits under contracting initiated this fiscal 
year. While there will be no significant benefit changes, it simplifies 
the old contracts, and provides performance incentives and guarantees. 
It also distinguishes health plan management, which includes such 
activities as financing, claims, payment rates, marketing, and benefit 
design, from healthcare delivery. Some major elements of the old 
TRICARE contracts have been sifted out into separate contracts to allow 
companies with particular competencies in these contract areas provide 
even better service and quality healthcare.
    The most obvious change is the transition from 12 regions to three, 
and enhancing leadership in each region by putting a Flag, General 
Officer or SES as director. This is a significant step in transforming 
TRICARE. These Regional directors have a key role in enhancing 
participation of providers in TRICARE and in implementing the plan to 
improve TRICARE Standard for those who choose to use it, and will also 
be responsible for integration of military treatment facilities with 
civilian networks, ensuring support to local commanders and overseeing 
performance in the region. Rear Admiral James A. Johnson, Medical 
Corps, is on board in the TRICARE West Region.
    Medical commanders within these regions will also have an enlarged 
role and additional responsibilities under the new contracts, with the 
focus on accountability. Commanders will take on responsibilities 
formerly managed by the TRICARE contractor, including patient 
appointing, utilization management, use of civilian providers in 
military hospitals, and other local services.
    The transition to the new TRICARE contracts in TRICARE West is 
going well, and all the services are working closely with TMA to make 
the transition phase as seamless as possible for our patients.
      closure of u.s. naval hospital roosevelt roads, puerto rico
    On February 12, 2004, U.S. Naval Hospital Roosevelt Roads, Puerto 
Rico officially closed its doors to patient care, ending more than 47 
years of healthcare service to Department of Defense beneficiaries. The 
last time a Naval Hospital closed was almost nine years ago when Naval 
Hospital Long Beach closed as a result of the Base Realignment and 
Closure.
                                e-health
    Naval Medicine continues to be on the forefront of technology with 
the development of Naval Medicine Online (NMO). This website allows one 
tool for all of Naval Medicine to obtain and access information from 
anywhere around the world. This technology will be the key to knowledge 
sharing throughout Naval Medicine as an enterprise, allowing the right 
information to be obtained by the right people at the right time--
whenever and wherever it is needed.
    NMO contains knowledge tools including File Cabinet that allows 
individuals to share documents and other electronic files; protected 
chat rooms that will allow users to have secure communications with 
patients or other Naval Medicine personnel and news services that 
provide information of relevance to the Naval Medical community.
    A key new function of NMO is the developer whiteboard. This tool 
allows Naval Medicine to leverage the brainpower of our workforce by 
placing software code in a secure area and allowing members of Naval 
Medicine to modify the code, making improvements useful to Naval 
Medicine. NMO also has online video teleconference capabilities and 
allows Naval Medicine personnel access to the Department of Veterans 
Affairs lessons learned database.
    The Navy Marine Corps Intranet (NMCI) is a long-term initiative 
between the Department of the Navy (DON) and the private sector to 
deliver a single integrated and coherent department-wide network for 
Navy and Marine Corps shore commands. Under NMCI, EDS and their 
partners will provide comprehensive, end-to-end information services 
for data, video and voice communications for DON military and civilian 
personnel and deliver global connectivity to make our workforce more 
efficient, more productive, and better able to support the critical war 
fighting missions of the Navy and Marine Corps.
    Naval Medicine is committed to transitioning to NMCI infrastructure 
and services where feasible. The Naval Medicine--NMCI shared vision is 
to create a single Navy and Marine Corps Enterprise-wide Network that 
provides seamless access to and exchange of comprehensive healthcare 
information throughout Naval Medicine and the Military Health System 
Community of Interest.
    The Naval Medicine--NMCI transition strategy incorporates four 
parallel endeavors. They are:
  --1. Transition of BUMED Headquarters into NMCI (800 Seats)
  --2. Transition of non-clinical Naval Medical Department Commands 
        into NMCI (5,900 Seats)
  --3. Completion of a Composite Health Care System Computer-based 
        Patient Record (CHCS II) NMCI Interoperability Beta Test at 
        Naval Medical Center, Portsmouth, VA (72 Seats). The Military 
        Health System's (MHS) largest, and most critical, network-
        centric information system, CHCS II forms the core of DOD's 
        computer-based patient record initiative, and as such, is and 
        will be broadly integrated across the enterprise at the center 
        of the MHS healthcare delivery mission. The Beta Test will 
        document infrastructure and network performance characteristics 
        to include: Interoperability, Accessibility, Continuity of 
        Business Operations, Quality of Service, Information Assurance, 
        and Clinical Provider Productivity.
  --4. Transition of all clinical Navy Medical Department Commands into 
        NMCI (38,300 seats).
    Naval Medicine is partnering with Electronic Data Systems (EDS), 
Science Applications International Corporation (SAIC), and Booz-Allen & 
Hamilton (BAH) to complete the financial analysis of our transition 
endeavors. We expect positive economies in transitioning to NMCI, which 
include robust information security, email server consolidation, 
network operations center consolidation, and uniform seat management 
services across the Naval Medicine Enterprise.
                            medical research
    Naval Medicine also has a proud history of medical research 
successes from our laboratories both here in the United States as well 
as those located overseas. Our research achievements have been 
published in professional journals, received patents and have been 
sought by industry as partnering opportunities.
    The quality and dedication of the Naval Medicine's biomedical 
research and development community was exemplified this year as Navy 
researchers were selected to receive prestigious awards for their work. 
CAPT Daniel Carucci, MC, USN, received the American Medical 
Association's Award for Excellence in Medical Research for his work on 
cutting edge DNA vaccines. His work could lead to the development of 
other DNA-based vaccines to battle a host of infectious diseases such 
as dengue, tuberculosis, and biological warfare threats. Considering 
the treat of biological terrorism, DNA vaccine-based technologies have 
been at the forefront of ``agile'' and non-traditional vaccine 
development efforts and have been termed ``revolutionary''. Instead of 
delivering the foreign material, DNA vaccines deliver the genetic code 
for that material directly to host cells. The host cells then take up 
the DNA and using host cellular machinery produce the foreign material. 
The host immune system then produces an immune response directed 
against that foreign material.
    In the last year, Navy human clinical trials involving well over 
300 volunteers have demonstrated that DNA vaccines are safe, well 
tolerated and are capable of generating humoral and cellular immune 
responses. DNA vaccines have been shown to protect rodents, rabbits, 
chickens, cattle and monkeys against a variety of pathogens including 
viruses, bacteria, parasites and toxins (tetanus toxin). Moreover, 
recent studies have demonstrated that the potential of DNA vaccines can 
be further enhanced by improved vaccine formulations and delivery 
strategies such as non-DNA boosts (recombinant viruses, replicons, or 
exposure to the targeted pathogen itself). A multi-agency Agile Vaccine 
Task Force (AVTF) comprised of government (DOD, FDA, NIH), academic and 
industry representatives is being established to expedite research of 
the Navy Agile Vaccine.
    Naval Medicine is developing new strategies for the treatment 
radiation illness. Adult Stem Cell Research is making great strides in 
addressing the medical needs of patients with radiation illness. The 
Anthrax attack on the Congress and others reminded us of the threat of 
weapons of mass destruction, to include ionizing radiation. Radiation 
exposure results in immune system suppression and bone marrow loss. 
Currently, a bone marrow transplant is the only life saving procedure 
available. Unfortunately, harvesting bone marrow is an expensive and 
limited process, requiring an available pool of donors. In the past 
year, Naval Medicine researchers have developed and published a 
reproducible method to generate bone marrow stem cells in vitro after 
exposure to high dose radiation, such that these stem cells could be 
transplanted back into the individual, thereby providing life-saving 
bone marrow and immune system recovery.
    In this same line of research, Naval Medicine is developing new 
strategies for the treatment of combat injuries. We are developing new 
therapies to ``educate'' the immune system to accept a transplanted 
organ--even mismatched organs. This field of research has demonstrated 
that new immune therapies can be applied to ``programming stem cells'' 
and growing bone marrow stem cells in the laboratory. Therapies under 
development have obvious multiple use potential for combat casualties 
and for cancer and genetic disease.
    Other achievements during this last year include further 
development of hand-held assays to identify biological warfare agents. 
During the 2001 anthrax attacks, Navy scientists analyzed over 15,000 
samples for the presence of biological warfare (BW) agents. These hand-
held detection devices were used in late 2001 to clear Senate, House 
and Supreme Court Office Buildings and contributed significantly to 
maintaining the functions of our government. The hand-held assays that 
are used by the DOD were developed at Naval Medical Research Center 
(NMRC). Currently NMRC produces hand-held assays for the detection of 
20 different biological warfare agents. These assays are supplied to 
the U.S. Secret Service, FBI, Navy Environmental Preventive Medicine 
Units, U.S. Marine Corp, as well as various other clients.
    Naval Medicine's overseas research laboratories are studying 
diseases at the very forefront of where our troops could be deployed 
during future contingencies. These laboratories are staffed with 
researchers who are developing new diagnostic tests, evaluating 
prevention and treatment strategies, and monitoring disease threats. 
One of the many successes from our three overseas labs is the use of 
new technology, which includes a Medical Data Surveillance System 
(MDSS). The goal of the MDSS is to provide enhanced medical threat 
detection through advanced analysis of routinely collected outpatient 
data in deployed situations. MDSS is part of the Joint Medical 
Operations-Telemedicine Advanced Concept Technology Demonstration 
(JMOT-ACTD) program. Interfacing with the shipboard SAMS database 
system, MDSS employs signal detection and reconstruction methods to 
provide early detection of changes, trends, shifts, outliers, and 
bursts in syndrome and disease groups (via ICD-9 parsing) thereby 
signaling an event and allowing for early medical/tactical 
intervention. MDSS also interfaces with CHCS and is operational at the 
Army's 121st Evacuation Hospital in South Korea, and is being deployed 
at the hospital and clinics at Camp Pendleton. Currently, MDSS may have 
an opportunity to collaborate with other industry and service-related 
efforts for the purpose of developing homeland defense-capable systems. 
Homeland defense initiatives are currently being coordinated through 
the Defense Threat Reduction Agency.
    Noise-Induced Hearing Loss (NIHL) is one of the most common 
military disabilities with over 353,116 new cases reported in 2003 
despite aggressive hearing conservation programs in the military. 
Military related NIHL is very costly. When disability costs for 
tinnitus and aircraft accidents related to communication problems are 
included, costs for military related hearing loss may exceed $1 billion 
annually. Additionally, NIHL may degrade warfighter performance, 
mission accomplishment, and survivability. Today's hearing conservation 
programs are based on fit and frequency dependent personal hearing 
protection devices (HPDs), engineering solutions, and noise avoidance; 
which are helpful but do not provide adequate protection around today's 
noisier weapons systems. Accordingly the Navy has taken the lead in 
research to elucidate the mechanisms underlying NIHL. The results have 
lead to the development of a safe oral nutritional supplement that has 
proven in laboratory settings to enhance resistance and healing to 
inner ear damage from noise. The efficacy of these nutritional 
supplements to prevent and treat NIHL is being studied in two joint 
military-civilian clinical trials lead by the Naval Medical Center, San 
Diego. If these trials succeed, we believe that a proven and effective 
treatment and prevention strategy, when combined with hearing 
conservation measures, could be dramatically reduced. A conservative 
estimate based on the robustness of the biological response in 
preclinical data suggests that a 50 percent reduction in hearing 
related injury is possible.
                    naval medicine and sea power 21
    Naval Medicine is totally committed to the Chief of Naval 
Operations' transformational vision for projecting decisive joint 
capabilities from the sea--Sea Power 21. Examples of transformation 
abound throughout Naval Medicine where hard work identifying 
efficiencies and cutting costs have resulted in opportunities to 
support recapitalization. These include the ongoing efforts to reduce 
variation in costs across our MTFs as well as among clinics within 
MTFs. Optimization efforts focusing on maximizing the fixed 
capabilities of our facilities to the greatest extent possible are 
active, ongoing, and will continue into the future. Transformation is 
not limited to shore facilities and includes remaking our fleet assets 
such as the reconfiguration of forward medical assets from cold war era 
fleet hospitals to the smaller, more agile and more flexible platforms 
and units described earlier in my statement.
    We are right sizing our active military force to the best mix of 
active, and civilian or contract personnel to bring the right 
capability to bear at the right time, and in alignment with the CNO's 
vision. We have reconfigured and integrated our Naval Reserve 
components to shape missions along with the active component, creating 
one force, assuring the very best use of the skills and talent our 
Reserve medical personnel bring to the mission. Further, Naval Medicine 
is committed to the growth and development of our people through 
investments in leadership that are directly in support of Sea Warrior 
by ensuring the right skills are in the right place at the right time.
    Naval Medicine will continue to seek aggressively opportunities to 
pursue efficiencies that improve our primary mission of Force Health 
Protection and do our part to return resources for recapitalization of 
the Navy. We are affecting positive change throughout Naval Medicine, 
embracing and implementing the CNO's vision for the Navy, and I am 
confident that we are on the correct course for the challenges ahead.
                               conclusion
    Naval Medicine has been successful in accomplishing its mission 
over the years, and with your support, the military benefit has become 
one of the most respected healthcare programs in the world. We know 
from Navy's quality of life surveys that among all enlisted personnel 
and female officers, the number one reason these service members stay 
Navy is the exceptional healthcare benefit.
    You have allowed us to provide our service members, retirees and 
family members a benefit that is worthy of their service, and clearly 
articulates the thanks of a grateful nation for their selfless service. 
With your support, we have opportunities for continued success, both in 
the business of providing healthcare, and the mission to supporting 
deployed forces and protecting our citizens throughout the United 
States.
    In just a few short months, I will leave this office, and will 
retire after serving more than 32 years in the United States Navy. I 
wish to thank this committee for its support to Naval Medicine, and to 
me during my time as the Navy's Surgeon General. It has been a 
privilege to serve.

    Senator Stevens. General Taylor, it is nice to welcome you 
back.
STATEMENT OF LIEUTENANT GENERAL GEORGE PEACH TAYLOR, 
            JR., SURGEON GENERAL, UNITED STATES AIR 
            FORCE
    General Taylor. Thank you, Mr. Chairman. Mr. Chairman and 
members of the committee, it is a privilege and a pleasure to 
be here today.

                        OPERATION IRAQI FREEDOM

    Much has happened since we met here 1 year ago when we had 
just embarked on Operation Iraqi Freedom. A year later we have 
found that most of our concepts were validated. Some require 
more work, but most importantly the men and women of the Air 
Force Medical Service have again served their country with 
phenomenal talent, capability, and dedication. The lessons we 
have learned in Afghanistan, Iraq, indeed, wherever we are 
deployed, and even at home have helped us to hone our force 
central capabilities, ensuring a fit and healthy force, 
preventing illness and injuries, providing care to casualties, 
and sustaining and enhancing human performance.

                           MEDICAL READINESS

    We are doing many things to ensure our force is fit and 
healthy before they deploy. Our preventive health assessments 
and individual medical readiness program ensures that health 
requirements and screenings have been met before deployment. 
This program has been adopted DOD-wide and is clearly 
responsible, in great part, for the 4 percent non-battle 
disease injury rate in DOD that you have been hearing about, 
the lowest in history.

                   POST-DEPLOYMENT HEALTH ASSESSMENTS

    I would add that our post-deployment health assessments, 
equally important, are going extremely well. Our Active and 
Reserve component personnel have returned for deployments and 
nearly 99 percent have completed these assessments with a 
provider. Our people are coming back in better health because 
of individual disease prevention efforts but also because of 
the incredible deployment health surveillance program that all 
three of us have fielded. From our preventive aerospace 
medicine teams to our biological augmentation teams, we are 
helping to protect the area of responsibility from biological 
and environmental threats. We are using amazing technology such 
as our rapid pathogen identification systems (RAPIDS) which can 
determine the identity of pathogens in only a few hours. In the 
future, we hope to reduce this time even further through new, 
more advanced, indeed breakthrough genome-based technologies.
    We have shared with you over the past few years our success 
in our light, lean, and mobile expeditionary medical system, 
known as EMEDS, but before we left for Iraq a year ago, we 
realized EMEDS did not have the protection we needed for 
chemical weapons. Within 30 days, Air Force medics developed a 
mature nuclear, biological and chemical (NBC) treatment module 
that could care for 100 radiologic, biologic, or chemical 
casualties. This is the level of ingenuity we have in our armed 
forces in all the services.
    Your staff had the opportunity to view other technical 
marvels that are saving lives in the battlefield like the 
laptop size ultrasound machine, the ventilator that is the size 
of a football, a complete surgical package that fits in a 
backpack.

                         AEROMEDICAL EVACUATION

    Aeromedical evacuation continues to be the lynch pin in our 
deployed medical operations. In addition to the critical care 
air transport teams you have heard about, we continue to field 
patient support pallets that allow us to use all available 
airlift and have added an aeromedical evacuation center to our 
air operations center to allow smooth integration with all DOD 
and, indeed, allied air operations in the theater.
    From our perspective, the story of Private Jessica Lynch's 
rescue is an excellent example of the near seamless integration 
of the Air Force and our sister services. Following her rescue 
from an Iraqi hospital, Army medics, Air Force aeromedical 
evacuation troops, and special operations members transported 
her thousands of miles using three different aircraft and 
provided care in the air during her entire journey until she 
reached the safety of an Army hospital in Landstuhl, Germany, 
all accomplished in less than 15 hours. And this same scenario 
has repeatedly saved the lives of many other, less famous, but 
equally courageous young heroes.
    Together the three of us partner closely to see that health 
care from the foxhole to home station is seamless. Indeed, I 
would tell you that this is a case study in the application of 
the joint capabilities, the best of the Army, Navy, and Air 
Force, to meet our Nation's needs.

                            COMBAT MEDICINE

    Combat medicine is an ever-evolving art, and we cannot 
afford to coast for one minute on these successes. We recognize 
the critical value of developing new and better technology and 
enhancing human performance. Our human performance initiatives 
cross the spectrum from battling combat fatigue, to enhancing 
vision through corneal refractive surgery, to creating systems 
that will protect our pilots and our aircraft sensors from 
laser damage. While all these exciting high-tech programs are 
taking place, we are also quietly caring for our members and 
their families back home.

                                TRICARE

    We anticipate the promising next generation TRICARE 
contracts to be a smarter way of doing business as revised 
financing methodology is fielded throughout all U.S. based 
military health treatment facilities. We are working hard with 
health affairs and the Congress to ensure that our incentives 
and our accountability are properly aligned for this increased 
and more flexible local responsibility for patient care funds. 
While we prepare for next generation TRICARE and for the 
enhancement of relationships with the civilian community and 
our partners in the Department of Veterans Affairs, we are 
always aware of the direct connection between this peacetime 
health care and the readiness of our troops.
    The Air Force Medical Service has answered the call and 
will continue to do so. We will work to resolve tough issues 
from the fiscal hurdles to challenges of recruiting and 
retention. And wherever we go to perform our mission, you can 
see the results of your support to the troops, and we thank you 
for this dedication.

                           PREPARED STATEMENT

    Finally, as the last witness and anecdotally, scarily I am 
going to be moving to the right-hand side of the table here 
this next year, I would like to take a moment to focus on my 
two comrades in arms. Jim Peake and Mike Cowan are two of the 
finest Americans I have had the pleasure to meet. There are 
really no finer examples of the American medic than these two 
gentlemen to my right. They dedicated the heart of their adult 
lives to the men and women in harm's way. We will miss them, 
and our Air Force wishes them godspeed and fair tail winds.
    Thank you, Mr. Chairman.
    [The statement follows:]
Prepared Statement of Lieutenant General (Dr.) George Peach Taylor, Jr.
    Mister Chairman and members of the Committee, it is a pleasure to 
be here. When we last met, I described how our transformation efforts 
were saving lives during combat operations in support of the war 
against terrorism. The week before my testimony, we had just begun 
combat operations in Iraq. Now, a year later, major combat in Iraq has 
ended, but the mission and danger continue. Although many of my 
comments here today address the Air Force Medical Service's 
contribution to combat operations, I assure you that the care we 
provide to families and retirees is still of great importance. It 
continues to improve even as we are engaged in operations around the 
globe.
    And, of course, we truly are engaged around the globe. Like our 
sister services, every step in our transformation is to advance our 
ability to operate worldwide with lightning speed. This is reflected in 
the Air Force's six Concepts of Operation, or CONOPS. CONOPS are a 
statement of our desired end result, or effect, that the Air Force 
brings to the battle. The first three are Global Mobility, Global 
Strike, and Global Response. The others are Nuclear Response, Homeland 
Security and finally Space and Command, Control, Communications, 
Computers, Intelligence, Surveillance and Reconnaissance. That's a 
mouthful, so we refer to it as Space-C\4\ISR. The medics provide 
fundamental support to all six.
    Global Mobility, Strike, and Response CONOPS require the AFMS to 
provide medical care anywhere at any time to support humanitarian and 
warfighting operations. This demands that our medics travel fast and 
far, so they pack light, very light. Some of our Expeditionary Medical 
System medics travel with just a 70-pound pack. One small 5-person team 
carries enough to perform 10 life-saving surgeries in the field under 
battle conditions. And our aeromedical evacuation capabilities permit 
us to quickly fly into hostile environments, pluck injured members from 
the field, and fly out, often providing critical care in flight.
    The Air Force's Nuclear Response CONOPS provides a deterrent 
umbrella under which our conventional forces operate. Medics support 
this CONOP by ensuring that commanders can rely on the medical and 
psychological health of the human element of the nuclear force. We also 
develop plans for the care of casualties and refugees in a radiological 
event of a terrorist or national origin. We assess health hazards and 
provide recommendations to protect responding personnel or our 
combatants within any hazardous zone.
    The Homeland Security CONOPS recognizes that if someone attacks our 
homeland again, Air Force medical personal will be an invaluable asset 
bringing a wealth of manpower and expertise to the crisis. In such a 
contingency, our base clinics and hospitals become part of the local 
health care disaster network. They offer their ability to help local 
authorities detect and identify chemical, biological, and nuclear 
weapons, and we aid in the treatment of those exposed to them.
    The final CONOPS, Space-C\4\ISR, serves to integrate the other 
five. Simply put, it is the network of intelligence, sensors, 
satellites, and communications that allow us to orchestrate our forces 
worldwide. Every unit and every function of the Air Force is tied into 
this capability. Each contributes information to it and uses 
information from it. Air Force medics use this capability to monitor 
health threats worldwide, to coordinate care from combat to CONUS, and 
to maintain visibility of our patients no matter where they are within 
the joint medical system.
    We have now been in Iraq over a year. The AFMS has used this time 
to review its performance there through a Capabilities Review and Risk 
Assessment--a process that drives a hard look at our performance--from 
this process we learn what we did right; and what we can do better. 
These lessons learned help to hone our four central AFMS capabilities 
of: Ensuring a fit and healthy force; preventing illness and injuries; 
providing care to casualties; and enhancing human performance.
Ensuring a Fit and Healthy Force
    The first capability we provide the Air Force is that of ensuring a 
fit and healthy force. Unhealthy troops cannot deploy. A commander who 
is short of troops cannot fight; cannot win. We keep troops healthy so 
commanders can do both.
    While providing a fit and healthy force is ultimately every 
commander's responsibility, the AFMS plays a critical role in defining 
what is fit, what is healthy . . . how do we get them that way, how do 
we keep them that way.
    Once recent step is the implementation of the Air Force Chief of 
Staff's revised fitness program--a significant change in fitness 
standards and how we monitor them. The program is now based upon push-
ups, sit-ups, and a mile-and-a-half run. To this we add body 
composition measurements and a strong focus on unit exercise programs. 
This model includes the Guard and Reserve who must meet the same 
standards as their active duty counterparts.
    The program is only a couple months old, but we know airmen accept 
and appreciate it. They must like it--I find it much harder lately to 
find an open weight bench at the gym, so I know first-hand that our 
troops are enthused about the program.
    Fitness results will be available on the Air Force's secure web to 
commanders and leadership, allowing them to know in near real-time what 
percentage of our troops are fit to fight.
    Of course, our dedication to health goes far beyond a yearly 
fitness test. We employ a life-cycle approach to care. We surround 
troops with continual health monitoring and evaluations from the day 
recruits first put on an Air Force uniform, during every visit to the 
in-garrison or expeditionary clinic or hospital throughout their 
career, and especially during their transition to veteran status. We 
honor our commitment to our retirees; we are there.
    An important tool of ensuring a fit and healthy force has been our 
Preventive Health Assessment program. It ensures that at least once a 
year, every Airman has an assessment for changes in his or her health 
and for needed health screening or immunizations, and has the 
opportunity for a medical exam, if needed.
    Additionally, preventive health assessments are provided before 
members deploy and immediately upon their return. Such screenings were 
an interest item for both the DOD and Congress last year. We are 
pleased to report our success. For the 61,000 Air Force personnel 
deployed from March 1 through December 31, 2003, 99 percent completed 
their post-deployment health assessment--which included a face-to-face 
appointment with a medic and 97 percent had serum samples collected for 
submission to DOD repository.
    The medical information from all screenings and appointments is 
captured in an innovative information system called the Preventive 
Health Assessment and Individual Medical Readiness program, or PIMR. 
PIMR data, like that of our new fitness program, are available on the 
web to Air Force leadership worldwide.
    The next version of the Composite Health Care System--CHCS II--is 
another computer information system that will provide significant 
benefit to the AFMS as well as the entire DOD health care. Even in its 
current decade-old form CHCS is an amazing system. It captures every 
visit, prescription, lab result, and procedure provided to every 
patient.
    We first deployed CHCS in the late 1980s when computer screens were 
black and white and a mouse on your desk was cause for alarm. The 
upgraded CHCS II will have the look and feel of a web site. It will 
also be faster and easier to learn. More importantly, CHCS II will 
interface with the numerous other programs that have come on line since 
it was first introduced. CHCS II marches us down the path toward an 
electronic medical record that will solve many problems for us, 
including that of lost or fragmented medical records. Additionally, 
CHCS II will be deployable, so it will be the same program used in the 
field and at home.
    CHCS II, like its predecessor, will be deployed worldwide, accessed 
by thousands of users simultaneously, and contain the patient records 
of up to 8.8 million eligible beneficiaries. It is the largest health 
information system in the world--and an invaluable tool in keeping our 
troops--and their families--healthy.
    Once we have assured that only fit healthy troops are sent to the 
area of operations, we take great effort to ensure they stay that way. 
This falls to our next capability, that of preventing casualties.
Preventing Casualties
    We are experiencing unparalleled success in the prevention of 
illness and injury during Operation Iraqi Freedom. A telling example of 
this success is our low Disease Non-Battle Injury Rate--we call it the 
``D-N-B-I rate'' for short. The DNBI rate describes the percentage of 
troops who become sick or hurt from things other than enemy activity; 
things like dental problems, car accidents, the flu, broken bones, 
etcetera.
    Historically, more troops are removed from battle because of 
accidents or illnesses than from enemy fire. In Operation Desert Storm, 
the DNBI rate was about 6 percent. During the current Iraqi conflict, 
only 4 percent (DOD rate) of illnesses and injuries were non-combat 
related. This is the lowest DNBI rate in history. We seek ways to make 
it lower yet. One of our doctors in Iraq jokingly suggested that if we 
were to cancel intramural basketball games in theater we could 
eliminate many sprained ankles and drop that DNBI rate another percent. 
The important point is that we continue to address all the challenges--
including sports injuries--that reduce our combatant capabilities.
    Much credit for the low DNBI goes to the preventive health 
assessments and pre-deployment screenings I mentioned. These allow us 
to identify personnel with pre-existing or uncontrolled medical 
problems; conditions that would worsen under the stress of deployment. 
These folks--if allowed to deploy--are a huge source of DNBI. By 
pulling them out of the deployment line and caring for them back home 
in-garrison, we not only decrease the DNBI rate, we also ensure these 
members get the health care they need to make them worldwide-qualified 
in the future.
    The Deployment Health Surveillance program is another critical 
piece of preventing casualties. Before airmen arrive in large numbers 
to establish a base in foreign territory, a special team of medics--
called the Preventive Aerospace Medicine, or PAM team--has already been 
there. They have surveyed the environment for biological and 
environmental threats, and have stood up surveillance equipment to 
detect and identify such threats.
    When it comes to total ``battlespace awareness,'' PAMs and another 
EMEDS team called the Biological Augmentation Team, or BAT team, are 
invaluable. These teams take on the same importance as the radar, 
intelligence, and security specialists whose mission it is to detect, 
identify, and deter enemy attacks. In the same manner that a radar 
operator surveys the skies for threats, our medics survey the 
environment with equipment to detect chemical, biological, radiological 
or nuclear--CBRN--threats. In combat, speed counts. That radar operator 
must detect the presence of an airborne object and then quickly 
identify it--friend or foe. The sooner that operator can do both, the 
faster we can react--the safer our people are. In the same way, our 
teams and their equipment act quickly to detect, identify, and counter 
CBRN threats.
    For example, it used to take up to a week to detect and confirm the 
presence of dangerous biological and chemical weapons--too long. 
Imagine a biological agent loose in one of our bases in Iraq for a week 
before we were able to identify and contain it. Even the most 
conservative estimates predict that 30 percent of our troops would 
become seriously ill or worse.
    With RAPIDS technology, we eliminate the deadly delay between the 
time a pathogen is released and when we become aware of its presence. 
The aptly named RAPIDS stands for the Rapid Pathogen Identification 
Systems; a fielded and proven system that can determine the identity of 
pathogens within a few hours; much better than 4 to 7 days it used to 
take. Using new genome-based technologies, we hope to reduce the time 
even further.
    Another tool in the Air Force Medical Service toolbox is the Global 
Expeditionary Medical System, or GEMS. This rugged, laptop-based system 
serves as a deployable, electronic medical record for every patient 
encounter in the combat zone. To date, it has logged nearly 107,000 
patient encounters in Afghanistan and Iraq. But it does more than that. 
It also tracks chemical, physical, and radiological hazards and even 
tracks the results of food inspections and living conditions in the 
field. GEMS provides commanders a theater-wide overview of the health 
of their forces. Its sophisticated epidemiology tracking features allow 
it to identify potential disease outbreaks very early in the courts of 
outbreaks or a chemical or biological attack.
    I have described systems and processes we have in place that ensure 
oversight of our airmen's health before they deploy, while they are in 
the field and even after they return. But we must remember that combat 
is inherently dangerous. In spite of our best efforts to prevent it, 
some of our troops will fall ill, and some will be wounded. Thus the 
critical need for our third capability; that of restoring the health of 
the sick or injured--casualty care.
Casualty Care
    We have completed the conversion of our large-footprint field 
medical facilities into small, rapidly deployable Expeditionary Medical 
System--or EMEDS--units. Our performance in Iraq validates that the 
EMEDS concept works. It saves lives.
    These units can be found throughout the area of operations. They 
often provide care from the point of injury, at tented facilities 
removed from the front, and during aeromedical evacuations as they 
transport the patient from the theater entirely. When the U.N. Building 
in Baghdad was car bombed last August, killing 20, EMEDS surgeons and 
their staff were only minutes away, and cared for numerous injuries on 
the spot.
    Shortly before the start of combat operations in Iraq we added a 
new capability to EMEDS; hoping against--but preparing for--Iraq's 
potential use of chemical weapons, we created EMEDS Supplemental NBC 
Treatment Modules--or NBC pallets, as our troops call them. Each module 
contains 25 ventilators and medical supplies to care for 100 
radiological, biological, or chemical casualties. I find it 
extraordinary that it took only 30 days for these packages to mature 
from the concept stage until the first pallet was loaded onto an 
aircraft for delivery.
    While NBC pallets provide the tools to treat NBC casualties, the 
EMEDS' hardened tents and infrastructure offer a protective shelter in 
which our medics can render that care. Each can be equipped with 
special liners and air handling equipment that over-pressurizes the 
tents' interiors. Clean, filtered air is pushed in; contaminated air is 
kept out. Protected water distribution systems work the same way, 
ensuring a safe, potable water supply even in contaminated 
environments.
    I continue to be impressed with the enabling technologies that 
permit the development of things like Push Pallets or advanced air and 
water-handling systems. During operations in Iraq we have relied on 
these and other technical marvels, like a lap-top sized ultrasound 
machine, a ventilator unit the size of a football, and a chemistry 
analyzer that--during Desert Storm--required its own tent; now it fits 
in the palm of your hand. Our people are saving lives with these 
technologies around the globe as we speak. There are EMEDS operating in 
Iraq and 11 other countries in support of Air Force operations.
    Operation Iraqi Freedom also validated our new aeromedical 
evacuation concept of operations. A significant advancement in this 
mission is our ability to take advantage of back-haul aircraft, which 
has tremendously accelerated the aeromedical evacuation process. This 
has eliminated the need for patients to wait days for a designated C-9 
or C-141 aeromedical evacuation mission to pass through their area. 
Patient Support Pallets--or PSPs--make it far easier to turn any Air 
Force mobility aircraft into an aeromedical evacuation platform. PSPs 
are a collection of specially packed medical equipment that can be 
installed into cargo and transport aircraft within minutes. The plane 
that just landed to deliver weapons is quickly converted to carry 
wounded patients.
    Let me share with you an example of PSPs work. In Baghdad, a 5-
year-old, deathly ill Iraqi girl was brought to one of our allied 
locations. She was scheduled to fly to Greece for medical treatment. 
Her condition was so poor that upon arrival at the clinic she was 
placed on a ventilator. Doctors determined she was too ill to survive 
and she was removed from the flight. One of our nearby medics heard of 
the situation. He determined that leaving that little girl behind to 
die was simply not an option. He, and other members of his Aeromedical 
Evacuation team, grabbed one of our PSPs--we have 41 of them 
strategically placed around the globe--and within an hour had converted 
a section of the Greek aircraft into a small critical care bay. Their 
precious cargo was loaded--with her ventilator--and she was flown to 
Greece to receive care. We are the only country in the world that can 
do this on a regular and sustained basis for our military personnel.
    This demonstrates that PSPs allow us the flexibility to convert not 
only our own aircraft into AE platforms, we can also take advantage of 
our allies' aircraft. This dramatically increases the availability of 
aeromedical evacuation opportunities to our troops. It's like one of 
our medics told me: ``If it flies, and we have elbow room, we can do 
our thing. Our thing is saving lives.''
    The medic I spoke of is a member of one of our Critical Care Air 
Transport Teams. We call them CCATS. These CCAT teams are comprised of 
a physician, a nurse, and a cardiopulmonary technician. They are 
specially trained to work side-by-side in the air with our aeromedical 
evacuation crews to provide critical care under the extremely difficult 
environment of flight.
    Recently, one of our aeromedical evacuation crews augmented by a 
CCAT team flew into Baghdad on a C-130, under black-out conditions and 
while taking fire to retrieve three severely wounded soldiers. These 
troops, too, needed ventilators to help them breathe. They were quickly 
loaded and even before the aircraft could take off again, our CCAT 
teams were providing life-saving care to their patients. While in the 
air, the aircraft was diverted to Talil where U.S. forces had come 
under attack. Two more men were critically wounded there and needed 
immediate aeromedical evacuation. Both of these troops also required 
ventilators.
    All five soldiers were flown that night to an Army medical facility 
in Kuwait. The Air Force medics on that mission are proud of their 
accomplishment--never before, or since, has there been a combat AE 
mission in which a team cared for five patients on ventilators in one 
aircraft. I'm proud of them, too. Without the AE concept and the skills 
our medics brought to the theater, each of those five soldiers would 
have succumbed to their injuries.
    Another enhancement to our aeromedical evacuation capabilities is 
the placement of an AE cell in the Air Operations Center. This permits 
the smooth integration of our actions with all other DOD or allied air 
operations in the theater. The story of Private Jessica Lynch's rescue 
provides a famous example of how all these assets--the AE cell, 
aeromedical evacuation crews and CCATS, patient support pallets, and 
the use of backhaul aircraft--all come together in a successful 
operation. Following her retrieval from the Iraqi hospital, Army 
medics, Air Force Aeromedical Evacuation troops, and Special Operations 
members transported her thousands of miles, used three different 
aircraft, and provided care in the air during her entire journey until 
she reached the safety of an Army hospital in Landstuhl, Germany. All 
this was accomplished in less than 15 hours.
    Like so many of our missions, Jessica Lynch's AE mission could not 
have been accomplished without the near-seamless integration of our 
sister services. Medical and AE operations serve as the perfect example 
of the joint application military capabilities.
    I also must give praise to the backbone of our AE capability, our 
Guard and Reserve. Fully 87 percent of our AE structure is Air Reserve 
Component members. They have assisted their active duty counterparts in 
transporting over 13,700 patients from OEF and OIF, of which about 
2,300 were urgent or priority missions.
    As I hope I have made clear, EMEDS capabilities span the geography 
of operations from the farthest forward immediate surgical capability, 
throughout the area of operations, to include aeromedical evacuation to 
facilities around the globe. EMEDS has vastly improved how we care for 
casualties, but we still face challenges. Perhaps one of the most 
significant of which is caring for victims of weapons of mass 
destruction.
    Although this country has recently seen two bio-chem attacks--the 
anthrax attack two years ago, and the fortunately unsuccessful ricin 
scare of January--we have yet to experience a large scale Weapons of 
Mass Destruction attack. Therefore, we can never know just how 
successful our response to such an attack will be. I guarantee our 
response would be superior to any other nation's on earth--but we 
always strive to expand the envelope of our nation's capability.
    To enhance our response even more, AFMS personnel are implementing 
Code Silver. Code Silver is a program that offers tabletop exercises 
emphasizing biological and chemical warfare responses by our medical 
facilities. We will focus on how our facilities interact and relate to 
the rest of the base and with the local civilian community. Forty Air 
Force medical facilities and the communities surrounding them will 
participate in Code Silver exercises in 2004.
    The fourth and critical capability we bring to the warfighter is 
the enhancement of human performance.
Enhance Human Performance
    As the size of our military decreases and the capability of each 
individual platform increases, the relative importance of every 
individual also increases. Today's airman receives superior training so 
that they can maintain and operate the most sophisticated equipment and 
weapons systems in the world. But the stress and exhaustion of combat 
operations leads to fatigue. Fatigue dramatically erodes the Airman's 
ability to react quickly and think clearly. It eliminates the 
intellectual and technological advantages we bring to the battle.
    Commonly used methods of combating fatigue involve careful studying 
of our airmen's mission schedules, their diets, sleep patterns, even 
their biorhythms, to mitigate the impact of drowsiness upon their 
missions. These are all important to maintaining wakefulness, because 
at the very least, fatigue degrades mission performance. At the very 
worst, it kills. In battle, fatigue is a deadly enemy.
     We also find we can enhance human performance by enhancing vision. 
We do so through corneal refractive surgeries--commonly known as PRK 
and LASIK. These procedures are provided to non-flying and non-special 
duty airmen. We began offering them after an exhaustive literature 
review and extensive expert conference conclusions revealed that the 
operations are, indeed, safe, effective, and potentially cost-saving. 
In the near future these procedures will be offered to some aviators 
and special duty members. We continue to study corneal refractive 
surgeries to see what the effects of time or the stresses of the 
cockpit--like pressure changes and jarring--have on our flyer's eyes. 
The results thus far are highly encouraging. One thing is for sure, 
they are very highly desired by our troops.
    Good eyesight is, of course, critical to our forces. An enemy who 
can temporarily or permanently blind one of our troops will have 
succeeded in removing that Airman from combat. One method for 
inflicting such an injury is through directed energy, or lasers. In the 
little-more-than 40 years since the laser's invention, it has grown 
from something found only in a few science labs and an occasional James 
Bond movie, to a technology so common that one can find lasers in every 
supermarket scanner, in DVD players; and I have even seen them sold as 
cat toys. Lasers are also weapons--and are capable of injuring or 
destroying eyesight. The proliferation of lasers poses a growing threat 
to our pilots and troops.
    In response to this challenge, we have created protective eyewear 
and faceplates that absorb and deflect laser light. The devices save 
our pilots from damaging and potentially permanent eye damage from 
these weapons. We continue to study ways to detect the presence of 
lasers in battlespace and methods for protecting our men and women 
against them.
    Another challenge we encounter in enhancing human performance is 
our need for ever-increasing amounts of information and communication; 
especially that which flows between our EMEDS troops on the ground, our 
aeromedical evacuation crews in the air, and our medics in permanent 
facilities who receive patients from the area of operations. Our 
success at converting any transiting mobility aircraft into an 
aeromedical platform outpaced our ability to create the information 
systems to track the patients using them. It is difficult to keep 
oversight of the location and condition of thousands of patients on a 
worldwide scale.
    Fortunately, the U.S. Transportation Command Regulating and Command 
& Control Evacuation System or TRAC\2\ES [Tray-suhs] is helping us 
overcome that challenge. TRAC\2\ES is a DOD information system that 
allows us to track the location and status of patients from the moment 
they enter the aeromedical evacuation system in the theater of 
operations, as they fly to a higher level of care, until they are 
safely back in a garrison medical facility.
    I have described some of what we learned during current operations 
in Iraq, but before closing, I would like to mention a few our 
successes here on the home front.
                             the home front
    We are always developing avenues to provide great and cost-
effective care. One way to do so is to seek out partners who share our 
dedication to the care of patients and can join us in a better way of 
doing business. We continue to strengthen just such a relationship with 
our partners at the Department of Veterans Affairs. Of the seven 
current Joint Ventures between the DOD and VA, four of them are at Air 
Force medical facilities: Elmendorf in Alaska, Travis in California, 
Kirtland in New Mexico, and Nellis in Nevada.
    These are not the only locations in which the VA and DOD work 
together to provide care. We are pursuing several additional Joint 
Venture locations and already have nearly 140 sharing agreements 
between the Air Force and VA throughout the United States. These are 
great examples of partnering with the VA.
    We are also developing the exciting possibility of expanding the 
traditional concept of Joint Ventures to other major healthcare 
institutions. For example, we believe that a unique three-way joint 
venture between the DOD, VA and the University of Colorado Hospital 
will be a cost-efficient way of caring for all our beneficiaries. This 
concept is receiving not only strong support from DOD leadership and 
local VA officials, but also all of the Colorado Veterans organizations 
and the Colorado state congressional leadership.
                   next generation tricare contracts
    We are passionate about our mission and confident of continued 
success, yet there are some uncertainties in the future that warrant 
mention. As you know, the DOD is in the process of fielding new 
contracts to replace our original TRICARE contracts. This transition is 
the focus of a great deal of management attention. Our ability to 
smoothly change contractors and governance will be closely watched by 
our stakeholders. Not only will there be just three TRICARE regions, 
revised financing will be expanded nationwide.
    This is a methodology to place the entire costs of a TRICARE 
enrollee's care in the hands of the local Medical Group Commander. She 
pays the private sector care bills as well being responsible for the 
direct care system--that care we provide to our enrollees in our Air 
Force clinics and hospitals. Revised financing has proven to be an 
effective tool in those regions where it is currently being used. This 
is an important advance, leveraging what we've learned in allowing the 
Commander to select the most effective and most efficient location for 
health care. So, the dollars allocated to the direct care system are 
critical, but just as critical are the dollars allocated for revised 
financing. With this in mind, two-way flexibility between the private 
sector care and direct care accounts is necessary for revised financing 
to function successfully. The Air Force appreciates the congressional 
intent to protect direct care funding, but we recommend that the Fiscal 
Year 2005 Defense Appropriations Act language remove the separate 
appropriation for Private Sector Care to allow the flexibility to move 
funds to wherever care is delivered without a Prior Approval 
reprogramming.
                                 budget
    For fiscal year 2004, the Congress's budget adequately funds our 
direct care system. However, we do have challenges with the private 
sector care budget--the health benefits purchased from civilian 
providers for our TRICARE beneficiaries. The TRICARE Management 
Activity (TMA), not the Services, manages all of these funds to include 
those for Revised Financing.
    Two issues will pose significant fiscal challenges as we try to 
estimate what our private sector care costs will be.
    The first issue is the increased use of TRICARE. TRICARE offers a 
very comprehensive benefit. With civilian healthcare plans raising co-
pays and cutting back on benefits, more retirees are dropping their 
civilian healthcare and are relying exclusively on TRICARE. As more 
people opt for our heath care program, costs for the entire TRICARE 
benefit rise. Correctly forecasting this cost is crucially important 
and placed pressure on the Department to handle these increases.
    In addition to the enhanced TRICARE benefits the Department of 
Defense offered to activated Reserve Component members and their 
families during fiscal year 2003, the National Defense Authorization 
Act of Fiscal Year 2004 included even more new benefits. Because the 
new reserve health program is temporary, it offers us the ability to 
assess the impact of these benefits after the trial period. We will 
review the effects of these programs on reservists and their families 
as they transition to and from active duty and look at the overall 
effect on retention and readiness. We have concerns that health care 
benefits will be enhanced permanently before a full assessment of the 
impact can be completed, as well as concerns over the potential cost of 
new entitlements for reservists who have not been activated.
    Consideration must also be given to the impact on the active duty 
force if similar health care benefits are offered to reservists who are 
not activated. OMB, DOD and CBO are working together to develop a model 
and a resulting five-year cost estimate to price the proposal to expand 
TRICARE health benefits for all reservists without regard to 
employment, medical coverage, or mobilization status as proposed in the 
Reserve and Guard Recruitment and Retention legislation. Preliminary 
results indicate that this could range from $6 billion to $14 billion 
over five years. Final scoring of this proposal should be completed by 
the end of March.
    The influx of retirees and their families and of increased Guard 
and Reserve beneficiaries have greatly increased private sector care 
costs, which DOD will meet with internal reprogramming actions.
    These bills are a must-pay, and they affect far more than our 
ability to provide the right care at the right place in the most 
efficient manner. Care for our military families is not just a medical 
issue--readiness is inseparable from family health. It is unmeasurable, 
but undeniable, that an Airman's physical and mental fitness to deploy 
is tied to the well-being of his or her family. We must provide our 
troops piece-of-mind that in their absence their loved ones will have 
their social, mental, and health care needs met.
    A final challenge we encounter in providing care is that of the 
recruitment and retention of our active duty and reserve component 
medical professionals, especially physicians, dentists and, nurses. The 
civilian health care environment offers significantly more attractive 
financial incentives than the Air Force, and we appreciate your support 
of recruitment and retention bonuses, special pay programs, and 
critical tools such as the Health Professions Scholarship Program and 
the Health Professions Loan Repayment Program. These are vital to our 
ability to attract qualified professionals and keep them in the Air 
Force.
                                summary
    No other military in the world has the expertise, willingness to 
devote the resources, or the capabilities of the United States when it 
comes to caring for troops and their families, in times of war or in 
peace.
    One of our medics--a surgeon--just returned from four months in 
Baghdad. He was asked, ``What one word sums up your experiences 
there?'' He said, ``Satisfied . . . I was caring for people who put 
their lives on the line for this country. I know that I made a 
difference. That is satisfying.''
    It truly is satisfying to make a difference. We do. And we are 
proud to bring the special skill of Air Force medics to the service of 
our warriors--both present and past--and to their families. I thank you 
for your continued support of our medical service and our Air Force. We 
are proud to make a difference, and we are anxious to answer the call 
again.

    Senator Stevens. That was very generous, General, and 
deserved. Of course, Senator Inouye and I hate to see such 
young men retire.
    I do not expect it right now. There is no rush, but when 
this pace slows down, I would like the committee to have sort 
of a flow chart on how you decided to disperse the wounded from 
Afghanistan and Iraq. We have medical facilities in Europe. We 
have them in Tripler. We have them in Alaska. We have them 
here. And I wonder if we developed a plan to utilize the full 
scope of our facilities, given the air transport that is 
available today and its worldwide capabilities. But no rush, 
just sort of a long-range study to see what we did and see if 
there is some way we might help you to do it better for the 
interest of the people involved.
    I have the impression that the worst cases have come to 
Washington. General, is that right? Have the worst cases come 
to Bethesda and Walter Reed?
    General Peake. Sir, initially that was absolutely the case. 
Now as our units are back and the soldiers are flown through, 
we regulate them to wherever they need. If it is burn 
treatment, they will go to Brook. If the care is available and 
they live near or at Fort Hood, they will go to Fort Hood. It 
just depends on the level of the severity of their injuries. 
Any of our medical centers really can take care of fairly 
sophisticated injuries.
    What we did was concentrate our amputee care at Walter Reed 
because we wanted to have the absolute best. It really started 
with Afghanistan, which was the most heavily mined area in the 
world, and we therefore anticipated the potential for having 
amputees. So we married up with the Veterans Administration 
(VA) and all the smart people that we could find and focused 
that as an area of a center of excellence.
    Senator Stevens. Well, it is my impression that because of 
body armor and better helmets, we are having more real serious 
injury to the limbs of our service men and women. Is that 
observation correct?
    General Peake. Sir, I think that is correct. Really as the 
article talked about yesterday that Senator Leahy mentioned, 
what we are seeing are folks with bad extremity injuries and 
head and neck injuries who otherwise would not have made it to 
us because their thorax would have been injured as well. Now 
they are making it through to the definitive care for their 
amputees.
    Senator Stevens. Has the surge to Bethesda and Walter Reed 
been such that it has required reallocation of funds?
    General Peake. Sir, we have put a lot of money into the 
amputee center specifically to get that ginned up. This c-leg 
that was referred to can cost anywhere from $80,000 to $100,000 
for a single limb, but that is what we are doing. It is the 
right thing to do and we will continue to do that. Truly we 
have been augmented with GWOT funds, global war on terrorism 
funds, out of the supplemental last year because these are 
operational issues not programmed issues. In fact, I am 
anticipating getting another $244 million this year from 
somewhere in DOD to be able to--because that is what we are 
spending--prosecute the medical aspects of the global war on 
terrorism.
    Senator Stevens. Are the facilities that we were able to 
put into Ballad modern enough and capable enough to take a 
substantial part of this surge?
    General Peake. Sir, we have modular combat support 
hospitals in Ballad, in Baghdad. In Ballad, they are in 
basically deployable medical system (DEPMEDS) facilities. In 
Baghdad, we have moved them into one of Saddam Hussein's old 
hospitals. We have them in DEPMEDS facilities at Mosul and 
Tikrit, as well as what we have down in Kuwait. So we have 
created a system----
    Senator Stevens. I do not want to belabor this. Sometime I 
would like to pursue it and see what the schedule is and how 
that flow was from those facilities into more permanent 
treatment facilities and how quickly these people got back near 
their homes.
    We had understood that the facilities in the Washington 
area have started to limit new beneficiaries. Are new enrollees 
now being turned away? I am not talking about people coming 
back from the war zone, just new enrollees of people who are 
eligible for treatment.
    General Peake. Sir, we have limited enrollment in the 
military treatment facilities with capacity. What you want to 
be able to do is appropriately treat the people that you have 
enrolled and give them that care. They can still enroll in 
TRICARE within the civilian part, the contractor part of the 
managed care system under TRICARE Prime.
    Senator Stevens. These are primarily retirees.
    General Peake. Yes, sir.
    Senator Stevens. Is that part of the problem of taking care 
of the increased surge from the war zones?
    General Peake. No, sir. It is not part of that.
    Senator Stevens. It is a limitation of the facilities 
themselves to take on the new retirees?
    General Peake. It is the facilities and the staffing and so 
forth.
    Senator Stevens. And TRICARE for Life.
    General Peake. Right, sir.
    We have an increase in unique users across our system. If 
you look at our retirees, just the retirees over and under 65, 
from 2000 to now, it is about a 60 percent increase in retirees 
of unique users.
    Senator Stevens. I will move on to my co-chairman, but this 
committee was critical of the number of hospitals that were 
closed in the last base closure round and urged that some of 
them be maintained as satellites for other military health 
facilities. Are you considering reopening any?
    General Peake. Sir, our manpower came down 34.5 percent in 
the Army from 1989. So you have to be able to staff a hospital 
to run it. It is really the people not just the facilities.
    Senator Stevens. I will get into that later.
    Senator Inouye.
    Senator Inouye. Thank you.

                          NON-COMBAT INJURIES

    General Taylor just reminded me of an article I read a few 
weeks ago that more men in the Revolutionary and Civil Wars 
died as a result of dysentery, more than bullets. What 
percentage of the personnel who are now being hospitalized are 
hospitalized for non-combatant injuries?
    General Taylor. Do you know the percentage? The only number 
I can give you is the idea of the people that we moved through 
the aeromedical evacuation system. Of the 15,000 or so people 
we moved from the air evacuation system this last year, between 
3,000 and 4,000 were for battle injuries. The rest were for 
disease non-battle injuries. That gives you some estimate. It 
is probably somewhere on the order of one-quarter to one-third 
are actually due to battle injuries. The rest are disease non-
battle injury (DNBI) rates.
    The interesting part, as General Peake said, is the chance 
of dying in theater is much less than historically we have ever 
had, and Jim probably has the statistics on that to tell you, 
if you are injured in battle, if you make it to a medic, what 
your chances of surviving are. Jim, do you want to add to that?
    General Peake. Sir, our killed in action (KIA) rate is 
about 13 percent. If you look at the theater of operation in 
Iraq, it is what the KIA rate is, compared to about 20 percent 
as what we have run historically from a KIA rate.
    But you are right, sir, about the importance of DNBI and 
our preventive medicine measures. We actively review that and 
pursue it. I will give you an example of having to do with eye 
injuries. Our chief in his rapid fielding initiative for our 
soldiers insisted that every soldier get the Wiley X protective 
glasses. I have had two e-mails from the field now talking 
about how our eye injury rates have dropped down. We had 
studied our injuries coming back and had 99 serious eye 
injuries just because of lack of ballistic protection for the 
eyes. That has changed dramatically and part of it is because 
we have got leaders like Pete Chiarelli as the 1st Cavalry 
(Cav) commander who said we will wear the eye protection. That 
is one of your checkpoints as you go out on patrol. So those 
kinds of things are important.
    But if you think about the population we have got over 
there, it is 150,000 people, and so people get sick. People 
have routine injuries. There are motor vehicle accidents. When 
you burn the latrines, you have people that get burned in 
fires. Those kinds of things are part of what we are seeing and 
we wind up taking care of all of that as it comes back through 
our system.
    Admiral Cowan. Sir, if I could add to that. We used to 
accept DNBI as sort of, well, that is just the way it is, and 
we do not anymore. So our efforts are very aggressively aimed 
at making it no more dangerous and no more likely to become 
sick or injured when deployed than if you were at home.
    It does not just start when we deploy. Our attention to the 
health and the fitness to include the flexibility, endurance, 
social stability, family stability of each of our individuals 
to help them go be those sticky soldiers and sailors and airmen 
that will stay in the field and have the capability to do so. 
So that is very much the thrust of force health protection, to 
drive those DNBI's down. Part of it is putting healthy people 
out there that are likely to survive.
    Senator Inouye. Do we have enough research money to look 
into this matter?
    Admiral Cowan. I would say that there are always more 
projects that could be done. I think the money that we have now 
has allowed us to focus on near to midterm research development 
and ultimately acquisition that gets to the issues that we know 
to be the most important. There are others out there that more 
resources would allow us to get to and probably concentric 
circles of greater research risk. So no absolute money would be 
enough or too much.

                     PROTECTIVE BODY ARMOR RESEARCH

    Senator Inouye. I would like to follow up on the chairman's 
questioning. We have been advised that additional research is 
now being done to develop protective body armor for extremities 
and for the head. Can you give us any status report on that?
    General Peake. Sir, I have had the program manager for the 
helmet project over in the office and married him up with our 
head and neck consultant so that we could evaluate the kinds of 
injuries that we are actually seeing with what he is projecting 
for the next generation of combat helmets. Already we have 
improved the helmet from what we had even in Desert Shield/
Desert Storm with better protection inside and better ballistic 
protection from rounds. So we are marrying them up.
    One of the discussion points is what kind of face 
protection that we could have because we have folks standing 
outside the hatches when they are on patrol as an example. So 
the medics are not the primary developers of the body armor, 
but we are actively collaborating.
    The Armed Forces Institute of Pathology is analyzing the 
body armor that comes back to understand where the 
vulnerabilities are. We know already that the axilla is an area 
where it can be penetrated. It saves you from a front-on hit, 
but it can come through the side as an example. So they are 
looking at ways to modify and increase the protection for 
soldiers in that regard.
    Admiral Cowan. Sir, we have a combat registry that was 
initiated by the Army--and all services use it now--that allows 
us to track, in a statistical way, patterns of wounding. For 
example, we are finding with improvised explosive devices that 
the Iraqis are using at the roadside, that our soldiers get 
blasts from above. A helmet does not help. They get eye 
injuries. So General Peake alluded to the glasses.
    We are also finding now that the trunk and the thorax is 
protected. We are seeing lots of people with shoulder injuries. 
So now the researchers are looking into putting a protective 
pad on the shoulder. So the nature of the combat and the nature 
of the vehicles people are in matter, but now we can track that 
and be responsive like we could not in the past.
    Senator Inouye. I realize that it is part of the policy of 
our Defense Department to make certain that every person in 
uniform carries his or her load. In the medical personnel, 
there are some who are extremely specialized and trained. For 
example, we have sent surgeons to Iraq who are some of the 
finest in the land when it comes to knee, shoulder, or hip 
replacement. I do not suppose they have any hip replacement or 
knee replacement in Iraq. Why do we have to keep them there for 
6 months?
    General Peake. Sir, right now they are potentially there 
for 1 year for the Army, and what we are trying to do is have 
them there for 6 months. We have been rotating our reservists 
at 90 days and we think that that is going to allow them to 
stay in the Reserves. We are actively--as a matter of fact, I 
have got the program on my desk now to carry forward, and I 
have talked to some of the leadership in theater about being 
able to rotate our folks out. I could run down the list. Jack 
Chiles, who is the Deputy Commander at Baghdad, is one of our 
premier anesthesiologists. We have subspecialists over there 
because really that is why we have them in the Army is so that 
we can have the kind of quality forward deployed. But what we 
want to do is get them back so that they can maintain their 
skills and be used effectively and efficiently in the long run.
    But it is an issue of being very, very busy as an Army and 
everybody counts for being able to go forward and take care of 
those soldiers. So I absolutely appreciate what you are saying. 
I know many of the folks that you are talking about personally 
and we intend to carry this forward for the active guys to 
rotate those specialties at 6 months. As I say, with the 
reservists we are sticking to the 90 days because we think that 
is what it is going to take to keep them in the Reserves.
    Senator Inouye. My time has expired. I will wait until my 
turn comes up again.
    Senator Stevens. Senator Leahy, you are recognized for 5 
minutes.
    Senator Leahy. Thank you, Mr. Chairman. I have watched 
these 5-minute clocks here for the last 20 minutes, but I will 
try to stay somewhat close to it.
    General Peake, in one of your answers to the question about 
the increase in injuries based on the different type of 
fighting, are we seeing an increase in blindness, blinding 
injuries?
    General Peake. Sir, we saw some very serious eye injuries 
and that is why we have put this focus on the eye protection. 
So we are seeing a drop-off now. We will analyze it to see if 
it has really made that huge a difference.
    Senator Leahy. Please do because I get episodic stories on 
that. We can replace an arm. We can replace a leg. And I do not 
say that in a cavalier fashion by any means. It is still a 
difficulty, but it is not as devastating by any means to a 
person continuing with their life as blindness is.
    I heard your discussion of the--I have kind of watched 
that. We actually put together one of the newer, lighter 
helmets in Newport, Vermont. They are working around the clock. 
I have tried on the old helmet and the new one and there is a 
remarkable difference in the weight. They are both pretty 
heavy.
    General Peake. Yes, sir.
    Senator Leahy. But it is a big difference.
    I read that New York Times article on the incidence of 
post-traumatic stress disorder, this Coming Home article. It 
was troubling in the sense not that there is post-traumatic 
stress disorder. All three of you have had far more experience 
in this than I. You know this happens in our soldiers, our 
sailors, our airmen, marines. Hundreds, if not thousands, of 
these people are seeing horrific things that they have never 
really been prepared for prior to going there, including men 
and women who see their own fellow Americans killed before 
their eyes.
    But the article goes into the question, do we really have 
the things set in place to take care of them when they come 
back here? It said that a number of them are not identifying 
it, even though they feel they have these symptoms of post-
traumatic stress disorder, because they are afraid it will look 
bad on their service records so they are not getting whatever 
counseling they might get. If they stay in the service, they 
have problems of having this untreated. If they go into 
civilian life, again the same thing. They have the problem of 
being untreated.
    Do we have provisions to really treat this? Do we have 
provisions to give the counseling, to do the identifying of it, 
number one; treat it, number two, and with useful numbers of 
our armed services at work trying to retain them and their 
skills in our services?
    General Peake. Well, sir, there are a lot of pieces to 
this.
    Senator Leahy. I understand.
    General Peake. I think we have and are addressing it 
aggressively. I will speak for the Army particularly because we 
have had the biggest bulk of folks on the ground facing those 
things recently.
    This post-deployment screening is more than just checking 
off a piece of paper or a computer chip and sending it in. It 
entails a face-to-face discussion with a provider who has a 
sensitivity to those kinds of things. You are right, sir, that 
some people may or may not report at that point.
    We have concern about the stigma that goes with an approach 
to mental health providers, and so the Army has invested in 
having what we call the Army One Source which offers up to six 
visits without any link to the military at all, like a civilian 
commercial establishment or industry might do. They can pick up 
a telephone and get an immediate contact and get into those six 
visits.
    We have really tried to push to get our combat stress units 
integrated out into the units so that they get to know people. 
So they are less threatening and they are a part of the team 
using sort of the chaplain's model, if you will, because we 
want to make that kind of thing accessible.
    Senator Leahy. You mentioned the pre- and post-deployment 
questionnaires they fill out and I have seen those. I had 
raised the same concern about 10 years ago. Do we have a 
tracking system? Do we know how to follow this? Do we have 
things that, as we go through the periodic health baselines--
they report to a physician when they are in Iraq or 
Afghanistan, wherever for something. I do not know what we have 
that can show this baseline from beginning to end to, among 
other things, have it so readily available even without the 
individual names, but quantitatively and qualitatively 
throughout the military so that you get an indication of we are 
having far more of these, far less of these. It would certainly 
be helpful to other parts of the Government, the VA, for 
example. It would be very helpful to them, far easier to assess 
disability claims that often come up, reliable data for 
epidemiological studies later on. But we do not have something 
that can really do that, do we, General?
    General Peake. Sir, we are heading in that direction. We do 
not have.
    Senator Leahy. What can we do to help you head a little 
faster?
    General Peake. Well, we are in the process of trying to 
field what we call CHSCII which is basically a computerized 
patient record across all three services over the next 30 
months. This post-deployment screening is actually going into a 
centralized database so that we can query those fields, and 
that would be available to the VA as well.
    Senator Leahy. But suppose you have, say, a Sergeant Peake 
out there who has 2 or 3 years in there, been deployed 
different places, to have some way that wherever they are, they 
could immediately go back and see Sergeant Peake--I do not mean 
to pick on you by any means, but it would be, okay, they were 
at Fort Benning and this is what was done. They were in 
Afghanistan. This was done. We moved him to Iraq and this was 
done. Now we have him at Fort Hood and this was done, but be 
able to pull up immediately and know now that you are at Fort 
Hood, you are being treated, for them to be able to tell 
immediately without having to go through all kinds of 
paperwork, to be able to say, okay, this is what happened to 
the sergeant in each of these other places. But we do not have 
that, do we?
    General Peake. Sir, that is what I am saying. In Mobile, 
Alabama, we will have a central database that really has a 
virtual record, electronic record, for each soldier, sailor, 
airmen, and marine. And that is what we will have by the end of 
30 months.
    Senator Leahy. The reason I mention this, General, you 
would get strong support as far as the money is concerned from 
both Republicans and Democrats on this committee because we 
have to continuously make decisions on where is the money going 
to the VA, where is the money going to go whether it is what 
Admiral Cowan or General Taylor or anybody else asks us for, 
where is the money coming from if we have to make choices. The 
only way you can make choices is with the best information, and 
if the disease is not malaria or whatever else, but they are 
post-traumatic stress syndrome, if it is eye injuries, if it is 
stress fractures, or whatever it might be, we can put the money 
in there. We could also put the designing of equipment. We can 
do everything else.
    So I would urge you to keep that as a real priority so that 
we not only can track the individual person but that we could 
have collectively, whether it is for the VA or for anything 
else, we can do that. And also when somebody comes in with a 
disability claim years later, we can actually track and know 
exactly what happened.
    I know I went over, Mr. Chairman, but I know this is 
something you are interested in too. I just really want to 
stress to them that it is a matter that we are all concerned 
with.
    Senator Stevens. Thank you very much, Senator.
    We do want to move on to the next panel, but I want to give 
us each about 3 or 4 minutes for a second round.

                            MEDICAL RESEARCH

    Let me just make a statement to all of you. In the past 
bills, we have had a continual increase in medical research 
funding. We have had money for neurofibrosis, diabetes, 
juvenile diabetes, ovarian cancer, breast cancer, prostate 
cancer, leukemia and other blood related cancers, tuberous 
sclerosis, and manganese health research, head and brain 
injuries, molecular medicine, muscle research. We had about 
three-quarters of a billion dollars earmarked last year.
    I want you to take a look at that and tell us what of that 
is related to your current problems related to the war. I think 
we must emphasize war research in this. These people deserve 
the best and we have got to do everything we can to improve the 
type of treatment we can give them. I am not saying I am going 
to recommend we cut them out entirely, but I am going to 
recommend we reduce the research for non-war-related injuries 
and concentrate for this year that money in fiscal year 2005 on 
the real problem of trying to deal with this massive increase 
in these injuries.
    I do not know if the committee is going to agree with me or 
not because there are enormous groups behind all those other 
concepts, but I do believe that we should emphasize the 
research for the basic people that need the treatment now. 
Those other research concepts are going on year after year 
after year. These people need help now. So we are going to try 
to concentrate on that if we can.

                      MEDICAL AND DENTAL SCREENING

    Other than that, let me ask you this. We enacted 
legislation to make medical and dental screening, as well as 
access to TRICARE available to service members once they are 
alerted for active duty. How is that working out? Is it 
possible to do anything more? The former service reservists 
have told us that post-deployment medical screening has been 
improved, but it falls short of identifying the care that 
returning soldiers need. Those two things, upon being called up 
and released. What needs to be done? General?
    General Peake. Well, sir, I think the opportunity to get 
them screened and to provide the care to bring them up to 
deployable standards before they are activated is important. It 
keeps us from wasting time at mob stations and that kind of 
thing. What we need to discipline ourselves better on--and I 
think we are really pushing in that direction--is to be able to 
have that data available to commanders so they know who needs 
what and insist that they maintain the appropriate standard.
    In regards to the soldiers coming back, this post-
deployment screening that I referred to makes sure that we 
identify at least what they will declare to us, but then they 
have the opportunity for VA care for 2 years for service-
connected issues, as well as the opportunity to be in TRICARE 
for, right now, up to 180 days after their separation. So we 
are very interested in trying to make sure that they do get the 
kind of care that they need and the process is in place to do 
that.
    Senator Stevens. Admiral.
    Admiral Cowan. I would echo, sir, what General Peake said. 
There are lots of pushups that have to be done to get some of 
the reservists ready when they come in, but we have not had 
major difficulties doing that to get them up to a level of 
deployment health that they need to be able to go.
    We believe that the policies for the screening, the post- 
and pre-deployment, the annual health assessment that we do are 
about right, and any failures on individual cases would be 
failures of execution that we work through on a daily basis to 
be as seamless as we can.
    Senator Stevens. Thank you.
    General Taylor.
    General Taylor. The Air Force relies heavily on our Reserve 
component, and over the last 5 years, from the air war over 
Serbia to today, we have constantly had to activate Guard and 
Reserves to help us. So our system is built on a fairly strong 
program during peacetime to ensure folks are ready to deploy. 
So we have had less of a problem on activation.
    I think it is an extremely generous benefit from the 
Congress to ensure that we can have access to health care upon 
notification of orders, and then the 180 days afterwards 
becomes very important to us.
    Also in the Air Force, we have run a system that requires 
the Assistant Secretary of the Air Force to sign off on any 
medical mobilization extensions, which puts a driving force on 
us medics to make sure we are taking care of our people as 
quickly as possible.
    So the combination of those two have made our numbers of 
folks that have had issues smaller. Very clearly, we have not 
had the kind of catastrophic injuries that the marines and the 
soldiers have had over the last year.
    Senator Stevens. Thank you.
    I am going to put in the record Karl Vick's Washington Post 
report of the lasting wounds of this war that was in the 
Washington Post on April 27. I will put it in the record at 
this point.
    [The article follows:]

               [From The Washington Post, April 27, 2004]

 The Lasting Wounds of War; Roadside Bombs Have Devastated Troops and 
                         Doctors Who Treat Them
              (Karl Vick, Washington Post Foreign Service)
    The soldiers were lifted into the helicopters under a moonless sky, 
their bandaged heads grossly swollen by trauma, their forms silhouetted 
by the glow from the row of medical monitors laid out across their 
bodies, from ankle to neck.
    An orange screen atop the feet registered blood pressure and heart 
rate. The blue screen at the knees announced the level of postoperative 
pressure on the brain. On the stomach, a small gray readout recorded 
the level of medicine pumping into the body. And the slender plastic 
box atop the chest signaled that a respirator still breathed for the 
lungs under it.
    At the door to the busiest hospital in Iraq, a wiry doctor bent 
over the worst-looking case, an Army gunner with coarse stitches 
holding his scalp together and a bolt protruding from the top of his 
head. Lt. Col. Jeff Poffenbarger checked a number on the blue screen, 
announced it dangerously high and quickly pushed a clear liquid through 
a syringe into the gunner's bloodstream. The number fell like a rock.
    ``We're just preparing for something a brain-injured person should 
not do two days out, which is travel to Germany,'' the neurologist 
said. He smiled grimly and started toward the UH-60 Black Hawk thwump-
thwumping out on the helipad, waiting to spirit out of Iraq one more of 
the hundreds of Americans wounded here this month.
    While attention remains riveted on the rising count of Americans 
killed in action--more than 100 so far in April--doctors at the main 
combat support hospital in Iraq are reeling from a stream of young 
soldiers with wounds so devastating that they probably would have been 
fatal in any previous war.
    More and more in Iraq, combat surgeons say, the wounds involve 
severe damage to the head and eyes--injuries that leave soldiers brain 
damaged or blind, or both, and the doctors who see them first 
struggling against despair.
    For months the gravest wounds have been caused by roadside bombs--
improvised explosives that negate the protection of Kevlar helmets by 
blowing shrapnel and dirt upward into the face. In addition, firefights 
with guerrillas have surged recently, causing a sharp rise in gunshot 
wounds to the only vital area not protected by body armor.
    The neurosurgeons at the 31st Combat Support Hospital measure the 
damage in the number of skulls they remove to get to the injured brain 
inside, a procedure known as a craniotomy. ``We've done more in eight 
weeks than the previous neurosurgery team did in eight months,'' 
Poffenbarger said. ``So there's been a change in the intensity level of 
the war.''
    Numbers tell part of the story. So far in April, more than 900 
soldiers and Marines have been wounded in Iraq, more than twice the 
number wounded in October, the previous high. With the tally still 
climbing, this month's injuries account for about a quarter of the 
3,864 U.S. servicemen and women listed as wounded in action since the 
March 2003 invasion.
    About half the wounded troops have suffered injuries light enough 
that they were able to return to duty after treatment, according to the 
Pentagon.
    The others arrive on stretchers at the hospitals operated by the 
31st CSH. ``These injuries,'' said Lt. Col. Stephen M. Smith, executive 
officer of the Baghdad facility, ``are horrific.''
    By design, the Baghdad hospital sees the worst. Unlike its sister 
hospital on a sprawling air base located in Balad, north of the 
capital, the staff of 300 in Baghdad includes the only ophthalmology 
and neurology surgical teams in Iraq, so if a victim has damage to the 
head, the medevac sets out for the facility here, located in the 
heavily fortified coalition headquarters known as the Green Zone.
    Once there, doctors scramble. A patient might remain in the combat 
hospital for only six hours. The goal is lightning-swift, expert 
treatment, followed as quickly as possible by transfer to the military 
hospital in Landstuhl, Germany.
    While waiting for what one senior officer wearily calls ``the 
flippin' helicopters,'' the Baghdad medical staff studies photos of 
wounds they used to see once or twice in a military campaign but now 
treat every day. And they struggle with the implications of a system 
that can move a wounded soldier from a booby-trapped roadside to an 
operating room in less than an hour.
    ``We're saving more people than should be saved, probably,'' Lt. 
Col. Robert Carroll said. ``We're saving severely injured people. Legs. 
Eyes. Part of the brain.''
    Carroll, an eye surgeon from Waynesville, Mo., sat at his desk 
during a rare slow night last Wednesday and called up a digital photo 
on his laptop computer. The image was of a brain opened for surgery 
earlier that day, the skull neatly lifted away, most of the organ 
healthy and pink. But a thumb-sized section behind the ear was gray.
    ``See all that dark stuff? That's dead brain,'' he said. ``That 
ain't gonna regenerate. And that's not uncommon. That's really not 
uncommon. We do craniotomies on average, lately, of one a day.''
    ``We can save you,'' the surgeon said. ``You might not be what you 
were.''
    Accurate statistics are not yet available on recovery from this new 
round of battlefield brain injuries, an obstacle that frustrates combat 
surgeons. But judging by medical literature and surgeons' experience 
with their own patients, ``three or four months from now 50 to 60 
percent will be functional and doing things,'' said Maj. Richard 
Gullick.
    ``Functional,'' he said, means ``up and around, but with pretty 
significant disabilities,'' including paralysis.
    The remaining 40 percent to 50 percent of patients include those 
whom the surgeons send to Europe, and on to the United States, with no 
prospect of regaining consciousness. The practice, subject to review 
after gathering feedback from families, assumes that loved ones will 
find value in holding the soldier's hand before confronting the 
decision to remove life support.
    ``I'm actually glad I'm here and not at home, tending to all the 
social issues with all these broken soldiers,'' Carroll said.
    But the toll on the combat medical staff is itself acute, and 
unrelenting.
    In a comprehensive Army survey of troop morale across Iraq, taken 
in September, the unit with the lowest spirits was the one that ran the 
combat hospitals until the 31st arrived in late January. The three 
months since then have been substantially more intense.
    ``We've all reached our saturation for drama trauma,'' said Maj. 
Greg Kidwell, head nurse in the emergency room.
    On April 4, the hospital received 36 wounded in four hours. A U.S. 
patrol in Baghdad's Sadr City slum was ambushed at dusk, and the battle 
for the Shiite Muslim neighborhood lasted most of the night. The event 
qualified as a ``mass casualty,'' defined as more casualties than can 
be accommodated by the 10 trauma beds in the emergency room.
    ``I'd never really seen a `mass cal' before April 4,'' said Lt. 
Col. John Xenos, an orthopedic surgeon from Fairfax. ``And it just kept 
coming and coming. I think that week we had three or four mass cals.''
    The ambush heralded a wave of attacks by a Shiite militia across 
southern Iraq. The next morning, another front erupted when Marines 
cordoned off Fallujah, a restive, largely Sunni city west of Baghdad. 
The engagements there led to record casualties.
    ``Intellectually, you tell yourself you're prepared,'' said 
Gullick, from San Antonio. ``You do the reading. You study the slides. 
But being here . . ..'' His voice trailed off.
    ``It's just the sheer volume.''
    In part, the surge in casualties reflects more frequent firefights 
after a year in which roadside bombings made up the bulk of attacks on 
U.S. forces. At the same time, insurgents began planting improvised 
explosive devices (IEDs) in what one officer called ``ridiculous 
numbers.''
    The improvised bombs are extraordinarily destructive. Typically 
fashioned from artillery shells, they may be packed with such debris as 
broken glass, nails, sometimes even gravel. They're detonated by remote 
control as a Humvee or truck passes by, and they explode upward.
    To protect against the blasts, the U.S. military has wrapped many 
of its vehicles in armor. When Xenos, the orthopedist, treats limbs 
shredded by an IED blast, it is usually ``an elbow stuck out of a 
window, or an arm.''
    Troops wear armor as well, providing protection that Gullick called 
``orders of magnitude from what we've had before. But it just shifts 
the injury pattern from a lot of abdominal injuries to extremity and 
head and face wounds.''
    The Army gunner whom Poffenbarger was preparing for the flight to 
Germany had his skull pierced by four 155 mm shells, rigged to detonate 
one after another in what soldiers call a ``daisy chain.'' The shrapnel 
took a fortunate route through his brain, however, and ``when all is 
said and done, he should be independent. . . . He'll have speech, 
cognition, vision.''
    On a nearby stretcher, Staff Sgt. Rene Fernandez struggled to see 
from eyes bruised nearly shut.
    ``We were clearing the area and an IED went off,'' he said, 
describing an incident outside the western city of Ramadi where his 
unit was patrolling on foot.
    The Houston native counted himself lucky, escaping with a 
concussion and the temporary damage to his open, friendly face. Waiting 
for his own hop to the hospital plane headed north, he said what most 
soldiers tell surgeons: What he most wanted was to return to his unit.

    Senator Stevens. Senator Inouye.
    Senator Inouye. Thank you very much.

                      MEDICAL PERSONNEL SHORTAGES

    According to information we have received, the Army Reserve 
had 3,000 physicians in 1991 and today they are 1,550. The 
Naval Reserve went from 2,191 in 1900 to 1,000 today. The Air 
Force currently has 761 physicians.
    We have been advised that the Air Force is short on 
dentists, nurses, occupational therapists, and is relying on 
incentive pay and ongoing initiatives for school loan repayment 
options for recruiting and retention. The Army is short on 
nurse anesthetists, general surgeons, anesthesiologists, 
neurosurgeons. The Navy is short on nurses and dental corps 
personnel.
    I realize that we will not have the time today, but can you 
advise this committee as to what you are doing about this or 
what can be done and what can be done by this committee? If you 
could, please provide us a brief response.
    Admiral Cowan. Sir, we will respond to that in more detail 
in the immediate future.
    Part of the reduction of reservists for the Navy is an 
intentional part of the transformation of the Navy because we 
use our reservists in different ways. Part of the cuts in 
Reserves were actually cuts of billets not people. They were 
billets that we could not match the skill next to. We now use 
our Reserves as more of an integrated force than in the past. 
So the degree of risk that we may be running with our Reserve 
assets is only perhaps marginally larger or the same as it was 
before.
    That being said, we do have ongoing difficulties with 
shortages in specific areas, and I will provide you information 
on the programs that we are working to improve those.
    [The information follows:]

    The Medical Corps currently has shortages in anesthesiology, 
surgery, urology, neurosurgery and radiology. The Medical Corps 
primarily uses the Health Professions Scholarship Program and the 
Uniformed Services University of the Health Sciences, as it's primary 
accession pipeline. Students are recruited for these programs and then 
get into specialties based on the Navy's need and the availability of 
training positions. Another method to increase the number of critical 
shortage specialists is the use of fellowship training to entice 
specialists in critical areas to remain on active duty. In addition, a 
new training program in radiology at Naval Medical Center Portsmouth, 
Virginia was opened in 2003, which will increase the number of 
graduating radiologists per year from in service training programs.
    The Nurse Corps continues to focus on a blend of initiatives to 
enhance our recruitment and retention efforts, such as:
  --Diversified accession sources, which also include pipeline 
        scholarship programs (Nurse Candidate Program, Naval Reserve 
        Officer Training Corps, Medical Enlisted Commissioning Program, 
        and Seaman to Admiral Program).
  --Pay incentives (Nurse Accession Bonus, Certified Registered Nurse 
        Anesthetist Incentive Special Pay, and Board Certification 
        Pay).
  --Graduate education and training programs, which focus on Master's 
        Programs, Doctoral Degrees, and fellowships. Between 72-80 
        officers/year receive full-time scholarships based on 
        operational and nursing specialty requirements.
  --Successful recruiting incentives for reservists in critical wartime 
        specialties include: the accession bonus and stipend program 
        for graduate education.
    The Medical Service Corps is comprised of 32 different health care 
specialties in administrative, clinical and scientific fields. The 
educational requirements are unique for each field; most require 
graduate level degrees, many at the doctoral level. End of fiscal year 
2003 manning was at 98.2 percent, however, difficulties remain in 
retaining highly skilled officers in a variety of clinical and 
scientific professions. Entomology and Physiology are currently 
undermanned by more than 10 percent. Entomology has not met direct 
accession goals since fiscal year 1999 and Physiology has not met 
direct accession goals since fiscal year 1998. Use of the Health 
Services Collegiate Program (HSCP), a Navy student pipeline program, 
was instituted for the Entomology community in fiscal year 2002 and for 
the Physiology community in fiscal year 2003. The use of HSCP for these 
communities seems to be an effective means to achieve the accession 
goals for these communities.
    The Dental Corps currently have their greatest shortages in general 
military dentists; endodontists (root canal specialists); Oral and 
Maxillo-Facial Surgeons and prosthodontists. The Dental Corps uses the 
Health Professions Scholarship Program (HPSP) as it's primary accession 
pipeline. Dental students are recruited for these programs and then get 
into specialties based on the Navy's need and the availability of 
training positions. At the present time, recent graduates are being 
deferred for residency training in these shortage areas on a case-by-
case review.

    General Peake. Sir, I mentioned the 90-day rotations to be 
able to enable dentists, nurse anesthetists, and physicians to 
be able to be away from their practice a reasonable period and 
still be able to be incorporated back into that practice when 
they get there. Even with that 90 days, it is stressful. I have 
had one say, well, I can do 90 days, but I cannot do 90 days 
every year, that kind of notion. So the OPTEMPO is part of it.
    I think we are about to restructure our Reserves so that we 
have a United States Army Reserve medical command that will 
allow us to focus the management of all of those critical 
assets in a more homogeneous way. So there is a restructuring 
initiative that is going on.
    The other aspects of it are on the active side, and so we 
have to keep a close eye on that, given the OPTEMPO and 
PERSTEMPO as well. So I think the issue of restructuring our 
bonuses is important and we need to be able to look forward to 
getting that updated because we have not really updated it in a 
while.
    General Taylor. We will respond in more detail to you, 
Senator.
    I also think for the reservists in particular it is 
difficult in today's medical practice. Many of the providers 
operate very close to the margin. So taking them out for long 
periods of time oftentimes can destroy a practice.
    So all of us--and you heard from General Peake--are trying 
to work ways where we can bring them on active duty for short 
periods of times, particularly through a volunteer system, so 
they could support perhaps 30 days every couple of years. So we 
are all actively trying to work ways of doing that. We have 
been aggressively trying to do that so that it counts as 2 
years' worth of points and 1 year, one 30-day activation. So we 
are working real hard to do that.
    Certainly pay and environment of care is an important 
aspect, as well as trying to make continued service in the 
Guard and Reserve for our folks who elect to leave active duty 
an important piece of a smooth transition from being on active 
duty status. We are hoping to be able to gather more folks up 
to serve in these critical positions in the Guard and Reserve. 
We have not seen a radical drop in physicians in particular 
within the Guard and Reserves, but it is very troublesome 
seeing how much we used them in the last couple of years.

                        RECRUITING AND RETENTION

    Senator Inouye. There are certain statistics we watch very 
carefully. One, obviously, is recruiting and retention of 
active duty medical personnel. Are we in good shape?
    General Peake. Sir, we are in the Army on the Health 
Professions Scholarship Program (HPSP), of course, with the 
Uniformed Services University of the Health Sciences (USUHS), 
but really in the larger extent it is our health professional 
scholarship programs. Those costs have increased significantly 
to the point where I had to look into other sources of funds 
other than what we had programmed just because the tuition 
costs have gone up so much as we put people out into civilian 
training, which is tremendously important for us. That is 
really our best recruiting tool.
    I know Debbie Gustke will talk more about nursing in the 
next panel, the kinds of things that we are doing to try to 
encourage nurses to join our Army as well.
    I think what General Taylor talked about in terms of 
environment of care is terribly important. We have to have a 
quality system and the kind of quality places for them to come 
in and practice. Otherwise, they really will not want to be a 
part of a second-rate organization. So we have got to keep that 
first-rate.
    Senator Inouye. Thank you, Mr. Chairman.
    Senator Stevens. Well, we would like to pursue that 
conversation with you and your successors. I know some medical 
people up my way who would welcome a chance to have a quarter 
of 1 year away from their practice and to have some different 
surroundings. If they had a commitment that they would not be 
yanked out for 1 year later, they might make that commitment. 
We need to devise some innovative programs to give particularly 
these young doctors who get stuck in some place and they do not 
get a chance to travel. It will give them a chance to get 
involved and be active duty for 2 months a year or something 
like that and give them a commitment they will not be called up 
for longer in a certain period, whatever it is, and have some 
bonuses involved in that training. It might be easier to do 
that than to get more scholarships and whatnot, to get more 
people who really end up by not being available anyway after 
they have left the service.
    We want to thank you again. General Peake and Admiral 
Cowan, we have enjoyed your participation in our process here 
and we respect your commitment to your military service and 
your medical profession. So we wish you well.
    General Taylor, you will be over at the left-hand side of 
the table next year. So we will look forward to that. I 
remember when I was sitting down at the end of this table once 
when an old friend of mine, who was the chairman--I had known 
him years before--he called me over and he said, do you know 
how much seat time you are going to have to log to get to sit 
where I am sitting?
    So cheer up. You moved very quickly.
    We will proceed to the nursing now and hear from the Chiefs 
of the service nursing corps. We thank you very much, Admiral 
and Generals.
    Your nursing corps is vital to the success of our military 
medical system as any part of it. We thank you for your 
leadership and we look forward to hearing from you. We welcome 
you again. We are going to hear from Colonel Deborah Gustke, 
the Assistant Chief of Army Nurse Corps. We welcome Admiral 
Nancy Lescavage, Director of the Navy Nurse Corps, and from the 
Air Force, we have General Barbara Brannon, Assistant Surgeon 
General for Nursing. We welcome you all back warmly. None of 
you are leaving us this year, are you?
    Colonel Gustke. Yes, sir.
    Senator Stevens. I yield to my good friend and co-chairman.
    Senator Inouye. I would like to join you in congratulating 
and thanking all of the nurses here.
    Major General Brannon, I believe you are the first to be a 
major general.
    General Brannon. I am, sir, in the Air Force.
    Senator Inouye. Congratulations.
    General Brannon. Thank you for the great honor. It is very 
humbling.
    Senator Inouye. Let us hope that you are the first of many.
    I am especially proud to see Admiral Lescavage here. I have 
special pride in that she served on my staff for a while as a 
fellow.
    We will hear from Colonel Gustke. Some day, if you stick 
around, you will have a star as well.
    I understand that the Army has been operating without a 
Nurse Corps chief since General Bester retired. I understand 
that you will also be retiring.
    Colonel Gustke. Yes, sir.
    Senator Inouye. Don't you want to wait until you receive 
your star?
    Seriously, I would like to thank you for your many years of 
service to our Nation. Thank you so much.
    Colonel Gustke. Thank you, sir.
    Senator Stevens. Thank you all. Your statements will appear 
in the record in full. We will look forward to your comments. 
Colonel, we call on you first.
STATEMENT OF COLONEL DEBORAH A. GUSTKE, ASSISTANT 
            CHIEF, ARMY NURSE CORPS
    Colonel Gustke. Mr. Chairman and distinguished members of 
the committee, thank you for the opportunity to update you on 
the Army Nurse Corps.
    As of April 2004, we have deployed over 814 Army nurses to 
places such as Afghanistan and Iraq, serving as members of 
forward surgical teams in support of our deployed divisions, 
and as staff within our 31st Combat Support Hospital, 67th 
Combat Support Hospital, and 325th U.S. Army Reserve Field 
Hospital.
    We have numerous Reserve nurses who are serving in back-
fill roles in our medical treatment facilities. Furthermore, 
158 Reserve and National Guard nurses are serving as case 
managers at the regional medical commands, mobilization sites, 
and at the community-based health care initiatives which were 
established to provide medical holdover management for soldiers 
impacted deployment.
    We have a very strong focus on reintegration of our 
personnel once they return home and are continuing to assess 
whether the rapid deployment tempo is impacting retention. I am 
pleased to tell you that last year in fiscal year 2003 we 
experienced the lowest attrition rate in the past 5 years. We 
continue to collect data from Army nurses and the reasons for 
attrition have remained constant over the last few years 
without any new emerging trends.
    At home we continue to leverage all available incentives 
and professional opportunities in recruiting and retaining both 
our civilian and military nursing personnel. Simply put, the 
direct hire authority for registered nurses authorized by 
Congress has substantially benefitted our hiring efforts. In 
fiscal year 2003 we achieved an unprecedented 94 percent fill 
rate of documented civilian registered nurse positions, an 
overall turnover rate of less than 14 percent. Our hiring 
reflects improvement over the past 3 years for registered 
nurses.
    We continue, however, to have barriers in hiring our 
licensed practical nurses and strongly affirm that direct hire 
authority needs to be extended to include this extremely 
valuable nursing population.
    We believe that we have strong recruitment and retention 
tools to address the long-term impact of the decreased nursing 
pool on our military nursing recruiting efforts. Although the 
Army Nurse Corps was below our fiscal year 2003 budgeted end 
strength, the decrement is less than in the past 2 years. We 
are confident that the recruiting and retention strategies in 
place, such as the increased accession bonus and the health 
loan repayment program, will continue to help reduce the 
decrement in future years.
    We also increased the number of soldiers who are sponsored 
to obtain their baccalaureate nursing degree through the Army 
enlisted commissioning program. We continue to take aggressive 
measures to strengthen nurse accessions through the Army 
Reserve Officer Training Corps and the United States Army 
Recruiting Command. We offer Reserve Officer Training Corps 
(ROTC) nurses scholarships at nearly 200 nursing schools and 
have increased the collaborative relationship between our 
health care recruiting resources in ROTC and the United States 
Army Recruiting Command (USAREC).
    Army nurses continue to be at the forefront of relevant 
nursing research that is focused on our research priorities of 
readiness and nursing practice. We have nearly 90 research 
studies currently in progress and continue to foster 
involvement in the research process at all levels of our 
organization. Our research accomplishments include the 
development of 23 evidence-based standardized treatment 
guidelines for musculoskeletal injuries most common to 
soldiers.
    Our Military Nursing Outcomes Database study, known as 
MilNOD is now in the fourth year of study and has resulted in 
the development of staffing and patient safety reports for the 
Army hospitals. This study also affirms our strong belief in 
collaborative nursing research as we have influenced the 
development of the Veterans Affairs Nursing Outcomes Database 
with a similar design. This project truly demonstrates what is 
best about nursing research and Federal nursing collaboration.
    Along with our Federal nursing colleagues, our commitment 
to the tri-service research program and the graduate school of 
nursing at the Uniformed Services University of the Health 
Sciences remains very strong. Both these programs are distinct 
cornerstones of our Federal nursing education and research 
efforts and clearly demonstrate nursing excellence.
    Thank you, sir, for your continued support of both these 
exemplary programs as it enables us to continue to produce 
advances in nursing education, research, and practice for the 
benefit of our soldiers and their family members and our 
deserving retiree population.
    Finally, Senators, we are firmly determined to meeting and 
overcoming any challenge that we face this year and are 
committed to meet the uncertain challenges of the future. We 
are further motivated by the impressive, steadfast courage and 
sacrifice demonstrated by all the fine men and women in uniform 
who are serving our great Nation. We will continue our mission 
with a sustained focus on readiness, expert clinical practice, 
sound educational preparation, professionalism, leadership, and 
the unfailing commitment to our Nation that have been 
distinguishing characteristics of our Army nurses and 
organization for over 103 years.
    As I conclude my 32 years of service in the Army Nurse 
Corps, I am most proud of all the tremendous civilian and 
military nursing personnel that represent this great Army Nurse 
Corps.

                           PREPARED STATEMENT

    Thank you again for your support and for providing the 
opportunity for us to present the extraordinary efforts, 
sacrifices, and contributions made by all Army nurses who 
always stand ready, caring, and proud. Thank you, sir.
    Senator Stevens. Thank you very much.
    [The statement follows:]
            Prepared Statement of Colonel Deborah A. Gustke
    Mr. Chairman and distinguished members of the committee, I am 
Colonel Deborah A. Gustke, Assistant Chief, Army Nurse Corps. Thank you 
for providing the opportunity this year to update you on the state of 
the Army Nurse Corps. I am pleased to represent Brigadier General 
William T. Bester, Chief of the Army Nurse Corps, who is currently 
transitioning to retirement after a very distinguished thirty-five year 
military career. The past year has been challenging for our great 
Nation as well as for the Army Nurse Corps. We have sustained a 
deployment rate in recent months not seen since the Vietnam era and I 
am extremely proud to report that the Army Nurse Corps has again 
demonstrated our flexibility and determination to remain ready to serve 
during these challenging and difficult times.
    We remain very engaged in our Army's efforts in support of 
operations around the world. As of March 2004, we have deployed over 
814 Army nurses to places such as Afghanistan and Iraq. Our nurses are 
providing expert care in every health care setting. There are Army 
nurses on Forward Surgical Teams performing immediate life-saving care 
to our soldiers. We have Army nurses assigned to the combat divisions 
who are responsible for educating and sustaining our enlisted combat 
medics--our linchpin to soldier care. Army nurses perform both clinical 
and leadership roles in the two deployed Combat Support Hospitals (CSH) 
and one Field Hospital. At present, the 31st Combat Support Hospital 
from Fort Bliss, TX and the 67th CSH from Wuerzberg, Germany are on the 
ground in Iraq and the 325th Field Hospital, United States Army 
Reserve, headquartered from Independence, MO, is currently on the 
ground in Afghanistan. These units in Iraq recently conducted a 
seamless transition with the 28th CSH from Fort Bragg, NC and the 21st 
CSH from Fort Hood, TX, who have now safely returned home. We are 
firmly supporting organized reintegration programs for the members of 
these units at their home stations to ensure that the transition to 
home is as supportive and successful as possible. We are truly proud of 
the Army nurses and all the medical personnel who served and are 
currently serving with these and all the medical units.
    Our Reserve Nurse Corps officers are demonstrating the necessary 
leadership and clinical expertise in support of current operations in 
many settings around the world. In addition to the nurses in theater, 
numerous other Reserve nurses are serving in backfill roles in our 
Medical Treatment Facilities (MTFs). Furthermore, 158 Reserve and 
National Guard nurses are serving as case managers at the Regional 
Medical Commands, mobilizations sites and at the community based health 
care initiative sites, established to provide medical holdover 
management for soldiers impacted by deployment. With the addition of 
Army nurse case managers in June 2003, the flow and disposition rate of 
medical holdovers has increased dramatically. Army nurses possess the 
necessary mix of leadership and clinical skills to perform nursing care 
in any setting and in any role. I strongly believe that we have fully 
demonstrated this throughout our one hundred and three year history, 
and especially since September 11, 2001.
    The current world environment is not without challenges for the 
Army Nurse Corps in several arenas. The National nursing shortage 
continues to impact the ability of the Army Nurse Corps to attract and 
retain nurses. Although we are encouraged by recent increases in 
nursing school application numbers, concerns continue over the lack of 
nursing school capacity due to the availability of adequate faculty. We 
wholeheartedly support initiatives that attract and retain nursing 
school faculty and believe that it will be critical to continue 
developing programs necessary to meet current and future faculty 
shortfalls.
    We have worked diligently in the past year to minimize the impact 
of a decreased nursing personnel pool on our civilian nurse strength. 
Civilian nurses continue to comprise the majority of our total nurse 
workforce and have performed exceptionally during the recent staffing 
transitions at our MTFs as our active and reserve nurses mobilize in 
support of operations around the world. Our civilian nurses have 
demonstrated true resiliency and the willingness to absorb the 
necessary roles to ensure that we don't miss a beat as we provide 
expert nursing care to our beneficiaries.
    We continue to have success with the Direct Hire Authority. In 
fiscal year 2003, we achieved a 94 percent percent fill rate of 
documented civilian Registered Nurse positions and an overall turnover 
rate of 14 percent. These numbers reflect continued improvements over 
the past three years and the high fill rate percentage demonstrates 
that Direct Hire Authority is successful. We will continue to monitor 
strategies to address retention efforts such as supporting 
opportunities for continuing education and professional development 
programs for our civilian Registered Nurses. Although in fiscal year 
2003, for the first time in three years, we experienced a decline in 
the fill rate for civilian Licensed Practical nurse positions, but we 
experienced a decreased turnover rate. In fiscal year 2003, it took an 
average of 84 days to fill a Licensed Practical Nurse position, nearly 
30 more days than the Army standard of 55 days. We're reviewing the 
options we have to ease the recruitment and hiring lag that we 
currently experience in this valuable nursing personnel population.
    The Army Nurse Corps remains actively engaged in a DOD effort to 
simplify and streamline civilian personnel requirements and prepare our 
processes to compliment the evolving National Security Personnel System 
(NSPS). We support having the flexibility necessary to respond to the 
rapidly changing civilian market and are encouraged by the projected 
use of pay banding to facilitate regional hiring and retention 
differences. We are now able to implement the needed flexible special 
pay strategies within the pay system and are pursuing financing 
strategies to execute this authority this fiscal year. In addition, we 
are ready to implement the clinical education template currently 
required in the legislation in order to ensure consistency of hiring 
practices.
    We believe that we have assertively leveraged strong recruitment 
and retention tools to address the long-term impact of the decreased 
nursing pool on our military nurse recruiting efforts. Although the 
Army Nurse Corps was below our fiscal year 2003 end-strength of 3,381 
by 154, this decrement has closed since fiscal year 2002 and we are 
confident that the recruitment and retention strategies in place will 
continue to help reduce future shortfalls. We continue to take 
aggressive measures to strengthen our position in both the Army Reserve 
Officers' Training Corps (AROTC) and United States Army Recruiting 
Command (USAREC) recruiting markets. We now offer AROTC nursing 
scholarships to students at approximately 200 nursing schools across 
the country. One of the greatest recruiting tools for AROTC and nursing 
is the Nurse Educators Tour to the AROTC Leader Development and 
Assessment Course at Fort Lewis, WA. This course is the capstone 
evaluation program for AROTC cadets in the summer between their junior 
and senior years and impressively demonstrates the finest qualities of 
our future officers. In the past, we were limited to hosting 30 nurse 
educators, but now have secured resources to host up to 150 educators. 
Last summer, 104 nurse educators came to Fort Lewis and left with a new 
found appreciation for the benefit of AROTC training as well as for the 
Army Nurse Corps as a tremendous environment for their students to 
practice the art and science of nursing. Upon returning to school last 
fall, one nurse educator personally escorted five nursing students to 
the AROTC cadre to discuss scholarship options. It is clearly evident 
that the influence of nurse educators on prospective Army Nurses is 
integral to our efforts in AROTC and we will continue to foster those 
strong relationships.
    We have also taken strides to increase the collaborative 
relationship between our health care recruiting resources in AROTC and 
USAREC. This collaborative non-competitive partnering was initiated to 
maximize the Army Nursing presence on campus and to present a unified 
Army Nurse Corps team to the nursing students and faculty. As of 
February 2004, this collaborative effort has resulted in 60 referrals 
to USAREC by AROTC Nurse Counselors. We will continue to support this 
professional partnering in nurse recruiting.
    Regarding compensation incentives, we have been successful in 
increasing the accession bonus and are working towards incremental 
increases up to our authorized level in future years. We are 
particularly proud to report that the Health Professions Loan Repayment 
Program (HPLRP), implemented at the end of fiscal year 2003 and 
continuing into fiscal year 2006, has been very successful. We have 
been able to optimize the use of this program for both new accessions 
as well as for retention of our fine company grade Army Nurse Corps 
officers. We believe that these incentive programs, coupled with 
established professional leadership and clinical education programs, 
are instrumental in our efforts to retain Army nurses during the early 
phase of their careers. Finally, we continue to be extremely successful 
in providing a solid progression program for our enlisted personnel to 
obtain their baccalaureate nursing degree through the Army Enlisted 
Commissioning Program. Our intent is to consistently sponsor 85 
enlisted soldiers each year to complete their nursing education to 
become Registered Nurses and subsequently, Army Nurse Corps officers. 
We have married the support framework of these soldiers to our AROTC 
resources at the various colleges and universities in order to ensure 
that our enlisted soldiers have the support and mentoring they so 
richly deserve while they are pursuing their nursing studies. Graduates 
from this program continue to provide the Army Nurse Corps with nurses 
who are strong soldiers and leaders.
    Our focus on retention of our junior nurses will always be 
important and in fact, in fiscal year 2003, we experienced the lowest 
attrition rate in the past five years. We believe that the robust 
compensation strategies such as their base pay, allowances, the Health 
Professions Loan Repayment Program (HPLRP) and the Incentive Specialty 
Pays for our Certified Registered Nurse Anesthetists (CRNA) have been 
paramount in our effort to recognize individuals for their tremendous 
efforts and sacrifices, especially during the continued high 
operational tempo. We continue to collect data from Army nurses who 
choose to leave the Army and are analyzing the recent data to assess 
any impact that the swift deployment tempo may have on our retention 
efforts. The results to date do not reflect that the losses are related 
to deployment, but we will continue to track and assess this very 
closely.
    Each year, the Army Nurse Corps continues to sponsor the largest 
number of nurses, compared to any Service, to pursue advanced nursing 
education in a variety of specialty courses as well as in masters and 
doctoral programs. We know that this education program, coupled with 
the military leadership development, positively impacts improved 
clinical practice environment, mentoring relationships, and role 
satisfaction.
    It is a pleasure to be able to highlight good news stories about 
nurses affiliated with the Army Medical Department (AMEDD) Center and 
School and at the many MTFs around the world who are working tirelessly 
to improve the clinical, education, research, and leadership 
environments. At the AMEDD Center and School, we have increased our 
training capacity for CRNAs in order to address a critical shortfall in 
this specialty. This involved opening a clinical training site at 
Brooke Army Medical Center, in San Antonio, TX, that allows us to 
produce an additional four CRNA nurses each year. As a result, we will 
increase our ability to fill the operational requirements for these 
nurses as well as decrease the current costs of contracting civilian 
CRNA personnel in our facilities.
    Army Nurses are integral to the Army Medical Reengineering 
Initiative at all levels of our organization. To support the conversion 
of our enlisted/officer Licensed Practical Nurse (LPN) to an expanded 
level of patient care capability, Army Nurses designed and implemented 
a new educational program of instruction for the LPN training program. 
This improvement refocused training to include a greater emphasis on 
critical care and trauma skills in support of the revised wartime 
mission of these soldiers. Our first class, under the improved program 
of instruction, began in late 2003 and we are confident that this 
training will produce the highly trained Practical Nurse sought by the 
Army. Army Nurses are also very proud to be an integral part of the 
transformation of the new enlisted Healthcare Specialist Military 
Occupational Specialty (91Ws). We are imbedded in the training units as 
leaders and educators. In fact, there are 32 Army Nurse Corps officers 
directly assigned to the combat divisions who are working to ensure 
that our 91W soldiers sustain their training and preparation needed to 
provide the most far forward care. Over the past year, as they have 
throughout history, our medics have performed admirably and we are very 
proud to serve side by side with these exceptional soldiers. We will 
continue to steadfastly support all aspects of this transformation 
until it is completed and sustainment training practices are well 
established.
    The Army Nurses at Tripler Army Medical Center, Hawaii have 
implemented a professional practice model for all its nurses. The model 
is a standards and role-based model that clearly delineates the role of 
the nurse and provides more consistent tools for use in the performance 
evaluation process. This process has significantly assisted our new 
nurses in understanding role expectations as well as assisted our nurse 
leaders in clearly articulating expectations to the nursing staff. This 
process is ongoing and we are exploring the potential of expanding this 
concept to other MTFs. The Army Nurses from Hawaii are also in demand 
around the Pacific Rim and have established professional dialogue with 
the Royal Thai Nurses, The Australian Nurse Corps, and the New Zealand 
Defence Corps. In addition, Army Nurses have presented on clinical and 
professional nursing issues in Bangkok, Thailand and Hanoi, Vietnam. We 
will continue to sponsor this professional collaboration in the spirit 
of international cooperation and mutual benefit.
    Last year, we presented information on the Combat Trauma Registry 
initiative that was employed at Landstuhl, Germany and contained 
retrospective data entered on soldiers injured in Afghanistan in 
support of Operation Enduring Freedom. I am pleased to report that this 
database is now termed the Army Medical Department Theater Trauma 
Registry (AMEDD TTR) and is a web-based system, with DOD interface, now 
capable of concurrent data collection and casualty reporting. The AMEDD 
TTR collects data on all casualties, all U.S. military personnel and 
any NATO and allied military personnel and local nationals, treated at 
U.S. facilities in Operation Iraqi Freedom. Army Nurses in partnership 
with experts from the Institute of Surgical Research, Walter Reed Army 
Medical Center, Landstuhl Army Medical Center, the Armed Forces 
Institute of Pathology and the Navy Health Research Center have worked 
tirelessly on this project. It is expected that the results of this 
data collection and analysis will provide information pertinent in the 
development of improved medical training, equipment, and practice 
modalities for future operations.
    Army nurses continue to be at the forefront of nursing research 
focused on the five Army Nurse Corps research priorities of 
identification of specialized clinical skill competency training and 
sustainment requirements, issues related to pre-, intra-, and post-
deployment, issues related to the nursing care of our beneficiaries in 
garrison, nurse staffing requirements and their relationship to patient 
outcomes, and finally, issues related to civilian and military nurse 
retention. Today I will share with you our progress and accomplishments 
in these five priority areas.
    The Military Nursing Outcomes Database (MilNOD) project is now in 
the fourth year of study and incorporates research efforts across the 
military nursing services. The participating sites include Walter Reed 
Army Medical Center, Madigan Army Medical Center, Womack Army Medical 
Center, Dewitt Army Community Hospital, Malcolm Grow Air Force Medical 
Center, Naval Hospital Bremerton and Naval Hospital Whidbey Island. 
This project is collecting data to support evidence-based clinical and 
administrative decision-making and create a reliable and valid database 
consisting of standardized nurse staffing and patient safety data. In 
addition, the investigation team is working with the California Nursing 
Outcome Coalition (CalNOC), a repository of staffing and patient safety 
data from 120 California hospitals, to benchmark data from like 
facilities. Although still in progress, this project has resulted in 
very promising findings to include the development of staffing and 
patient safety reports for the Army hospitals. The content of these 
reports meets the JCAHO compliance measures for staffing effectiveness 
measures and is being used by the nursing leadership in staffing 
pattern decisions. In addition, the MilNOD data on patient safety 
related to pressure ulcers revealed that nurses at Walter Reed were 
noticing that some of the ill or injured patients returning from 
deployment were experiencing pressure ulcers. This finding led to a 
discussion of pressure ulcer prevention in the field setting and 
resulted in the sharing of pressure ulcer prevention protocols from the 
Medical Center with the Combat Support Hospital in theater. In 
addition, nurses determined that the field litters currently used to 
support and transport patients did not provide the necessary padding 
protection against the development of pressure ulcers. This finding 
opens up a whole new area for potential inquiry and intervention. The 
MilNOD project is a tremendous long-term effort by nurses in all three 
services and has now influenced the development of the Veteran's 
Affairs Nursing Outcomes Database (VANOD). This project truly 
demonstrates what is best about nursing research and Federal Nursing 
collaboration.
    Army nurse researchers at Madigan Army Medical Center have also 
developed 23 evidence-based standardized treatment guidelines for 
musculoskeletal injuries most common to soldiers. These guidelines 
provide information on patient education, exercise regimes with 
photographic aids, diagnostic information, and medical profile 
information. There have been hundreds of requests for these guidelines 
from deploying units as well as from providers at MTFs at home and each 
of these guidelines may be found on-line at the Madigan Army Medical 
Center website.
    Our Nursing Anesthesia students continue to add to our growing body 
of knowledge in nursing anesthesia care for our beneficiaries at home 
or our soldiers in a deployment setting. This past year, several 
studies were done on monitoring techniques, warming techniques, gender 
differences in medication dosage levels and the impact of medication 
use on pain perception. We are extremely proud of the research that all 
our students accomplish while they are completing very vigorous 
programs of study.
    Our civilian nurses are also very involved in nursing research. 
Nurse researchers at Fort Carson, CO received a National Institutes of 
Health grant to study self-diagnosis of genitourinary infection of 
deployed women. The study plan is to develop a safe and accurate field 
expedient self-diagnosis and treatment kit for genitourinary infections 
to be used by military women deployed to austere environments. In a 
preliminary study involving over 800 military women, the investigators 
learned that 87 percent of these women experienced symptoms of 
infection at some point during the deployment. Nearly half of the women 
reported that the symptoms resulted in decreased work performance and 
24 percent reported lost hours of work time. It is evident that the 
outcomes of this research could have a positive impact on readiness and 
women's health in the deployed environment. This study has far reaching 
implications for other humanitarian organizations that send women to 
areas in which the needed health care may not be readily accessible or 
available.
    The Army Nurse Corps research priorities are extremely timely and 
relevant to the research being conducted by our civilian nursing 
colleagues. A study recently completed in December 2003 by Lieutenant 
Colonel Patricia Patrician, an Army Nurse Corps researcher from Walter 
Reed Army Medical Center, focused on assessing the Army hospital work 
environment in order to describe the work environment attributes, nurse 
burnout, job dissatisfaction and intent to leave the Army workforce 
from the perspectives of military and civilian staff nurses. The second 
purpose was to compare these results to published reports from civilian 
hospitals. As we know, recruitment and retention has been tied to 
positive work environments, such as those that exist in magnet 
hospitals. The final sample from the Army study consisted of 957 
Registered Nurses who worked in inpatient settings within the Army's 23 
hospitals in the United States. The sample represented 64 percent 
civilian and 36 percent military nurses. The study results concluded 
that nurses working in Army hospitals rated Army hospitals more 
favorably as compared to the ratings of a group of civilian hospitals 
in terms of work environment. Nurses who work in Army hospitals 
experience less burnout and less job dissatisfaction than those in 
civilian hospitals. Finally, when taking into consideration normal 
military rotations and rotations within a hospital, Army nursing 
personnel are less likely than civilian nurses to leave their current 
positions within one year. Research of this nature helps us maintain 
our healthy work environment as well as remain competitive with our 
civilian counterparts in recruitment and retention.
    Our support and appreciation for the Uniformed Services University 
of the Health Sciences (USUHS) is also very strong. USUHS continues to 
provide us with professional nursing graduates who continue to excel in 
their programs of study and subsequent professional military careers. 
We are pleased that both the Clinical Nurse Specialist Program in 
Perioperative Nursing as well as the Doctoral Program in Nursing are 
successfully progressing in their inaugural year. These programs were 
established as a result of an identified need in the military services 
and the Graduate School of Nursing leadership and staff worked 
tremendously hard to develop and execute both of these programs. USUHS 
will continue to be our cornerstone educational institution and remains 
flexible and responsive to our Federal Nursing needs. We look forward 
to a continued strong partnership to maintain the necessary numbers of 
professional practitioners to support our complex mission.
    The Army Nurse Corps experienced the loss of two tremendous Army 
Nurse Corps officers this past year, one whose legacy of leadership and 
influence will forever have an impact on the Corps and one whose young 
career ended much too soon. Brigadier General (Retired) Lillian Dunlap, 
our 14th Chief, Army Nurse Corps, passed away in April 2003. She had a 
long and illustrious life, both personally and professionally. BG 
Dunlap served in the 59th Station Hospital in the southwest Pacific 
area of New Guinea, Admiralty Islands and the Philippines during World 
War II and during her 33 year career, held almost every position 
available in the Army Nurse Corps from staff duty nurse to nurse 
counselor, chief nurse, 1st U.S. Army during Vietnam, director of 
nursing services, instructor and director of nursing science at our 
Academy of Health Sciences. Without a doubt, one of BG Dunlap's most 
powerful and lasting achievements was the elevation of the educational 
level of nurses in the Army Nurse Corps. Her support and guidance 
assured the success of the baccalaureate degree in Nursing as the 
standard for entry into practice for Army Nurses--a standard that the 
Army Nurse Corps once again reaffirms today as the minimum educational 
requirement and basic entry level for professional nursing practice. We 
appreciate your continued support of this endeavor and your commitment 
to the educational advancement of all military nurses. BG (R) Dunlap's 
legacy will endure and she will be known as an Army nurse who opened 
many doors for the future of Army nursing and ``gave that handful 
more'' to everything that she did. We salute her self-less service.
    Captain Gussie Mae Jones was born in Arkansas and was one of eight 
children. She began her Army career by enlisting in 1988 as a personnel 
clerk and climbed to the rank of sergeant. In 1986, Captain Jones 
earned a bachelor's degree in business administration from Arkansas 
University Central. She was selected above her peers to attend the Army 
Enlisted Commissioning Program and earned her second bachelor's degree 
from Syracuse University in 1998. It was in nursing that she found her 
passion. Her career as a registered nurse and a commissioned officer 
began in September 1998 at Brooke Army Medical Center in San Antonio. 
After completing our specialty course in critical-care nursing in 2002, 
she was assigned to William Beaumont Army Medical Center, where she 
excelled in nursing in the intensive care setting. Assigned as a 
Professional Officer Filler (PROFIS) to the 31st Combat Support 
Hospital, Captain Jones deployed with her unit to Iraq in February of 
this year. An emerging leader and dedicated nurse, Captain Jones was 
admired by her fellow soldiers. On March 7, 2004, Captain Jones died of 
natural causes in Baghdad, Iraq surrounded by the soldiers with whom 
she served. Captain Jones devoted 15 years of her life to the service 
of her Country and the United States Army. She was a soldier and 
consummate professional nurse whom we are extremely proud to have had 
in the Army Nurse Corps. CPT Jones represents the best in Army nursing. 
We will never forget her sacrifice and willingness to serve. She will 
be sorely missed.
    Finally Senators, we are firmly determined to meeting and 
overcoming any challenge that we face this year and are committed to 
meet the uncertain challenges of the future. We will continue with a 
sustained focus on readiness, expert clinical practice, sound 
educational preparation, professionalism, leadership and the unfailing 
commitment to our Nation that have been distinguishing characteristics 
of our Army nurses and our organization for over 103 years. As I 
conclude my 32 years of service in the Army Nurse Corps, I am most 
proud of all the tremendous civilian and military nursing personnel 
that represent this great Army Nurse Corps. Thank you again for your 
support and for providing the opportunity to present the extraordinary 
efforts, sacrifices and contributions made by Army nurses who are all 
ready, caring and proud.

    Senator Stevens. Admiral Lescavage.
STATEMENT OF REAR ADMIRAL NANCY J. LESCAVAGE, DIRECTOR, 
            NAVY NURSE CORPS
    Admiral Lescavage. Good morning, Chairman Stevens, Senator 
Inouye. I am Rear Admiral Nancy Lescavage, the 20th Director of 
the Navy Nurse Corps and the Commander of the Naval Medical 
Education Training Command. It indeed is an honor and a 
privilege to speak before you during my third year in this 
position and to highlight the achievements and issues of our 
5,000 Navy nurses, both Active and Reserve.
    The Navy Nurse Corps' exceptional performance during the 
past year clearly demonstrates operational readiness as we 
continue to meet our primary mission. In support of Operation 
Iraqi Freedom, we had 500 nurses deployed and there were over 
400 filled reserve mobilization requests to maintain the 
continuum of care in our military treatment facilities. In 
addition, there were over 400 active and Reserve Navy nurses 
involved in additional training exercises.
    Through a variety of activities, ranging from direct care 
to the conduct of research in support of our operational 
forces, Navy nurse fleet support has been well received by our 
line community. For example, nurse practitioners assigned to 
the Norfolk Naval Base see fleet sailors on board ship or while 
underway. Through the newly established force nurse initiative 
with the U.S. Atlantic fleet and Pacific fleet, Navy nurses are 
now integral to fleet level oversight and lend guidance and 
assistance to aircraft carrier medical departments and our 
aviation squadrons.
    At our naval health research centers, Navy nurse 
researchers are leading the way in research projects focused on 
things like women's health initiatives and casualty care.
    Numerous training opportunities across the Federal and the 
civilian sectors have been essential to maintaining critical 
Navy nursing specialty skills that are required in the 
operational environment. As one example, over 50 Navy nurses 
have successfully rotated through the Navy trauma training 
program with Los Angeles (L.A.) County and the University of 
Southern California Medical Center to enhance their combat 
trauma skills. Also, through established agreements between six 
military treatment facilities and local trauma centers, an 
additional 50 Navy nurses have also benefitted from this 
specialized training.
    Across naval medicine, military and civilian nurses are 
leaders, clinical experts, and researchers in a variety of 
programs from population health to specific disease management. 
The Joint Population Health Office at Naval Medical Clinic 
Pearl Harbor has been labeled as a benchmark for population 
health in the Navy with their comprehensive screening and 
assessment program to individualize patient care.
    Through the vast worldwide case management program across 
Navy medicine, the collaborative efforts of 93 civilian nurse 
case managers have resulted in an estimated cost avoidance of 
$6.4 million through recaptured workload, decreased lost 
training days, and better managed care. In addition, innovative 
nurse managed clinics include a 24-hour/7-day-a-week nurse call 
center which supports increased accessibility, post-deployment 
stress briefings and disease management, to name a few.
    In the area of research, we value its contribution to 
quality patient care and the practice of our nursing 
professionals anywhere from utilizing evidence-based medicine 
to establishing innovative health care programs. Through a 
comprehensive research-based practice initiative, focused on 
patient falls, for example, National Naval Medical Center 
Bethesda has become a model in promoting patient safety for 
civilian, as well as our military facilities.
    As an outcome of one of our TriService nursing research 
program funded grants, we now assign more seasoned Navy nurses 
with specific critical care expertise to our aircraft carriers 
to better meet our operational mission. Many of our research 
grant findings are collaboratively shared across the services 
and presented worldwide at numerous professional conferences 
and in professional publications.
    Your continued support of TriService nursing research is 
greatly appreciated.
    With the Nation's focus on the overall nursing shortage, it 
is important to address our recruitment and retention efforts. 
Our goal is to shape the force with the right number of Navy 
nurses in the right specialties, more importantly at the right 
time in the right positions. That is done to meet our mission 
in all care environments and to become the premier employer of 
choice for our Navy nurses and civilian nurses.
    Naval medicine has historically been able to meet military 
and civilian recruiting goals and specialty nursing 
requirements to this point. We had a slow start this year, 
specifically in active duty recruiting, with our most recent 
report of attaining only 26 percent of our goal although we are 
only midway through the recruiting year. We have recently been 
successful in increasing the accession bonus, and that occurred 
late January of this year. We are also in the process of 
seeking funding for the health professional loan repayment 
program.
    Fortunately, the good news is we have other pipeline 
scholarship programs, for instance, our ROTC programs and 
seaman to admiral, to help meet our recruiting needs. Based on 
our projected gains and losses for this year, we predict a 
deficit of 98 for a desired end strength of 3,176 active duty 
nurses.
    As for our Reserve component, we are right on track with 
recruiting and we predict 100 percent fill of our billets. Our 
Reserve nurses are at 105 percent end strength.
    To meet nursing specialty mission requirements and promote 
retention, I do have to say our graduate education scholarship 
programs and specialized training for those on active duty have 
been extremely successful in retaining our active duty nurses. 
Our retention numbers are very high. Our Navy nurses love 
education. We continue to focus on our operationally related 
nursing specialties, for example, operating room, critical 
care, anesthesia, and emergency room nurses, as well as 
academic programs that will propel our nurses into the 
forefront of health care planning and policy in obtaining 
Ph.D.'s and MBA's and public health graduate degrees.
    In addition to civilian universities, we also send our 
students to the Uniformed Services University of Health 
Sciences. Your continued interest in the USUHS Graduate School 
of Nursing and their doctoral, perioperative, family nurse 
practitioner, and anesthesia nursing programs is greatly 
appreciated.
    In closing, I again do appreciate your tremendous support 
with legislative initiatives and the opportunity to share the 
accomplishments and issues that face our great Navy Nurse 
Corps. I consistently see our nurses as dynamic leaders and 
innovative change agents in all settings, both in our MTF's and 
in combat. I remain truly proud of the corps and our civilian 
nurses as they stand ready to promote, protect, and restore the 
health of all entrusted to our care.

                           PREPARED STATEMENT

    I look forward to continuing to work with you during my 
tenure as the Director of the Navy Nurse Corps. Thank you, 
sirs, for this great honor and privilege.
    Senator Stevens. Thank you very much.
    [The statement follows:]
         Prepared Statement of Rear Admiral Nancy J. Lescavage
    Good morning Chairman Stevens, Senator Inouye and distinguished 
members of the Committee. I am Rear Admiral Nancy Lescavage, the 20th 
Director of the Navy Nurse Corps and Commander of the Naval Medical 
Education and Training Command. It is an honor and a privilege to speak 
before you during my third year in this position and to highlight the 
achievements and issues of our 5,000 Navy nurses.
    Our performance during Operations Enduring Freedom and Iraqi 
Freedom clearly demonstrated operational readiness as we continue to 
meet our primary mission. I would now like to address Navy Nurse Corps 
impact in the areas of readiness and homeland security; nursing 
initiatives; education and training; jointness and research.
                    readiness and homeland security
    In support of Operation Iraqi Freedom, we had 500 nurses deployed 
from over eighteen facilities to the Hospital Ship COMFORT, Fleet 
Hospitals, Casualty Receiving Treatment Ships, Shock Trauma Platoons, 
and with the Marines. To maintain the continuum of care back at our 
Military Treatment Facilities, there were over 400 filled Reserve 
mobilization requests, the second largest recall since Desert Storm. In 
addition, there were over 400 Active and Reserve Navy Nurses involved 
in training exercises, such as Fleet Hospital Field Training, 
Operational Readiness Evaluations, Hospital Ship MERCY Exercises, Cobra 
Gold, West African Outreach Program, Operation Arctic Circle and 
Combined Armed Exercises. Throughout all operations and exercises, our 
military and civilian nurses readily adapted; remarkably delivered 
outstanding care; and achieved mission accomplishment at our facilities 
and while deployed.
    In addition to meeting the medical needs of our Navy and Marine 
Corps team ``in theater,'' readiness also includes preparing health 
care personnel at Navy hospitals and clinics around the world to 
respond to a natural disaster or terrorist attack. Nurses are at the 
forefront of emergency preparedness across Naval Medicine in a variety 
of roles. Within Naval Medicine's Homeland Security Office at the 
Bureau of Medicine and Surgery, there are two Navy nurses executing a 
comprehensive ``Disaster Preparedness, Vulnerability, Analysis, 
Training and Exercise Program'' to identify vulnerabilities in training 
and to test each military treatment facility's emergency response plan. 
Their effectiveness was recently put to an immediate test during the 
third training day at Naval Hospital Charleston, when a real disaster 
occurred. Forty-four participants, two local hospitals and the 
Charleston County Emergency Medical System provided topnotch care for 
the casualties involved in a bus accident. In addition, we have several 
Navy nurses collaborating with local community disaster planning 
programs, promoting well-coordinated response plans, such as at Naval 
Hospital Pensacola and Naval Hospital Charleston.
Training
    Optimizing available training opportunities across the Federal and 
civilian sectors is essential in maintaining critical nursing specialty 
skills that are required in all operational environments. Great success 
is attributed to the Navy Trauma Training Program in conjunction with 
the Los Angeles County/University of Southern California Medical 
Center, one of the nation's finest Level I Trauma Centers. Since its 
inception in the fall of 2002, over fifty Navy nurses have successfully 
rotated through this program to enhance their combat trauma skills and 
to further increase medical readiness with their respective platform 
teams. Due to intense follow-up with health care team graduates in the 
field, many operational lessons have been incorporated into their 
curriculum. The program has received positive national press coverage 
through television, nursing magazines and newspapers, praising the Navy 
faculty as experts in the most current trauma standards.
    Trauma training is further enhanced through established agreements 
between six military treatment facilities with local trauma centers and 
critical care settings for over 50 nurses at San Diego, Bethesda, 
Jacksonville, Camp Pendleton, Bremerton, and Charleston. Other training 
opportunities include web-based critical care courses, such as the 
``American Association of Critical Care Nurses Essentials of Critical 
Care Orientation'' and other instructor presentations, which provide 
continuing education credit. To support dual critical specialty skills 
in the operational environment, the Association of Perioperative 
Registered Nurses nursing curriculum for Perioperative Nurses Training 
has been adapted for critical care nurses. As an adjunct to traditional 
platform training, the nursing staff at Naval Medical Center San Diego 
conducted ``Operational Skills Days'' to enhance their clinical skills 
and didactic foundation. When operational needs required immediate 
training, Navy nurses were sent to Naval Hospital Okinawa to assist 
with Forward Resuscitative Surgical System training.
    In short, our Senior Nurse Executives are very resourceful in 
seeking educational resources and skills enhancement training to meet 
platform and specialty requirements, particularly when located in 
smaller, remote facilities or overseas. These clinical training 
opportunities have also expanded to other required nursing specialties, 
such as labor and delivery, nursery and mother infant nursing for our 
Naval Hospitals at Guam and Keflavik through clinical programs in 
facilities stateside and overseas. In addition, we continue to place 
strong emphasis in developing a solid clinical foundation for our 
graduate nurses through Nurse Intern Programs at several of our 
facilities, providing a good mix of clinical rotations tailored to 
varied patient acuity and specialties resulting in better prepared 
nurses.
    Related to operational training while supporting community needs, I 
would like to highlight three unique military training exercises. The 
Civil-Military Innovative Readiness Training Program with our reserve 
nurses helps to rebuild America in underserved areas through Operation 
Arctic Care in Alaska. Partnership efforts include regional, state and 
local communities with Guard and Reserve units in providing exceptional 
medical care. Through our nurses' sound leadership and detailed 
coordination in the deployment and movement of these units, operational 
and combat readiness skills of the military units are enhanced. While 
on the exercise, the health care team on the Hospital Ship MERCY 
provided medical care to eighty-three Seattle veteran-eligible patients 
last summer, lauded by the Seattle Post for their community support. 
While in the Pacific Northwest, our health care professionals met with 
Canadian health care counterparts to discuss response plans for a major 
earthquake scenario. In addition, during the recent Southern California 
fire, our hospital ship provided housing and hot meals for over 100 
military families.
At the Deckplate
    The expanding direct Fleet support by our Navy nurses has been well 
received by the Navy and Marine Corps communities. Our two nurse 
practitioners assigned to the Norfolk Naval Base see 300 Fleet sailors 
a month onboard ship or while underway for wellness and readiness 
efforts alone. They also function as trainers and consultants and have 
developed a CD-ROM for Fleet implementation of the Preventive Health 
Assessment Program. Women's Health Nurse Practitioners have provided 
clinical exams for females onboard the U.S.S. Kennedy and also serve as 
instructors for the gynecological portion of the Independent Duty 
Hospital Corpsman curriculum. Through the newly-established Force Nurse 
Initiative with Commander, Naval Air Force U.S. Atlantic Fleet and 
Commander, Naval Air Force U.S. Pacific Fleet, two Navy nurses are now 
integral to Fleet level oversight, guidance and assistance to aircraft 
carrier medical departments and aviation squadrons. Professional 
nursing and technical recommendations are also provided on Force Health 
Protection, Shipboard Medical Training, Medical Department Quality 
Assurance, Infection Control, the acquisition of new medical equipment 
and other programs.
    Preventive Health Assessment Nurse-Run Clinics, such as in our 
Naval Hospitals at Pensacola and Corpus Christi, have been praised by 
the Navy Line Community for promoting healthy, physically fit Naval 
Forces as program compliance dramatically increased. With the addition 
of a mental health clinical nurse specialist, the Outreach Program at 
Corpus Christi has further expanded suicide awareness briefs and other 
services.
    Within the operational nursing division at our Naval Health 
Research Centers, our nurse researchers are leading funded research 
projects focused on women's health issues and casualty care. In 
addition, they collaboratively developed research-based methods for 
providing surgical support during special operations at sea and in 
caring for the Medical and Security forces at Camp Delta in Guantanamo 
Bay, Cuba. These are just a few examples of how Navy nurses at the 
deckplate are involved in diverse activities ranging from direct care 
to the conduct of research in support of our operational forces.
                          nursing initiatives
    Across Naval Medicine, Navy nurses are involved in the planning and 
implementation of a variety of programs as leaders, clinical experts 
and researchers from population health to specific disease management. 
Military and civilian nurses are valued catalysts across our facilities 
directing patient safety initiatives and leading collaborative teams to 
evaluate patient outcomes that reduce error, variability, and cost. 
Several nursing initiatives include implementation of the JCAHO 
National Patient Safety goals, skin care studies, staffing 
effectiveness project, the management of diabetic patients, inpatient 
bed utilization, and medication/non-medication related near misses and 
actual events.
    Navy nurses at our three Healthcare Support Offices have been 
primary movers in linking the clinical aspects of Naval Medicine with 
strategic and annual business planning efforts to create more efficient 
practices and improve outcomes. Their most significant impact is in 
relating the clinical processes to business rules and interpreting the 
data relative to true clinical practices. In addition, nurse leaders 
and researchers are very involved with Navy Advisory Boards, Joint 
Readiness Clinical Advisory Boards and nationwide studies to 
collaborate on clinical advances and identify specific metrics to 
demonstrate efficient business practices.
Joint Population Health Programs
    Through the Joint Population Health Program across three 
California-based Naval Hospitals at San Diego, Camp Pendleton, and 
Twenty-Nine Palms, masters and doctorally-prepared nurses demonstrate 
savvy in program implementation, policy, practice and research to shape 
the health status of Naval forces and all eligible beneficiaries, while 
focusing on quality, cost and access. The Joint Population Health 
Office at Naval Medical Clinic Pearl Harbor, Hawaii has been labeled as 
a benchmark for population health in the Navy. Based on a comprehensive 
screening and assessment process, the program addresses Preventive 
Health Assessments (Active Duty); adult and children immunization and 
health maintenance status; and health education literature and classes 
based on individual needs. Statistically proven results support the 
benefits of both of these programs.
Case Management
    In today's rapidly changing health care environment, nurse case 
managers play a crucial role in helping patients and providers select 
the most appropriate level of care in the most cost-effective setting. 
Optimal outcome is best exemplified through the Case Management Program 
across Navy Medicine based on the collaborative efforts of 93 civilian 
nurse case managers. Their focus on Active Duty, Exceptional Family 
Member Program families, patients with multi-system medical problems, 
targeted disease management entities and frequent emergency room users 
resulted in recaptured workload, decreased lost training days, enhanced 
patient/provider satisfaction and better managed care. The Active Duty 
Trauma Nursing Case Management Program at Naval Medical Center, San 
Diego coordinated the health care needs of 87 Operation Iraqi Freedom 
wounded and 233 non-operational trauma patients. Among other programs, 
such as at Naval Hospital Guam, nurse case managers have been 
responsible for reducing emergency room visits and inpatient admissions 
for chronically ill patients by responding to hundreds of consults and 
processing catastrophic, complex, high risk, high-cost health care 
requests.
Nurse-managed Clinics
    The rise in nurse-managed or nurse-run clinics has demonstrated the 
art and science of nursing in facilitating wellness, prevention and 
health maintenance towards self-management for patients. The nature of 
registered nurse practice in collaboration with physician champions 
meets the standards of the American Academy of Ambulatory Nurses 
through the use of research-based clinical practice guidelines, 
spanning across the spectrum from neonates to geriatric patients.
    Using the latest technological advances in wound care, nurses at 
Naval Hospitals Pensacola and Portsmouth enhance the care of complex 
battlefield injuries. Within Family-Centered Care, nurses plan, 
coordinate, and provide direct care and case management through a 
variety of programs, such as Postpartum Care Clinics. Home Action Plans 
for Pediatric Pulmonary patients at three of our facilities reduced 
admission rates by 50 percent. Other innovative nursing initiatives 
include: a nurse call center supporting 24/7 accessibility; post-
deployment stress briefings; and disease management (diabetes, 
hyperlipidemia, and hypertension), to name a few.
    Successful open access initiatives as a result of the innovative 
leadership of nurses at Naval Hospitals Pensacola and San Diego have 
increased patient satisfaction; decreased emergency room visits and 
unscheduled walk-in appointments; and improved patient/provider 
matching. With the assistance of the Institute for Healthcare 
Improvement at Naval Hospital Great Lakes, demand and patient flow 
processes were reviewed; inefficiencies were identified; new business 
plans were developed; and appointments were adjusted to maximize 
access. Success has migrated these processes to other clinics and 
clinical support areas as well.
                                research
    We value research as an essential component to quality nursing 
care, from utilizing evidence-based practice to conducting research. 
For example, at Naval Medical Center Portsmouth, adult patients with 
bladder problems are now scanned for urinary retention resulting in an 
87 percent reduction in catheterizations. Upper respiratory infection, 
urinary tract infection, diabetes and asthma clinical practice 
guidelines have improved clinical parameters and therefore decreased 
the number of appointments. In support of patient safety, an evidenced-
based practice initiative for a more comprehensive risk assessment and 
protocol for ``falls'' was implemented at National Naval Medical Center 
Bethesda and has become a model for civilian and military facilities. 
The Sports Medicine and Reconditioning Team at Naval Medical Center San 
Diego includes a nurse researcher to evaluate ``return to duty'' time 
and re-injury rates of our Sailors and Marines to identify areas for 
improvement. Through a multidisciplinary research study, MedTeams 
strive to eliminate errors in the obstetrical area, increase patient 
satisfaction, and enhance collegiality and collaboration among health 
care professionals.
    We continue to focus on advancing the practice of military specific 
nursing and its response to requirements of military readiness and 
deployment. The TriService Nursing Research Program has conducted Grant 
Management Workshops, which provided invaluable mentorship and 
training, resulting in an increased number of higher quality grant 
submissions. Research results are collaboratively shared across the 
services and are further disseminated to other facilities. Many of our 
research grant findings have been presented worldwide in numerous 
nursing conferences and in at least ten professional publications.
                           joint initiatives
    There are several examples of joint programs across our Federal 
agencies, which combine the talent of our health care teams to provide 
quality care. Nurses at Naval Hospital Great Lakes are involved in 
coordinating a partnership program for active duty treatment and 
inpatient care with the North Chicago Veterans Affairs Medical Center. 
Nurses at Naval Hospital Corpus Christi are involved in the business 
planning and management of specialty care with their local Department 
of Veterans Affairs Hospital.
    Combined training initiatives and the mutual sharing of clinical 
expertise are beneficial, particularly for our overseas duty stations. 
Noteworthy coordinated efforts include a mental health nursing program 
with Walter Reed Army Medical Center in Washington, DC; an Obstetrics 
Course at Langley Air Force Hospital; Labor and Delivery training at 
Landstuhl Army Medical Center; assisting Madigan Army Medical Center 
with their medic (Licensed Practice Nurse) clinical training; and 
providing Advanced Cardiac Life Support and Pediatric Advanced Life 
Support classes for the Air Force at our Naval Medical Clinic in 
London.
                 professional nursing in naval medicine
    Our goals are to shape the force with the right number of people in 
the right specialties, to meet the mission in all care environments, 
and to become the premiere employer of choice. Accomplishing this 
requires close attention to the national nursing issues; the pursuit of 
available recruitment and retention initiatives; and the alignment of 
our military and civilian nurses to meet Naval Medicine needs.
    The Department of Health and Human Services and other independent 
studies project that the current national nursing shortage of several 
hundred thousand registered nurses may add up to 750,000 by 2020. 
Despite recent increases in the number of nursing school entrants, the 
nation could have a long way to go in making a dent in the overall 
shortfall. We carefully monitor civilian compensation packages to 
maintain the strength of our military and civilian nursing work force 
by offering a variety of incentives.
Recruitment and Retention
    Through our diversified accession sources, pipeline scholarship 
programs, pay incentives, graduate education programs, specialized 
training opportunities and varied retention initiatives, Naval Medicine 
has historically been able to meet military and civilian recruiting 
goals and specialty nursing requirements to this point. We presently 
have 96.4 percent of our authorized active duty billets filled and 100 
percent fill for our Reserve component. We continue to focus on our 
operationally-related nursing specialties, such as medical-surgical, 
critical care, perioperative and anesthesia, as well as women's health 
nurse practitioner and certified midwives. Although we had a slow start 
in recruiting this year when compared to the past 10 years, we expect 
to meet our active and reserve recruiting goals this fiscal year.
    Our civil service workforce challenges have been identified in 
remote locations stateside and overseas, as well in certain 
specialties, such as labor and delivery. Recruiting and retention 
incentives are utilized and career ladders initiated where possible.
Graduate Education
    Graduate education program and specialized training have been 
extremely successful in meeting our nursing specialty mission 
requirements and promoting retention. This year, we are sending two 
nurses to the recently established Doctoral Program at the Uniformed 
Services University of Health Sciences (USUHS). In addition, we 
continue to send several of our students to the USUHS anesthesia, 
family nurse practitioner and perioperative nursing programs.
Nurse Leadership
    Navy nurses continue to function in pivotal executive roles to 
impact legislation, health care policy and medical delivery systems. 
Executive nurse leaders in the Active and Reserve component are in key 
command positions as Commanding Officers and Executive Officers; at the 
Bureau of Medicine and Surgery Headquarters as Deputy Surgeon General 
and Deputy Directors; and other staff positions at Tricare Management 
Activity, Health Affairs.
    As leaders, we value mentorship, which is accomplished via many 
innovative formal programs and informal forums with our enlisted 
personnel, Naval Reserve Officer Training Corps students, Medical 
Enlisted Commissioning Program students, junior nurses, and novice 
researchers.
Recognition
    Our nurses are recognized for their exceptional talent, outstanding 
leadership and professional nursing community involvement and have 
received clinical practice awards through the American Association of 
Critical Care Nurses, the Sigma Theta Tau Nursing Honor Society; the 
Association of Women's Health, Obstetric and Neonatal Nurses; and the 
American Academy of Ambulatory Care Nurses. Our integral presence has 
also been documented through an extensive list of journal publications. 
For example, the June 2003 Critical Care Nursing Clinics of North 
America was specifically dedicated to military and disaster nursing. In 
addition, our professional achievements have been highlighted in many 
forums at the Academy of Medical-Surgical Nurses Conference, the 
Association of Perioperative Nurses Workshop, the California Nurse 
Leader Workshop, and at the Institute for Health Care Improvement 
Conference.
                               conclusion
    In closing, I appreciate the opportunity to share the 
accomplishments and issues that face the Navy Nurse Corps. I see our 
nurses as dynamic leaders and innovative change agents in all settings.
    I remain truly proud of our Navy military and civilian nurses as 
they stand ready to promote, protect, and restore the health of all 
entrusted to our care anytime and anywhere.
    I look forward to continuing to work with you during my tenure as 
the Director of the Navy Nurse Corps. Thank you for this honor and 
privilege.

    Senator Stevens. General Brannon, my daughter is taking 
Chinese and she has learned to read from right to left. I have 
not, so although you do have the star, I start from the left. 
Please proceed.
STATEMENT OF MAJOR GENERAL BARBARA C. BRANNON, 
            ASSISTANT AIR FORCE SURGEON GENERAL, 
            NURSING SERVICES
    General Brannon. Thank you, Chairman Stevens, Senator 
Inouye. It is a great honor and pleasure to again represent 
your Air Force nursing team. What a dynamic time in the history 
of our Nation. Our soldiers, sailors, airmen, and marines 
continue to valiantly support the global war on terrorism in 
dangerous and unpredictable environments. They can count on the 
support of Air Force nursing, active duty, Guard, and Reserve, 
officer and enlisted. We are one team ready anytime to go 
anywhere at our Nation's call to provide robust medical support 
to combat units, to victims of natural disasters, and to those 
in need of humanitarian or civic assistance.

                                  IRAQ

    To support Operations Enduring Freedom and Iraqi Freedom, 
2,328 nurses and medical technicians deployed as members of 24 
EMEDS units, treating more than 200,000 patients, combat 
casualties and those suffering non-combat injury and disease. 
Six nurses provided outstanding leadership as EMEDS commanders 
in diverse locations around the globe.

                         AEROMEDICAL EVACUATION

    Aeromedical evacuation is a vital link in combat casualty 
care and a key Air Force capability. Since last spring, we have 
flown over 3,200 missions and supported more than 40,000 
patient transports. Our ability to provide critical care in the 
air, using specialized transport teams, has bridged the gap 
between point of trauma and definitive medical treatment.

                               RECRUITING

    Air Force independent duty medical technicians provide 
vital care in remote and deployed locations. They are jacks of 
all trades, from providing medical and dental services, to 
protecting troops from bioenvironmental hazards.
    On the home front, we continue to aggressively organize, 
train, and equip the nursing forces we need. A robust 
recruiting program is essential to keep our nurse corps strong. 
Fiscal year 2003 was our most successful recruiting year since 
1998, yet we were still 100 nurses below our requirement. 
Thanks to your tremendous support, this year we are offering an 
increased accession bonus or loan repayment to new accessions. 
We are optimistic that this will result in a more successful 
recruiting year.

                               RETENTION

    Retention is the other dimension of force sustainment. Air 
Force retention remains strong at 93 percent. So despite 
missing our requirement for 5 years, we were only 118 nurses 
below our authorized end strength last year.
    Education and training and research ensure we deliver top 
quality nursing care. Air Force nurse researchers stay on the 
cutting edge of military nursing science, and I am proud to 
report that 21 are actively engaged in Tri-Service nursing 
research program studies with a very strong emphasis on 
operational research.

                         EDUCATION AND TRAINING

    The Uniformed Services University Graduate School of 
Nursing is aggressively developing programs to meet the needs 
of Federal nurses. Their new perioperative clinical nurse 
specialist program is the only one in the Nation and includes 
preparation for practice in deployed environments. Three Air 
Force nurses are in the inaugural class.

                                RESEARCH

    Their new Ph.D. program will promote nursing research 
relevant to Federal health care and to military operations. 
Although the program is in its first year, the response has 
been overwhelming with 12 nurses currently enrolled.
    We continue to look for opportunities to capitalize on the 
strength of our enlisted force and to provide avenues for 
progression to a bachelor's degree in nursing. There is great 
interest in the programs and growing our own nurses will 
provide a strong nurse corps and ease our recruiting 
requirements.
    This has truly been an extraordinary year for our nurse 
corps and we have reached two major milestones. Colonel Melissa 
Rank's nomination to Brigadier General marks the first nurse 
corps selection at an all-corps promotion board, and as you 
mentioned, I was also promoted to Major General in August and I 
am truly honored by the trust that has been placed in me.

                           PREPARED STATEMENT

    Mr. Chairman, Senator Inouye, I am very proud to lead the 
19,000 men and women of Air Force nursing, active duty, Guard, 
and Reserve. Thank you for your tremendous support and for 
again allowing me to share Air Force nursing accomplishments 
and just a few of our plans for the future.
    [The statement follows:]
         Prepared Statement of Major General Barbara C. Brannon
    Mister Chairman and distinguished members of the committee, it is 
an honor and great pleasure to again represent your Air Force Nursing 
team. What a dynamic time in the history of our nation! Last year, at 
this time, our allied forces had toppled the regime of Saddam Hussein 
and focus had shifted to peacekeeping and humanitarian relief for the 
Iraqi people. Today, the fighting continues and our soldiers, sailors, 
marines and airmen continue to make the ultimate sacrifice for their 
nation. Terrorist organizations continue their campaign of carnage 
throughout the world, and horror is commonplace on front-page news. 
This war is far from over.
    Our nation has expressed pride and grateful appreciation for the 
selfless sacrifice of our soldiers, sailors, airmen and marines. The 
American Soldier is Time magazine's Person of the Year. And the 
American public holds the nursing profession in very high esteem. In a 
recent Gallup poll, Nursing was rated the most honest and ethical 
profession.
    As our military men and women fight far from home, they count on 
great medical support in theater and for their loved ones at home. 
Nursing plays a pivotal role in Air Force healthcare in both arenas. 
Lieutenant General Taylor has highlighted the importance of Preventive 
Health Assessments, Individual Medical Readiness, and post-deployment 
health assessments. All these programs, in which nursing personnel have 
key administrative roles, have been integral to the success of 
deployment health. The disease non-battle injury rate of 4 percent for 
this conflict is the lowest ever achieved. That translates to more 
healthy people ready to execute the mission.
    Active duty, guard and reserve Nurse Corps officers and aerospace 
medical service technicians also serve around the world to provide 
robust medical support to our combat units, victims of natural 
disasters, and those who need humanitarian or civic assistance. It is 
my honor to share some of our activities in support of deployment and 
training and some of the stories of our everyday heroes.
    Our first priority, and our greatest success, is our ability to 
maintain constant mission readiness for any contingency. We deploy 
anytime, anywhere at our nation's call. To support Operations ENDURING 
FREEDOM and IRAQI FREEDOM, 725 nurses and 1,603 medical technicians 
deployed as members of 24 Expeditionary Medical Support units, or 
EMEDS. Five of these deployed units have been equipped with chemical 
and biological protection to counter potential threats. Our EMEDS teams 
have treated more than 171,000 casualties, those injured in combat and 
those with non-combat injuries and disease. I am very proud to report 
that six nurses were deployed as EMEDS commanders during the past year. 
These nurse leaders, in charge of deployed wing medical facilities, 
were absolutely outstanding in meeting healthcare needs of combined and 
coalition forces in such diverse locations as Saudi Arabia, Romania, 
the United Arab Emirates, Bahrain, and Diego Garcia.
    Aeromedical Evacuation has had a starring role in Operation IRAQI 
FREEDOM and continues to be a critical core competency for the Air 
Force. It is battle tested and it works, providing state-of-the-art in-
flight medical care for transport of U.S. and coalition forces. The 
system has exceeded all expectations in providing life-saving care 
during transport of the sick and injured from battlefields to their 
home units. Since last spring, we have flown over 3,200 missions and 
supported more than 40,000 patient transports without a single in-
flight combat-related death. We have transformed the aeromedical 
evacuation system from one relying on specific aircraft and dedicated 
missions, to an integrated multiplatform capability, which uses 
available aircraft and prepositioned aeromedical evacuation crews. 
Through the vision and ingenuity of our leadership, we have overcome 
numerous challenges and have continued to move forward, demonstrating 
flexible, timely support to combat operations.
    Our Flight Nurses and Aeromedical Evacuation Technicians are 
seamlessly integrated with Medical Service Corps Officers, front-end 
aircrews, maintenance crews, and ground medical units in areas of 
operations. Combining the capability of the Critical Care Air Transport 
Teams (CCATT) with Aeromedical Evacuation crews has brought definitive 
care closer to the point of injury, faster than ever before. The 
additional capabilities of the CCATT makes it possible to safely 
transport stabilized patients by air, reduces the requirement for in-
theater beds, and gets injured troops to definitive care in hours 
rather than days.
    Major Dan Berg was a member of the Critical Care Air Transport Team 
that cared for a 19-year old soldier whose convoy had been hit by 
rocket-propelled grenades. Major Berg provided care to the critically 
injured patient throughout the 10\1/2\ hour flight. Only able to 
communicate by writing on a notepad, the young soldier wrote that he 
never expected such care so far from home. Major Berg showed the young 
man his flight suit patch, which bore the promise, ``Committed to the 
Wounded Warrior.''
    Nurses play a vital role in tailoring the aeromedical evacuation 
system to meet needs of our forces. The Andrews AFB team converted the 
base gymnasium into a 100-bed contingency aeromedical staging facility 
(CASF). Eighty-five medical professionals activated from the 459th 
Aeromedical Staging Squadron staffed the facility, working with a 
smaller active duty team from the 89th Medical Group. During peak 
operations, personnel at the CASF managed up to 6 inbound overseas 
missions per week with 50-70 patients per mission. Many of the patients 
were transported directly from the flight line to Walter Reed Army 
Medical Center and the National Naval Medical Center, but up to 92 
patients remained overnight in the CASF for further air transport. 
Within the past 12 months, the CASF team supported over 850 aeromedical 
evacuation flights and coordinated over 15,700 patient movements. Great 
teamwork between our Air Force components and sister services made this 
mission a resounding success.
    Seamless integration with the medical teams of our sister services 
has been critical in many locations during Operation ENDURING FREEDOM 
and IRAQI FREEDOM. Major Kathryn Weiss, a nurse anesthetist from 
Hurlbert Field, deployed with the Army's 10th Special Forces Group to 
Northern Iraq to provide frontline emergency medical capabilities in an 
imminent danger area within the range of enemy artillery. The team 
treated casualties suffering from bullet and shrapnel wounds as well as 
those injured in motor vehicle crashes. The team was recognized by the 
award of the Bronze Star for their meritorious achievements.
    Major Weiss is just one example of the tremendous capability of our 
Certified Registered Nurse Anesthetists. They are frequently part of 
our Mobile Field Surgical Teams, substituting for anesthesiologists. 
Seventeen of the twenty-seven certified registered nurse anesthetists 
who deployed in 2003 were filling anesthesiologist taskings and 
provided top-notch surgical support.
    Our Air Force Independent Duty Medical Technicians are linchpins in 
health care delivery in remote and deployed locations. They are ``jacks 
of all trades'' and masters of health care modalities from routine and 
emergency medical and dental care, to biomedical environmental 
management. IDMTs are invaluable in the full spectrum of military 
missions to include Special Operations, EMEDS, Forward Air Controllers, 
Combat Communications and coalition team activities.
    Recently one of our IDMTs, MSgt James Koss from Tyndall Air Force 
Base, accompanied a coalition force in Iraq and provided support in 
medical intelligence, personnel and field sanitation, force protection, 
medical pre-screening and coordination of medical care. His preventive 
health initiatives were key to a low rate of heat related injuries and 
disease outbreaks.
    In Iraq, Nurse Corps Colonel David Adams, Director of Force Health 
Operations for the Office of the Assistant Secretary of Defense for 
Health Affairs, served as Chief of Strategic Planning for the Coalition 
Provisional Authority in Baghdad. Colonel Adams assisted the Minister 
of Health in identifying healthcare system needs and then coordinating 
support from other nations. Colonel Linda McHale, an Air Force Reserve 
Individual Mobilization Augmentee is mobilized to work with the Iraqi 
Minister of Health in establishing training programs for nurses and 
medical technicians.
    In French Village, Iraq, a three-member team from the 122nd Indiana 
Air National Guard Fighter Wing set up a medical clinic to restore 
health care for the villagers after their civilian clinic had been 
looted and destroyed by insurgents earlier in the year. Captain (Dr.) 
Jeff Skinner, Senior Master Sergeant Tommie Tracey and Senior Airman 
Matt Read collected donations of essential items for the clinic, 
including children's vitamins and a play set for the waiting room. When 
all was ready, they assisted with the grand opening of the new 
facility.
    In addition to providing service in Operation ENDURING FREEDOM and 
IRAQI FREEDOM, Air Force Nursing actively supports Homeland Security 
and humanitarian relief. Air Force Lieutenant Colonel Linda Cashion, 
Chief of Air Force Homeland Security Medical Operations, was the first 
nurse to complete a fellowship with the National Disaster Medical 
System, part of the Federal Emergency Management Agency. She provided 
valuable assistance in planning and implementing the Disaster Relief 
Program and expertly developed the nursing role for Disaster Medical 
Assistance Teams. Colonel Cashion was also instrumental in coordinating 
care for 26 critically burned victims in the Rhode Island nightclub 
fire.
    Air Force nursing support of humanitarian missions reaches around 
the globe. Chief Master Sergeant Virginia Thompson, an Air Force 
aeromedical technician at Randolph Air Force Base, participated in a 
two-week mission to El Salvador last year where the team of eleven 
medical personnel treated 3,000 patients. This humanitarian mission not 
only advanced host-nation health, but also afforded our military 
medical personnel valuable experience applicable to future humanitarian 
missions.
    During another humanitarian effort, First Lieutenant Lynn 
Zuckerman, Master Sergeant Baron Stewart and Staff Sergeant Patricia 
Fernandez from the 375th Medical Group, Scott Air Force Base were part 
of an eight person team that participated in a U.S. Southern Command 
sponsored mission to Guatemala. The team provided medical care to the 
under-served Guatemalan population in the isolated villages of San 
Sebastian, San Jose Caben, Rincon and Chim. During this mission, 5,600 
patients received treatment for a wide range of conditions including 
gastrointestinal illnesses from parasitic infection and chronic 
debilitating disease from arthritis and heart disease.
    Air Force nursing vigorously supports international partnerships. 
Personnel from the 435th Medical Group, Ramstein Air Base, participated 
in EUCOM-directed multinational mass casualty exercise. Nurses and 
medical technicians trained over 100 medical students in Georgia, the 
independent state of the former USSR, on a variety of skills to include 
moulage, self-aid buddy care, and advanced trauma management. The team 
also improved medical support in the community by training 30 local 
civil defense authorities in mass casualty and disaster management. The 
U.S. Ambassador to Georgia praised the team's tremendous support in 
providing much-needed training.
                           skills sustainment
    Air Force medics could not succeed in our expeditionary deployments 
without targeted training to ensure clinical currency. The Readiness 
Skills Verification Program (RSVP) continues to ensure that our 
personnel are trained in the wartime skills they need and that they 
stay current in those skills. The training is accomplished at home 
station and at multiple off site locations. As I mentioned last year, 
at our Centers for Sustainment of Trauma and Readiness Skills (C-STARS) 
programs, we partner with civilian academic centers to immerse our 
nurses, medical technicians, and physicians in all phases of trauma 
management to sharpen combat casualty care skills.
    We now offer this terrific program at three locations: The Shock 
Trauma Center in Baltimore, The University of Cincinnati Medical 
Center, and Saint Louis University Hospital. By expanding the program, 
we have been able to train more medics each year. Over the last 2\1/2\ 
years, 334 nurses and medical technicians have completed the training; 
almost half of these were trained in 2003.
    First Lieutenant John Cleckner, a critical care nurse preparing to 
deploy on an EMEDS validated the program's importance by saying, ``This 
experience allowed me to significantly update and hone my trauma 
skills. Now I'm confident that I am ready.''
    As part of the C-STARS program, nurses complete an Advanced Trauma 
Life Support Course, and medical technicians complete the Pre-Hospital 
Trauma Life Support course. Both courses teach aggressive trauma care 
techniques and how to adjust standard treatment when projectiles and 
velocity impact the victim. These competencies are essential to care of 
wartime casualties.
                        recruiting and retention
    We have a robust recruiting program, which is essential to keeping 
the Nurse Corps healthy and ready to meet the complex challenges in 
healthcare and national security. Numerous incentive programs have been 
instituted to prevent a nursing shortage in the Air Force, but 
shortfalls continue to be an enormous challenge both nationally and 
internationally. Last year, the Bureau of Labor Statistics reported 
that registered nurses are at the top of ten occupations with the 
largest projected job growth through the year 2012. One positive sign 
is that the number of enrollments in entry-level baccalaureate programs 
increased by 16.6 percent last year, although there were an additional 
11,000 qualified students turned away due to limitations in faculty, 
clinical sites, and classrooms. Employer competition for nurses will 
continue to be fierce and nurses have many options to consider.
    Quality of life and career opportunities, coupled with other 
incentives, are critical recruiting tools for Air Force Nursing. Fiscal 
year 2003 was our most successful recruiting year since 1998. Although 
we have recruited approximately 70 percent of our goal each year since 
fiscal year 1999, we have seen an increase in the number of new 
accessions each year. Last year, we recruited 16 percent more nurses 
than in fiscal year 2002, and I attribute the increase largely to our 
educational loan repayment program. In order to compensate for our 
current shortfall and projected separations, our fiscal year 2004 
recruiting goal is 394 nurses. Funding is available to offer new 
accessions either a $10,000 accession bonus or up to $28,000 for 
educational loan repayment. We have $5.2 million available to fund 
these initiatives in fiscal year 2004 and are hopeful that our 
accession numbers will exceed last year. As of March 31, 2004, we have 
brought 108 new nurses onto Active Duty--on par with last year and 
about 27 percent of goal. We attract some of the best nurses in the job 
market today, although most are very junior with respect to experience 
level.
    This year we continue to recruit nurses up to the age of 47 to 
boost our ranks. We commissioned 25 nurses over age 40 last year, and 
although they are not retirement eligible, they provide tremendous 
support during their time on active duty. They have the critical skills 
and clinical leadership we need to meet our peacetime and wartime 
readiness mission, as well as years of clinical experience to share 
with our novice nurses.
    Our slogan, ``we are all recruiters,'' continues to rally support 
as we tackle the challenge of recruiting. I have fostered more 
effective partnering with recruiting teams to maximize recruiting 
strategies and success. Among other activities, we have increased 
nursing Air Force ROTC quotas from 29 in fiscal year 2003 to 35 in 
fiscal year 2004, and 100 percent of our quotas have been filled.
    I take advantage of every occasion to highlight the tremendous 
personal and professional opportunities in Air Force Nursing. I 
encourage nurses to visit their alma mater and nursing schools near 
their base to market quality of life and professional opportunities as 
an Air Force Nurse. This has proven to be a powerful recruiting tool.
    We have also expanded media exposure of the outstanding 
accomplishments of our people and their support of troops in Operation 
IRAQI FREEDOM. This past fall, Secretary of Defense Rumsfeld's visit 
with our aeromedical evacuation teams in Baghdad was highlighted in 
print media, and Major Keith Fletcher, an Air National Guard Nurse from 
the 379th AES Mobile Aeromedical Staging Facility, was featured in a 
photo with the Secretary. Air Force Reserve nurse Major Tami Rougeau 
was selected as one of the ``Heroes Among Us'' by the National Military 
Family Association, and she rode in the Rose Bowl Parade with other 
honorees. Another Air Force Nurse Corps star, Captain Cynthia Jones 
Weidman of Scott Air Force Base, Illinois, was awarded the American Red 
Cross Florence Nightingale Medal, one of the highest honors in the 
nursing profession. She was the first Air Force Nurse to receive the 
medal, and the first military nurse since 1955. Air Force nurses 
present very positive images in the news.
    Retention is the other key dimension of force sustainment. Our 
retention remains strong at 93 percent and, despite not meeting our 
recruiting goal for five successive years, we were only 143 nurses 
under our authorized end strength of 3,862 at the end of fiscal year 
2003.
    Lieutenant Colonel John Murray, one of our doctorally-prepared 
Nurse Corps officers, developed a standardized, web-based officer 
assessment tool to identify what influences officers to remain on 
active duty or separate from the Air Force. The pilot study began in 
January 2004 with a sample of Nurse Corps officers. The assessment tool 
will help identify targets of opportunity to enhance quality of life 
and professional practice. We continue to recommend Reserve, National 
Guard, and Public Health Service transfers for those who desire more 
stability in their home base but wish to continue military service and 
can meet deployment requirements.
                                research
    Air Force nurse researchers stay on the cutting-edge of advancing 
the science and practice of nursing. I am proud to say that twenty-one 
Air Force nurses are actively engaged in TriService Nursing Research 
Program (TSNRP) funded initiatives.
    Air Force researchers are leaders in the Department of Defense and 
the Nation in operational nursing research. In fiscal year 2003, 
nursing research at Wilford Hall Medical Center continued to focus on 
care of the war fighter in military unique and austere environments. A 
study on the thermal stresses onboard military aircraft led to 
evaluation of products designed to maintain body temperature in 
critically injured patients during aeromedical evacuation. This will 
identify devices that are effective in maintaining temperature control 
to improve support and survivability of casualties.
    The TSNRP-funded Air Force Combat Casualty Aeromedical Nursing 
research study describe the experiences of AE crewmembers in providing 
combat casualty care to gather information that can be used to improve 
AE nursing practice. The study also aims to pilot a research instrument 
to measure characteristics of casualties in different locations and the 
nursing care required. This study will influence AE combat casualty 
care and future training.
    Another study, ``Recruitment Decision Making for Military Nursing 
Careers'' is being conducted collaboratively by military nurse 
researchers at Keesler AFB and nursing researchers at the University of 
South Alabama. The goal of this study is to describe factors that 
influence nursing students in considering military nursing careers. 
This study will help identify the characteristics of individuals 
interested in military service and guide recruiting services in 
deploying recruiting initiatives.
                               education
    The Graduate School of Nursing at the Uniformed Services University 
has demonstrated tremendous flexibility and capability in meeting the 
needs of uniformed nurses. They began a clinical nurse specialist 
master's program at the request of the Federal Nursing Chiefs and also 
inaugurated a Ph.D. nursing program. The Perioperative Clinical Nurse 
Specialist program is the only one in the nation and includes special 
preparation for operating in a field environment so graduates are ready 
for deployment challenges. Three Air Force nurses are in the inaugural 
class.
    The Ph.D. program was established to meet the evolving need for 
nursing research relevant to federal health care and military 
operations. It affords federal nurses the opportunity to study in a 
unique environment and gain exceptional qualifications to lead in 
research, education, and clinical practice. Although the program is in 
its first year, the response has been overwhelming, and twelve nurses 
are enrolled either full or part time.
                       nursing force development
    Nursing has vigorously embraced the Force Development initiative 
launched last summer by Air Force Secretary James G. Roche and our 
Chief of Staff, General John P. Jumper. General Jumper describes the 
construct as making sure ``we place the right technical and leadership 
skills in the right places with the right people who are educated and 
trained for success''.
    Each officer career field has a dedicated Development Team (DT) to 
guide the assignments and educational opportunities for each officer. 
Our Nurse Corps DT has already played a substantial role in selecting 
chief nurses for our facilities, best assignments for our Colonels on 
the move and educational programs and candidates we will sponsor.
    We continue to work on opportunities to capitalize on the knowledge 
and experience of our enlisted force, and provide them more avenues to 
acquire advanced training and credentials. Eight medical technicians 
will graduate from the Army's Licensed Practical Nurse training course 
in April 2004 and we are looking at ways to increase LPN numbers. The 
Air Force Reserve is piloting an initiative to send new enlisted 
nursing personnel to a civilian LPN program. We have reviewed Navy 
enlisted baccalaureate scholarship programs and are reviewing similar 
opportunities for our enlisted personnel to earn a bachelor's degree 
and a commission in the Nurse Corps. This has great potential to reduce 
our recruiting deficit by ``growing our own'' nurse corps officers from 
our enlisted ranks.
    The global war on terrorism and a resource constrained environment 
has driven us to look even harder at efficiencies in nursing force 
utilization. Recent research has shown that a more educated nurse 
force, implementation of higher nurse-to-patient ratios, and better 
nursing work environments contribute to improved patient safety and 
lower patient morbidity and mortality. The Air Force Medical Service 
chartered Product Line Analysis and Transformation Teams to study 
civilian healthcare industry staffing models and best practice 
benchmarks. The new models they identified for nursing are being used 
to adjust staffing requirements.
    The Nurse Corps Top Down Grade Review mentioned in my testimony 
last year is progressing, and we have identified the need to rebalance 
Nurse Corps grade authorizations to better meet readiness and in-
garrison healthcare requirements, and provide healthy career 
progression and promotion opportunities more in keeping with those of 
line officers and other medical service corps. Another aspect of our 
grade review was to determine the number of active duty nurses required 
for deployment and other military unique requirements. With this 
process, we have identified opportunities to civilianize many nurse 
positions. The methodology employed in the Nurse Corps study is being 
applied to all other career fields in the Air Force Medical Service to 
determine force structures and appropriate civilian/military mix.
    This has been an extraordinary year by all measures, and our Nurse 
Corps also reached two big milestones in our history. The nomination of 
Colonel Melissa Rank to Brigadier General marks the first selection of 
a nurse corps officer by an ``all corps'' promotion board. It is a 
testament not only to her outstanding performance but also reflects the 
magnitude of leadership and talent we have in our Air Force Nurse 
Corps. I was also promoted on the first of August to Major General, 
another Air Force first. It is a great honor and very humbling. I am 
grateful to have the opportunity to continue to serve. For the first 
time in history, we will have two active duty nurses concurrently 
serving the Air Force as general officers.
    Mister Chairman and distinguished members of the Committee, it has 
been a joy and great honor to lead the 19,000 men and women of our 
active, guard and reserve total Air Force Nursing team. Thank you for 
your tremendous advocacy and stalwart support to our great profession 
of nursing and for inviting me to share the accomplishments of Air 
Force Nursing once again.

    Senator Stevens. Thank you all very much.
    I am going to yield to the patron saint of military nurses, 
my co-chairman.
    Senator Inouye. I thank you very much.

                        RECRUITING AND RETENTION

    Nurses are all angels to me. They are very important.
    As all of you have indicated, our major concern is 
recruiting and retaining. I just want to make certain that 
these programs continue.
    For example, the Tri-Service nursing research program is 
not funded. I was told it is number nine on the USUHS priority 
list. Do you believe this committee should override that and 
fund it?
    General Brannon. Well, sir, if I may speak, I think the 
Tri-Service nursing research program initiatives have 
tremendous impact on the progress in military science for 
operationally nursing. I think it is a unique funding stream 
and allows us to do many great studies. I would hate to lose 
that avenue.
    Senator Inouye. If it is not funded, would it have any 
impact or implication on patient care?
    General Brannon. Yes, potentially. At aeromedical 
evacuation, we have a Tri-Service nursing research funded 
program that is looking at the environment of the various 
aircrafts and how we can mitigate some of the heat and cold 
concerns to provide a more stable transport environment for 
patients. That very clearly would adversely impact patients if 
we cannot complete that research. That is just one of many 
examples.
    Admiral Lescavage. Sir, I echo what General Brannon just 
said. I believe research is key to our future. As you queried 
the previous panel of our Surgeons General, you did also 
mention the subject of research. Research is quite competitive. 
There are never enough dollars for any type of research, as you 
well know.
    Should the funding go away, I see our nursing projects 
certainly as very important, but I know all of the good work, 
some 75 ongoing projects right now--some of them would not get 
the attention they need, and we would suffer from not being 
able to do it all. But I am certain we also would keep the 
highly relevant ones going, for instance, in the combat arena.
    We very much appreciate the funding that we get every year 
and frankly do not want to live without it.
    Senator Inouye. We have a graduate school of nursing, 
Colonel, and also a doctoral program. Should they be continued?
    Colonel Gustke. Yes, sir, most definitely. We have had the 
opportunity from the Army's perspective for the last 3 or 4 
years to use the Uniformed Services University (USU) program 
strictly for education of our family nurse practitioners, and 
without that program, we would not have the necessary funding 
to do that.
    Additionally, this past year we had our first inaugural 
year of the perioperative nursing program which, of course, is 
an extremely, go-to-war skill. This year we have educated four 
to six perioperative nurses from the Army and we will continue 
to do so every year. We have been extremely fortunate in 
educating additional certified registered nurse anesthetists 
(CRNAs), which again is another go-to-war mission that is 
important for us. Without this program, it would have a severe 
impact upon our ability to do so.
    Senator Inouye. Do these programs have any impact on 
recruiting and retention?
    Colonel Gustke. Well, sir, I would say the ability for our 
nurses to attend long-term health education is a very big 
retention carrot. Many of our nurses say that once they hit 
that 6th, 7th, 8th year--it is between the 4th and 6th years 
when we lose a number of our nurses. So we probably have our 
biggest retention problems, if we have any, at any particular 
given year. And many of our nurses say the ability to go back 
to graduate school and for the military to pay that bill for 
them to get their advanced education is extremely important to 
them. It is one of the reasons they come in. It certainly is 
not pay. It certainly is not incentive pay of any kind, but it 
is the ability to advance their education. I think to lose that 
capability would have a severe impact upon our retention.

                  LOAN REPAYMENT PROGRAMS AND BONUSES

    Senator Inouye. We have been impressed upon, that in about 
10 or 15 years, we will have a nursing shortage of about 
400,000 nurses in this country. Obviously, that will have an 
impact upon the military nurse corps. Do these loan repayment 
programs and bonuses make a difference?
    Colonel Gustke. Yes, sir. I will tell you from our 
perspective, this is our inaugural year in using the health 
loan repayment plan. We have got three programs in effect 
currently for recruitment. First, if individuals used health 
professions loan repayment program (HPLRP), they come in for 3 
years. Second tier, they can use HPLRP with an accession bonus 
of $5,000 and come in for 6 years, and the third tier is for 
them to just accept a $10,000 bonus and come in for 4 years. 
Under those plans, this past year we have seen anywhere from 12 
to 15 applicants come in the Army Nurse Corps each month. With 
these continued programs, we firmly believe that we will be 
able to meet our mission this year for the first time in 3 
years, our USAREC recruitment mission. So having spoken to the 
folks out in the field and the recruiters, they want to keep 
these initiatives going, and we would also certainly like to 
see an increase in our accession bonus as the years progress to 
see where we are competitively with the civilian market. But it 
has been extremely good to us this past year.
    Senator Inouye. I suppose you all agree.
    General Brannon. Yes. Of the almost 100 nurses that have 
been recruited so far this year, 60 percent have taken a loan 
repayment and 40 percent the increased accession bonus. I just 
came from a recruiting conference yesterday and they applauded 
the efforts, that they are making a tremendous difference 
because we are more competitive with the civilian facilities. 
So thank you.
    Admiral Lescavage. It is my belief nurses anywhere want 
three things: to be appreciated, which we do very well I 
believe in the military; to be compensated, our pay is very 
good; and to be educated. The pipeline programs I mentioned in 
my testimony, the ROTC programs, really help us out with 
bringing nurses into the Navy and then the issue is to retain 
them. We offer about 80 scholarships a year. As I visit our 
facilities, I always ask the question, who has been to duty 
under instruction. A fair amount of hands will go up. And who 
wants to duty under instruction, the scholarships we give while 
on active duty. Many, many hands go up. It is sort of a fever 
that has been created, and it is our best retention tool. I 
myself have had two scholarships from the Navy. It is highly 
valued.
    Senator Inouye. Well, I am certain I speak for the 
committee, and I speak for all of my colleagues in thanking all 
of you for your service to this Nation.
    On a personal note, I spent just about 20 months in 
military hospitals, and if it were not for nurses, I do not 
suppose I would be sitting here. So to you, thank you very 
much.
    Senator Stevens. Well, I did not spend that long, but I 
spent my time in military hospitals too. I think that the 
Senator is right. You have the calling of the angels.

                SURGE CAPABILITY FROM GUARD AND RESERVE

    My only question would be, is there enough emphasis on a 
surge capability in time of war, as I have talked to my 
previous panel, for doctors and surgeons in particular? Do we 
have a surge capability from the Guard, Reserve? You mentioned 
total force. You mentioned it somewhat too, Colonel. But I 
don't want to be offensive, but I do not sense the commitment 
to the ongoing capability of former members of the service to 
have plans to bring them back in if needed. Can you comment? Do 
we have sufficient plans really to call up additional people 
from Guard and Reserve if they are needed?
    Colonel Gustke. Well, sir, I will tell you from the Army's 
perspective, we have three things in place currently. We have 
not skipped a beat in providing patient care to date, no matter 
what facility you will go to. We have the GWOT dollars to 
supplement with our contract civilian nurses, which has been 
very successful. We have integrated Reserve units as back-fills 
in our medical treatment facilities, both in CONUS and 
overseas, and then we have also used our 91 percent fill rate 
for our civilians which has been very successful, the direct 
hire authority.
    We also have had a number of military nurses call up and 
want to come back on active duty. So there is a program in 
place at our branch right now to look at that plan, should we 
ever need that to come to fruition. But for right now, sir, I 
think what we have in place is working very well, and should 
the need arise, we will look at that and get back in more 
detail on it, sir.
    Senator Stevens. Admiral.
    Admiral Lescavage. Sir, I feel fully confident that we are 
ready. During my tenure, what we have done, actually before we 
ever went into Iraq, was to look at our critical specialties, 
make sure not only do we have the numbers, but that we have 
provided the training that they need. And that is in areas of 
nurse anesthesia, operating room, emergency room, and critical 
care. What happened, once we did go into Iraq, I, as Colonel 
Gustke just described, received many calls from previous active 
duty to come back, our reservists. We are manned at 105 
percent. The key to the Reserves is to get more in the middle 
grades. We have many in the senior grades. So we are now 
tweaking that to try to recruit more middle grade officers into 
the Reserves. But, sir, I feel we are ready.
    Senator Stevens. General.
    General Brannon. Well, we are a total nursing team, and we 
have relied heavily on our Reserve and Guard brethren to 
support the nursing missions, particularly aeromedical 
evacuation. I will say some has been mobilization. Most of the 
positions are really being filled with willing volunteers at 
this point. So I remain always impressed and astonished at the 
commitment from our Reserves and our Guard.
    Senator Stevens. Thank you very much.
    My mind goes back to the time that I introduced an 
amendment to change the draft laws to draft women. It was 
defeated, as we expected, but we also then defeated the draft. 
We have relied on volunteer entrants to all of our services, 
and retention of some of those people who retire or leave 
before retirement for the purpose of surge capability in the 
cases of war and emergencies. So I think we sometimes forget 
the numbers that we were part of, 6 million and 7 million men. 
All-out war requires an enormous capability.
    I am not sure we have that capability today under the 
volunteer service, but I think we have to find some way, as I 
mentioned to the doctors, to try and see if we can provide the 
incentive for some people to be trained and just be literally 
reserved for crisis or all-out war, not for just the temporary 
surges in numbers. We are still in a fairly small war in 
comparison to the time when the two of us were in the service. 
God forbid we will ever have to do it. But I am not sure we 
have plans to do it. That is what bothers me. I would like to 
talk to you about it sometime in the future.

                     ADDITIONAL COMMITTEE QUESTIONS

    But meanwhile, I do appreciate what you have done, and I 
echo what my friend says about the admiration we have for all 
of the people that are in your service. They are not all women, 
as a matter of fact. You are all women, but I have met many 
male nurses in the service, and I commend them and we commend 
all of you. Thank you for your service.
    [The following questions were not asked at the hearing, but 
were submitted to the Department for response subsequent to the 
hearing:]
        Questions Submitted to Lieutenant General James B. Peake
            Questions Submitted by Senator Patrick J. Leahy
    Question. General Peake, I am pleased to hear of the progress that 
the Army is making in its efforts to develop modern alternatives to the 
deployable medical field systems, or ``DEPMEDs,'' that we've had in 
service for so many years. Is it true that the Army would like to begin 
fielding an alternative to DEPMEDs as early as calendar year 2005 once 
a final design is decided?
    Answer. The Army's Transformation Objective requires a Force that 
is strategically responsive and dominant at every point on the spectrum 
of operations. Heavy forces must be more strategically deployable and 
more agile with a smaller logistical footprint, and light forces must 
be lethal, survivable, and tactical.
    For more than 20 years the Department of Defense has employed 
Deployable Medical System (DEPMEDS) hospitals for any significant 
deployment of combat forces. Whether configured as the Navy's Fleet 
Hospital, the Air Force's Air Transportable Hospital, or the Army's 
Combat Support Hospital, each service uses essentially the same concept 
of moving special purpose medical shelters, both tents and ISO 
shelters, with a very low level of pre-integrated equipment, which 
required a significant number of transport containers. As a result of 
transformation throughout DOD, the need to rapidly deploy a range of 
scaleable, modular medical capabilities, which have the flexibility to 
be tailored and packaged to support a full range of combat operations, 
has become paramount. Accordingly, the concept for the Future Medical 
Shelter System (FMSS) shall respond to the joint requirements of the 
U.S. Army and the U.S. Navy.
    The FMSS shelter concept integrates the majority of medical 
supplies and equipment directly into the ISO containers thus 
eliminating separate packaging for these items and reducing the need 
for additional transport shelters and reducing weight and cube of the 
DEPMEDS hospital by approximately 30 percent. Consequently, the 
strategic deployability (air, ship, and truck transport volume) 
requirements are correspondingly reduced. Additional benefits of 
integration are enhanced tactical mobility as a result of the decreased 
time required to set up and prepare a DEPMEDS hospital for operation, 
conservation of the fighting strength by providing CONUS standards of 
medical care for soldiers deployed in world wide operations, and the 
ability to operate in all climates due to the environmentally 
controlled and chemical-biological overpressure protected environment. 
The fully modular system with integrated plug-and-play capability will 
have the required flexibility to be tailored and packaged to support 
the full range of combat operations.
    The Army is currently managing three separate Congressionally 
funded FMSS initiatives, Oak Ridge National Laboratories (ORNL), Mobile 
Medical International Corporation (MMIC), and EADS-Dornier. Each is 
developing a design for an Operating Room ISO container. ORNL and MMIC 
will deliver prototypes to the Army in May 2004 and July 2004 
respectively. EADS-Dornier is funded to provide engineering drawings of 
the OR ISO by December 2004.
    The FMSS program is in the Concept & Technical Development/Systems 
Development & Demonstration phases of development. Much work remains to 
ensure that these units are suitable for military use. It is unlikely 
that this could be accomplished by 2005 due to the fact that there is 
no funding available for further development or testing. There was no 
fiscal year 2004 Congressional Appropriation for the FMSS and the Army 
has no funding to support development or procurement of these 
initiatives, however, it is desired to begin replacing our aging 
DEPMEDs containers with these new enhanced capabilities as soon as 
possible. With your assistance and additional RDT&E funds, we should be 
able to achieve a procurement decision by the end of fiscal year 2006. 
As a reminder, the original DEPMEDs procurement was funded through 
direct Congressional Appropriation. Due to the projected cost of 
replacing DEPMEDS and current DOD funding priorities, this approach is 
the most likely scenario for a successful procurement of a DEPMEDs 
replacement.
    Question. General Peake, in that the hard-shell mobile hospital 
alternatives you are developing deploy very quickly and feature 
nuclear-biological-chemical protective capability, do you see these 
units having a possible role in disaster or terrorist incident response 
either at overseas U.S. bases or in this country?
    Answer. I believe the hard-shell mobile hospital alternative you 
refer to is the Chemical Biological Protective Shelter (CBPS). The CBPS 
is not exactly a mobile hospital alternative, however, it provides a 
highly mobile, self-contained, contamination free, environmentally 
controlled medical treatment area for forward deployed medical 
treatment units. (Battalion Aid Stations, Division & Corps Med 
Companies and Forward Surgical Teams). The CBPSs are complexed to 
provide these capabilities.
    The CBPS is a 300 square foot, air beam, soft wall shelter rolled 
up and transported on the rear of a Highly Mobile Multipurpose Wheeled 
Vehicle with Light weight Multipurpose Shelter and a trailer mounted 
Tactical Quiet Generator. The system can process 10 Litter/ambulatory 
patients per hour. It is Type Classified Standard with full materiel 
release and is currently in procurement through the Joint NBC Defense 
Program.
    The CBPS could have a role in disaster or terrorist incident 
response as it provides a contamination free environmentally controlled 
environment for treatment and surgery. Its capacity, however, is 
limited.
    Question. Do you and Dr. Winkenwerder anticipate use of this type 
of mobile diagnosis/treatment center in medical diplomacy missions 
where the Pentagon is trying to win the ``hearts and minds'' of 
ambivalent local populations in places like the Philippines, Middle 
East, and the Western Horn of Africa?
    Answer. The Chemical Biological Protective Shelter (CBPS) provides 
a contamination free environmentally controlled environment for the 
provision of sick call, advanced trauma life support and surgery on the 
contaminated battlefield. The CBPS currently is in the initial stages 
of procurement and is in short supply.
    I believe the CBPS can provide a small mobile medical treatment 
facility (clinic like capability) for diagnosis/treatment in medical 
diplomacy missions. This use must be coordinated between the Department 
of Defense and Department of State.
                                 ______
                                 
            Questions Submitted by Senator Richard J. Durbin
                           blood substitutes
    Question. I have heard of advances the Army and the Navy are making 
in developing blood substitutes for treating combat wounded. I know the 
Army has successfully completed Phases I and II with Northfield 
Laboratories in Illinois and are working with the FDA for approval, as 
well as the lab, to complete Phase III which would provide for clinical 
trials. I believe it is critical that we continue to support these 
efforts as they have significant battlefield applications, as well as 
first responders in a natural disaster or terrorist attack.
    Would you explain what these blood substitutes are, and why they 
are important to the future of combat casualty care and your assessment 
of their prospects for success for all services?
    Answer.
What are blood substitutes
    The most common approach that has been taken to develop blood 
substitutes is to harvest hemoglobin, the natural molecule that carries 
oxygen to vital tissues, from either human or bovine (cattle) sources. 
The hemoglobin is then subjected to proprietary processes to remove 
unwanted materials and to remove or inactivate potential infectious 
agents. Other proprietary processes are used to build the individual 
hemoglobin molecules into chains of hemoglobin. This process is 
believed to reduce or eliminate toxic effects caused by individual 
molecules of hemoglobin. Once processing is completed the hemoglobin is 
ready for use as a means to provide oxygen-carrying capability to 
subjects who have lost significant amounts of blood. These preparations 
are referred to as hemoglobin-based oxygen carriers (HBOC). Other 
approaches are being pursued but they are much earlier in their 
development and will not be ready, if ever, for many years.
Potential utility for the military services
    Combat injury on the battlefield typically occurs in the absence of 
ready availability of packed red blood cells (PRBC), the derivative of 
whole blood that is normally required to manage patients who have 
severe bleeding. Most deaths that result from severe bleeding on the 
battlefield occur within the first hour of injury. It has been 
difficult to solve this problem because medics on the battlefield 
cannot carry PRBC. PRBC must essentially remain refrigerated until 
used. HBOC have the advantage that they are much more stable when 
removed from refrigeration and can therefore be carried on the 
battlefield for at least limited periods (days to weeks) and remain 
safe for human use. Thus, more ready availability of HBOC on the 
battlefield may provide a bridge for the casualty with life-threatening 
hemorrhage that will permit survival until evacuation from the 
battlefield can be accomplished.
Prospects for success of HBOC
    An early HBOC developed by the Baxter Corporation was developed and 
tested in the 90's and subsequently abandoned during advanced clinical 
testing when an excessive (unexpected) number of deaths occurred among 
patients treated with the product in their Phase 3 study.
    Currently, two smaller companies, Northfield Laboratories, Inc., 
Evanston, IL and Biopure Corporation, Cambridge, MA have developed new 
products incorporating new processes that it is hoped will mitigate the 
toxicity problems seen with the Baxter product. Both Northfield and 
Biopure have conducted animal and human studies of their products that 
have both so far shown promise. However, large, phase 3 clinical 
studies that demonstrate both safety and effectiveness remain to be 
completed. Northfield Laboratories began a Phase 3 study in trauma 
patients outside of the hospital in December 2003 and plans to complete 
this study in 2005. If this study is successful (shows both safety and 
effectiveness), the company anticipates licensure sometime in 2006. 
Biopure Corporation, in collaboration with the Naval Medical Research 
Center, plans to begin a Phase 3 study of their HBOC in trauma patients 
outside the hospital later in 2004. If successful, licensure might be 
anticipated in 2006 or 2007.
    The Army and the Navy have continued to collaborate and remain 
connected with both companies to help shape and ensure that their 
products will have maximal relevance for military as well as civilian 
application. In that regard, the Navy has recently assumed sponsorship 
of the Phase 3 study that will be conducted with the Biopure 
Corporation HBOC. The Army is collaborating with Northfield 
Laboratories to make their HBOC available to Special Operations Forces 
casualties on the battlefield in a controlled, pre-licensure treatment 
protocol.
                            dental research
    Question. As I am sure you are all aware, a DOD review panel in 
2000 confirmed the need for the military dental research but found that 
it is hampered by discontinuous funding streams. Last year, the 
Committee included language in its report that ``directed'' the 
Department to sufficiently fund the military dental research program at 
the Great Lakes naval base. Last year Congress added $2 million for 
dental research, which was actually only about half of what was 
requested.
    Could you tell this Committee how much the Army and Navy are each 
putting into this program for fiscal year 2005?
    Answer. The U.S. Army, through U.S. Army Medical Research and 
Materiel Command, Combat Casualty Care and Walter Reed Army Institute 
of Research fund the U.S. Army Dental and Trauma Research Detachment at 
$1.687 million of which some support is provided for infrastructure and 
$1.08 million is available for U.S. Army Dental Research.
    Question. It is my understanding that one of the biggest problems 
for deployed Soldiers is avoiding gum disease--like trench mouth. What 
are the Army dental researchers at Great Lakes doing to address this 
problem to prevent dental emergencies for deployed Soldiers?
    Answer. The U.S. Army Dental Trauma and Research Detachment 
(USADTRD) is approaching reduction of the historically constant 15.6 
percent emergency rate in deployed Soldiers from several different 
avenues. Firstly, (USADTRD) is developing a rapid PCR that will, if 
successful, identify those Soldiers who are most susceptible to 
accelerated deterioration of oral health during deployments. Once 
identified, special measures, including diet and special oral hygiene 
aides, can be prescribed specifically for that Soldier to prevent 
becoming an emergency/evacuation. The single largest focus of USADTRD's 
science program is the development of a safe, efficacious anti-
microbial peptide that can be added to military rations and control 
dental plaque caused disease. It is anticipated this peptide will be 
delivered via chewing gum, and will be effective in reducing/preventing 
oral diseases even in the face of heightened stress levels and 
decreased oral hygiene due to the optempo experienced during 
deployments. Currently of the 15.6 percent emergency rate, 75 percent 
of those emergencies are related to dental plaque. USADTRD is 
projecting at least a 50 percent decrease in plaque related 
emergencies. This will be a significant force multiplier for the 
warfighter.
    Question. The Navy dental researchers at Great Lakes have developed 
several new products and pieces of equipment that allow corpsmen to 
treat warfighters in the field saving time and money. Can you tell us 
about some of that equipment?
    Answer. In keeping in line with current U.S. Army doctrine, the 
U.S. Army Dental and Trauma Research Detachment (USADTRD) has developed 
and fielded a miniaturized dental field unit and operating system 
(DeFTOS). This dental field unit significantly reduces the weight and 
cube of dental equipment used in deployed environments. This reduction 
allows dental equipment to be closer to the warfighter, permitting much 
more rapid return to duty following evacuation for dental emergencies 
as well as saving very valuable transportation assets for other 
requirements. Currently USADTRD is also working to greatly reduce the 
weight, size and electrical requirements for field sterilizers. By 
accomplishing this, the U.S. Army will not only benefit with a smaller, 
lighter sterilizer, but due to a lessened electrical requirement, a 
great deal more weight and cubes will be saved by a far smaller 
electric generator.
                                 ______
                                 
            Questions Submitted by Senator Dianne Feinstein
    Question. The antimalarial drug mefloquine has been identified as 
causing severe side effects such as psychosis, aggression, paranoia, 
depression and thoughts of suicide, even after use of the drug has 
stopped. Could you please tell me why another quinolone, ciprofloxacin, 
is being given to soldiers to self administer when consuming suspicious 
foods in Iraq when the side effects from one quinolone have the 
potential to be compounded by the second?
    Answer. Mefloquine is a 4-quinolinemethanol derivative. 
Ciprofloxacin is a fluoroquinolone that is an antimicrobial agent, used 
to kill bacteria. The two drugs are not related. There are no known 
drug interactions between mefloquine and ciprofloxacin. Furthermore, it 
is not Army policy to give ciprofloxacin for self-administration when 
consuming suspicious foods. In fact, Soldiers are cautioned against 
consuming foods on the local economy. Soldiers have a variety of foods 
provided for them, including Meals-Ready-To-Eat, T-rations, which 
consist of containers of pre-packaged foods and fresh rations, which 
are thoroughly inspected for quality.
    Question. DOD has begun an investigation into psychiatric adverse 
events in soldiers and plans a study of mefloquine. DOD has stated that 
it has not included in its assessments several incidents in soldiers 
who have taken mefloquine or soldiers who do not demonstrate blood 
levels of the drug. FDA's News Release of July 9, 2003 states that 
``Sometimes these psychiatric adverse events may persist even after 
stopping the medication.'' What is being done by DOD to investigate the 
incidents of suicides in soldiers while on or returning from 
deployment? Any investigations should include soldiers who consumed 
mefloquine and committed suicide or committed other acts of violence 
whether there were residues identified in their blood or not. What is 
DOD's timeframe for conducting a review of these cases and conducting 
other studies of the effects of mefloquine?
    Answer. The DOD uses all of the currently recommended antimalarial 
medications, basing their choice on medical and operational 
considerations for each mission. All of these medications have 
potential side effects, and, the risks and benefits of each are 
considered by our operational surgeons, when recommending a medication 
for malaria prophylaxis. Recently, the antimalarial drug mefloquine has 
been highlighted in news reports, alleging severe adverse side effects 
potentially related to this medication. DOD is committed to finding 
answers to the questions raised by these reports.
    Dr. Winkenwerder, Assistant Secretary of Defense for Health 
Affairs, has asked an expert panel of independent physicians, 
scientists, epidemiologists, and ethicists from highly respected 
civilian institutions and academia to recommend study designs that are 
best suited to answering questions surrounding antimalarial 
medications. Based on these recommendations, Health Affairs has 
commissioned two studies. The first, to be led by the Deployment Health 
Research Center at the Naval Health Research Center (NHRC) in San 
Diego, will look at the (comparative rates of adverse events (including 
neuropsychiatric)) associated with antimalarial use. A preliminary 
descriptive study is underway and preliminary results should be 
completed within one to two months. Based on the recommendations of the 
expert panel, the NHRC will then partner with a civilian academic 
institution to perform a retrospective cohort analysis of the data to 
determine the comparative rates of adverse outcomes associated with 
each of the antimalarial medicines. The details of this thorough 
analysis are being developed now. We anticipate that this study will 
take 12-18 months to complete.
    A second study will address the questions raised about suicides in 
our deployed and recently deployed service members. The Armed Forces 
Institute of Pathology is leading this study. The first step will be a 
comprehensive review to characterize all suicides in DOD. They will 
then partner with a civilian academic institution to perform a case 
control analysis in order to better understand the myriad of potential 
attributable risk factors with these deaths. Use of the antimalarial 
medication mefloquine will be one factor assessed in this study. 
Planning for this study is underway, and we anticipate this extremely 
thorough analysis to take 18 to 24 months to complete.
    The creditability of this work will hinge on the fact that it will 
be comprehensive and validated by the medical community. A non-federal 
oversight board will oversee both of these study efforts--DOD will be 
working with the American Institute of biological Sciences.
    Question. What are you doing to specifically recognize and report 
adverse events that are potentially associated with mefloquine 
consumption in deployment situations? What kind of reporting systems 
are available to deployed physicians, medics and or soldiers for 
reporting adverse events?
    Answer. Once a health care provider has determined that an adverse 
event is likely due to mefloquine or any drug, they first document it 
in the patient's health record. Then, they would ensure that the 
information is reported. If they were in a deployed medical treatment 
facility that has Internet connectivity, they would access the web site 
for the Joint Medical Workstation (JMeWS) system, and code the patient 
encounter as an adverse drug event. In more remote combat areas, mobile 
Army medical personnel use laptops to input patient encounter 
information through Composite Health Care System II--Theater (CHCS-II-
T).
    Question. What support is provided for soldiers reporting adverse 
events who are taking mefloquine? What is the Standard Operating 
Procedure for a managing a soldier with side effects from mefloquine 
consumption, knowing that stopping the drug is insufficient as the 
effects can persist after stopping the product, while on deployment or 
here is the United States?
    Answer. If a Soldier experiences severe side effects with 
mefloquine, then the medication will be stopped and the medical needs 
of the Soldier will be taken care of. It is important to understand 
that treatment is individualized according to the type of reaction and 
what treatment is indicated for that particular adverse event. When 
Soldiers have any health concerns that may be related to deployment, no 
matter which deployment nor how long ago the deployment occurred, we 
use an evidenced-based clinical practice guideline called the post-
deployment evaluation and management guideline. Service subject matter 
experts from the Department of Defense and Veterans Health Affairs 
developed this guideline. It is used in the primary care setting in 
screening, evaluating and managing the post-deployment health concerns 
of service members. It provides an algorithm to systematically and 
comprehensively address health concerns by reinforcing a partnership 
with the Soldier patient. A detailed medical history is taken; followed 
by a medical exam, appropriate laboratory tests and consultative 
services, if indicated. It also serves to enhance the continuity of 
care and foster the establishment of therapeutic relationships.
                                 ______
                                 
          Questions Submitted to Vice Admiral Michael L. Cowan
            Questions Submitted by Senator Richard J. Durbin
                            dental research
    Question. As I am sure you are all aware, a DOD review panel in 
2000 confirmed the need for the military dental research but found that 
it is hampered by discontinuous funding streams. Last year, the 
Committee included language in its report that ``directed'' the 
Department to sufficiently fund the military dental research program at 
the Great Lakes naval base. Last year Congress added $2 million for 
dental research, which was actually only about half of what was 
requested. Could you tell this Committee how much the Army and Navy are 
each putting into this program for fiscal year 2005?
    Answer. The Navy's Military Dental Research Program is primarily 
conducted by the Naval Institute for Dental and Biomedical Research 
(NIDBR) located at the Great Lakes Naval Station. NIDBR's total funding 
for fiscal year 2004 and the requested budget for fiscal year 2005 is 
summarized in the following table.

                                                      NIDBR
                                             [Dollars in thousands]
----------------------------------------------------------------------------------------------------------------
                                                                                                    Fiscal Year
                Funding Source                                   Research Area                         2004
----------------------------------------------------------------------------------------------------------------
DHP, Navy....................................  Mercury Abatement................................            $910
RDT&E, Navy..................................  Science and Technology Projects..................          $1,130
RDT&E, Navy..................................  Transition/Advanced Development..................            $761
RDT&E, Navy..................................  Congressional Add................................          $1,154
RDT&E, Navy..................................  General Purpose Test Equipment and Maintenance...            $236
DHP, Navy....................................  Longitudinal Risk Assessment.....................            $162
US-EPA.......................................  Mercury Hygiene Training.........................             $30
Commercial Research and Development Agreement  Creighton University.............................             $85
                                                                                                 ---------------
      Total Program..........................  .................................................          $4,468
                                                                                                 ===============
Various......................................  NIDBRI Fiscal Year 2005 Request..................          $4,863
----------------------------------------------------------------------------------------------------------------

    The NIDBR request in fiscal year 2005 assumes that research funding 
is available in fiscal year 2005 in the same amounts as in fiscal year 
2004. In fiscal year 2005 NIDBR has additional requirements for 
supplies and equipment and maintenance. Science and Technology projects 
have not been awarded for fiscal year 2005.
    Question. It is my understanding that one of the biggest problems 
for deployed Soldiers is avoiding gum disease--like trench mouth. What 
are the Army dental researchers at Great Lakes doing to address this 
problem to prevent dental emergencies for deployed Soldiers?
    Answer. We would respectfully defer comment on Army dental research 
to the Army Surgeon General.
    Question. The Navy dental researchers at Great Lakes have developed 
several new products and pieces of equipment that allow corpsmen to 
treat warfighters in the field saving time and money. Can you tell us 
about some of that equipment?
    Answer. Recent achievements/products/equipment developed by the 
Naval Institute for Dental and Biomedical Research (NIDBR) in support 
of the Warfighter in all deployed venues include:
    Treatment of Dental Emergencies CD-ROM.--NIDBR has developed and 
deployed a dental treatment CD-ROM that aids Independent Duty Corpsmen 
in the diagnosis and treatment of common dental emergencies. This tool 
assists corpsmen in providing necessary emergency treatment to deployed 
personnel in venues where there is no immediate access to dental 
officer.
    Rapid Salivary Diagnostics.--NIDBR continues the development of 
rapid, simple, non-invasive salivary diagnostic tests to assess 
militarily relevant diseases such as tuberculosis and Dengue Fever, and 
anthrax immunization status of military personnel at risk or preparing 
for deployment. Currently, assays for clinic and battlefield-use using 
two methods: lateral flow and fluorescence polarization are being 
developed to provide corpsman and non-medical personnel a means for 
early diagnosis of personnel in the field who have contracted these 
diseases. This rapid diagnostic capability will allow for appropriate 
treatment and quicker return to duty or necessary evacuation to a 
higher echelon of medical care.
    Far-forward Interim Dental Restorative Material/Dressing.--NIDBR 
continues to develop and test a new novel dental material and delivery 
system that can be used to treat dental emergencies in the deployed 
environment, thereby reducing MEDEVACs and keeping Warfighters on 
station. The far-forward dental dressing has been designed for use by 
first responders as a method to treat a wide variety of urgent dental 
problems encountered by the deployed Warfighter.
    Authorized Dental Allowance List (ADAL) Field Dental Operatory Test 
and Evaluation.--NIDBR continues to test, evaluate, and validate new 
and existing components of the Marine Corps ADAL to ensure the deployed 
dental delivery systems will withstand the rigors of field use during 
an operational deployment.
                                 ______
                                 
            Questions Submitted by Senator Dianne Feinstein
    Question. The antimalarial drug mefloquine has been identified as 
causing severe side effects such as psychosis, aggression, paranoia, 
depression and thoughts of suicide, even after use of the drug has 
stopped. Could you please tell me why another quinolone, ciprofloxacin, 
is being given to soldiers to self administer when consuming suspicious 
foods in Iraq when the side effects from one quinolone have the 
potential to be compounded by the second?
    Answer. A three-day supply of ciprofloxacin is commonly supplied to 
travelers (both civilian and military) for the emergency treatment of 
diarrhea, in the event that they are incapacitated and not able to 
receive immediate medical attention. Ciprofloxacin is usually 
prescribed for this type of treatment because it should either 
significantly improve or cure about 70 percent of bacterial 
gastroenteritis episodes. While it is theoretically possible for one 
quinolone to potentiate the side effects of another, this has not been 
shown to be a problem with mefloquine and ciprofloxacin. The possible 
association between mefloquine and ciprofloxacin with adverse events 
has been speculated upon, however, there have been no well-documented 
cases of problems due to this drug combination. Whenever mefloquine and 
ciprofloxacin are prescribed together, the theoretical risk of 
interaction must be weighed against their proven life saving benefits.
    Question. DOD has begun an investigation into psychiatric adverse 
events in soldiers and plans a study of mefloquine. DOD has stated that 
it has not included in its assessments several incidents in soldiers 
who have taken mefloquine or soldiers who do not demonstrate blood 
levels of the drug. FDA's News Release of July 9, 2003 states that 
``Sometimes these psychiatric adverse events may persist even after 
stopping the medication.'' What is being done by DOD to investigate the 
incidents of suicides in soldiers while on or returning from 
deployment? Any investigations should include soldiers who consumed 
mefloquine and committed suicide or committed other acts of violence 
whether there were residues identified in their blood or not. What is 
DOD's timeframe for conducting a review of these cases and conducting 
other studies of the effects of mefloquine?
    Answer. The Office of the Assistant Secretary of Defense for Health 
Affairs (ASD (HA)) is coordinating a DOD study of adverse events 
associated with mefloquine, including any possible connection with 
suicide. Recommendations for the proposed study have been developed by 
a select sub-committee of the Armed Forces Epidemiological Board (AFEB) 
and will be presented to ASD (HA) and the AFEB. Questions regarding 
whether the anticipated study will include soldiers involved in 
specific incidents or how blood levels of mefloquine will be approached 
should be referred to ASD (HA).
    Question. What are you doing to specifically recognize and report 
adverse events that are potentially associated with mefloquine 
consumption in deployment situations? What kind of reporting systems 
are available to deployed physicians, medics and/or soldiers for 
reporting adverse events?
    Answer. Reporting of adverse events associated with mefloquine, or 
any other medication, is addressed by Naval Medicine's Risk Management, 
Patient Safety and Operational Health Care Quality Assurance programs. 
Operational units are required by the Chief of Naval Operations to 
track adverse drug reactions as a part of the Operational Health Care 
Quality Assurance program. These units use U.S. Food and Drug 
Administration guidelines for the reporting of adverse drug reactions.
    Any provider, civilian or military, may submit adverse drug 
reactions to the U.S. Food and Drug Administration (FDA). The FDA 
accepts adverse drug reaction reports via website, telephone or mail. 
In addition, these drug reactions must be monitored at the local level 
through the Operational Health Care Quality Assurance Program.
    Question. What support is provided for soldiers reporting adverse 
events who are taking mefloquine? What is the Standard Operating 
Procedure for a managing a soldier with side effects from mefloquine 
consumption, knowing that stopping the drug is insufficient as the 
effects can persist after stopping the product, while on deployment or 
here is the United States?
    Answer. Individuals experiencing possible side effects from 
mefloquine are provided support through their local primary care 
provider. Management of adverse side effects from medication involves 
prevention through proper screening, choice of medication, appropriate 
monitoring, and above all, stopping the suspected medication. U.S. Food 
and Drug Administration guidelines advise discontinuing mefloquine if 
side effects occur. Due to the long half-life of mefloquine, adverse 
reactions to mefloquine may occur or persist up to several weeks after 
the last dose.
    Standard of care for managing a patient with an adverse reaction to 
Mefloquine is to change the patient's medication, monitor the patient 
for resolution of side effects and refer the patient to appropriate 
clinical specialists for persistence of any psychiatric or neurological 
side effects.
                                 ______
                                 
   Questions Submitted to Lieutenant General George Peach Taylor, Jr.
            Questions Submitted by Senator Dianne Feinstein
                               mefloquine
    Question. The antimalarial drug mefloquine has been identified as 
causing severe side effects such as psychosis, aggression, paranoia, 
depression and thoughts of suicide, even after use of the drug has 
stopped. Could you please tell me why another quinolone, ciprofloxacin, 
is being given to soldiers to self administer when consuming suspicious 
foods in Iraq when the side effects from one quinolone have the 
potential to be compounded by the second?
    Answer. Ciprofloxacin (an antibiotic) is used for the prevention or 
treatment of certain type of traveler's diarrhea, often caused by 
consuming poorly prepared or inappropriately stored food. During 
deployments, our public health officials work very hard to ensure that 
the food that our airmen consume is safe.
    Our healthcare providers prescribe prophylactic medications in 
accordance with the Centers for Disease Control and Prevention (CDC) 
recommendations, Food and Drug Administration license, and the 
manufacturers' prescribing information. While the concomitant 
administration of mefloquine and quinine or chloroquine (another 
antimalarial) may produce electrocardiographic (heart conduction) 
abnormalities, there is no scientific evidence to suggest that the use 
of ciprofloxacin would compound the adverse reactions that may be 
associated with mefloquine use. It is within the standard of care to 
prescribe both mefloquine and ciprofloxacin. Both are excellent 
pharmaceutical agents for force health protection.
    Question. DOD has begun an investigation into psychiatric adverse 
events in soldiers and plans a study of mefloquine. DOD has stated that 
it has not included in its assessments several incidents in soldiers 
who have taken mefloquine or soldiers who do not demonstrate blood 
levels of the drug. FDA's News Release of July 9, 2003 states that 
``Sometimes these psychiatric adverse events may persist even after 
stopping the medication.'' What is being done by DOD to investigate the 
incidents of suicides in soldiers while on or returning from 
deployment? Any investigations should include soldiers who consumed 
mefloquine and committed suicide or committed other acts of violence 
whether there were residues identified in their blood or not. What is 
DOD's timeframe for conducting a review of these cases and conducting 
other studies of the effects of mefloquine?
    Answer. A loss of any airmen to suicide is tragic. For many years, 
Air Force leaders have been very committed to preventing suicides. Our 
nationally recognized suicide prevention program educates leaders as 
well as individual airmen on how to identify at-risk individuals and 
intervene when necessary to prevent suicides. Since the program's 
inception, our suicide rates have continued to decline.
    We, along with our Sister Services and the Assistant Secretary of 
Defense for Health Affairs, are very concerned about the number of 
suicides among deployed troops and potential adverse outcomes of 
mefloquine. At the May 12, 2004 meeting of the Armed Forces 
Epidemiological Board (AFEB), the ASD/HA accepted the Board's 
recommendations to formally study the factors associated with suicide 
and to study outcomes potentially related to mefloquine. His staff is 
currently determining the exact details, such as time frame.
    Question. What are you doing to specifically recognize and report 
adverse events that are potentially associated with mefloquine 
consumption in deployment situations? What kind of reporting systems 
are available to deployed physicians, medics and/or soldiers for 
reporting adverse events?
    Answer. All our deployed military treatment facilities have 
capabilities to report reportable medical events. Reportable medical 
events include adverse events associated with vaccinations and certain 
medical conditions. If an airman sees a healthcare provider for an 
adverse event associated with medication use, it is documented in the 
airman's medical record and the DD Form 2766 (Adult Prevention and 
Chronic Care Flowsheet). The DD Form 2766 accompanies deployed 
personnel to the field and is returned to the individual's medical 
record upon re-deployment. While providers are not required to report 
adverse events that are not out of the ordinary (i.e., adverse events 
that have been reported in the package inserts for the individual 
pharmaceutical agent), they are required to report unusual adverse 
events associated with a medication directly to the Food and Drug 
Administration. In the 10 years that the Air Force has used mefloquine, 
it has not had a significant reportable event associated with 
mefloquine administration.
    Question. What support is provided for soldiers reporting adverse 
events who are taking mefloquine? What is the Standard Operating 
Procedure for a managing a soldier with side effects from mefloquine 
consumption, knowing that stopping the drug is insufficient as the 
effects can persist after stopping the product, while on deployment or 
here is the United States?
    Answer. If an Airman experiences symptoms while on mefloquine, a 
healthcare provider evaluates him or her. If necessary, the medication 
is discontinued and an alternative medication is substituted. Airmen 
are instructed to seek care for any medical concerns, including those 
associated with any medication use. All Airmen receive a post-
deployment briefing and a face-to-face medical visit with a healthcare 
provider prior to returning home. Airmen are also provided with 
information on how to seek medical care, either through our medical 
treatment facilities or the VA system.

                          SUBCOMMITTEE RECESS

    Senator Stevens. We are going to conclude the testimony 
here today. We will reconvene on May 5 at 9:30 a.m., when we 
hear from nondepartmental witnesses on the total budget for 
defense. Thank you very much.
    [Whereupon, at 11:50 a.m., Wednesday, April 28, the 
subcommittee was recessed, to reconvene at 9:30 a.m., 
Wednesday, May 5.]
