[Senate Hearing 109-]
[From the U.S. Government Publishing Office]



 
       DEPARTMENT OF DEFENSE APPROPRIATIONS FOR FISCAL YEAR 2006

                              ----------                              


                         TUESDAY, MAY 10, 2005

                                       U.S. Senate,
           Subcommittee of the Committee on Appropriations,
                                                    Washington, DC.
    The subcommittee met at 10:07 a.m., in room SD-192, Dirksen 
Senate Office Building, Hon. Ted Stevens (chairman) presiding.
    Present: Senators Stevens, Inouye, and Mikulski.

                         DEPARTMENT OF DEFENSE

                            Medical Programs

STATEMENT OF LIEUTENANT GENERAL KEVIN C. KILEY, M.D., 
            SURGEON GENERAL, DEPARTMENT OF THE ARMY

                OPENING STATEMENT OF SENATOR TED STEVENS

    Senator Stevens. My apologies, gentlemen. Too many 
telephones and e-mails. It is one of those things.
    We do welcome you to our hearing today to review the 
Department of Defense (DOD) medical programs. We have two 
panels scheduled. First, we will hear from the Surgeons 
General, followed by the Chiefs of the Nursing Corps. Joining 
us today from the Army, we have Surgeon General Kevin Kiley and 
Admiral Donald Arthur from the Navy. We welcome you both in 
your first hearing before us and look forward to working with 
you closely. We welcome back General Peach Taylor from the Air 
Force.
    The President's fiscal year 2006 request for the defense 
health program is $19.8 billion, an 8.9 percent increase over 
fiscal year 2005. The request provides for health care for over 
8.9 million beneficiaries and the operation of 70 inpatient 
facilities and 1,085 clinics.
    Despite the increase for this year's funding, the 
subcommittee remains concerned that the funding may not be 
sufficient to meet all of the requirements. We recognize that 
the continuing conflict in Iraq and the global war on 
terrorism, along with rising costs of prescription drugs and 
related medical services, will continue to strain your 
financial resources requested in this budget. And they will 
place a demand on our medical service providers, both those 
deployed in combat and those manning the posts here at home.
    Senator Inouye and I are familiar with the value of 
military medicine, and we are interested in hearing from you 
regarding continuing operations.
    Let me yield to my good friend from Hawaii.

                 STATEMENT OF SENATOR DANIEL K. INOUYE

    Senator Inouye. Thank you very much, Mr. Chairman. I want 
to join you in welcoming our witnesses this morning as we 
review the state of the Department's medical programs. General 
Taylor, we welcome you back to our subcommittee.
    It is our hope that this hearing will spotlight the 
numerous medical advances achieved by the men and women of the 
medical corps and also accelerate improvement and progress 
where it might be needed. The chairman and I, since World War 
II, have followed the advances in personnel protection and 
combat casualty care which have changed the fate of thousands 
of our military men and women.
    The improvements in battlefield protection and combat care 
have given our military the lowest level of combat deaths in 
history. While there is still regrettable loss of life in Iraq 
and Afghanistan, the fact that we are saving hundreds of lives, 
which could not have been saved in past military operations, is 
proof that these advances are paying off. Several factors 
contribute to this change, and we have read your testimony and 
you have outlined several of them, including medical training 
and facilities operated by the services.
    The training our medical personnel can receive cannot be 
equated with the private sector. One cannot deny that there are 
major differences in the medical requirements of our men and 
women serving in the military to the care required in your 
average civilian hospital. The personnel training and 
facilities of our medical system are all part of the elaborate 
network that feed off each other. Today these pieces are all 
connected and are continuing to make historic advances. 
However, it appears that this system could be on a brink of 
destruction.
    We have been told that there is a chance that the Uniformed 
Services University of Health Sciences and Walter Reed Medical 
Center are potential targets for the base realignment and 
closure (BRAC). I hope not, because I believe this would be a 
tragic mistake. Our military medical facilities are essential 
to winning the global war on terrorism, and as you may know, 
the Senate included language in the supplemental conference 
report directing that funding available to the Department of 
Defense should not be used to close any military medical 
facility which is conducting critical medical research or 
medical training or caring for wounded soldiers. It is our hope 
that this message is received by the Department loud and clear 
before the BRAC list is compiled.
    As a footnote to all of this, the chairman and I have, 
throughout the years, visited with our troops, and in each 
visit, we find that the major concern of all of them has been 
health care. Is my wife being cared for? Are the pediatricians 
working on my child? And I think we should keep in mind that 
there are many men and women who enlist because of the 
availability of health care.
    It is no secret that we are having problems at this time in 
recruiting and retaining, and if we take this benefit away, 
then I think we will have real problems. So we look forward to 
discussing this and many other issues that are crucial to the 
military medical system.
    Once again, I would like to thank the chairman for 
continuing to hold hearings on these issues that are important 
to our military and their families. I thank you very much, Mr. 
Chairman.
    Senator Stevens. Yes, sir.
    General Kiley, do you want to go first? We cannot figure 
out who should be first. Please, we would be glad to have your 
testimony.
    General Kiley. Sir, I would be happy to.
    Chairman Stevens, Senator Inouye, and distinguished members 
of the subcommittee, I am Lieutenant General Kevin Kiley, and I 
am honored to serve as the 41st Surgeon General of the United 
States Army.
    Our medical department, our Army Medical Department 
(AMEDD), is at war in support of our Army, defending our great 
Nation in the global war on terrorism. Since September 2001, 
the Army has been involved in the most prolonged period of 
combat operations since Vietnam. One key indicator of the 
success of our medical training, doctrine, and leadership is 
our casualty survivability. During Vietnam, approximately 24 
percent of all battle casualties died. As recently as Operation 
Desert Shield/Desert Storm, 22 percent of our battle casualties 
did not survive their wounds. In Operation Iraqi Freedom, less 
than 10 percent of these soldiers, marines, sailors, and airmen 
have died of their wounds.
    This improved survivability is due to superior training of 
our combat medics, leveraging technology to provide 
resuscitative surgical care far forward on the battlefield, the 
superb efforts of the Air Force's critical care aeromedical 
evacuation teams, and the advanced research and state-of-the-
art care available at our major medical centers such as 
Landstuhl, Walter Reed, Brooke, and Madigan, as well as other 
sister services.
    This phenomenal improvement in survivability is also due to 
great teamwork on the part of the three services, the United 
States (U.S.) medical industry, and the Members of Congress who 
have supported numerous advancements in combat casualty care. 
On behalf of the Army, I would like to thank you for your 
tremendous support over the years and tell you how much I look 
forward to working with this subcommittee to improve even 
further our ability to sustain the health of the Army family, 
whether it be in combat or at camps, posts, and stations around 
the world in support of the global war on terrorism.
    I would like to take a few minutes to explain how the 
entire Army Medical Department integrates its multiple 
functions to project and sustain a healthy and medically 
protected Army. We are most certainly an AMEDD at war. Since 
the spring of 2003, the Army has sustained a deployed 
population averaging 125,000 soldiers in Southwest Asia, while 
maintaining our global commitments around the world. We have 
mobilized more than 349,000 Reserve component soldiers.
    The demands placed on the Army Medical Department to 
support this effort across the entire spectrum of operations is 
significant. To support the deployed force, more than 36,000 
Army medics, physicians, nurses, dentists, allied health care 
professionals, health care administrators, and our enlisted 
personnel have deployed into Southwest Asia. Nearly 20,000 of 
these personnel are active duty component, and this total 
represents approximately half of the Army's active medical end 
strength not involved in long-term training, our residencies 
and internships. Many of these soldiers are deploying for the 
second time in 4 years. On the battlefield, they have provided 
care to more than 21,000 injured or ill soldiers who were 
evacuated from theater to Landstuhl Regional Medical Center and 
then hospitals in the United States, often within 1 or 2 days 
of injury, and have also cared for more than 16,000 Iraqi 
nationals, coalition soldiers, and U.S. civilians. Fifty-one 
AMEDD personnel have made the ultimate sacrifice in Iraq and 
Afghanistan.
    In theater, our Active and Reserve component medical units 
deliver a standard of care comparable to what soldiers and 
their families receive at our installations here in the United 
States. Technological advancements and improved aeromedical 
evacuation allow us to reduce our initial medical footprint in 
theater to 6 percent of the deployed force, down from 14 
percent in Operations Desert Shield and Storm. Innovative 
medical health care providers have introduced techniques 
normally found in major medical centers to our deployed combat 
support hospitals. As an example, Lieutenant Colonel Trip 
Buckenmaier pioneered the use of advanced regional anesthesia 
and pain management while deployed with the 31st Combat Support 
Hospital with tremendous success. This technique allows 
complicated surgical procedures to be performed on a conscious 
soldier using spinal anesthesia and nerve blocks. It holds 
great promise to improve patient recovery and minimize 
postoperative complications common with general anesthesia, 
certainly as well as making those soldiers much more 
comfortable.
    Back in the United States, our Army Medical Command 
supports the deployment of active component and mobilization 
and deployment of Reserve component units. Our medical 
treatment facilities conduct pre- and post-deployment medical 
screening to ensure soldiers are medically ready to deploy and 
to withstand the rigors of the modern battlefield. Nearly 
23,000 mobilized Reserve component soldiers have developed an 
illness or an injury during their mobilization that required 
the Army to place them in a medical holdover status. 
Approximately two-thirds of these soldiers are returned to the 
Army in a deployable status in an average time of approximately 
93 days from entering medical holdover.
    All of our major medical centers are engaged in providing 
the best possible treatment and rehabilitation to combat 
casualties. You are familiar with the tremendous care provided 
at Walter Reed Army Medical Center, but just as noteworthy is 
the care provided to wounded soldiers at William Beaumont, 
Womack, Madigan, Darnall, Eisenhower, and Tripler Army Medical 
Center, as well as some of our relatively smaller facilities at 
Forts Carson, Stewart, Riley, and Drum, among others.
    We recently expanded our medical amputee program to include 
a second amputee center at Brooke Army Medical Center in San 
Antonio, Texas. This center, collocated with the Institute for 
Surgical Research and the Army Burn Unit, will allow us to 
build upon the innovative care delivered at Walter Reed and to 
export advances in the treatment and rehabilitation of amputees 
and extremity injuries to not only military facilities but the 
rest of the medical community.
    During this period of unprecedented operational tempo, we 
have maintained and improved the quality of care we deliver to 
soldiers, their families, and our retirees. Despite less than 
100 percent backfill for deployed health care providers, we 
have maintained workload levels in our direct health care 
facilities. It is true that private sector workload is 
increasing, but not because we are doing less work at our 
facilities. As we have had to prioritize workload to support 
casualty care and deployment medical screening, family member 
and retiree care has, in some cases, shifted to the private 
sector. Additionally, families of mobilized Reserve component 
soldiers now have TRICARE available to them as their health 
insurance in many areas where military facilities do not exist 
or do not have the capacity to absorb the additional enrollees.
    We have also completed a successful transition to the next 
generation of TRICARE contracts. The reduction in the number of 
regions, a national enrollment database, and increased 
flexibility on the part of market managers, our military 
treatment facility (MTF) commanders, will greatly enhance our 
ability to support ongoing mobilization and deployments, Army 
transformation, and upcoming base realignment and closure 
decisions.
    In closing, I want to emphasize that the defense health 
program is a critical element of Army readiness. Healthy 
soldiers capable of withstanding the rigors of modern combat, 
who know their families have access to quality, affordable 
health care, and who are confident when they retire they will 
have access to that same quality health care, is an incredibly 
powerful weapons system. Every dollar invested in the defense 
health program does much more than just provide health 
insurance to the Department's beneficiaries. Each dollar is an 
investment in military readiness. In Operation Iraqi Freedom 
(OIF) and Operation Enduring Freedom (OEF), that investment has 
paid enormous dividends, and in my visits to Iraq, I can 
document that personally.

                           PREPARED STATEMENT

    Again, I would like to thank you for your past and future 
support and, sirs, I look forward to answering your questions. 
Thank you.
    Senator Stevens. Thank you very much, General.
    [The statement follows:]

        Prepared Statement of Lieutenant General Kevin C. Kiley

    Mr. Chairman and distinguished members of the Committee, thank you 
for your support of the Army Medical Department (AMEDD) which is 
providing world class care to Soldiers in Operations Enduring and Iraqi 
Freedom (OEF/OIF). Without your support we would not have had the 
resources to develop and refine multiple health care initiatives 
designed to enhance and improve medical care for Soldiers and their 
families before, during and after deployments. The AMEDD is at war and 
is spread around the world with an unprecedented operational tempo. I 
returned from my first visit to Iraq in mid-March and am extremely 
proud of the remarkable professionalism and compassionate performance 
of the entire AMEDD team in combat, preparing units for deployment and 
return, and maintaining the health of Soldiers, retirees, and their 
families at home.
    In Iraq and Afghanistan, the United States and our allies continue 
to struggle with forces opposed to freedom. Soldiers know that from the 
91W combat medic riding alongside them in convoy, to the aid station 
and combat support hospital, and throughout the evacuation chain to 
Landstuhl Regional Medical Center and on to home-station hospitals in 
the States, they will receive rapid, compassionate care from the 
world's best military medical force.
    Our medical force in Iraq and Afghanistan has saved hundreds of 
lives--Soldiers, civilians and even those who fight against us--due to 
remarkable battlefield techniques, patient transportation and 
aeromedical evacuation, and state-of-the-art equipment and personnel. 
Battlefield health care for OEF and OIF has been enhanced by placing 
state-of-the-art surgical and medical care far forward on the 
battlefield providing life saving care within minutes after injury. 
This far forward care is integrated with a responsive and specialized 
aeromedical evacuation that quickly moves patients to facilities for 
follow-on care. Improved disease prevention and environmental 
surveillance has reduced the rate of non-combat disease to the lowest 
level of any U.S. conflict. In OIF, more than 91 percent of all 
casualties survive their wounds, the highest survivability rate of any 
US conflict.
    We owe this improvement to several advancements. Improvements in 
tactics and protective equipment allow Soldiers to survive previously 
lethal injuries. The best trained combat medics and far forward 
resuscitative care, have also contributed to survivability. Our combat 
support hospitals in Iraq and Afghanistan support a full range of 
medical specialties, including many subspecialties like cardio-thoracic 
and neurosurgery. Technology now allows the Military Health System to 
deliver the same care available at Brooke Army Medical Center or Walter 
Reed in Mosul, Baghdad, or Kandahar. Today's Soldiers deserve better 
than essential life-saving care while deployed, they deserve the same 
superb quality care available to them and their families here in the 
United States. I am proud to say that we are doing just that today on 
the battlefields of Southwest Asia.
    I would like to highlight several ongoing successes. Since January 
2002, the U.S. Army Trauma Training Center, in association with the 
Ryder Trauma Center, University of Miami/Jackson Memorial Hospital, 
Miami, FL, has trained 32 Forward Surgical Teams and Combat Support 
Hospital surgical elements deploying in support of the Global War on 
Terrorism--more than 650 Active and Reserve Components (RC) healthcare 
providers. The training program has evolved to provide bonafide total 
team training to physicians, nurses, and medics, all focused on care of 
the acutely injured patient. This unique multidisciplinary pre-
deployment clinical training has displaced deployment ``on-the-job'' 
clinical training as the appropriate training method to ensure safe, 
effective combat casualty resuscitative surgery and care--it is 
clinical teamwork that makes a tremendously positive difference in care 
of the wounded. The Center is recognized as the Department of Defense 
(DOD) Center of Excellence for Combat Casualty Care Team Training and 
received the 2005 DOD Patient Safety Award for Team Training.
    Uncontrolled bleeding is a major cause of death in combat. About 50 
percent of those who die on the battlefield bleed to death in minutes, 
before they can be evacuated to an aid station. Tourniquets, new blood-
clotting bandages and injectable clot-stimulating medications are 
saving lives on the battlefield.
    All Soldiers are taught to stop bleeding as a Common Task, 
including applying a pressure dressing and a tourniquet, if needed. 
Currently all Soldiers have the means of using a tourniquet. The new 
Soldier Improved First Aid Kit (IFAK) includes a next-generation 
tourniquet. This tourniquet allows a trained, isolated Soldier to stop 
bleeding in an arm or leg. Between March 2003 and March 2005, U.S. Army 
Medical Materiel Center-Southwest Asia issued 58,163 tourniquets (four 
types) to CENTCOM-deployed units. Since April 1, 2004, a total of 
193,897 tourniquets have been issued to Army units deploying to 
theater. This includes 112,697 of two tourniquets proven 100 percent 
effective in control of severe bleeding (Combat Application Tourniquet 
or CAT and SOFTT). Beginning April 1, 2005 all new Soldiers will 
receive specific instruction on the CAT during Basic Combat Training. 
By the end of June 2005, deployed Soldiers without an approved 
tourniquet will all have received the CAT through the U.S. Army 
Medical Materiel Center-Southwest Asia, which placed an order for 
172,000 CATs and 56,000 SOFTTs in mid-March 2005. The vendors expect 
to fill the complete order of 228,000 by the end of June or earlier. In 
fact, by the end of April more than 121,000 of these tourniquets have 
been shipped to Qatar for distribution throughout the CENTCOM theater 
of operations. Soldiers deploying for the next rotation of OIF/OEF will 
either be issued the CAT as an individual item or the IFAK (which 
contains the CAT) through the Rapid Fielding Initiative (RFI) 
sponsored by Program Executive Office: Soldier.
    The U.S. Army Medical Research and Materiel Command continues to 
study a variety of agents which help control moderate to severe 
bleeding including a bandage made of chitosan (HemCon), a 
biodegradable carbohydrate found in the shells of shrimp, lobsters and 
other animals. Chitosan bonds with blood cells, forming a clot. 
Chitosan was shown to be effective in stopping or reducing bleeding in 
more than 90 percent of combat cases, without known complications. The 
Food and Drug Administration (FDA) cleared this bandage for use in 
November 2002. Army combat medics are using this bandage in Iraq and 
Afghanistan today.
    War is stressful for Soldiers and their families. The AMEDD has 
taken several steps to help minimize stresses associated with frequent, 
prolonged deployments. There are a wide array of mental health assets 
in Theater. These include Combat Stress Control teams and other mental 
health personnel assigned to combat units and hospitals. We have 
conducted three formal Mental Health Assessments, two in Iraq and one 
in Afghanistan. The reports of the most recent Assessments are pending 
DOD review and release.
    Soldiers receive post-deployment briefings as they return home 
focusing on the challenges of reintegration with families and 
employers. Soldiers are cautioned that their families have changed and 
grown, and that they may have a different role. They are also warned 
about possible symptoms of deployment-related stress, such as 
irritability, bad dreams, and emotional detachment.
    The post-deployment health assessment includes several mental 
health questions. The document is reviewed by a licensed healthcare 
provider. If Soldiers answer positively to the mental health questions, 
the provider may direct further evaluation and/or treatment.
    The Assistant Secretary of Defense (Health Affairs) recently 
announced a DOD policy to require all Service Members to receive a 
second post-deployment mental health assessment 90 to 120 days after 
redeployment. Soldiers may be hesitant to admit or are unsure they are 
experiencing mental health issues when they first return. They are more 
likely to develop or recognize problems and report them three to six 
months later, after the ``honeymoon'' period has worn off. We are 
working diligently to identify and assist Active, Reserve, and National 
Guard Soldiers who experience post-deployment difficulties. There is 
more work to be done in this area and we continue to refine and improve 
our ability to identify and provide early and effective treatment to 
Soldiers who are experiencing post deployment mental health issues.
    A Joint Theater Trauma Registry (JTTR) is now becoming a reality, 
modeled after the civilian standard established by Public Law 101-590, 
Trauma Care Systems Planning and Development Act. The JTTR pulls 
together the medical records of wounded (and deceased) Soldiers cared 
for in battlefield hospitals, and includes both their pre-hospital care 
and subsequent care in CONUS. When complete, the JTTR will present the 
most comprehensive picture of war wounds ever assembled. This medical 
database is invaluable for real-time situational awareness and medical 
research. By combining the JTTR with other personnel and operational 
databases, we anticipate its increased value will lead to improvements 
in Soldier Personal Protective Equipment (e.g. body armor), vehicle 
design, and small unit tactics.
    We remain committed to providing high quality, expert medical care 
to all Soldiers who become ill or injured in the line of duty. There is 
only one standard of medical care for all Soldiers regardless of 
Active, Reserve, or National Guard status. That is why we created the 
Medical Holdover (MHO) program. In an effort to report MHO patient data 
up and down the chain, we created a Medical Holdover module in our 
Medical Operational Data System (MODS), a proven system with robust 
capabilities for patient tracking and Soldier health reporting. Once we 
were convinced that the data was timely and accurate, we began to 
integrate data from other systems, eliminating so-called 
``stovepipes''. We started with Medical Evaluation Board (MEB) tracking 
data, and now have three more patient tracking and administrative 
systems feeding into MODS. Those measures were so successful that every 
Army major command involved in MHO operations now uses MODS as the sole 
source for information on MHO Soldiers. To further enhance MODS' 
capabilities, we expect to have pay and finance, and personnel data 
integrated over the next 90 days.
    Management and expeditious disposition of MHO Soldiers must balance 
a great number of factors. First, healing takes time. If all combat 
operations ceased today, we would still have MHO patients to care for 
one and one half years from now. Another factor is the simple fact that 
no one knows Soldier health care better than the AMEDD. We know best 
how to treat Soldiers, when Soldiers are fit to return to duty, and 
when they have to undergo a Medical Evaluation Board. For the RC 
Soldier, however, an Army MTF may be hundreds of miles away from home 
and typically, what a Soldier wants most when he or she returns from a 
deployment is to go home.
    In an effort to allow RC MHO Soldiers to receive care close to 
their homes, the Army developed the Community Based Health Care 
Initiative (CBHCI). CBHCI provides top quality health care for ill and 
injured RC Soldiers. It increases the Army's medical treatment, command 
and control, and billeting capacities. Thus, the CBHCI allows the Army 
to reunite Soldiers with their families. The principal instruments of 
the CBHCI are the Community Based Health Care Organizations (CBHCOs). 
These are units staffed primarily by mobilized National Guard Soldiers. 
Their mission is to provide case management for, and ensure command and 
control of healing RC Soldiers. The CBHCOs acquire health care from 
Army, Navy, and Air Force facilities; the VA; and the TRICARE network. 
They represent the Army's commitment to take care of our Soldiers and 
their families with speed and compassion.
    Accession of Health Care Professionals into our Active force is 
becoming a more significant challenge. We are starting to see a 
downturn in our Health Professions Scholarship applicants for both the 
Medical and Dental Corps. Since student scholarship programs are the 
bedrock of Army Medical Department accessions, I have directed my staff 
to closely monitor this trend. We rely on these scholarship programs 
because direct recruitment of fully qualified physicians, dentists and 
nurses is difficult due to the extremely competitive civilian market 
for these skill sets.
    Likewise I am concerned about the retention of health care 
professionals. Their successful retention is a combination of 
reasonable compensation, adequate administrative and support staffs, 
appropriate physical facilities, equity of deployments and family 
quality of life. Changes in Special Pay ceilings have allowed us to 
increase the rates we now offer physicians that sign a four year 
contract. We also have increased the dollar amount that we pay our 
Certified Registered Nurse Anesthetists to improve their retention 
rates. We will continue to evaluate and adjust rates to improve our 
retention efforts. At the same time, we have developed and implemented 
programs to affect the non-monetary issues positively effecting 
retention. We have implemented policies that ensure equity of 
deployments by maximizing our deployment pool, providing adequate 
notification of impending deployment, and providing a predictable 
period of family separation. All of these assist us in the retention of 
our active component medical force.
    The Commander, U.S. Army Recruiting Command and I are working 
diligently toward the establishment and implementation of new and 
enhanced initiatives to reverse these emerging trends. Some of these 
include increasing the recruitment of Physician Assistants; the 
development of a program to allow serving officers to obtain a Bachelor 
of Science in Nursing and the direct involvement of my senior medical 
and dental consultants in the recruitment effort to continue to tell 
the story of the practice of Army Medicine. Of equal concern to me are 
the recruitment challenges facing the Army Reserve and National Guard. 
I fully support all of the actions being taken by the Chief of the Army 
Reserve (CAR), LTG Helmly, and the Director, National Guard Bureau, LTG 
Schultz) as they deal with the unique issues surrounding Army Reserve 
recruitment efforts in the current operational environment.
    As with Recruitment, my staff and I continue to work hand in hand 
with the CAR and the Director of the Army National Guard to determine 
programs necessary for adequate retention. RC Soldiers have continually 
answered the call to service and it is critical that we develop the 
appropriate programs to ensure that their expertise and experience are 
not lost. Considering that over 50 percent of the total Army medical 
force is in the Reserve Components, issues surrounding the financial 
and family impact of extended and recurring deployments must be 
addressed and resolved if we are to retain a viable medical force for 
future operations.
    Several related Army and DOD initiatives are creating temporary and 
permanent population changes on our Army installations. They include: 
support of GWOT pre- and post-deployment health; Modularity--now known 
as Army Modular Force (AMF); Training Base Expansion; the Integrated 
Global Basing and Presence Strategy and Base Realignment and Closing 
(BRAC) 2005. These major population shifts create a tremendous 
challenge for Army Medicine as we try to adjust to meet local and 
regional medical markets.
    As we rebalance the military Health System in the affected markets, 
our continued focus is to provide quality health care that is 
responsive to commanders and readily accessible to soldiers and 
families. We are working very closely with commanders, installations, 
arriving units, family support groups and the local communities 
surrounding our installations to ensure that access and quality of 
healthcare remain high. We are leveraging all available AMEDD, DOD and 
VA health care capacity in each locale. We are working closely with our 
TRICARE Regional Offices and Managed Care Support Contractors on 
market-by-market business case analyses to strike the right balance 
between Direct Care and Purchased Care capacity.
    It should be noted that these are solutions pending release of BRAC 
2005, after which the AMEDD will develop permanent plans for 
rebalancing health service support across installations and regions. 
During fiscal years 2005 and 2006, at many installations, even our 
temporary expansions may lag the arrival of Soldiers and family 
members. In the interim, we are extending clinic hours, hiring 
additional staff, and temporarily increasing referrals to TRICARE 
network providers to insure continuity of care.
    The AMEDD is actively engaged in the DOD Patient Safety Program, 
which is a system-wide effort to reduce medical errors combined with 
non-attributional reporting and multi-disciplinary analysis of events. 
The goal is the trending of incidents, identification of lessons 
learned and the implementation of best practices that can be propagated 
system-wide by the Patient Safety Center. The AMEDD is making 
significant strides in creating a culture of patient safety where staff 
is comfortable reporting patient safety events in an environment free 
of intimidation. We are improving error reporting by increasing 
leadership awareness at all levels through multiple approaches 
including collaborative training efforts with the DOD Patient Safety 
Program.
    Communication is the number one causal factor in almost all patient 
safety events. The AMEDD Patient Safety Program has made major 
advancements in team training in targeted high-risk environments such 
as emergency departments, labor and delivery units, and intensive care 
units. DOD's Pharmacy Data Transaction Service (PDTS), implemented in 
2001, established a centralized, automated drug data repository 
integrating all DOD patients' medication data from medical treatment 
facility pharmacies, the 54,000 TRICARE retail network pharmacies and 
the TRICARE Mail Order Pharmacy. As a direct result of this system's 
ability to screen all patients' medications against the complete 
medication profile, PDTS has prevented over 60,000 clinically 
significant drug-drug interactions, which would have otherwise resulted 
in patient harm. In 2004, a multi-year strategic Army Pharmacy 
automation initiative was implemented and focused on preventing 
medication errors and improving medication-use safety through the 
integration of automation technology at all Army pharmacies worldwide. 
This initiative will reduce and prevent medication errors that often 
lead to increased utilization of more costly healthcare.
    The AMEDD continues to work with DOD to improved medical care for 
RC Soldiers and their family members. RC Soldiers and their families 
now receive TRICARE coverage not only while on active duty but also 
before and after. This can lessen the worries of deployed personnel 
about their family members' health and also serve as an incentive for 
experienced Soldiers to remain in the Reserve after their deployment. 
When a RC Soldier is called to active duty for more than 30 days in 
support of a contingency operation, they and their family members have 
full TRICARE coverage up to 90 days before the start of active duty. 
The coverage is the same as that provided for family members of any 
active duty Soldier, including options for TRICARE Prime and TRICARE 
Prime Remote and eligibility for family dental coverage. To ensure 
continuity of care, these Reservists and family members continue to 
receive TRICARE coverage for 180 days after leaving active duty under 
the Transitional Assistance Management Program (TAMP). After TAMP, 
Soldiers may choose to continue TRICARE coverage for their families for 
up to 18 months under the Continued Health Care Benefits Program 
(CHCBP) or to enroll in the new TRICARE Reserve Select (TRS) program, 
scheduled to be implemented on April 26, 2005. Under TRS, Soldiers 
agreeing to serve in the Selected Reserve may receive one year of 
purchased TRICARE Standard coverage for their families for each 
consecutive 90 days spent on active duty in support of a contingency 
operation.
    From June to November 2004, TRICARE transitioned from eleven 
contract regions and seven contracts to three CONUS regions. The new 
generation of contracts is performance-based and designed to maximize 
the efficient use of military treatment facilities while flexibly using 
civilian healthcare resources when appropriate. Portability of benefits 
between regions is improved and several functions, such as pharmacy and 
the administration of TRICARE for Life have been consolidated into 
nation-wide contracts. As part of the transition to the new contracts, 
measures are being taken to improve coordination between military 
facilities and civilian network providers and to make access to care 
more patient-centered. TRICARE Online (TOL) offers patients better 
information about their choice of appointments and allows them to make 
appointments after normal duty hours, while reducing the rate of ``no-
shows.'' Over 50,000 appointments were made through TOL in 2004, and 
the program is being expanded to include more facilities. A commercial-
off-the-shelf web-based electronic fax service is providing efficient 
transmission of referrals from military treatment facilities to network 
providers. After a successful pilot at 30 facilities, a contract has 
been awarded to provide this service Army-wide. The Enterprise-Wide 
Referral and Authorization process is a high-priority effort to use 
net-centric technology and improved business processes to streamline 
and standardize the referral and authorization of care to network 
providers. The goals of the three-phase plan are to increase patient 
satisfaction, make the referral process more efficient, and to optimize 
allocation of military and civilian healthcare resources. The current 
short-term phase is standardizing several critical processes while 
emphasizing improved handling of urgent referrals.
    The Army continues to improve the quality of healthcare for 
Soldiers and families stationed overseas. The Vicenza Birthing Center 
initiative was driven by cultural differences between child birth 
procedures in local Italian hospitals and U.S. expectations for 
obstetrical and gynecological care. These differences have had an 
adverse impact on family member morale and Soldier readiness for a 
number of years. In multiple venues, U.S. Soldiers and family members 
of the Vicenza community have, with one voice, asked for a safe, 
reliable and accessible U.S. standard of healthcare, particularly in 
regard to obstetrical services. With the deployment of the 173rd 
Airborne Brigade, this concern is even more acute and being championed 
by the U.S. Army Europe Commander. In response to this need, the AMEDD 
developed an interim solution by establishing a temporary birthing 
center at the Vicenza Army Health Clinic. This birthing center will 
accommodate the needs of the vast majority of normal pregnancies and 
births. We will continue to depend on our Italian host nation hospitals 
for emergency obstetrical care. In these cases, care is comparable to 
U.S. standards. The birthing center is currently under construction and 
will be operational by 8 June 2005.
    On December 13, 2002, the Military Vaccine Agency (an executive 
agency of the Army Surgeon General) began implementation of DOD's 
Smallpox Vaccination Program in support of the national smallpox 
preparedness plan announced by the President. The Smallpox Vaccination 
Program is using the existing FDA-licensed smallpox vaccine consistent 
with its label. The program is tailored to the unique requirement of 
the Armed Forces. Like civilian communities, DOD ensures preparedness 
by immunizing personnel based on their occupational responsibilities. 
These include smallpox response teams and hospital and clinic workers, 
as well as designated forces having critical mission capabilities. Like 
other vaccinations, this will be mandated for designated personnel 
unless they are medically exempt. The last year includes both major 
advances and major setbacks in the Military Immunization Program. Since 
December 2002, the DOD has vaccinated more than 770,000 personnel 
(Army: more than 410,000 personnel [military + civilian]) against 
smallpox, representing the largest cohort of smallpox-protected people 
on Earth. These vaccinations have been conducted with great care to 
exempt people with personal medical conditions that bar smallpox 
vaccination. Review by military and civilian experts shows that adverse 
events after smallpox vaccination have been at or below historical 
rates expected among smallpox vaccines. In early 2003, DOD and Army 
clinicians and scientists identified an elevated risk of heart 
inflammation (myo-pericarditis) in male smallpox vaccines in their 20s. 
Our follow-up of these cases shows them to have a rapid and high degree 
of recovery. With clinical teams focused at Brooke and Walter Reed Army 
Medical Centers, we continue to follow these patients and provide them 
state-of-the-art care, to learn more about the condition.
    The Department lost an important countermeasure against anthrax 
weapons in October 2004, when a U.S. District Court judge enjoined 
operation of the Anthrax Vaccination Immunization Program (AVIP) for 
inoculation using Anthrax Vaccine Adsorbed (AVA) to prevent inhalation 
anthrax. Anthrax spores continue to be the#1 threat among bioweapons. 
Until the injunction, the DOD had administered 5.2 million doses of AVA 
to 1.3 million people (Army: more than 1.9 million doses to over 
500,000 people), as well as assisting with 20 human safety studies 
described in 34 publications in medical journals. In April 2005, the 
Court agreed to allow the DOD to restart the AVIP under a U.S. Food and 
Drug Administration Emergency Use Authorization and the Army is 
preparing to administer AVA to individuals between 18 and 65 years of 
age who are deemed by DOD to be at heightened risk of exposure due to 
attack with anthrax. The terms of the Emergency Use Authorization allow 
Soldiers to refuse receiving the AVA without penalty after reviewing 
educational information on AVA. I expect we will restart the program 
under the Emergency Use Authorization by mid-May 2005 for Soldiers 
serving in, or deploying to, Southwest Asia and Korea.
    Army scientists continue their work in research and development of 
new vaccines, including adenovirus vaccines, malaria vaccine, and 
plague vaccine. These vaccines are needed to protect against microbes 
that threaten Soldiers in basic training, in tropical locations, or as 
bioweapons, respectively. Adenovirus vaccine research involves tablets 
to protect against a militarily relevant respiratory germ. Malaria is 
one of the leading infectious causes of death around the world. The 
Walter Reed Army Institute of Research's malaria research program is a 
world leader in this field. Plague vaccine research is centered at the 
US Army Medical Research Institute of Infectious Diseases, another 
world-class asset of the U.S. Army.
    During all this unprecedented activity and keen competition for 
limited resources, the courage, competence and compassion of the 
AMEDD's people amaze me. Despite the long hours, separation from 
family, danger, and hardship required to fight the Global War on 
Terrorism, they remain firmly committed and motivated to provide the 
best possible support for American Soldiers, their families, and all 
others who are entrusted to their care. Nothing saddens us more than to 
lose a Soldier. With your continued support, the AMEDD will continue to 
do everything possible to prevent these terrible losses whether from 
battle wounds or non-battle illnesses and injuries. We will always 
remember our core mission: to preserve Soldiers' lives and health 
anywhere, anytime, in war and in peace. We will never forget the 
Soldier.
                                 ______
                                 
        Biographical Sketch of Lieutenant General Kevin C. Kiley

    Lieutenant General Kevin C. Kiley, M.D., is a 1972 graduate of the 
University of Scranton, with a bachelor's degree in biology. He 
received his medical degree from Georgetown University School of 
Medicine in 1976. He served a surgical internship and then an 
obstetrics and gynecology residency at William Beaumont Army Medical 
Center, El Paso, Texas, graduating in 1980.
    His first tour was with the 121st Evacuation Hospital in Seoul, 
South Korea, where he was the chief of OB/GYN services from 1980 to 
1982. He returned to the residency training program at William Beaumont 
Army Medical Center and served as Chief, Family Planning and Counseling 
Service. He then served as Assistant, Chief of the Department of OB/GYN 
until February 1985.
    He was assigned as the Division Surgeon of the 10th Mountain 
Division, a new light infantry division in Fort Drum, New York. In July 
1985, he assumed command of the newly activated 10th Medical Battalion, 
10th Mountain Division. He served concurrently in both assignments 
until May 1988. He returned to William Beaumont Army Medical Center, 
where he first served as the Assistant Chief, then Chairman of the 
Department of OB/GYN.
    In November 1990, he assumed command of the 15th Evacuation 
Hospital at Fort Polk, Louisiana, and in January 1991, he deployed the 
hospital to Saudi Arabia in support of Operations Desert Shield and 
Desert Storm. Upon his return, he was assigned as the Deputy Commander 
for Clinical Services at Womack Army Medical Center, Fort Bragg, North 
Carolina, from November 1991 to November 1993.
    He is a 1994 graduate of the U.S. Army War College, Carlisle 
Barracks, Pennsylvania. He assumed command of the Landstuhl (Germany) 
Regional Medical Center and what is now the U.S. Army Europe Regional 
Medical Command at Landstuhl, Germany, June 30, 1994. He also served 
concurrently as the Command Surgeon, U.S. Army Europe and 7th Army from 
September 1995 to May 1998.
    In April 1998 he assumed the duties as; Assistant Surgeon General 
for Force Projection; Deputy Chief of Staff for Operations, Health 
Policy and Services, U.S. Army Medical Command; and Chief, Medical 
Corps. On June 5, 2000 he assumed duties as Commander of the U.S. Army 
Medical Department Center and School and Fort Sam Houston and continued 
as Chief of the Medical Corps. He served as the commander of Walter 
Reed Army Medical Center and North Atlantic Regional Medical Command 
and Lead Agent for Region I from June 2002 to June 2004.
    Lieutenant General Kiley assumed the duties of Acting Commander, 
U.S. Army Medical Command on 8 July 2004. After receiving Senate 
confirmation of his nomination, he was sworn in as the 41st Army 
Surgeon General and assumed the duties as Commanding General, U.S. Army 
Medical Command on October 4, 2004. He was promoted to the grade of 
Lieutenant General on October 12, 2004.
    He is a board-certified OB/GYN and a fellow of the American College 
of Obstetricians and Gynecologists.
    Among his awards and decorations are the Distinguished Service 
Medal, Defense Superior Service Medal, Legion of Merit (three Oak Leaf 
Clusters), Bronze Star Medal, Defense Meritorious Service Medal, 
Meritorious Service Medal (two Oak Leaf Clusters), Army Commendation 
Medal, The Army Superior Unit Award (one Oak Leaf Cluster), the ``A'' 
professional designator, the Order of Military Medical Merit, and the 
Expert Field Medical Badge.

    Senator Stevens. Senator Mikulski, I was not looking in 
your direction. Did you have an opening statement?
    Senator Mikulski. I will do that when I get to my 
questions.
    Senator Stevens. Thank you. I apologize for not recognizing 
you.
    Admiral Arthur.

STATEMENT OF VICE ADMIRAL DONALD C. ARTHUR, MEDICAL 
            CORPS, SURGEON GENERAL, UNITED STATES NAVY
    Admiral Arthur. Yes. Good morning, Chairman Stevens, 
Senator Inouye, Senator Mikulski. Thank you very much for 
having us here this morning.
    I am not going to read my statement. You have read that and 
I appreciate that.
    Senator Stevens. All of your statements will be printed in 
the record as if read.
    Admiral Arthur. Yes, sir. I would like to make some general 
comments and to reiterate some of what is in here, but not all 
of it.
    First, I would like to highlight that we have a series of 
priorities in Navy medicine, and the first will always be our 
readiness. We break readiness down into a number of different 
factors.
    The first and foremost is to make sure that our sailors and 
marines and whatever soldiers, airmen, and coast guardsmen we 
take care of are ready for their duties and are a healthy 
population, as well as their families so that they have the 
confidence that they can go and deploy and we will take care of 
their families.
    Our second readiness priority is to be ready ourselves to 
deploy in whatever manner we are asked to. I was in Iraq in 
December and January. I noticed we had so many significant 
improvements in how we do business in the combat arena over 
Desert Storm where I served with the marines. We had, for 
example, digitized radiography. We had computers all over. We 
had a lot of advanced systems. The thing that was the most 
critical to the care of wounded soldiers and marines over there 
was the training that the corpsmen and medics got. The corpsmen 
and medics were there and delivered the care right at the time 
of wounding. The training of the surgical teams, the rapid 
medevac, and the incredibly great service at Landstuhl on the 
way back to the United States. I think you can be very, very 
proud of the care that your wounded soldiers, marines, sailors, 
airmen, coast guardsmen are getting over there. As Senator 
Inouye said, it is the best in history with the lowest disease 
non-battle injury rate and the greatest survivability in the 
history of combat.
    A third priority for our readiness is homeland security, 
and this is an area of great concern for me because I think 
that in some sectors of our Government, we have not yet fully 
prepared for an attack on our homeland. We have a program with 
the Bethesda Military Medical Center compound, as well as the 
National Institutes of Health (NIH) compound right next door, 
and the Suburban Hospital Trauma Center, to form a mega-center 
which could respond to casualties in the National Capital area, 
and you should be seeing more about that very soon.
    Our second priority is to continue to deliver the quality 
health care for which we have become well known. We have the 
advantage of being a health care system as opposed to much of 
the rest of America where I believe we have a disease care 
industry. We get paid not by how many procedures and how many 
immunizations we give, but we get paid by our line and the 
number of soldiers, sailors, airmen, and marines we have on 
duty, and that is our metric for success.
    The Chief of Naval Operations (CNO) interviewed me 1 year 
ago for this job that I am currently honored to hold, and he 
asked me could our casualties be seen and treated at civilian 
hospitals, and I said, well, sure they could. They can be very 
well treated at Johns Hopkins or at Mayo Clinic. But those 
hospitals would not understand two things that are critical to 
our treatment of our casualties.
    Number one, that the soldiers, sailors, airmen, and 
marines' injuries are not just to that person, they are to his 
or her entire family. These are family injuries.
    The second thing that civilian hospitals will not 
understand about our casualties is that even lying at Bethesda 
or Walter Reed, these marines and soldiers are still in combat. 
They still remember the stresses that they incurred in combat 
and we care for them in a way that civilian hospitals could not 
do just because we have the background and we have shared that 
combat experience with them.
    We have another advantage in our delivery of quality health 
services in our collaboration with the Veterans Administration 
(VA). Yesterday Secretary Nicholson opened up the joint DOD-VA 
clinic at Pensacola, Florida. We have joint clinics which we 
are building in Great Lakes and Charleston, South Carolina that 
I think will be of great benefit to both veteran populations.
    Our third priority is to help shape the force of the 
future, not to meet the needs of yesterday but meet tomorrow's 
needs, which will include not just the traditional combat 
casualty care, but also homeland security, stability 
operations, and the global war on terror requirements. This may 
require that we shape our forces differently, that we have some 
different capabilities than we thought we would need if only 
our missions were combat casualty care, and I refer to the 
recent mission of Mercy in Banda Aceh taking care of tsunami 
and disaster relief victims over there. They needed surgeons. 
They needed the combat casualty care type of specialties, but 
they also needed pediatricians, OB-GYN specialists, preventive 
medicine specialists, and all of those specialties that are not 
necessarily planned for combat casualty care.
    We are focusing on Active and Reserve integration; that is, 
that we more fully incorporate our Reserve component in our 
active duty warfighting plans. We now have six Active duty 
fleet hospitals, for example, and two Reserve fleet hospitals. 
We would like to have just eight fleet hospitals that combine 
Active and Reserve components to be more fully integrated.
    One other integration effort that I think would be of great 
benefit is to better integrate the three service medical 
departments in how we train, equip, recruit, supply, and how we 
deploy so that we can be as fully interoperable in the combat 
arena as we can be.
    And last, I would like to thank you very much for your 
support and the encouragement that you have given us in finding 
the best casualty care management for the veterans that are now 
over there in OIF and OEF.
    I apologize. I will have to leave before my colleague, Rear 
Admiral Lescavage, testifies. I have to fly out of town, but we 
are very proud of the accomplishments of our Navy Nurse Corps 
as a member of our team.

                           PREPARED STATEMENT

    Senator Inouye, you mentioned that you were proud of the 
accomplishments of our Medical Corps. I would say one of the 
great benefits of our Medical Department is that we are not 
just a medical corps or a nurse corps of a medical service 
corps or dental corps or a hospital corps. We are a 
combination. We are the team. It is that teamwork, that 
synergistic effort of all of our corps together, that really 
makes us strong. You do not find that in civilian institutions, 
and that is what I think makes our military medical departments 
great.
    Thank you very much.
    Senator Stevens. Thank you, Admiral.
    [The statement follows:]

          Prepared Statement of Vice Admiral Donald C. Arthur

    Chairman Stevens, Ranking Member Inouye, distinguished members of 
the subcommittee, I welcome the opportunity to share with you how Navy 
Medicine is taking care of our nation's Sailors, Marines, and their 
families.
    As our nation continues to fight the Global War on Terror, Navy 
Medicine will continue to meet the health care needs of our 
beneficiaries, active duty, military retirees, and eligible family 
members. These efforts reflect our unrelenting commitment to our 
primary mission--Force Health Protection. The components of Force 
Health Protection are: (1) preparing a healthy and fit force; (2) 
deploying medical personnel to protect our warriors in the battlefield; 
(3) restoring health on the battlefield; (4) providing care to our 
retired warriors through TRICARE for Life; and (5) providing world-
class health care for all beneficiaries.
Priorities
    To meet the needs of those entrusted to our care, Navy Medicine 
established five priorities to meet our unique dual mission. That dual 
mission is first, to support and protect our operational forces while 
working in concert with the Chief of Naval Operations' and Commandant's 
vision for the Navy-Marine Corps team, and second, to provide health 
care to their family members and retirees.

            Readiness
    Readiness is our number one priority. To be ready, Navy Medicine 
must be responsive, agile and aligned with operational forces. We need 
to have the right people with the right capabilities ready to deploy in 
support of the Navy-Marine Corps team.
    In current operations, Navy Medicine has made significant 
advancements in the health care provided by First Responders and 
improved surgical access during the critical ``golden hour.'' In 
addition to improving health care after traumatic battlefield injuries, 
Navy Medicine is also curbing infectious disease outbreaks, decreasing 
occupational injuries, and providing preventive medicine and mental 
health care services.
    An outstanding example of Navy Medicine's more capable, flexible 
and responsive force is the creation of the Expeditionary Medical 
Facility (EMF). These facilities, with similar capabilities as Fleet 
Hospitals, are lighter and more mobile and can be set up within 48 
hours. EMFs may be used independently or in combination with the 
theater's joint health system for evacuation, medical logistics, 
medical reporting, and other functions, ensuring better 
interoperability with the Army and the Air Force. The flexibility of 
EMFs continues to evolve to meet operational requirements and provide 
robust medical care for major conflicts, low-intensity combat, 
operations other than war, and disaster/humanitarian relief operations.
    We are also expanding the role of Navy Medicine on the battlefield 
with the 1,000 Sailors either deployed overseas or preparing to deploy 
with Maritime Force Protection Command units. These Sailors receive a 
half-day in training from doctors and hospital corpsmen in how to use 
special medical kits. These ``Point of Injury'' kits contain items like 
an easy to use tourniquet, a specialized compression bandage, QuikClot 
(a product designed to stop bleeding), antibiotic and pain medications. 
These kits are designed for self-care or buddy care in the minutes 
before a corpsman arrives on the scene.
    The Global War on Terror has challenged us to broaden our view of 
medical readiness. Our Military Treatment Facilities (MTF) are prepared 
to respond to any contingency, to provide expert health care to 
casualties returning from theater, and be ready to support the Nation's 
needs in collaboration with the National Disaster Medical System. 
Additionally, Navy Medicine launched three major initiatives to meet 
the needs of disaster preparedness focused on staff, supplies and 
systems.
    Using the Strategic National Stockpile as a model, we are planning 
for additional equipment to enhance the capabilities of local MTFs. We 
developed a successful multi-service online medical and emergency 
management educational tool, as well as an Emergency Management Program 
Readiness Course that has become the DOD Medical training standard. The 
Disaster Preparedness, Vulnerability Analysis Program (DVATEX) was 
developed to evaluate military, federal, and local community 
responsiveness. This program goes beyond assessing MTF threat 
vulnerability and capability assessment; it also provides training in 
medical and operational management.
    Collaboration with other organizations, including other federal and 
civilian agencies, is essential for effective and efficient disaster 
response. A local example of this type of collaboration is taking place 
at the National Naval Medical Center in Bethesda, Maryland. Because of 
its proximity to the National Capital Region, the National Naval 
Medical Center established a disaster preparedness and response 
coalition with the National Institutes of Health and Suburban Hospital 
Healthcare System in Bethesda. Recently, they conducted a joint 
disaster drill involving Montgomery County and municipal emergency 
response organizations and other members of the local area hospital 
network.
    Delivering a more fit and healthy force, mitigating the risk of 
injury or illness, and providing more effective resuscitation of 
battlefield casualties will enhance Navy Medicine's readiness and 
ability to prosecute the Global War on Terror. Medical research and 
development is a critical enabler of this effort. Our research 
investments allow us to transform into a defensive weapon system that 
will promote health and fitness, protect people from injury and 
disease, and effectively reduce, manage and rehabilitate casualties. In 
addition, these research investments and capabilities help Navy 
Medicine respond to the current and future needs of the Fleet and Fleet 
Marine Force.
    Navy scientists conduct basic, clinical, and field research 
directly related to military requirements and operational needs. 
Current studies focus on the efficacy trials for blood substitutes to 
treat combat casualties; new treatment modalities for musculoskeletal 
injuries and acute acoustic barotrauma; and solutions for the emerging 
threats of combat stress, among others. Our medical research laboratory 
facilities equal those at modern academic and industrial institutions. 
Beyond this capacity, a number of these laboratories have unique test 
equipment and specialized software for pursuing research on current and 
projected biomedical problems. Research is further supported in other 
Navy laboratories as well as in partnership with the Army and Air 
Force, and other Federal agencies.
    Research in non-government laboratories is promoted through an 
active collaborative research and technology transfer program that 
develops cooperative research and development agreements with 
universities and private industry to ensure that research products from 
our laboratories benefit the entire country. Navy-supported medical 
research efforts have influenced the civilian practice of medicine, 
assisted the Ministries of Health in developing nations, and provided 
technology for other Federal initiatives.
    Our overseas research facilities are national assets serving the 
strategic interests of the regional Combatant Commander and the local 
Ambassador. They bring unique surveillance capabilities and advanced 
laboratory capabilities to areas where infectious diseases are a 
significant threat to our personnel. These capabilities were recently 
leveraged in the tsunami relief effort in Banda Aceh. In addition to 
supporting the mission of Force Health Protection, the overseas labs 
are strategic partners in promoting Theater Security Cooperation. 
Lastly, they are developing a new alliance with the Centers for Disease 
and Control to further that agency's efforts in mitigating the risk 
that emerging infectious diseases pose to the health of our citizens 
and our economy.

Quality, Economical Health Services
    Navy Medicine's second priority is providing quality, cost-
effective health services. While focusing on quality health care, Navy 
Medicine has recognized the need to provide the best possible health 
care within our resource constraints. Through careful business 
planning, Navy Medicine aligned MTF operations to focus on the 
preservation of health, and the prevention of disease and injury. 
Recently, the Naval Health Clinic in Pearl Harbor instituted a new 
Individual Health Readiness (IHR) program. The goal of this program is 
to ensure each Pearl Harbor Sailor is healthy and mission-ready. It was 
established to build and improve total Navy Regional Hawaii health 
readiness in response to a growing number of shore and sea Sailors 
deploying. The IHR program ensures each Sailor has an up-to-date health 
assessment to determine deployment limiting conditions, dental 
readiness, immunization status, lab studies and individual medical 
equipment needs to ensure the command's level of health readiness--both 
dental and medical--is 95 percent or better.
    An enterprise focused on quality must understand what products or 
services have value to its customers and the metrics used to measure 
the delivery of quality health care. In meeting quality standards, Navy 
Medicine must take into consideration regulatory compliance 
requirements, the working environment, as well as evaluating the 
patients' experience.
    The many facets of quality control provide us with constant 
opportunity to evaluate health care delivery. For example, creating a 
fit force translates into improved Medical Readiness for our warriors, 
while ensuring a highly trained and ready Medical team to provide 
compassionate quality care for the wounded, injured, or sick. In 
addition, Navy Medicine has designated a Combat Operational Stress 
Consultant to serve as the Navy and Marine Corps subject matter expert 
on combat and operational stress. This consultant will allow Navy 
Medicine increased oversight and further development of prevention and 
mental health care efforts for our military personnel.
    We established a family-centered care program to enhance patient 
safety, health, cost efficiency and patient and staff satisfaction. We 
are currently working with the TRICARE Management Activity and the 
other services to ensure that the program is widely available. In 
addition, we have coordinated our efforts with other related entities 
within Navy Medicine, such as the Perinatal Advisory Board, to optimize 
our efforts.
    Increased cooperation and collaboration with our federal health 
care partners is essential in providing quality care. As an extension 
of our ability to care for our patients, Navy Medicine's partnership 
with Veterans Affairs medical facilities continues to grow and develop 
into a mutually beneficial partnership. Although not directly related 
to the Military Health System, it is imperative that Navy Medicine 
strengthens its relationship with the Department of Veterans Affairs. 
This begins with the seamless transfer of care for injured service 
members to the VA and includes sharing resources to optimize our 
efforts and avoid duplicating services.
    The care for Sailors and Marines who transfer to and receive care 
from a VA facility while convalescing is coordinated through the VA 
Seamless Transition Coordinator. This full time VA staff member is co-
located at National Naval Medical Center and interacts with OEF/OIF 
Points of Contact at each VA Medical Center. The Seamless Transition 
Program was created by former Veterans' Affairs Secretary Principi 
specifically to address the logistical and administrative barriers for 
active duty service members transitioning from military to VA-centered 
care.
    Although recently-wounded Sailors and Marines differ from the VA's 
traditional rehabilitation patient in age and extent or complexity of 
injury, Navy Medicine and the VA must adapt to meet their needs. In the 
past, patients were admitted to the VA's rehabilitation service with 
multiple clinical services addressing individual requirements. To 
enhance continuity, clinical outcomes, and improved family support, 
National Naval Medical Center physicians now remain as the Case 
Managers throughout the transition process. Currently, weekly 
teleconferences to review Bethesda transfer patients are conducted with 
primary transfer sites, such as the VA Medical Center in Tampa, 
Florida. In addition to site visits and teleconferences, Navy Medicine 
will continue to coordinate with other facilities, forge relationships, 
share best practices, and enhance delivery to all of our patients. This 
level of interaction and cooperation will need to continue at every 
level to ensure the care of our wounded warriors is never compromised.
    With regard to the sharing of resources, the level of sharing 
between DOD and VA health care activities has improved. Navy Medicine 
supports Commanding Officers who pursue sharing and collaboration with 
VA facilities in their communities. In fact, Navy Medicine currently 
manages 28 medical agreements and 45 dental agreements through the 
Military Medical Support Office (an office that coordinates health care 
for active duty members who are stationed in remote areas without local 
Military Medical Treatment Facilities).
    Some of these agreements represent efforts to consolidate support 
functions for the medical facilities. However, other more comprehensive 
examples of resource-sharing efforts between the agencies include: the 
Navy Blood Program at Naval Hospital Great Lakes which uses the North 
Chicago Veterans Affairs Medical Center spaces to manufacture blood 
products in exchange for blood products, precluding the need for Navy 
to build a new blood center at Naval Hospital Great Lakes; and the DOD/
VA Federal Pharmacy Executive Steering Committee (FPESC) which was 
charted to oversee joint agency contracts involving high dollar and 
high volume pharmaceuticals designed to increase uniformity and improve 
the clinical and economic outcomes of drug therapy in both systems.
    Navy Medicine is also partnering or planning to partner with the VA 
in five hospital/ambulatory care center construction projects. Naval 
Hospital Pensacola is working with the VA on a joint-venture outpatient 
medical care facility; Naval Hospital Charleston has a future VA 
construction start for a Consolidated Medical Clinic (CMC) aboard Naval 
Weapons Station Charleston, SC; Naval Hospital Great Lakes is 
considering Joint Ambulatory Care Clinic adjacent to the North Chicago 
Veterans Affairs Medical Center's main facility; Naval Hospital Guam is 
considering a project where the VA would accept an adjacent site to 
construct a small freestanding community-based outpatient clinic from 
Navy; and Naval Hospital Beaufort is also considering a future project 
with the VA.
    Guided by Navy Medicine leadership, last year each MTF developed a 
comprehensive business plan focused on meeting operational readiness 
requirements while improving population health. These plans emphasize 
such areas as improved contingency planning, pharmacy management, 
clinical productivity, implementation of evidence-based medicine, 
advanced access, and seamless referral management for beneficiaries. 
Navy Medicine is currently in the process of creating a system that 
will allow MTF commanders to monitor their performance in these areas 
so they can better balance measures of operational readiness, customer 
satisfaction, internal efficiency and human capital development.
    Beginning in the early 1990's, Navy Dentistry began consolidating 
its command suites from 34 commands to 15. The cost savings included 
the elimination of redundant officer, enlisted and civilian support 
personnel formerly involved in the administration of the separate 
command infrastructure. In 2004, Navy Dentistry again consolidated 15 
commands into three. The primary objective of the most recent dental 
consolidation was to integrate Dental Commands with the larger MTF 
command suite in the shared geographical area to eliminate more than 90 
duplicate administrative functions--all of this was accomplished 
without adverse impact on the dental health care delivered and in a 
manner that is transparent to the customers. The remaining three 
commands are the Dental Battalions supporting the Fleet Marine Force.
    As Navy Medicine strives to obtain long-term value through disease 
prevention and increased quality of life, each MTF business plan 
includes a preventive health initiative with the goal of exceeding 
national measures of breast health promotion, long-term asthma 
management and control of diabetes. Our leadership developed guidelines 
for these Navy-wide efforts and created tools to monitor performance in 
these areas. Next year, we plan to expand our efforts to address 
obesity, lack of exercise and tobacco use; with the goal of reducing 
the risk of long-term disabling illnesses.
    Finally, another critical component of providing quality care 
requires that Navy Medicine be an active participant in the 
implementation of the new TRICARE contracts. Although the TRICARE 
benefit structure remains the same, there have been changes in program 
administration that are intended to make health care delivery more 
customer-focused and support better coordination between MTFs and 
civilian provider networks. Organizational changes implemented to 
support the new business environment include the disestablishment of 
Lead Agents and the establishment of three TRICARE Regional Offices 
(TRO) aligned with the regional contracts in the United States--North, 
South, West. Each of the Services was responsible for providing a Flag/
General Officer or Senior Executive Service civilian dedicated for a 
TRO Director position: Army-North, Air Force-South, Navy-West. The Navy 
has named RADM Nancy Lescavage as the second TRO Director. RADM 
Lescavage is relieving retiring RADM James Johnson in June 2005.
Shaping Tomorrow's Force
    The Navy and Marine Corps are reshaping the fighting force by 
defining future requirements, including the medical requirements of the 
warfighters. As a result, Navy Medicine's third priority--Shaping 
Tomorrow's Force--focuses on recruiting, training, and retaining the 
most capable uniformed members to match manpower to force structure to 
combat capability. This is an important piece of the Department of the 
Navy's more comprehensive Human Capital Strategy.
    Navy Medicine is quickly transforming in concert with the Navy and 
Marine Corps to provide medical support to the fighting forces as they 
adapt to the changing nature of global warfare, including emerging 
missions such as: humanitarian operations, regional maritime security, 
providing care for detainees, and homeland defense--all of which place 
additional requirements on shaping the force of the future. Our 
uniformed personnel will participate in increasingly complex joint 
environments and move efficiently between forward deployed settings and 
fixed facilities ashore. We must be proficient and productive at the 
right cost.
    A recent example of the Navy Medicine's flexibility in engaging in 
a humanitarian mission would be the rapid response to the earthquake 
and tsunamis that struck the Indian Ocean. Within days, U.S.S. Abraham 
Lincoln and U.S.S. Bonhomme Richard were en route to assist those in 
need. U.S. helicopters from Lincoln and from Bonhomme Richard 
Expeditionary Strike Group, afloat in the Indian Ocean, proved 
invaluable in delivering relief supplies to remote areas. After the 
carrier strike group left, one of the Navy's hospital ships, U.S.N.S. 
Mercy, took over the mission and deployed with a robust medical 
capability and the support services appropriate for disaster relief. 
The ship offered shipboard health services and sea-based support to a 
variety of military and civilian support agencies, including U.S. non-
government organizations, involved in the relief effort. In addition, 
Sailors from the Navy Environmental Preventive Medicine Unit out of 
Pearl Harbor worked on improving sanitation and holding down mosquito 
populations, while ship's nurses went ashore and conducted classes on 
patient care.
    Currently, Navy Medicine is deployed afloat and ashore in five 
geographic regions, providing preventive medicine, combat medical 
support, health maintenance, medical intelligence and operational 
planning. This operational tempo, along with the nature of casualties 
from Operations Enduring and Iraqi Freedom, has created new demands for 
medical personnel in terms of numbers and types of specialties needed. 
As a result, Navy Medicine analyzed the uniformed and civilian 
communities of medical and dental providers to ensure it is meeting 
operational requirements as efficiently as possible.
    In order to meet the transformation requirements, the uniformed and 
civilian personnel composition of some Navy medical specialties will 
change in the near future. For example, over 1,700 non-readiness 
related military positions are being converted into civilian positions 
in 2005. We want to ensure operational requirements are fulfilled by 
uniformed personnel-while identifying those functions that can be 
performed by civilian or contractor personnel. Our intent is not to 
eliminate positions, but rather to reduce the number of active duty 
personnel performing non-readiness functions.
    A key component of Shaping Tomorrow's Force is the quality and 
innovative delivery of education and training provided to medical 
personnel. Streamlining our education and training assets has served us 
well as Navy Medicine embraces new technologies and methods of 
learning. These new technologies will have a profound impact upon 
quality of training and in saving money and time. By maximizing the use 
of remote-learning capabilities, Navy Medicine ensures that medical 
personnel have access to the right training at the right time. Also, we 
continue to study the value of advanced simulation training for our 
health care providers. By introducing simulated patients into the 
training curriculum, medical personnel are able to practice skills in 
an environment that will prepare them for real world situations.

One Navy Medicine: Active and Reserve
    Navy Medicine is one team. It is comprised of tremendously capable 
individuals--Active Duty, Reserve and Civilian. We must seamlessly 
integrate the talents and strengths of our entire workforce to 
accomplish our dual mission--Force Health Protection and quality health 
care to our beneficiaries.
    One of our goals is to better utilize the expertise of our Reserve 
force by increasing integration with the active duty component. We no 
longer have separate Active and Reserve fleet hospitals, but one fleet 
hospital system where Reservists work side-by-side with active duty 
personnel. The establishment of these Operational Health Support Units 
(OHSU) has created increased cooperation and collaboration between both 
components. In addition, consolidation of dental units into the OHSUs 
has been done to mirror changes implemented by Navy Medicine's active 
component.
    Reservists comprise 20 percent of Navy Medicine's manpower 
resources and their seamless integration with our active duty force is 
a major priority in achieving our ``One Navy Medicine'' concept. Since 
the beginning of Operation Iraqi Freedom, more than 3,700 Reservists 
have been activated to be forward deployed or to meet the needs of MTFs 
whose active duty personnel were deployed. In addition, the Navy's 
Expeditionary Medical Facility Dallas deployed earlier this year to 
Kuwait with 382 people, 366 of which were Reservists.
    Through an innovative Medical Reserve Utilization Program (MEDRUP), 
Navy Medicine's headquarters assumes operational control of medical 
Reservists called to active duty. They are selected using an 
information system that manages more than 6,000 Navy medical Reservists 
and matches personnel to requirements based on qualifications, 
availability and criteria. This system has proven indispensable in 
employing Reservists in support of the Global War on Terror.
    Finally, with regard to the Reserve Component, Navy Medicine 
provides physical and dental services to the Navy's Reserve Force 
(71,500) and Marine Corps Reserve (37,734) personnel in support of 
individual medical readiness--a critical component prior to 
mobilization.

Delivery of Joint Defense Health Services
    Navy Medicine's final priority addresses how we jointly operate 
with the Army and Air Force. Ideally, all U.S. medical personnel on the 
battlefield--regardless of service affiliation--should have the same 
training, use the same communications system and operate the same 
equipment because we are all there for the same reason--to protect our 
fighting forces. It should not matter whether the casualty is a 
Soldier, a Sailor, an Airman or a Marine. The individual should receive 
the same care, and service medical personnel should be similarly 
trained to provide this same level of care. Along with the Army and the 
Air Force, Navy Medicine is actively pursuing the concept of 
standardized operating procedures to ensure consistency of health care 
and interoperability of our medical forces through a Unified Medical 
Command. As a Unified Medical Command, the mission of our separate 
medical departments could implement reductions to the internal costs of 
executing our missions while providing a framework of interoperability 
among the services.
    Mr. Chairman, Navy Medicine has risen to the challenge of providing 
a comprehensive range of services to manage the physical and mental 
health challenges of our brave Sailors and Marines, and their families, 
who have given so much in the service of our nation. We have 
opportunities for continued excellence and improvement, both in the 
business of preserving health and in the mission of supporting our 
deployed forces, while at the same time protecting our citizens 
throughout the United States.
    I thank you for your tremendous support to Navy Medicine and look 
forward to our continued shared mission of providing the finest health 
services in the world to America's heroes and their families--those who 
currently serve, those who have served, and the family members who 
support them.

    Senator Stevens. General Taylor.

STATEMENT OF LIEUTENANT GENERAL GEORGE PEACH TAYLOR, 
            JR., M.D., AIR FORCE SURGEON GENERAL, 
            DEPARTMENT OF THE AIR FORCE
    General Taylor. Mr. Chairman, Senator Inouye, Senator 
Mikulski, and other members of the subcommittee, it is a 
privilege and pleasure to be here today. I look forward to 
working with you on our common goals to ensure a sustained high 
quality of life for our military members and their families. We 
appreciate your interest and support in providing for America's 
heroes.
    I am proud to say that the men and women of the Air Force 
Medical Service have done an exceptional job throughout 
Operations Nobel Eagle, Enduring Freedom, and Iraqi Freedom in 
providing the expeditious, state-of-the-art health care for 
Active duty and Reserve component personnel of all the 
services. We attribute our success to our continued focus on 
four health effects: providing care to casualties, ensuring a 
fit and healthy force, preventing disease and injury, and 
enhancing human performance.

                     EXPEDITIONARY MEDICAL SUPPORT

    Our light, lean, and mobile expeditionary medical support 
(EMEDS), is the linchpin of our ground mission. Our EMEDS 
modularity has supported our field commanders by ensuring the 
right level of medical care is provided to our warriors 
wherever they are. As important, the speed with which we can 
deploy EMEDS is unprecedented, making EMEDS the choice for 
special forces and quick reaction forces in the United States, 
as well as abroad.
    As part of a joint team, we now have more than 600 medics 
in 10 deployed locations, including running the large theater 
hospital in Balad, Iraq, and two smaller hospitals in Kirkuk 
and at the Baghdad International Airport. Just as in the 
States, these serve as regional medical facilities for all the 
services.
    Our approximately 400 aeromedical evacuation personnel, the 
majority of them Guard and Reserve, are doing incredible work, 
accomplishing more than 55,000 patient movements since the 
beginning of Operation Iraqi Freedom.
    In addition, partnering with our critical care air 
transport teams, our aeromedical evacuation system has made it 
possible to move seriously injured patients with astonishing 
speed, as short as 36 hours from the battleground to stateside 
medical care, unheard of even a decade ago.

                 DEPLOYMENT HEALTH SURVEILLANCE PROGRAM

    Caring for our troops also means ensuring that they are 
healthy and fit before they deploy, while they are deployed, 
and when they return home. We work very, very hard on our 
deployment health surveillance program. The payoff has been 
that we had the lowest disease non-battle injury rates of all 
time. That care extends beyond the area of operations. Since 
the first of January 2003, we have accomplished 100,000 post-
deployment assessments for Air Force Active duty and Reserve 
component personnel with 9.5 percent requiring follow-up for 
deployment related medical or dental health concerns. We are 
meticulously tracking every airman to ensure that he or she 
receives all the health care needed, including mental health 
help, which I would like to describe in some detail.
    We deploy two types of mental health teams to support our 
deployed airmen, a rapid response team and an augmentation 
team. We currently have 49 mental health personnel deployed for 
current operations, 31 of whom are supporting Army or joint 
service requirements. Behavioral indicators during OEF and OIF 
are encouraging. In our review of data from fiscal years 2000 
and 2004, child abuse rates remained virtually unchanged, and 
spouse abuse rates and alcohol-related incident rates actually 
declined over the past 5 years. To date, there have been no Air 
Force suicides in Iraq or Afghanistan during OEF or OIF.
    However, we are increasingly supporting Army and Marine 
operations. We need to be prepared for our Air Force troops to 
have greater exposure to traumatic stress. Initiatives to 
reassess the mental health status of our personnel, 90 to 180 
days post-deployment, will allow us to better monitor and 
address mental health needs as they emerge.

                          FIT TO FIGHT PROGRAM

    Another critical way we are protecting the health of Air 
Force members is with a revitalized physical fitness program 
that will improve their safety and performance in the 
expeditionary environment and help them survive significant 
injury and illness. Our fitness centers have seen an 
approximate 30 percent jump in use. I am proud to be part of 
General Jumper's strong push, fit to fight, an initiative that 
has focused on both the individual and commander 
responsibilities for health and well-being.

                 EPIDEMIC OUTBREAK SURVEILLANCE PROJECT

    Our prevention efforts also include cutting edge research 
and development, such as the epidemic outbreak surveillance 
project (EOS), an Air Force initiative that combines existing 
and emerging biodefense technologies that will eventually be 
deployed worldwide for near real-time total visibility of 
biological threats to our troops. Through gene shift 
technology, EOS will offer us the power of knowing when and who 
a disease is stalking. This is the incredible medicine of the 
future that will change how we do business forever, and we are 
doing it now in the Air Force.

   COMPOSITE OCCUPATIONAL HEALTH AND OPERATIONAL RISK TRACKING SYSTEM

    Another of our exciting initiatives, created with your 
help, is the composite occupational health and operational risk 
tracking system known as COHORT, a program that links Air Force 
information systems such as personnel and operational medical 
systems to surveillance activities, allowing us to track the 
occupational health of our personnel throughout their careers 
and beyond.
    We are also particularly grateful to this subcommittee for 
support of our crucial laser eye protectant initiative which 
will help us study, prevent, detect, and treat laser eye 
damage.
    We continue to partner with civilian institutions for 
training in critical care, such as our Center for Sustainment 
of Trauma and Readiness Skills (C-STARS) platform at Baltimore 
Shock Trauma, as well as groundbreaking research in 
telemedicine and other areas.

                                TRICARE

    Perhaps not as high-tech, but certainly one of the greatest 
tools we have to ensure the health of our troops is TRICARE. 
The TRICARE strategy is vitally important to us, even more so 
in wartime. It supplants direct care for the Active duty 
member, provides peace of mind that family members are taken 
care of, and ensures health care access for our Guard and 
Reserve members in all our communities. Peacetime health care 
through TRICARE cannot be separated from our primary wartime 
mission. We have one mission: to care for our troops and their 
families.

                           PREPARED STATEMENT

    There remain great challenges in our military health care 
system. These include sustaining a world-class environment of 
practice for our men and women practicing medicine and 
dentistry in military facilities around the globe. I am eager 
to work with the Congress as we mold and improve your military 
health care system, a system that has no peer, no rival, one 
that is true to those who work in it every day and one that is 
deserving of the sacrifice and dedication of men and women in 
uniform.
    Thank you, Mr. Chairman and members of the subcommittee.
    [The statement follows:]

   Prepared Statement of Lieutenant General George Peach Taylor, Jr.

    Mr. Chairman, Senator Inouye, and members of the committee; it is a 
pleasure to be here today to share with you stories of the Air Force 
Medical Service's success both on the battle front and the home front.
    Air Force medics continue to prove their mettle, providing first 
class healthcare to more than 1.2 million patients. Additionally, we 
continue to have medics far from home, supporting air and land 
operations from the Philippines to Kyrgyzstan to Iraq.
    The Air Force Medical Service, or AFMS, and medics from our sister 
services have undertaken the most significant changes in military 
medicine since the beginning of TRICARE. In the last few years, we have 
fielded the largest increase in benefits since the creation of Medicare 
and CHAMPUS in the mid-1960s.
    At the same time, we are medics at war. We have been engaged in 
battle for nearly 4 years. Not since Vietnam has our operations tempo 
been as elevated. Not since then has combat been as continuous. The 
Global War on Terror is the most significant engagement of this 
generation . . . and I am immensely proud of the medical and dental 
care we provide anywhere, anytime.
    Some have the opinion that wartime and peacetime care are two 
separate and distinct missions. I disagree strongly. We have one 
mission: to care for our troops, which includes their families. The 
home-station and deployment sides of that mission are inextricably 
linked. We are able to achieve the necessary balance because of our 
ability to focus on what we call our four health effects, the four most 
important services medics contribute to the fight. The four health 
effects are:
    (1) Ensuring a fit and healthy force
    (2) Preventing illness and injury
    (3) Providing care to casualties, and
    (4) Enhancing human performance
    These four effects are what medics must bring to the fight, 
everyday, from Whiteman Air Force Base in Missouri, to Balad Air Base 
in Iraq.

                    ENSURING A FIT AND HEALTHY FORCE

Air Force Fitness Program
    The Air Force's most important weapon system is the Airman. We 
invest heavily in our people to ensure they are mentally and physically 
capable of doing their job. They need to be; we ask them to launch 
satellites, fix aircraft, perform surgery, pilot multi-million dollar 
aircraft, and thousands of other tasks used to support and execute 
battle. Commanders need their Airmen to perform these tasks in harsh 
environments, under extreme stress, often under fire. If any of them is 
unfit or too ill to accomplish their roles, the mission suffers.
    The Roman General Renatus wrote that ``little can be expected from 
men who must struggle with both the enemy and disease.''
    In other words, if we aren't fit, we can't fight.
    Two years ago, General Jumper, our Chief of Staff, unveiled the Air 
Force's new program to improve fitness. The Fit to Fight initiative 
puts greater emphasis on physical fitness training to enhance not only 
the ability of Airmen to work in the challenging expeditionary 
environment, but also the ability to sustain significant injury and 
illness far from home and be able to survive field care and long-
distance aeromedical evacuation. Fit to Fight is working. Across the 
Air Force, fitness center managers report that usage of their 
facilities is up 30 percent. The results: before the program started 
only 69 percent of Airmen passed their fitness test. Now, even with 
more stringent requirements, we have an 80 percent pass rate.
    Additionally, a secure web site gives commanders up-to-the-minute 
reports on the status of their active duty, Guard, and Reserve troops' 
fitness levels. Now leaders know instantly what percentage of their 
troops are fit to fight.
    True fitness is measured by more than strength and stamina--it 
involves a whole person concept that includes physical, dental, and 
mental health. Our Deployment Health Surveillance program gives us 
visibility over each of these important health factors.
    We can never forget that we ask our fighting men and women to do so 
in harsh environments, far from home, far from sophisticated health 
care facilities. A healthy, fit warrior is much better able than a 
less-fit person to sustain a significant illness or injury and be 
stabilized for long distance travel.

Deployment Health Surveillance program
    Our fitness and Deployment Health Surveillance programs complement 
each other. The first provides healthy troops to the fight, the second 
maintains and monitors their health. We are very proud of our 
Deployment Health Surveillance program that has resulted in our lowest 
Disease Non-Battle Injury Rates (DNBI) of all time, about 4 percent 
across the Department of Defense. The Air Force Medical Service 
conducts a variety of activities that ensure comprehensive health 
surveillance for our Total Force Airmen pre-, during, and post-
deployment, and indeed, throughout their entire careers.
    Annual Preventive Health Assessments ensure each Airman receives 
required clinical preventive services and meets individual medical 
readiness requirements. This data is conducted globally and recorded in 
an AFMS-wide database--therefore, the health of each Airman, whether 
active duty, Guard or Reserve, can be tracked throughout his or her 
service and in any location. This is an invaluable medical readiness 
tool for commanders.
    Pre-deployment medical assessments are performed on every Airman 
who deploys for 30 or more days to overseas locations without a fixed 
medical facility. While deployed, the member is protected by preventive 
medicine teams who identify, assess, control and counter the full 
spectrum of existing health threats and hazards, greatly enhancing our 
ability to prevent illness and injury.
    These Preventive Aerospace Medicine teams, or PAM teams, are our 
unsung heroes. They are small units--usually only three or four 
people--including an aerospace medicine physician, bioenvironmental 
engineer, public health officer and an independent duty medical 
technician. Theirs are among the very first boots on the ground 
whenever we build a base in theater. Before the fence is raised and the 
perimeter secured, these medics are securing the area against 
biological and chemical threats. PAM teams sample and ensure the safety 
of water, food, and housing. They eliminate dangers from disease-
carrying ticks, fleas, and rodents. Ultimately, they can claim much of 
the credit for the extremely low Disease Non-Battle Injury Rate.
    As our troops redeploy, post-deployment assessments are conducted 
for the majority of Airmen in-theater, just before they return home. 
Commanders ensure that all redeploying Airmen complete post-deployment 
medical processing immediately upon return from deployment, prior to 
release for downtime, leave, or demobilization.
    During this process, each returning individual has a face-to-face 
health assessment with a health care provider. The assessment includes 
discussion of any health concerns raised in the post-deployment 
questionnaire, mental health or psychosocial issues, special 
medications taken during the deployment, and concerns about possible 
environmental or occupational exposures. The health concerns are 
addressed using the appropriate DOD/VA assessment tool such as the 
Post-Deployment Health Clinical Practice Guideline.
    Since the first of January 2003, we have accomplished 100,000 post-
deployment assessments for Air Force members, including almost 27,000 
from our Air Reserve Component, or ARC, personnel. Of these 
assessments, we identified approximately 6,500--or 9 percent--active 
duty and about 3,000--or 11 percent--ARC personnel that required a 
follow-up referral. This equates to only 9.5 percent of our returning 
personnel that require follow-up due to deployment-related medical or 
dental health concerns.
    To better ensure early identification and treatment of emerging 
deployment-related health concerns, we are currently working on an 
extension of our post-deployment health assessment program to include a 
re-assessment of general health with a specific emphasis on mental 
health. It will be administered within six months of post-deployment 
using a standard re-assessment process. The re-assessment will be 
completed before the end of 180 days to afford Air Reserve Component 
members the option of treatment using their TRICARE health benefit.
    I am pleased to report that a recent Government Accountability 
Office audit on Deployment Health Surveillance concluded that our 
program had made important improvements and that from 94 percent and 99 
percent of our Airmen were receiving their pre- and post-deployment 
assessments.
    To address the mental health needs of deployed Airmen, the Air 
Force deploys two types of mental health teams: a rapid response team 
and an augmentation team. Mental health rapid response teams consist of 
one psychologist, one social worker and one mental health technician. 
Our mental health augmentation teams are staffed with one psychiatrist, 
three psychiatric nurses and two mental health technicians. Deployed 
mental health teams use combat stress control principles to provide 
consultation to leaders and prevention and intervention to deployed 
Airmen. The Air Force currently has 49 mental health personnel deployed 
for current operations, 31 of whom are supporting Army or joint service 
requirements. We currently use psychiatric nurses at our aero-medical 
staging facilities to better address emerging psychological issues for 
Airmen being medically evacuated out of the combat theater.
    The Air Force is also in the process of standardizing existing 
redeployment and reintegration programs, which help Airmen and family 
members readjust following deployments. These programs involve 
collaborative arrangements among the medical, chaplain and family 
support communities. Airmen and their families can also take advantage 
of The Air Force Readiness Edge, a comprehensive guide to deployment-
related programs and services, as well as Air Force OneSource, a 
contractor-run program that provides personal consultation via the web, 
telephone or in-person contacts. AF OneSource is available 24 hours a 
day, and can be accessed from any location.
    After deployments, psychological care is primarily delivered 
through our Life Skills Support Centers, which deliver care for alcohol 
issues, family violence issues and general mental health concerns. 
Staffing of more than 1,200 professionals includes a mix of active 
duty, civilian and contract personnel who serve as psychiatrists, 
psychologists, social workers, psychiatric nurses and mental health 
technicians. We currently offer ready access to mental health care in 
both deployed and home-station locations.
    The Air Force also looked at several behavioral indicators from 
fiscal year 2000 to fiscal year 2004 to examine trends before and after 
initiation of OEF and OIF. Child abuse rates were virtually unchanged 
throughout the Air Force over the 5-year span, and spouse-abuse rates 
and alcohol-related incident rates actually declined somewhat over the 
past 5 years. To date, there have been no Air Force suicides in Iraq or 
Afghanistan during OEF and OIF. Since the onset of OEF (Oct. 7, 2001), 
there have been 125 suicides in the Air Force. Only four suicides 
involved personnel who had been previously deployed to Iraq or 
Afghanistan, representing a rate (4.2 per 100,000) much lower than the 
Air Force historical average over the last 8 years (9.7 per 100,000). 
The Air Force Chief of Staff has placed increased emphasis on adherence 
to existing Air Force suicide prevention policies in recent months, and 
the current very low rates so far for this fiscal year (7.1 per 100,000 
as of March 2, 2005) are encouraging.
    Our reviews indicate that deployed Airmen have faced less exposure 
to traumatic stress than their Army and Marine counterparts, and 
therefore have experienced less psychological impact during current 
operations. We must be prepared, however, for this to change. More 
recently, Air Force personnel have been called upon to support convoy 
operations. Additionally, future operations may place additional 
demands upon our Airmen, and we must be ready to respond. Initiatives 
to re-assess the mental health status of our personnel 90-180 days 
post-deployment will allow us to better monitor and address mental 
health needs as they emerge.

                         PREVENTING CASUALTIES

    Today's Global War on Terrorism will be with us for years to come. 
Terrorism confronts us with the prospect of chemical, biological, and 
radiological attacks. Of those, the most disconcerting to me are the 
biological weapons. Nightmare scenarios involving biologicals include 
rapidly spreading illnesses, ones so vicious that if we cannot detect 
and treat the afflicted quickly, there would be an exponential 
onslaught of casualties.
    Just as General Jumper talks about the need for our combatants to 
find, fix, track, target, engage and assess anything on the planet that 
poses a threat to our people--and to do so in near real time--so must 
medics have the capability to find biological threats, and to track, 
target, engage and defeat such dangers; whether they are naturally 
occurring--like Severe Acute Respiratory Syndrome, or ARS--or manmade, 
like weaponized smallpox.
    The rapidly advancing fields of biogenetics may provide the 
technology that allows us to identify and defeat these threats. Many 
consider the coupling of gene chip technology with advanced informatics 
and alerting systems as the most critical new health surveillance 
technology to explore--and we are doing it now in the Air Force.
Silent Guardian
    This evolving technology was tested recently in a Deployment Health 
Surveillance exercise in Washington, DC. The test started shortly 
before the inauguration and ended with the close of the State of the 
Union Address. The exercise, codenamed Silent Guardian, involved the 
military medical facilities that ring the National Capital Region. We 
placed teams in each of these facilities to collect samples from 
patients who had fever and flu-like illnesses. The samples were then 
transported to a central lab equipped with small, advanced biological 
identification unit--the ``gene chip'' I mentioned--capable of testing 
for, and recognizing, scores of common or dangerous bacteria and 
viruses. And when I say small, I mean that the gene-reading chip at the 
center of this system is smaller than a fingernail.
    To run this many tests using the technology we normally use today 
would require a large laboratory, two to five weeks, numerous staff, 
and thousands of swabs and cultures dishes. But this new analyzer is 
closer in technology to the hand-held medical tricorder used by Dr. 
McCoy in Star Trek than it is to the swab-culture-wait-grow method 
currently used.
    We knew the test results within 24 hours, not the days or weeks 
required in the past. All results were entered into a web-based program 
that tracks outbreak patterns on a map. Additionally, we had mechanisms 
in place to automatically alert medics and officials of potential 
epidemics or biological attacks.

Epidemic Outbreak Surveillance
    The systems used in Silent Guardian are a small part of the 
Epidemic Outbreak Surveillance project, or EOS, an Air Force initiative 
that combines existing and emerging biodefense technologies by using a 
``system of systems'' approach in a rigorous real-world testbed. This 
project is currently in the Advanced Concept Technology Demonstration 
phase, but we hope to eventually deploy this technology to military 
bases worldwide for near real-time, total visibility of biological 
threats to our troops. These threats are not just those of biological 
warfare, but I want this team to focus on threats to our troops from 
naturally occurring disease outbreaks, from adenovirus to influenza. 
Imagine the power of knowing when and who a disease was stalking!
    When fielded, EOS will integrate advanced diagnostic platforms, 
bio-informatic analysis tools, information technology, advanced 
epidemiology methods, and environmental monitoring. Alone, none of 
these provide a defense against a biological attack, either natural or 
manmade. Woven together, they create a biodefense system that permits 
medics to rapidly identify threats, focus treatment, contain outbreaks, 
and greatly decrease casualties.
    Another exciting advancement we expect to start transitioning this 
year is our technical ability to create an unlimited number of COHORTs 
of each Airman, which will provide occupational and medical 
surveillance from the time he or she joins the Air Force until 
retirement or separation, regardless of where the Airman serves or what 
job he or she performs. We will finally be able to tie together medical 
conditions, exposure data, duty locations, control groups, and 
demographic databases to globally provide individual and force 
protection and intervention, reducing disease and disability. These 
tools will be working in near real time, and eventually will be 
automated to work continuously in the background to always be searching 
for key sentinel events.
    Diabetes is another enemy that takes lives, and it too can be 
defeated. We have been collaborating with the University of 
Pennsylvania Medical Center to create Centers of Excellence for 
diabetes care. Diabetes can affect anyone--in or out of uniform--so 
this effort promises to improve the lives of all beneficiaries. 
Together, we are seeking ways to prevent and detect the onset of 
diabetes while providing proven, focused prevention and treatment 
programs to rural communities, minority populations, the elderly and 
other populations prone to this disease.

                             RESTORE HEALTH

High Survivability Rate
    We have enjoyed significant success in the third health effect we 
bring to the fight--that of restoring the health of our sick or injured 
warriors. Innovations in both technology and doctrine are dramatically 
improving survival rates of our troops on the battlefield.
    During the American Revolution, a soldier had only a 50/50 chance 
of living if injured on the battlefield. From the Civil War through 
World War II, about 70 percent of the injured survived their injuries. 
Aeromedical evacuation in Vietnam is partly responsible for increasing 
the survival rate to nearly 75 percent. During Operation IRAQI FREEDOM 
(OIF), 90 percent of those injured in combat survived their wounds. We 
attribute this success to the combination of our rapidly deployable 
modular Expeditionary Medical units, excellent joint operations, and 
our transformed aeromedical operations.
EMEDS
    The Expeditionary Medical Support concept, or EMEDS, has proven 
itself invaluable in OIF. EMEDS is a collection of small, modular 
medical units that have predominantly replaced our large, lumbering 
theater hospitals. Big things come in small packages, and there are at 
least three big benefits to these small EMEDS:
    First, by breaking up our large deployable medical facilities, we 
can spread our resources geographically to locations around the globe 
where they are needed the most; an efficient use of our assets.
    Secondly, EMEDS units are easier to insert far forward and 
integrate with other services, so our medics are closer to the action 
and closer to the wounded who need our lifesaving skills. For example, 
our Aeromedical Evacuation Liaison Teams and aeromedical staging 
facilities were loaded into humvees and provided direct combat service 
support to the Army V Corp and 1st Marine Expeditionary Forces convoys 
as they fought their way along the Tigris and Euphrates from northern 
Kuwait to Baghdad in 2003.
    Finally, these units are small, light, and lean. How small? The 
people and equipment comprising the entire Air Force medical support in 
OIF have taken up less than one percent of the cargo space of all 
assets headed to the war. EMEDS' small footprint allows us to pick them 
up and put them down anywhere quickly. We get to the fight faster. For 
example, in OIF, we opened 24 bases in 12 countries in a matter of 
months, each with a substantial EMEDS presence. That formidable 
presence served not only Air Force troops, but also ground forces 
throughout the region. To further ensure quality care, we deployed 
over-pressurized tents that are capable of keeping biological and 
chemical weapons from seeping into our medical facilities.
    EMEDS' modularity allows its components to be mixed and matched 
effortlessly with other EMEDS units or even another Service's assets to 
create the package of medical care required. Whether it's a small 
clinic or a large 250-bed hospital that does everything short of organ 
transplants, the right level of medical care is prescribed and provided 
to our warriors.
    The speed with which these EMEDS deploy is phenomenal. One of our 
first EMEDS units in theater was a 25-bed hospital based at the Air 
Force Academy in Colorado. The time elapsed from the moment EMEDS 
members got their telephone call notifying them of deployment, gathered 
and transported all 100 medics and their equipment, pitched their tents 
in Oman, and saw their first patient, was just 72 hours. Because of 
this capability, we are the medics of choice for Special Forces and for 
quick-reaction forces in the United States and abroad.
    Less than one month after the September 11th, 2001, attacks, a 
medical team supporting Special Operations saved the life of the first 
soldier severely injured while supporting Operation ENDURING FREEDOM. 
Exactly 3 years later, on September 11th, 2004, Air Force medics 
accomplished the miraculous save of a horribly wounded Airman in 
Baghdad. I will share this story later in my statement. But in between 
and since these two remarkable medical events, there have been volumes 
of compelling stories reflecting the awesome capabilities of the Air 
Force Medical Service and our joint Air Force-Army-Navy medical team as 
we care for our troops.

Caring for Iraqis
    Not all of our patients are American military members. Throughout 
this conflict, we have treated Iraqi civilians, our Iraqi allies, and 
even the enemy. After Saddam was toppled, we moved hospitals into 
places like Tallil, Baghdad International Airport, and Kirkuk, where we 
continue to treat all those caught in harm's way, whether friend or 
foe.
    To emphasize that point, I have two very compelling stories 
concerning the care we provide Iraqi nationals. The first involves a 
horribly wounded detainee believed to have received his wounds while 
engaged in combat against our troops. He was going to be transferred to 
an Iraqi hospital, but begged to remain with American doctors until his 
wounds were resolved. His words to our Air Force surgeon were, ``If I 
go, I will surely die. I trust only you.''
    This trust and faith in Americans plays a role in my next story, 
too. Air National Guard medics from the EMEDS at Kirkuk treated a group 
of badly injured Iraqis brought into camp by American soldiers. While 
the camp was under mortar fire, our medics worked to save the men. By 
morning, all were stabilized. They were transported to another medical 
facility the following day. Captain Julie Carpenter, a nurse, rode with 
one of the men, and because he was still in pain, she tried to provide 
some comfort. She would look in his eyes or hold his hand because, as 
she said, ``I wanted him to feel he wasn't alone; I imagine it was 
scary for him.''
    She thought little of the incident until days later she learned 
that the thankful families of these injured Iraqis approached American 
troops and provided information that led our troops to the location and 
the capture of Saddam Hussein.
    Expeditionary health care is a military tool that not only saves 
lives; it can turn confrontation into cooperation, revealing compassion 
to be the long arm of diplomacy.

Expeditionary Health Technology
    Restoring health in the expeditionary environment requires that our 
dedicated medical professionals are equipped with cutting-edge 
technology. For example, we are seeking techniques to convert common 
tap or surface water into safe intravenous (IV) solutions in the field. 
We are also developing the ability to generate medical oxygen in the 
field rather than shipping oxygen in its heavy containers into the 
field.
    Telehealth is another fascinating technology that enhances the 
capabilities of our medics. It allows a provider in Iraq to send 
diagnostic images such as X-rays through the Internet back to 
specialists located anywhere in the world, Wilford Hall Medical Center, 
for instance, for a near real-time consult. This insures that each 
Soldier, Sailor, Airman or Marine in the field has access to one of our 
outstanding specialists almost anytime and anywhere.

Aeromedical Evacuation
    Restoring health also means bringing casualties back from the front 
as quickly as possible to sophisticated medical care. The Air Force 
Medical Service makes its unique contribution to the Total Force and 
joint environment through our aeromedical mission and the professionals 
who perform it. The job of Aeromedical Evacuation crewmembers is not 
easy. They must perform the same life-saving activities their peers 
accomplish in hospitals, but in the belly of an aircraft at over 20,000 
feet. The conditions are sometimes challenging as crew members work 
under the noise of the engines or when flying through turbulence--but 
there is no place else they would rather be. TSgt Pamela A. Evanosky of 
the 315th Aeromedical Evacuation Squadron out of Charleston AFB said, 
``AE is exhausting duty. But I love it. I know everyday that I make a 
difference. This is the most honorable and rewarding work I could 
possibly ever do.''
    It truly is rewarding, and I am very proud to report, that Sergeant 
Evanosky and her fellow AE crewmembers have accomplished over 55,000 
patient movements since the beginning of OIF, and they have never lost 
a patient.

Critical Care Air Transport Teams
    Occasionally, our AE crews transport a patient who is so ill or 
injured that they require constant and intensive care. When that 
happens, our AE medical capability is supplemented by Critical Care Air 
Transport Teams, or CCATTs. These are like medical SWAT teams that fly 
anywhere on a moment's notice to retrieve the most seriously injured 
troops. Team members carry special gear that can turn almost any 
airframe into a flying intensive care unit (or ICU) within minutes. An 
in-theater EMEDS commander told me that CCATTs are a good news/bad news 
entity. He said, ``The bad news is, if you see the CCATT team jumping 
on a plane, you know someone out there is hurt bad. The good news is, 
if you see CCATT jumping on a plane, you know that someone will soon be 
in the miraculous hands of some of the best trained medics in 
existence.''
    No discussion of aeromedical evacuation is complete without 
recognizing the critical contribution of the Reserve Component. About 
88 percent of AF Aeromedical Evacuation capability is with the Guard 
and Reserve. I am deeply proud of and awed by their dedication and 
self-sacrifice in delivering sick and often critically injured troops 
from the battlefront into the care of their families and our medics at 
the home front.

The Miracle of Modern Expeditionary Medicine
    The seamless health care we provide with our Sister Services from 
battlefield to home station can be illustrated by the miraculous, life-
saving story of Senior Airman Brian Kolfage.
    Airman Kolfage suffered horrendous wounds when an enemy mortar 
landed near him. These mortars have a kill radius of 150 feet. Kolfage 
was about 10 feet away. The blast threw him half the length of a 
football field. It shredded both legs and his right arm. Normally, no 
one could survive such an injury, but an Air Force medic who was close 
by when the blast occurred was able to respond immediately.
    The field surgeons had Airman Kolfage on the operating table in 
five minutes and were able to stabilize him. Aeromedical Evacuation 
crews and CCATT teams transported him halfway around the world to 
Walter Reed Army Medical Center.
    Senior Airman Kolfage was airlifted from the site of injury over 
6,000 miles away to a hospital just 6 miles from where we now sit. And 
this all happened in a time span of just 36 hours. That is something 
that could not have happened in previous conflicts.
    Airman Kolfage lost both legs and his right hand. But he has 
definitely not lost his spirit. He arrived at Walter Reed flat on his 
back, but vows to walk out of there. I believe him. He takes vows 
seriously. As a matter of fact, he just exchanged them with his 
girlfriend--now wife--whom he recently married at Walter Reed.
    This is a miracle of modern technology, seamless joint medical 
operations, and the resiliency of youth. In any other war, this young 
man would have lost his life; now he has it all before him.
    Every day the Air Force Medical Service sees thousands of patients. 
We try to make a difference with each individual; in Airman Kolfage's 
case, we know for sure we made the ultimate difference.

                       ENHANCE HUMAN PERFORMANCE

    The fourth health effect we contribute to warfighting is the 
enhancement of human performance. Helping Airmen perform to the best of 
their abilities means we must have people who are highly trained, 
competent, and equipped with advanced technology that can both help 
them do their jobs and protect them while doing so. We are seeking to 
enhance human performance for our troops through cutting-edge research 
and development that will improve the safety and performance of our 
troops in the expeditionary Air Force.
    For example, we continue to pursue methods of enhancing our 
member's eyesight. Obviously, good vision has always been important to 
our troops, particularly pilots whose eyes may be their navigators. But 
detecting and protecting our troops' eyesight is especially critical 
now that Directed Energy Weapons, or Lasers, are widely available and 
capable of inflicting great injury to the eye.
    A laser pointed into an eye can temporarily or even permanently 
damage an Airman's vision, so we seek special lenses for eyewear and 
helmet shields that can block harmful laser rays. Detecting laser eye 
injuries can be difficult; treating such injuries is currently next to 
impossible. Consequently, we are fielding retinal surveillance units in 
high-threat areas to accomplish eye exams, always looking for evidence 
of laser damage. We are searching for valid therapies to treat these 
types of newly recognized injury patterns. No such therapy currently 
exists.
    Finally, we'll push the envelope on ocular technologies by trying 
to create vision devices that will allow our Airmen to see to the 
theoretical limit of the human eye, which some say is 20-over-8. If 
successful, this will provide our pilots and warriors the ability to 
see twice as far as an adversary.

The Changing AFMS Construct
    The AFMS faces the challenge of delivering these four health 
effects in times of significant change in the two constructs in which 
we operate; that of medicine and of military operations planning--how 
we fight wars.

Changes in Health Care
    Health care has changed radically in the past 15 years. In my 
tenure as a physician, advances in pharmaceuticals, diagnostics--like 
the CAT scan and MRI-fiber optic techniques such as laparoscopy, 
arthroscopy, and the use of stints for blocked arteries, and anesthesia 
breakthroughs have radically altered our military treatment facilities. 
In the private sector, small, full-service hospitals have gone the way 
of the eight-track tape, replaced by more efficient medical complexes 
that focus on outpatient care and ambulatory surgery.
    The same pressures that prompted civilian health care facilities to 
move to outpatient surgery have influenced transitions in the Air Force 
delivery of health care as well. Historically, we structured ourselves 
to have hospitals at most bases. We now have substantially transitioned 
our facilities to the point where fewer than 30 percent of our bases 
have hospitals. In fact, if you look today, we have fewer hospital beds 
in the entire Air Force, 740, than existed at the Air Force's Wilford 
Hall Medical Center in 1990, which had 855.
    Another important way the military has adapted to the changing 
health care construct is to operate much more closely with sister 
service and civilian hospitals to provide comprehensive patient care. 
For instance, the Landstuhl Army Medical Center in Germany--the first 
stop for many of our wounded returning from Afghanistan and Iraq--has a 
contingency of almost 300 permanent-party Airmen working side-by-side 
with their nearly 900 Army counterparts.
    We enjoy a similar sharing opportunity with the University of 
Colorado at Denver. Most of nearby Buckley Air Force Base's patient 
care assets are now located at the University's Fitzsimmons medical 
campus. Our close working relationship with the university hospital and 
its president, Dennis Brimhall, are responsible for the efficient and 
innovative use of medical resources and quality care for our 
beneficiaries.
    Strong relationships with civilian agencies--like that of our 
Center for Sustainment of Trauma And Readiness Skills, or C-STARS 
program--have benefited both our peacetime TRICARE and wartime AEF 
missions. The Air Force has three of these centers, one each in the 
Cincinnati University Hospital Trauma Center in Ohio, Saint Louis 
University Hospital in Missouri, and the R. Adams Cowley Shock Trauma 
Center in Baltimore. Military medics work in tandem with their civilian 
counterparts there to care for seriously ill or traumatically injured 
patients, patients seldom seen in military MTFs. These programs prepare 
our providers for deployment by exposing them to the wounds they will 
treat in combat. In the future, we will be looking for new ways to 
partner with these civilian institutions, such as in education and 
research and development.

Changes in War-Fighting
    The second construct change is that of the Air Force mission 
itself. When I entered the Air Force in the late 1970s, we planned, 
trained, and equipped our medics on the basis of the threats faced in 
two major operational plans of short duration. That construct is no 
longer valid, as can clearly be seen with the Global War on Terrorism.
    The Air Force created its Air Expeditionary Force structure, in 
part, in response to this new construct. The AFMS needed to restructure 
itself, too, so that it could face multiple commitments overseas of 
both short and long duration. Our nation requires that medics field 
combat support capabilities that are very capable, rapidly deployable, 
and sustainable over long periods. This has driven three additional 
changes to our medical system. Our people must be trained, current, and 
extractable to support the warfighter. Medics must be placed at 
locations where they can maintain the skills they need for their combat 
medicine mission. It is also vital that these locations must allow the 
medics to deploy easily without significantly interrupting the care 
they provide the base or TRICARE beneficiaries, especially at those 
locations with sustained medical education training programs.
    This is exactly the challenge that the Air Force Chief of Staff 
Gen. John P. Jumper issued to me in creating expeditionary medics: 
medics who are focused on developing the skills for the field and eager 
to deploy for four of every 20 months.
    We are assigning medics at large facilities into groups of five so 
that one team can be deployed at any one time while the other four 
remain to work and train at home stations. We are also reviewing the 
ratio of active-to-reserve medics and asking ourselves important 
questions: What mix of the active duty to reserve component will ensure 
the best balance between the ability to deploy quickly and the 
capability to surge forces when necessary?
    Finally, we are actively reviewing the total size of the AFMS to 
make sure that over the next few decades we can successfully fulfill 
our wartime mission while still providing the peacetime benefit to our 
members, retirees, and their families.

TRICARE
    The next generation of TRICARE contracts is now completely 
deployed. The transition was smoother than that experienced in the last 
contract transition in the 1990s. Service contracts are now in place to 
fully support the benefit enhancements to our active and reserve forces 
that were temporary in 2004, but made permanent by the fiscal year 2005 
National Defense Authorization Act. Although we experienced some 
challenges with referral management, both the government and our 
contractors are working to find solutions and we have seen improvement 
over the past several months. We will continue to work this issue 
aggressively as access both in the direct care system as well as the 
network continues to be closely monitored.
    The TRICARE benefit is generous, and many retirees who have the 
choice between our care and that offered by their civilian insurers are 
opting for the military's medical system. In spite of the increase in 
benefits and the ever-growing population to whom it is delivered, the 
TRICARE system continues to receive satisfaction ratings superior to 
that of civilian health care systems.

Working with the Department of Veterans Affairs
    Our concern about the care of our beneficiaries continues even 
after they have left the DOD system; therefore, the DOD/VA Resource 
Sharing Program continues to be a high priority for the Air Force 
Medical Service. The new Health Executive Council is making promising 
steps toward removing barriers that impede our collaborative efforts. 
We constantly explore new areas in which we can work to jointly benefit 
our patients and are currently finding these opportunities in 
information technology, deployment health medicine, pharmacy, and 
contingency response planning and patient safety programs. We are 
particularly proud of progress toward improving transitional services 
and the delivery of the benefit to our separating service members. 
These combined, cooperative efforts are a win-win-win for United 
States, the VA, and most importantly, our beneficiaries. Of course, I 
remain very proud of our numerous joint VA-Air Force operations, from 
Anchorage to Las Vegas, from Albuquerque to Travis Air Force Base 
California, we continue to team well with the VA.

Recruiting and Retention
    The AFMS continues to face significant challenges in the 
recruitment and retention of physicians, dentists, and nurses; the 
people whom we depend upon to provide care to our beneficiaries. The 
special pays, loan repayment programs, and bonuses to our active and 
reserve component medics do help, and I thank you for supporting such 
programs. Nearly 85 percent of nurses entering the Air Force say they 
joined in large part because of these incentives.
    We also recognize the importance of maintaining a modern and 
effective infrastructure in our military treatment facilities, from 
clinics to medical centers. The atmosphere in which our medics work is 
as important as any other retention factor. We have wonderful patients, 
patriotic and willing to sacrifice. They deserve not only the most 
brilliant medical and dental minds, but first class equipment and 
facilities. Every day, I strive to make that happen.

Conclusion
    The Air Force Medical Service is proud to be part of a joint 
medical team that provides seamless care to America's heroes, no matter 
what Service they are from. We can boast of a full-spectrum, effects-
based health care system. Our focus on a fit and healthy force coupled 
with human performance enhancement strategies and technologies, 
promotes maximum capability for our Total Force warriors. Our health 
surveillance programs keep them and their units healthy day to day, 
ready to take on the next challenge. When one of our warriors is ill or 
injured, we respond rapidly through a seamless system from initial 
field response, to stabilization care at our expeditionary surgical 
units and theater hospital, to in-the-air critical care in the 
aeromedical evacuation system, and ultimately home to a military or VA 
medical treatment facility. Across service lines, at every step, we are 
confident that our Soldiers, Sailors, Airmen and Marines--active duty, 
Guard and Reserve--are receiving the high level of medical care they 
deserve, from foxhole to home station.
    As we work to improve upon this solid foundation, the men and women 
of the Air Force Medical Service, at home or deployed, remain committed 
to caring for our troops. We appreciate your support as we build to the 
next level of medical capability.
    Thank you.

    Senator Stevens. Thank you very much, gentlemen.
    We have had enormous response as a volunteer military in 
terms of those people who have been coming in, particularly the 
younger people. What success have you had in terms of 
increasing enlistment of medical professionals and retaining 
them after they come in? For instance, are our bonuses and 
other initiatives giving you good enough tools to assure a 
sufficient number of reenlistments? No one is really talking 
about this so far as I can see. But it has got to be different 
now than it was back in the days of the draft. How are you 
doing in terms of recruitment and retention? General Kiley.

             MEDICAL PROFESSIONALS RECRUITING AND RETENTION

    General Kiley. Sir, thank you for the question. I think 
there are two parts to it. Our enlisted combat medic recruiting 
and retention appears to be going pretty well. As you know, our 
combat medics are emergency medical technician-basic (EMT-B) 
certified, and that seems to have been a draw for many young 
men and women to get the opportunity to get that certification.
    The area we are concerned with, which I think you are also 
asking about, is the area of our professional officer corps, 
recruiting and retaining them, both physicians and nurses. We 
are still short, in terms of our authorizations, against what 
we have on hand for both corps. Specifically, we project this 
year to be close to 200 nurses short in terms of our total end 
strength.
    Senator Stevens. What about doctors, physicians?
    General Kiley. Sir, we are probably close to that same 
number short in physicians. The dynamics are slightly different 
for the two corps. I think Colonel Bruno will tell you that 
there is a nationwide shortage of nurses and nursing starts in 
terms of young men and women who would like to go into nursing 
as a profession, a lot more that would like to than can get 
into school. That is one problem.
    We have not offered, until recently, the same level of 
scholarship opportunities that we are offering now, and we are 
starting to get some interest in scholarships in nursing school 
and also in ROTC.
    We have had some difficulty in retaining nurses. This is 
for the same reasons as we have with physicians. This is hard 
duty and deployment for 1 year. It is relatively new, even 
though we have been in the global war on terrorism since 9/11. 
For some, the potential for repetitive deployments has been a 
little bit of an issue.
    I am encouraged. We are taking some steps recently to 
increase bonuses and to look at other opportunities to get 
nurses on board.
    For physicians, recently the Congress increased the 
ceilings on retention bonuses for physicians. We have not fully 
funded those inside the services to the maximum for all 
physicians. There has been an effort between the three services 
to balance the amount of bonuses per specialty, focusing on 
combat-relevant specialists. I think the personnel tempo 
(PERSTEMPO), the deployment tempo, the long deployments have 
also been a challenge for some of our physicians also. About 
half of the physicians in our Army that are not in training as 
interns and residents have had at least one deployment, and 
many are on the second deployment. We have got some of our 
general surgeons that are on a third deployment now between the 
Bosnia and Kosovo, Afghanistan, and now Iraq operations.
    I think it is a little too early to tell in terms of long-
term retention for physicians what the personnel tempo of the 
physicians in terms of deployments and redeployments will be on 
retention. I am still encouraged. I just talked to a young 
physician the other day who took great pride in the fact that 
he spent 1 year with combat troops in Iraq and is now back in a 
training position, training the next generation of physicians. 
We have increased the bonuses and we continue to work that.
    We are also working to get clearer data which, believe it 
or not, tells us each physician, as they arrive at a point 
where they can actually make the decision do I get out or do I 
sign up for another bonus. We do not actually know the numbers. 
We have got a fair number of continuation data, how many 
doctors continue to stay on, and those numbers look relatively 
good. But I am authorized to 43-47 I believe, and I am at about 
41-50, plus or minus. The cycle changes. Over the summer we 
lose and gain, and then in the fall we lose and gain again.
    So I am concerned. I think we have been at our global war 
on terrorism and this deployment challenge for physicians and 
nurses long enough that those that have had bonuses that they 
are letting run out are now at the point where they are 
starting to let them run out.
    Our certified nurse anesthetists. We increased the bonuses 
for certified nurse anesthetist recognizing that we had a real 
retention problem. And the preliminary indications are that 
they have responded to those increased bonuses and that we have 
signed up a fairly large number of our critical nurse 
anesthetists.
    So it is a mixed picture right now. We are watching it 
pretty carefully. We have got a whole host of new plans and 
programs working with our recruiting command getting physicians 
and nurses engaged in going to facilities and talking to 
doctors and medical students as a way to bring them on board. 
So I think we do not have the final answer yet, but I remain 
concerned about that.
    Senator Stevens. You mentioned homeland security. Are you 
prepared to take on the problems of homeland security through 
your Reserve and Guard? Do you have enough medical people in 
those areas?
    General Kiley. Well, that also is an area of concern. As 
you know, we have a policy now, a 90-day boots on the ground, 
for physicians and dentists, so that they can preserve their 
private practices. I do think it is a challenge for the 
Reserves. The nature of health care in the private sector is 
such that physicians cannot afford in their practices to leave 
for 6 months or 1 year, and so they are very reluctant to sign 
up.
    We do watch the numbers very closely, and depending on the 
nature of the mission, we may be stretched very thin using 
medical reserves to support significant homeland defense 
operations. I do not have any more specific answer to that 
question. I know it is a concern for us.
    Senator Stevens. Do you have any comment on those 
questions, Admiral?

                       RECRUITMENT AND RETENTION

    Admiral Arthur. Yes, sir. Thank you. I think that was a 
very good, comprehensive answer, and I echo many of those 
sentiments. I would like to add just a couple of other things.
    I think there is a tremendous value to having an all-
volunteer service. I have talked with many veterans whose sons 
have died in combat, and one of the things they tell me is they 
are very proud of their son, that he--and in some cases a she, 
but not for us in the Navy--volunteered to go there, wanted to 
serve his country, and that he felt that he died in an 
honorable way. I do not think that that same sentiment is 
echoed for people who are conscripted to service.
    One of the great things, I think, about our medical system 
is the camaraderie that we have with other health care 
professionals who share the same core values that we have, the 
great training that we give, but the greatest benefit that I 
have seen is that we never ask any of our patients how sick 
they can afford to be. We give the right care every single 
time. I think it is those things that keep people in the Navy, 
the Army, the Air Force medical systems because it is a job 
satisfaction not only their professional lives, but they feel 
that they are not just not successful, but significant in their 
contributions to their Nation. So I think the voluntary service 
is of great value.
    Like the Army, we have difficulty in retaining those 
specialties who tend to have more deployments than others: the 
surgeons, the nurse anesthetists, the perioperative nurses, the 
combat medic equivalents in the Navy. But I think so far we are 
doing pretty well because people want to serve, and that is the 
volunteer aspect.
    I have gone over there in December and January and talked 
to thousands of our medical department folks out there. They 
all would like to be home, but when their time and their duty 
is done. They know what they are doing over there is important.
    Thank you.
    Senator Stevens. General Taylor.
    General Taylor. Sir, just a couple of points. From the 
Active duty side, we continue to be challenged in the Dental 
Corps and the Nurse Corps with sustaining the right number of 
folks. I believe we have most of the tools to shape the force 
properly and build the force properly. It is just putting these 
things in effect takes time. A lot of the cycling, particularly 
for the nurses, is in relation to the outside communities' 
shortage of nurses and the capability of nurses. So we are in 
competition for many of these and it makes it more difficult. I 
am sure that General Brannon will come in behind and talk about 
some of the efforts in pay, ROTC, and other activities that we 
are trying to do to recruit and retain nurses.
    I have to say one of the things that we have worked real 
hard on is placing our medics in an air expeditionary force 
structure so that they go out 120 days every 20 months. It is a 
system that can sustain itself. It is very enthralling to talk 
to medics, either in Iraq or Afghanistan or upon return, and 
how excited they are being able to participate in the 
activities and supporting the armed forces forward. This 
experience of deploying forward for most of our medics is a 
very important part of their life and their contribution to the 
service.
    From the Medical Corps perspective, we tend to be 
challenged in certain specialty types. We are working to adjust 
that specialty mix, but by and large, you know that most of the 
Medical Corps we get are through two very wonderful programs. 
The Uniformed Services University and our Health Services 
Professional Scholarship program continue to provide 
outstanding physicians for each of us in the services.
    From the Reserve component perspective, the Air National 
Guard is taking up the challenge of homeland security. Their 
greatest challenge, as they reform the Air National Guard to 
create military medical capabilities aligned along the FEMA 
regions, is getting the equipment, getting the training, and 
then getting the staff aboard to move into creating the 
capabilities to provide rapid medical response to a homeland 
security event. So I am working very hard with the Guard to try 
and help them restructure their medics in a way that provides 
not only capability for the Federal forces, as we deploy out, 
but provide a wonderful asset for the States and the Governors 
to use in case of a homeland security strike.
    Senator Stevens. We were disturbed when we heard that the 
Uniformed Services University of Health Sciences (USUHS) might 
be closed and equally disturbed when we heard that Walter Reed 
might be closed. We are monitoring both of those rumors.
    But one thing that disturbs me is the feeling that there 
just are not enough physicians, doctors, professionals who are 
willing to volunteer and stay in the service. Many of those in 
your profession have received substantial Federal assistance in 
their education. We used to have a requirement if the person 
got such assistance, a certain amount of time had to be 
dedicated to service in the military. That has been eliminated 
from our laws. What would you think about reinstating it? Is it 
still there? I do not think it is still there. Well, I will ask 
the staff.
    My information from home is we used to have a provision 
that said that they had to spend some time in places where 
there were not enough physicians in the civilian community, and 
that was one of the commitments that they made if they got 
their financial assistance during their medical education. But 
I do not think we still have the requirement of military 
service for those who have the assistance.
    General Taylor. Sir, as far as I understand it, in the 
Health Professions Scholarship program (HPSP), you owe 1 year 
for every year of training, and for those who go to the 
Uniformed Services University, they owe 7 years after their 
training.
    Senator Stevens. But is that military service?
    General Taylor. Military service.
    Senator Stevens. All right. We will get a report on that. 
Thank you.
    Senator Inouye.
    Senator Inouye. If I may follow up on that, is it not true 
that of the 3,600 graduates of USUHS, the retention rate is 
extraordinary? For example, the medium length of unobligated 
retention for physician specialists, not including USUHS grads, 
I believe is 2.9 years, but for USUHS grads, the unobligated 
service retention is about 9 years. Is that not correct?
    General Taylor. Senator, I do not think we know the 
specific numbers there. It is true it is universally understood 
that those who attend USUHS, because of their long commitment, 
stay longer in the service. You must complete USUHS, complete 
your medical residency training, and then the clock starts 
ticking on your 7 years of service. Certainly that is longer 
than the HPSP where they only owe 4 years. So it is true that 
they will stay longer.
    Senator Inouye. I am told that beyond the unobligated, 
there are 9 years for USUHS grads, medium rate.
    And further, we have been advised that if we compare USUHS 
to the four major physician accession centers, USUHS is cost 
effective. It sounds astounding, but I suppose it is correct.
    Does Walter Reed still maintain 40 medical specialty 
programs?
    General Kiley. To the best of my knowledge, yes, Senator, 
they do.
    Senator Inouye. Because I have been told that that is one 
of the major attractions for physicians in the military.

                           TRAINING PROGRAMS

    General Kiley. Yes, sir. What Walter Reed really is is the 
linchpin for Army medicine. There are very robust training 
programs across the entire spectrum, many of which are combined 
with training programs at the National Naval Medical Center. 
Many students in medical school that get an opportunity to 
rotate at Walter Reed really get excited about being in Army 
medicine and having an opportunity to serve at Walter Reed. 
Some of our best, not all, physicians in the military will 
actively seek to be assigned at Walter Reed because of its 
prestige, not only its location in Washington, DC, but the 
prestige of the research that goes on, the robustness and the 
size of the training programs that allow them to do research to 
train the next generation of physicians and certainly nurse and 
also enlisted personnel, all of whom train at Walter Reed.
    It is a very big, complex organization. It delivers very 
sophisticated tertiary level, university, academic level health 
care. And as you know, it is also our major receiving facility 
in the continental United States for combat casualties that are 
coming back where we apply those skills.
    So it has a recruiting and retention capability. It is 
recognized worldwide as are the prestigious Navy and Air Force 
facilities. So it is not without significance as it relates to 
not only that, but longevity, the same discussion you just had 
with continuation rates of physicians. Certainly many of the 
USUHS grads get an opportunity to rotate as medical students, 
like my daughter, and see that as a career potential for them. 
So there are significant second and third order effects to this 
facility, yes, sir.
    Senator Inouye. Admiral Arthur, during the ancient war, the 
one that the chairman and I were involved in--there was much 
talk about what we called section 8, mental cases. In this war 
we see pictures of amputees and blinded veterans and such, but 
very seldom hear about so-called section 8. What is their 
status? Do we have a lot?

                             COMBAT STRESS

    Admiral Arthur. Section 8 is the psychiatric. Okay. I think 
that is an Army term.
    We are, I think, just seeing the results of combat stress 
in our veterans. I think we have not truly had a major combat 
that our Nation's armed forces have been associated with since 
Vietnam. I think Desert Storm, Bosnia, Grenada, Panama--we have 
been in conflict, but not in such a sustained way.
    Having been in combat, I feel that 100 percent of the 
people who experience combat are in some way affected, some a 
little, some a lot more. I think we as the services need to be 
very sensitive to picking up the combat stress not because the 
children are affected or the spouses are affected or the jobs 
are affected, but because we are sensitive enough in our post-
deployment screening tools to see the effect and to treat it at 
its lowest level, by that I mean in garrison rather than 
sending someone to a hospital, if they go to a hospital to do 
the treatment as a outpatient rather than an inpatient and to 
return people to function.
    I think one of the best things that all three services have 
done is to enlist their retirees and other people in the 
communities so that we do not lose track of anyone who does not 
just return to garrison, but actually gets out of the service 
or goes back to Reserve duty and may not have the support that 
an Active duty member has. I think we are all very, very 
concerned about what I would call combat stress to ensure that 
we properly honor the services of the veterans and understand 
it.
    As I said in my opening statement, I think this is in the 
purview of the military. We know what combat stress is about 
because we have been there and we understand it. I think the 
more we can do that keeps our veterans from having to go to 
civilian centers where they are not as well prepared the better 
we will be, and that includes our Veterans Administration 
hospitals as we partner with them to treat veterans.
    Senator Inouye. Do you believe that we are adequately 
demonstrating this concern and sensitivity?
    Admiral Arthur. I believe that we adequately have attention 
being drawn to it. I think renewed collaboration that DOD has 
with the Veterans Administration in treating combat stress is 
refreshing. We have a lot of programs and I am encouraged by 
the amount of effort and attention that we are bringing to bear 
on this, all three services, right now.
    Senator Inouye. Thank you.
    General Taylor, we have just received a report that the Air 
Force is short in a large array of medical and dental fields. 
For example, the Air Force is now short in dentistry, 
anesthesiology, gastroenterology, rheumatology, pulmonary, 
cardiology, oncology, hematology, internal medicine, and it 
goes on and on. Is that a correct picture?
    General Taylor. Sir, we are short in certain areas. We are 
shorter in other areas than in some other ones. The way we have 
tried to adjust for that, of course, is to work on the pay and 
compensation for those specialties that are in the career 
field. We have been working actively with the recruiting 
services to recruit people, and then we have continued to work 
hard to mold new accessions into those specialty areas.
    Some of the ways that we have adjusted to that is to try 
and ensure that we place our military specialists in those 
locations where they can best maintain their skills. 
Concentrating internists in hospitals and moving them from the 
smaller clinics and into the hospitals has been one way to 
adjust for that. That would allow those small clinics then to 
contract for internal medicine referrals locally rather than to 
put a military internist in a small clinic forward.
    So most of these are trying to adjust to the correct size 
while we continue to press for new entries into the career 
field and that the pay and incentives remain intact. The other 
part of this is to try and ensure that people in those areas of 
expertise are practicing the full spectrum of their health care 
in our larger facilities.
    Senator Inouye. Are you noting success in your programs?
    General Taylor. Sir, I believe we are seeing success in 
that program. It is going to take time, as was mentioned by my 
colleagues here, to see how those incentives work. We 
appreciate what Congress has given us in terms of pay and 
retention and scholarship programs to recruit and retain these 
people, and we believe we have the adequate tools to do the 
work.
    Senator Inouye. Well, as one Member of the Congress, I 
would like to thank all of you for your service. Thank you very 
much.
    Thank you, Mr. Chairman.
    Senator Stevens. Senator.
    Senator Mikulski. Thank you very much, Mr. Chairman, and to 
our Surgeons General.
    First of all, as the Senator from Maryland, we are very 
familiar with military medicine in our State and so honored to 
have Naval Bethesda in our State. Walter Reed, though next 
door, we view as part of--we do not want to say part of our 
State, but certainly close to that. The hospital ship Comfort 
is based in Baltimore, and of course, we have USUHS, the 
uniformed services medical school, and up Route 270, of course, 
is Fort Detrick, though not literally under your command, 
certainly is coming up with the research that is so important 
in what you are doing. So we feel very strong about it.
    We too are really proud of what you are doing in 
battlefield medicine, acute care, and also the primary care 
that you provide to families. So we are on your side, and even 
my own primary care physician gave me an article from the 
Journal of American Medical Association (JAMA), the American 
medical journal, talking about the stunning results in what you 
have been able to do in battlefield medicine. It is beyond all 
expectation and all hope. I know gratitude will come to you the 
rest of your life in this.
    I am worried about the shortages that you are talking about 
with the physicians, and I too have been troubled about the 
rumored closing of both USUHS and Walter Reed.
    In terms of USUHS, I would like to be able to ask you, 
General Kiley, a couple of questions. First of all, is it true, 
picking up on Senators Stevens and Inouye, that the USUHS 
graduate serves a longer time than someone who has come through 
a conventional medical school, and could you share with us how 
committed they stay? All medicine is 24/7, but military 
medicine is 36/7. You work a 36-hour day.
    General Kiley. Senator, that is a great question. Thank 
you.

                   PROGRAMS FOR ASSESSING PHYSICIANS

    I think as General Taylor referenced, there are two general 
programs for assessing physicians, and the Uniformed Services 
University has the students go through an Active duty status 
with pay allowances and privileges. In exchange for those 4 
years as a medical student, the young doctors graduate and are 
commissioned as Medical Corps captains. And then they have a 7-
year obligation. The internship year right after medical school 
or, in many cases now, just the residency, internal medicine 
being 3, general surgery being 5 years, OB-GYN being 4 years, 
as an example--those 3, 4, or 5 years do not count in working 
off the obligation.
    Senator Mikulski. So they do not count toward the 7 years.
    General Kiley. That is correct. But they do count toward 
retirement. So these young physicians get through their 
training, and then they have a 7-year commitment. The intent, 
as I understand it, was pretty clear. I hear this routinely 
from my daughter, who is a USUHS graduate and finishing her 
second year of medicine residency, that they will get out to 
10, 11, 12, 13 years before they reach that first unobligated 
decision point. Many of them--and I cannot give you a number, 
but clearly early on and so some of the more senior 
physicians--many had prior service. So they already had some 
commitment into retirement.
    Senator Mikulski. But the bottom line is do they serve 
longer? Do you know that?
    General Kiley. Our best estimate is yes, Senator, they seem 
to because the HPSPers--the larger group, by the way, at least 
for the Army--we get 60 doctors every year from the Uniformed 
Services. We get between 250 to----
    Senator Mikulski. Well, I am not saying it is not a 
substitute for----
    General Kiley. No, ma'am. I understand.
    Senator Mikulski. So, in other words, USUHS--the Naval 
Academy does not do all of the officer corps for the Navy.
    General Kiley. But if you are a West Point graduate with a 
5-year obligation from West Point and you are a USUHS graduate 
with a 7-year obligation, those two are additive. So you are 
close to retirement before you can even decide----
    Senator Mikulski. Yes, but you might not be coming from 
West Point.
    General Kiley. That is correct.
    Senator Mikulski. You might be coming a different route.
    General Kiley. But the HPSPers--those only owe 4 years. 
They only owe 4 if they do a full 4-year scholarship.
    Senator Mikulski. So the HPSP is the scholarship program. 
Is that correct?
    General Kiley. Yes, ma'am.
    Senator Mikulski. Now, in terms of the scholarship program, 
as I understand it, last year you had less than one applicant 
per slot, while USUHS had 10 initial applicants for every slot 
getting into USUHS. Are you aware of that?
    General Kiley. I do not believe that the number was less 
than one applicant per slot. I believe it was about 1.1 to 1.2 
applicants per slot, which is down from what it used to be.
    Senator Mikulski. Yes, but that is not a lot.
    General Kiley. No, ma'am, it is not.
    Senator Mikulski. That is not a lot. And when you think 
that there are 10 people lining up to get into one slot in 
USUHS and we are talking about closing it, but it is barely one 
on one for the DOD HSP program, then I think we need to 
evaluate the scholarship program and find out why. But it is 
also a lesson saying let us not close USUHS.
    Now, we understand the military doctors are a military 
doctor rather than a doctor who is currently in the military.
    But as I understand it, first of all, you have got about 
1,000 vacant physician positions, and not only are you 
competing with those at Hopkins or Mercy, like in our own 
State, Suburban, which you just referenced, Admiral, but you 
are also competing with the VA. The VA can pay more than the 
military. Am I correct?
    General Kiley. I believe they can, yes, ma'am, at least in 
some specialties.

                          SCHOLARSHIP PROGRAM

    Senator Mikulski. Well, see, I think these are the issues 
that we need to look at, and they would not be necessarily the 
scope of this hearing. But I think we do need to look at the 
scholarship program.
    Senator Stevens. Would you say that again, Senator?
    Senator Mikulski. Well, today the Department of VA, as I 
understand it from my old work on the VA Subcommittee before we 
were reorganized, sir, can pay its civilian physicians more 
than DOD can under title 38. Therefore, not only are you 
competing with academic centers of excellence and community-
based medicine, but you are also competing even against the VA 
in many of the same geographic areas where people are serving. 
Again, I come back to military medicine being a 36/7 calling.
    So we do not want to short change the VA exactly because 
this seamless transition that you are developing and we are so 
enthusiastic about, but at the same time, if you are trying to 
get a surgeon, these specialties, but even in the primary care 
area, this would seem to be a challenge. And also VA is 
offering scholarships in nursing, scholarships in medicine and 
so on. So I think we need to look at this and how you are going 
to be competitive.
    My advice is that we should not close USUHS because USUHS 
might bring not only medical skill but a military culture as 
compared to simply training a doctor to be in the military. I 
think the military doctor has an influence on the doctor in the 
military to grasp this very unique culture that you are the 
leaders of.
    Do you see where I am? So I think we need to look at that.
    I would also think that we should look at perhaps debt 
reduction. When someone has completed their medical school, 
their debt in many instances is over $100,000. It is 
breathtaking for some. Then they think, I want a different life 
here and they are ready to think about this perhaps, but we 
should think about forgiving their debt as they entered the 
military. We already know then they have gotten through medical 
school. So it is not a crap shoot to know if they are going to 
make it. So I think we need some new thinking. Have you thought 
about this?
    Senator Stevens. That is a good idea. We ought to all think 
about that, Senator. That is a very good idea.
    Senator Mikulski. Yes. And then when they come in, 
essentially we swap debt for duty.
    General Kiley. Yes, ma'am.
    General Taylor. Yes, ma'am. We do have certain tools that 
fit that category. The question is whether we are effectively 
using them or do we have the wide range of authority to fully 
execute those. We do have some debt relief tools. We do have 
some recruiting tools, and I think it is a very good question 
as to whether we are effectively using them or we are limited 
in size and scope because of finances or congressional caps. I 
think it is worthy for us to look at it.
    General Kiley. I think you hit on it, $100,000 in debt. If 
you are coming out of Georgetown or George Washington (GW), you 
may be closer to $200,000 in debt based on the estimates of the 
cost. These young physicians then look at an Army salary with 
this debt on them, and it is very hard. Every year we have a 
couple physicians that come on Active duty, having incurred an 
obligation in ROTC in undergraduate, who have those kind of 
debts. They can sometimes struggle.
    We do have some programs that recognize some of that debt 
reduction, but the programs are not nearly robust enough to 
address some of the issues you have had.
    The second piece about the VA receiving more. One of the 
things the VA physicians, as I understand it, have as part of 
their retirement package is that these bonuses that they are 
given as physicians in the VA are all calculated into their 
retirement pay. They are not calculated into the military 
retirement pay.
    Senator Mikulski. Well, I think we need to then look at how 
the VA is doing it and perhaps some lessons learned.
    But the point of debt forgiveness is that perhaps when 
someone has completed their internship, they have got all this 
debt, this could be another recruitment time, or even when they 
have completed their residency. Some young people do not now 
want the hassle, the malpractice issues and the health 
maintenance organization (HMO), the insurance stuff, and the 
idea of being in the military would be very attractive to them.
    I know my time is up, but I am very keen on this 
recruitment and retention.
    Senator Stevens. I want to ask the three witnesses here if 
they will confer and give us a suggestion on how to flesh out 
the Mikulski plan. We have several provisions in Federal law 
that it is really payment rather than forgiveness because those 
loans are not made by the Federal Government primarily. I think 
they are mostly reinsured by the Federal Government. But I do 
think that you ought to give us a plan that would allow the 
services to entice young doctors and professionals to come into 
the services with an addition to their salary to repay those 
loans.

                  MEDICAL PROFESSIONALS LOAN REPAYMENT

    We do that here in the Senate to a certain extent. I do not 
know if you know that. It is not very much. We give the 
authority to a Senator to add to the salary an incentive 
payment for retention of employees who do have these debts. I 
have seen them come to my office with more than $100,000 and 
the lawyers coming in with almost $200,000.
    So I think this is probably one of the things that is a 
deterrent to enter Government service, and particularly 
military medical service. You ought to give us a plan. We will 
flesh it out and see if we cannot get the money for it this 
year.
    Senator Mikulski. Very good.
    Senator Stevens. We will call it the Mikulski plan.
    Senator Mikulski. Okay.
    Senator Stevens. Well, Sonny Montgomery had his plan. You 
have got yours.
    Senator Mikulski. Sounds good to me.
    [The information follows:]

                  Medical Professionals Loan Repayment

    The Health Professions Loan Repayment Program (HPLRP) has 
been a very important accession and retention tool to the Air 
Force Medical Service in certain areas. During the four year 
history of the current program, it has helped sustain the Nurse 
Corps Accession program, accounting for nearly half of the 
Nurse Corps accessions. It has also helped the Air Force Dental 
Corps to slightly improve the retention of general dentists 
(non-residency trained). Although HPLRP has been successful in 
some of our accession and retention endeavors, there is a low 
rate of HPLRP takers among physicians and residency-trained 
dentists.
    Physicians, dentists, and certain Biomedical Sciences Corps 
specialists tend to have larger debt burdens than other health 
professionals and, due to salary differences, have a greater 
potential for quickly paying off these loans working in the 
civilian sector versus the military. Physician and dental 
officer average debt load is $100,000-$120,000 with some even 
approaching $350,000. Health professionals have cited high 
student debt load as a major factor in their decision to 
separate from the Air Force.
    A few recommendations to improve the effectiveness of the 
health professions loan repayment program are: (1) make HPLRP 
tax free, perhaps mirroring the Indian Health Service Loan 
Repayment Program; (2) allow HPLRP service obligation to run 
concurrent with any other service obligation; (3) receive HPLRP 
appropriation to provide adequate quotas to improve the current 
program; and (4) establish an adequate accession bonus for 
physicians and dentists to augment the HPLRP as a more 
attractive accession tool. These improvements would help the 
military services attract and retain fully qualified health 
professionals especially in those extremely hard to recruit 
specialties.

    Senator Stevens. Thank you very much, gentlemen. We 
appreciate very much your service and your testimony here 
today. We look forward to hearing from you further about this 
idea, and I think it is a good one to pursue.
    We will now turn to the Nurse Corps. Thank you again for 
coming.
    We are now going to hear from the nursing corps. This 
subcommittee's view is that the nursing corps are vital to the 
success of our military medical system. We thank you for your 
leadership and look forward to your comments and telling us 
your challenges. From the Army, we will hear from Colonel 
Barbara Bruno, who is the Deputy Chief of the Army Nurse Corps. 
We welcome you here, Colonel. We will also hear from Admiral 
Nancy Lescavage, Director of the Navy Nurse Corps, and Major 
General Barbara Brannon, Assistant Surgeon General for Nursing 
Services for the Air Force.
    Your patron saint is my friend here from Hawaii, so I will 
yield to him.
    Senator Inouye. Welcome. Is this not Nurses Week?
    General Brannon. This is indeed.
    Colonel Bruno. It is.
    Senator Inouye. I think it is most appropriate that you are 
here, and I want to congratulate all of you and thank you for 
the service you are rendering to our country. It is very 
essential. We would rather listen to you than listen to me. So, 
Mr. Chairman.
    Senator Stevens. Senator Mikulski, comments?
    Senator Mikulski. I believe that the issues of recruitment 
and retention are actually severe in nursing because of the 
issues in the larger community. But again, for everybody who is 
at Naval Bethesda and we have seen you on the hospital ship 
Comfort, we are so appreciative of what you do, and want more 
of you.
    Senator Stevens. Colonel Bruno.
STATEMENT OF COLONEL BARBARA J. BRUNO, AN, DEPUTY 
            CHIEF, ARMY NURSE CORPS, UNITED STATES ARMY
    Colonel Bruno. Thank you very much. Good morning, Chairman 
Stevens, Senator Inouye, and Senator Mikulski. Thank you for 
your unwavering support to provide the best nursing care 
possible to American soldiers, their families, and eligible 
beneficiaries.
    I am Colonel Barbara Bruno, Deputy Chief of the Army Nurse 
Corps. It is a real honor and a privilege to speak to you this 
morning on behalf of Major General Gale Pollock, the Chief of 
the Army Nurse Corps. She is hosting an historic military 
medical conference in Hanoi, Vietnam today. She sends her 
regards and wishes she could be here.
    I am going to highlight specific achievements and concerns 
that relate to the ability of the Army Nurse Corps to serve a 
Nation at war. As of March 2005, 765 nurses have deployed to 17 
countries, in addition to Operation Enduring Freedom in 
Afghanistan and Iraqi Freedom.
    Caring for critically injured soldiers can be incredibly 
stressful to the deployed staff and to the staff within our 
medical treatment facilities. Nursing research conducted at 
Walter Reed showed that nurses' feelings and emotions, while 
caring for returning injured soldiers, mirrored their deployed 
nursing counterparts. Yet they experience them in different and 
more long-lasting ways. Whereas deployed nurses have short and 
intense exposures to patients with severe and devastating 
trauma, nurses in our fixed facilities have prolonged and much 
more personal experience. They experienced high levels of 
empathy with the injured and their families. This empathy is 
common amongst all health care providers and is described as 
compassion fatigue. Soldiers involved in health care receive 
awareness training and educational material regarding 
compassion fatigue.
    The shortage of nurses in the civilian sector does have a 
direct impact on the entire Federal nursing force. We continue 
to leverage available incentives and seek additional creative 
avenues to recruit nurses. To remain viable in a very tight 
labor market, we have to be competitive.
    One extremely successful recruiting tool we have used in 
the Army is the Army Medical Department enlisted commissioning 
program. This is a 2-year education completion program for 
enlisted soldiers who have acquired the appropriate 
prerequisites. The Reserve component has expressed interest in 
a similar program.
    Another successful initiative directed at civilian Federal 
nurses is the direct hire authority. With this program, the 
time delay between finding a candidate and acceptance of a job 
offer has been significantly reduced. We are optimistic that 
the National Security Personnel System will alleviate the 
obstacles to hiring civilian nurses.
    While recruiting is an obvious challenge, retention is of 
greater concern and a much less conspicuous one in nature. As 
the incentive gap with the civilian sector widens, it will be 
increasingly difficult to retain qualified nurses in military 
service, and for the Army this loss is twofold. We lose a 
superb soldier and a highly trained, experienced nurse.
    Successful retention of nurses is a combination of 
financial compensation, deployment equitability, and military 
benefit preservation. With the support of General Kiley, as he 
mentioned earlier, we have been very successful in the 
incentive specialty pay program for nurse anesthetists. The 
preliminary numbers reveal that 72 percent of the eligible 
nurse anesthetists have signed a multiyear contract since the 
increase in incentive pay. This information suggests a positive 
correlation between the increased pay and retention and 
provides us with good research for future retention strategies 
of other specialties.
    Our commitment to nursing research remains strong. Walter 
Reed Army Medical Center has partnered with Mount Aloysius 
College in Pennsylvania as part of a congressionally funded 
nursing telehealth applications initiative. This relationship 
provides a quality learning experience to nursing students in a 
rural environment. While students and faculty remained at Mount 
Aloysius, two Army nurses took care of various patients in the 
medical intensive care unit (ICU) at Walter Reed, bringing that 
clinical setting to rural Pennsylvania. Our commitment to 
addressing the nursing education insufficiencies exemplifies 
Army Nurse Corps leadership, innovation, and new approaches to 
solve problems.
    Nursing research is invaluable to excellent, evidence-based 
nursing practice. We thank you for your dedicated funding and 
continued support of the TriService nursing research program.

                           PREPARED STATEMENT

    The Army Nurse Corps continues to move forward with 
initiatives to improve the best nursing organization in the 
world. Our research is changing nursing practice globally, and 
Army nurses are highly valued throughout the world. With the 
continued support of Congress, Army Nurse Corps compassion and 
leadership will ensure that we are able to take care of our 
military men and women and that they receive the finest health 
care anytime anywhere.
    I thank you for this opportunity to speak to you today.
    [The statement follows:]

           Prepared Statement of Colonel Barbara J. Bruno, AN

    Mr. Chairman and distinguished members of the committee, thank you 
for your unwavering support to provide the best nursing care possible 
to American Soldiers, their families and eligible beneficiaries. In 
today's unprecedented environment of global, joint and collaborative 
military medical operations, we continue to see success in the Global 
War on Terrorism, and have made numerous improvements in nursing care 
delivery at home, abroad and on the battlefield.
    I am Colonel Barbara Bruno, Deputy Chief, Army Nurse Corps (ANC). 
It is an honor and privilege to speak to you today on behalf of Major 
General Gale Pollock, the 22nd Chief of the Army Nurse Corps. MG 
Pollock is hosting an historic military medical conference in Hanoi, 
Vietnam.
    Military forces engage in security cooperation activities to 
establish important military interactions, building trust and 
confidence between the United States and its multinational partners. 
The visible and purposeful presence of U.S. Military capabilities is an 
integral part of an active global strategy to ensure security and 
stability. The Asia Pacific Military Medicine Conference (APMMC) is one 
of the critical tools used to accomplish this.
    The APMMC is the premier medical conference in the Pacific Command 
(PACOM) area of responsibility. This conference provides a forum for 
U.S. Military health care providers and leaders to collaborate with 
Allied and friendly countries in the Asia-Pacific region. Topics of 
military medical significance such as interoperability, medical 
readiness, illnesses, battle injuries, medical technological 
advancements, force health protection, and disaster/consequence 
management are the primary foci of the APMMC.
    As the U.S. Army, Pacific Surgeon, MG Pollock will conduct 
bilateral discussions with senior delegates from over thirty countries 
attending the APMMC. These bilateral discussions provide a forum to 
plan future medical events with regional partners, and enhance 
influence and access to these nations in order to combat terrorism, 
transform alliances, and build coalitions for the future. This year's 
APMMC is in Hanoi, Vietnam. This is particularly significant as it is 
the first time the U.S. Military has ever co-hosted a conference of 
this magnitude with the country of Vietnam.
    The ANC is actively engaged in strategic planning to allow us to 
achieve the greatest benefit, both human and monetary. During this 
congressional hearing I will take the opportunity to highlight specific 
achievements and concerns that relate to the ability of the ANC to 
serve a Nation at war.
    Army Nurses possess the expert clinical skills, compassion, and 
leadership acumen requisite to execute the most challenging missions in 
austere environments. As of March 2005, 419 Active Component (AC) and 
151 Reserve Component (RC) nurses were currently deployed to 17 
different countries including Operation Enduring Freedom/Operation 
Iraqi Freedom (OEF/OIF). An additional 95 Army Nurses have supported 
other medical training missions as subject matter experts, trainers, or 
medical augmentees. Since our last testimony, our deployments total 
over 74,045 person-days.
    The 31st Combat Support Hospital (CSH) from Ft. Bliss, TX and the 
67th CSH from Wuerzburg, Germany transitioned at the end of the 2004 
calendar year with the 86th CSH from Ft. Campbell, KY and the 228th CSH 
(a combined AC/RC unit) from San Antonio, TX. The 115th Field Hospital 
from Ft. Polk, LA, is also in Iraq as medical support for Abu Ghraib 
Prison. The RC continues to take the lead in the medical support 
mission in Afghanistan with the 325th Field Hospital from Los Angeles, 
CA being replaced by the 249th Field Hospital from Independence, MO. In 
addition to the CSHs, 45 nurses deployed on eight Forward Surgical 
Teams (FST) in support of OEF/OIF and two RC CSHs deployed to Germany 
as backfill.
    Army Nurses are serving critical roles in direct support of the War 
on Terrorism at all ranks and skill levels. At the company grade level, 
nurses are instrumental in the leadership and direct supervisory 
training that combat medics receive during their Advanced Individual 
Training at Fort Sam Houston, Texas. This training provides combat 
medics with the critical knowledge they need to care for battlefield 
casualties. Often, the diverse clinical experience of the nurse is the 
only conduit between training and the trauma of war for these young 
medics. In addition, 44 Army Nurses are embedded with Divisions and 
Brigade Combat Teams providing direct nursing care to Soldiers in the 
field while also providing advanced training to combat medics prior to 
and during deployment.
    The value of the Advanced Practice Nurse (APN) has never been as 
evident as it is in today's Army. Their expanded roles in the health 
care delivery system make them a highly prized commodity. APNs in 
varying specialties utilize their expertise to ensure patients 
transition smoothly from point of entry through the healthcare system 
based on each patient's individual needs.
    The positive impact Army APNs are having on patient outcomes has 
created a tremendous demand for their services in various healthcare 
settings. Trauma Registry Coordinators, Nurse Practitioners, Nurse 
Anesthetists, Psychiatric Clinical Nurse Specialists, and senior-level 
Case Managers are just a few of the roles in which these highly 
educated nurses are serving.
    In late 2004, six Army APNs deployed to Iraq to serve as Trauma 
Registry Coordinators. These Army Nurses have been an integral 
component of the Army Medical Department's (AMEDD) Theater Trauma 
System. This demonstration project adopted the American College of 
Surgeons Committee on Trauma's model for civilian trauma care into the 
current theater of operation. The Theater Trauma System initiative has 
multiple components: pre-hospital care coordination, utilization of 
clinical practice guidelines for trauma management and patient 
movement, trauma research and integration of clinical information 
systems for care delivery, and command and control. The overarching 
goal has been to ensure ``the right patient, to the right provider, at 
the right location and right time.''
    A cornerstone of the Theater Trauma System is the Joint Theater 
Trauma Registry (JTTR). The JTTR application is used to capture data 
from non-integrated clinical and administrative systems within the 
AMEDD, our sister Services and the Department of Defense. The Trauma 
Registry Coordinators ensure that critical clinical data is collected 
in theater and incorporated into the JTTR to provide a comprehensive 
picture of trauma patients from point of injury through rehabilitation. 
To date, the JTTR contains more than 7,000 records of battle and non-
battle injuries of United States, Allied and enemy combatants. Our 
support of this initiative remains steadfast, for as the Theater Trauma 
System matures, JTTR data will be used to improve the overall quality 
of care provided to our injured Soldiers.
    An unprecedented move for Family Nurse Practitioners (FNP)--
substituting for Physician Assistants at Echelon II medical companies--
begins during the next rotation of OIF. These FNPs will provide primary 
care in field environments and initiate treatment for wounded soldiers.
    Our RC Army Nurses continue to demonstrate excellence in health 
care management. In addition to deploying nurses to theater, numerous 
others are serving in a backfill capacity in our Medical Treatment 
Facilities (MTF). Most noteworthy are the APNs serving as senior-level 
Case Managers at the Regional Medical Commands. These nurses are 
credited with the development of medical holdover case management and a 
patient tracking tool. They supervise 158 Army Reserve and National 
Guard nurses serving as Case Managers in MTFs and Community Based 
Healthcare Organizations located close to Soldiers' homes.
    These RC nurses functioning as Case Managers assist their physician 
colleagues to aggressively manage highly complex wartime patients to 
achieve positive outcomes for the 21,500 Soldiers who have required 
medical care following mobilization. Of the 16,453 Soldiers processed 
since the establishment of the medical holdover management program, 
10,868 Soldiers have returned to their units. This success, a direct 
result of compassionate care and attention to detail, clearly 
demonstrates the need for nurses in the ambulatory healthcare setting.
    Combat is demanding and taxing. Estimates are that between 3 
percent and 4 percent of the general adult population in the United 
States suffers from Post Traumatic Stress Disorder (PTSD) (Narrow, Rae, 
Robins & Regier, 2002). Among Gulf War veterans, estimates are that 
between 2 percent and 10 percent suffer from PTSD (Iowa Persian Gulf 
Study Group, 1997; Kang, Natelson, Mahan, Lee & Murphy, 2003). In a 
systematic review of 20 studies that compared the prevalence of 
psychiatric disorders in Gulf War veterans to a comparison group of 
veterans previously deployed for other conflicts not including current 
operations, Gulf War veterans were three times more likely to develop 
PTSD (Stimpson, Thomas, Weightman, Dunstan & Lewis, 2003). More 
recently, in a cross-sectional study of 3,671 Soldiers and Marines 
surveyed 3 to 4 months after returning from deployments to Afghanistan 
or Iraq, between 6 percent and 13 percent of the participants suffered 
from PTSD (Hoge et al., 2004). The prevalence of PTSD increased 
linearly with the number of firefights Soldiers experienced and being 
wounded.
    The Department of Defense and the Department of Veterans Affairs 
are taking a proactive approach to monitoring and treating PTSD. One of 
the 26 clinical practice guidelines jointly developed by the Army, Air 
Force, Navy, and Veterans Affairs addresses the management of Post-
Traumatic Stress. An Army nurse leads the clinical practice guideline 
effort at the Army Medical Command (MEDCOM) disseminating these 
evidence-based practice recommendations across the AMEDD.
    Caring for critically injured soldiers can be incredibly stressful 
for the deployed staff and the staff within our fixed MTFs. Nursing 
research conducted at Walter Reed Army Medical Center showed that 
nurses' feelings and emotions while caring for returning injured 
soldiers mirrored their deployed nursing counterparts, yet they 
experienced them in different and more long-lasting ways. Whereas 
deployed nurses have short and intense exposures to patients with 
severe and devastating trauma, nurses in our fixed facilities have 
prolonged and much more personal exposure. They experienced high levels 
of empathy with the injured and their families. This empathy is common 
among all health care providers and is described as ``compassion 
fatigue.'' Soldiers involved in healthcare receive awareness training 
and educational material regarding compassion fatigue.
    The shortage of nurses in the civilian sector continues to have a 
direct impact on the federal nursing force, both military and 
government service requirements. The AC accession mission for Army 
Nurses has not been met since 1998 while the RC has not met mission 
since 2002. At the end of fiscal year 2004, the AC ANC was 203 officers 
below its budgeted end strength of 3,415 and missed its goal of 
accessing 385 new officers by 48. The RC ANC also missed its accession 
goal of 507 new officers by 141.
    A recent study commissioned by the United States Army Accession 
Command, determined that specific offers and messages can improve the 
accession rate and help to relieve our shortages. The sample population 
included registered nurses, graduate nurses, and nursing students. 
Reducing minimum service obligations, adjusting deployment length, 
ensuring assignment preferences, and increasing financial incentives 
have the most potential impact on nurse accession. As a result of these 
findings, the Chiefs of Nursing for U.S. Army Cadet Command (USACC) and 
U.S. Army Recruiting Command (USAREC) have developed several 
initiatives aimed at increasing overall nurse recruitment.
    The first initiative from USACC is the Centralized Nurse 
Scholarship program. It was implemented to focus additional Reserve 
Officer Training Corps (ROTC) battalions on the nurse mission. They 
accomplished the initiative by increasing the number of schools 
actively recruiting nursing cadets from 47 to approximately 200 and 
using the nurse mission as a quantifier of success. They also 
consolidated Nursing Scholarships at USACC Headquarters, centralizing 
funds, and providing responsive access to scholarship resources 
wherever qualified nurse applicants are located. The new program also 
allows students to choose how their scholarship dollars are used. This 
benefits those students who may have received additional academic 
scholarships that are specified for tuition only. In addition, the 
tuition cap and book stipend were increased by $3,000 and $300 per year 
respectively.
    The second initiative from USACC is an expanded ROTC Nurse Educator 
Tour and Nurse Summer Training Program (NSTP). Showcasing ROTC's 
Leadership Development and Assessment Course (LDAC) and NSTP are 
significant recruiting tools available to Army Nursing. During the 
summer of 2004, 150 nurse educators were invited to attend the LDAC at 
Ft. Lewis, WA, in an effort to display the versatility of our nursing 
cadets in both the field training and clinical environments. The nurse 
educators who participated in this program witnessed nursing students 
during leadership training at the LDAC and then received a tour of 
Madigan Army Medical Center where they observed nursing students in the 
clinical setting during NSTP. Nurse educators participating in the tour 
left with a new-found dedication to Army ROTC and a better appreciation 
for the ANC as a whole. As a result of their positive experiences, many 
of these educators now require students returning from LDAC and NSTP to 
provide a presentation about the experience to their classmates, 
inviting more queries about the ANC as a career option. Most schools 
are now encouraging qualified students to consider Army ROTC and many 
are giving academic credit for NSTP completion. The success of this 
program has already made a significant impact in nursing student 
recruitment at these universities.
    In light of this success, USACC has experienced a greatly improved 
collegial relationship with all universities in attendance. In an 
effort to improve recruiting efforts while promoting the positive image 
of Army Nursing, focus has shifted this year to universities who have 
been less than supportive in the recent past. One hundred 
representatives from these universities have been invited to attend 
this years Nurse Educator Tour. This type of networking and partnering 
will increase a positive view of Army Nursing in the civilian 
community.
    While USAREC recruiting initiatives are similar in nature to those 
of USACC, their targeted population is larger and more diverse. They 
are solely responsible for recruitment of RC nurses and all other 
nurses and nursing students not eligible for ROTC.
    The Health Professional Loan Repayment Program (HPLRP) was 
instituted in fiscal year 2003 and targeted new accessions to provide 
nurses with an educational loan repayment benefit up to $29,000. Prior 
to HPLRP implementation, USAREC was limited to a sign-on bonus as their 
only financial incentive tool. To date, 345 AC nurses have benefited 
from this program.
    The Army Nurse Candidate Program (ANCP) targets nursing students 
prior to graduation who are not eligible for ROTC but are still fully 
qualified as a direct accession nurse. It provides a $1,000 monthly 
stipend and a $10,000 bonus paid in two increments. The ANCP provides 
USAREC the ability to recruit nursing students as early as their 
sophomore year. This program will give us the leverage to offer 
accession incentives to students much earlier in their education 
program which is essential when competing with the civilian market.
    The Army Enlisted Commissioning Program (AECP), used by AC enlisted 
Soldiers, is an extremely successful recruiting tool. The program 
provides a 2-year education completion program for enlisted Soldiers 
who have acquired the appropriate prerequisites. Currently 75 Soldiers 
are funded annually to obtain their Bachelor of Science Degree in 
Nursing.
    The last AC recruiting initiative we want to highlight is the 
accession bonus. Money is programmed through fiscal year 2008 to 
implement this plan. The current accession bonus is $15,000. The 
proposed increase is $5,000 per year through fiscal year 2008. With 
these targeted increases, USAREC believes we will become comparable to 
the standard sign on bonus of our civilian competition.
    Reserve Component accessions are a concern. Although their overall 
strength remains good, accession percentages have declined in the past 
2 years.
    While recruiting is an obvious challenge, retention is of greater 
concern, and much less conspicuous in nature. Unlike recruitment, the 
inability to retain a mid-level officer comes at a much higher expense. 
For the military, the loss is two-fold--a superb Soldier and a highly 
trained and experienced nurse.
    Nurses have continually answered the call to service and it is 
critical that we develop appropriate retention strategies to ensure an 
adequate force structure exists to support our fighting forces. Their 
successful retention is a combination of financial compensation, 
deployment equitability, and military benefit preservation.
    The critically low density area of concentration that is most 
severely affected by attrition is the Certified Registered Nurse 
Anesthetist (CRNA). CRNA actual end strength has fallen to 70 percent. 
With the support of Lieutenant General Kiley, The Army Surgeon General, 
Health Affairs and the Army, the ANC was successful in implementing a 
major restructuring of the Incentive Specialty Pay (ISP) program for 
CRNAs that addressed two issues important to this population. First, it 
provided the first increase in ISP in nearly 10 years to officers 
fulfilling their initial Active Duty Service Obligation (ADSO). This 
change was central to our retention strategy as disparity in pay for 
this population was identified as a major source of dissatisfaction. 
Additionally, the revised ISP structure provided the option to receive 
significantly higher annual ISP payments in exchange for incrementally 
longer service obligations, one to 4 years, after completing their 
initial ADSO.
    Preliminary numbers reveal that of the 116 CRNAs eligible to sign 
for multi-year contracts, 84 (72 percent) have done so. The information 
suggests a positive correlation and retention of other nursing 
specialties may require ISP programs. Our next specialty concerns are 
the operating room, intensive care unit (ICU), and emergency room (ER) 
nurses who are in high demand both in the Army and the civilian 
healthcare market.
    Financial compensation is also a retention initiative for our 
government service employees. Several civilian personnel initiatives 
are focused on alleviating government nursing shortages. Nursing has 
benefited from Direct Hire Authority (DHA). The time delay between 
finding a candidate and acceptance of a job offer was reduced from over 
100 days to an average of 19 days under DHA.
    Madigan Army Medical Center is participating in the first iteration 
of the National Security Personnel System (NSPS). This system 
recognizes the need to modernize the personnel system for the 
Department of Defense. The NSPS must significantly improve the 
personnel system for healthcare occupations.
    One initiative that demonstrates promise is the Army Civilian 
Training Education Development System (ACTEDS). This program is an Army 
Requirements-based system that ensures development of civilians through 
a blending of progressive and sequential work assignments, formal 
training, and self-development for individuals as they progress from 
entry level to key positions. ACTEDS provides an orderly, systematic 
approach to technical, professional, and leadership training and 
development similar to the military system. It provides civilian 
employees base documents specific for career development within their 
chosen profession. Several ACTEDS plans are now available to government 
civilian nurses.
    Another retention strategy currently implemented focuses on 
intrinsic rewards. The role of the Nursing Consultants to the Surgeon 
General is expanding to include input into the personnel deployment 
system and involvement with the officer distribution process for all 
critical wartime specialties. This strategy coupled with implemented 
policies to ensure equitable utilization of our deployment pool will 
assist us in the retention of highly educated professional nurses. 
Limiting the unknown for nurses by providing adequate notification of 
impending deployment and providing a predictable period of family 
separation should improve retention.
    Walter Reed Army Medical Center has partnered with Mount Aloysius 
College in Cresson, Pennsylvania as part of a phased 4-year Nursing 
Telehealth Applications Initiative. This relationship, which provides a 
quality learning experience to improve the academic preparation of 
nurses, will assist to alleviate the critical nursing shortage.
    The purpose of this study was to determine if the concept of a 
``Virtual Clinical Practicum TM'' was a viable venue for nursing 
students to gain clinical skills in the absence of physically visiting 
clinical sites. Nursing students attending Mount Aloysius College, a 
rural community, have no opportunity to experience an ICU environment. 
Using Telehealth Technology, nursing students observed and learned 
about the nursing care of complicated adult medical patients and 
experienced an ICU clinical experience remotely. While students and 
faculty remained at Mount Aloysius, the nurse experts, two ANC 
Officers, took care of various patients in the Medical ICU at Walter 
Reed.
    The professionalism and clinical expertise of the ANC officers was 
enthusiastically embraced by both the students and faculty. There are 
follow-on studies planned with this technology. Our commitment to 
address nursing education insufficiencies exemplifies ANC leadership, 
innovation, and new approaches to solve current problems.
    Nursing research, like the Nursing Telehealth Applications 
Initiative, is invaluable to excellent, evidence-based nursing 
practice. We thank you for your dedicated funding and continued support 
of the TriService Nursing Research Program. Army nurses along with 
their Federal and civilian colleagues are dedicated to the 
dissemination of knowledge and improvement of professional nursing 
practice.
    Army Nurses are conducting and participating in a number of studies 
specific to the care of deployed troops. Nurses at Walter Reed Army 
Medical Center are collaborating with their Air Force colleagues to 
assess aeromedical evacuation needs of war injured service members. At 
Brooke Army Medical Center, Army and Air Force Nurses are determining 
best methods to teach nurses how to care for chemical casualties and 
how to facilitate long term skills retention.
    Nurse researchers at several locations are investigating deployment 
experiences of AMEDD personnel to seek information on improving quality 
of care for wounded service members and the emotional health of nursing 
personnel. Compassion fatigue of nurses who are working at our fixed 
facilities is another area of ongoing inquiry.
    Nurses at Madigan Army Medical Center are enhancing Combat Medic 
skill sustainment using simulated battlefield conditions and SimMan, 
life-sized, computer-linked robots. This study will validate and 
standardize Combat Medic evaluation scenarios and template evaluator 
competencies.
    Madigan Army Medical Center is also studying the impact of head 
nurse leadership on retention of junior ANC Officers. This research 
will provide information about essential leadership competencies and 
performance expectations from ANC Officers.
    Nurses at Walter Reed Army Medical Center, Madigan Army Medical 
Center, and the Army Medical Department Center and School are 
coordinating the multi-site Military Nursing Outcomes Database (MilNOD) 
study being conducted at six Army, three Air Force, and four Navy 
facilities. This study is investigating the relationship of staffing to 
various nurse and patient outcomes. The study team continues to 
collaborate with the California Nursing Outcomes Coalition and the 
Veteran's Administration Outcomes Database Project (VANOD), building 
upon each other's collective experience in this unique work. The 
research team and collaborators, including the American Nurses' 
Association's National Database for Nursing Quality Improvement 
(NDNQI), created the National Nursing Quality Database Consortium and 
held an invitational methodology conference this past fall. The purpose 
of the conference was to learn from and work with researchers from 
other disciplines, who are at the cutting edge of new methods to 
analyze these types of data. The National Nursing Quality Database 
Consortium is hosting its first national conference this spring to 
share the knowledge gained from this collaboration with other 
colleagues in the nursing field.
    Recognizing the benefit of nursing research departments staffed 
with Doctorally prepared nurse researchers conducting militarily 
relevant nursing research, I am pleased to announce we have opened a 
research department at Tripler Army Medical Center, the fourth in the 
Army Medical Department. These nurses are working with the Hawaii 
Nursing Taskforce and Queen's Medical Center on a grant submission to 
study the Effect of Magnet Environments on Patient and Nursing 
Outcomes. Other research initiatives include evidence-based practice 
projects to develop standards of practice for pressure ulcer prevention 
and preparing children for surgery. Additionally, working with Pearl 
Harbor Naval Base and Hickam Air Force Base clinic nurses, military 
nurse researchers at Tripler will utilize research findings to 
standardize and implement the most appropriate nursing interventions 
and document measurable nursing outcomes for specific inpatient and 
outpatient military beneficiaries.
    Anesthesia students are very involved in research activities 
studying pain and re-warming techniques following surgery, and the 
effects of different anesthetic medication and adjunct therapies on 
patient outcomes. New technologies, such as piezoelectric technology, 
are also being studied. This technology allows a Soldiers' vital signs 
to be continuously monitored while being transferred from the field to 
a definitive care setting.
    In addition to our research activities, the ANC is dedicated to 
Soldier training and professional military education. Preparing our 
Soldiers to provide relevant, competent and professional care in any 
environment requires a robust training program. The ANC is constantly 
adapting our training programs to prepare Soldiers for their primary 
occupational specialty and go-to-war skills.
    The Department of Nursing Science (DNS) at the Army Medical 
Department Center and School (AMEDDC&S) is using research and lessons 
learned from our deployed colleagues to improve training. Among the 
many initiatives over the last year, trauma and burn care was 
incorporated into the ANC Officer Basic Course. Combat stress education 
was added to the Army Nurse Captains Career Course. Ethical treatment 
of all patients is highlighted in all of our courses. In addition, 
components of Warrior Ethos Training and simulation experiences are 
being incorporated into the program to better prepare Soldiers for 
combat survival. The U.S. Army School of Aviation Medicine is piloting 
a Joint Enroute Care Course to prepare ICU and ER Nurses and improve 
care for patients evacuated from the battlefield via rotary wing 
aircraft.
    The ANC extends our appreciation and recognizes the faculty 
leadership of the Uniformed Services University of the Health Sciences 
(USUHS) for their academic achievements and initiatives. The Graduate 
School of Nursing has been instrumental in providing highly trained, 
FNPs, CRNAs, and Doctorally prepared nurses. Graduates from these 
programs continue to enjoy a higher than average national pass rate on 
certification exams. We look forward to the May graduation of their 
first Peri-operative Clinical Nurse Specialist Course and the addition 
of a Military Contingency Medicine course.
    The ANC continues to move forward with initiatives to improve the 
best nursing organization in the world. Our research is changing 
nursing practice globally and the officers of the ANC are highly valued 
throughout the world. With the continued support of Congress, the 
clinical excellence, compassion, and leadership strengths of Army 
Nurses will ensure our military men and women receive the world's 
finest healthcare anywhere, anytime.

    Senator Stevens. Admiral Lescavage.

STATEMENT OF REAR ADMIRAL NANCY J. LESCAVAGE, NAVY 
            NURSE CORPS, UNITED STATES NAVY

    Admiral Lescavage. Good morning, Chairman Stevens, Senator 
Inouye, Senator Mikulski. I am Rear Admiral Nancy Lescavage, 
the 20th Director of the Navy Nurse Corps and Commander of the 
Naval Medical Education and Training Command in Bethesda, 
Maryland. It is indeed an honor and privilege to speak before 
you about our outstanding 5,000 Active and Reserve Navy nurses 
who continue to provide preeminent health care in all 
operational, humanitarian, and conventional settings. I want 
you to know our military and civilian nurses continue to 
proudly demonstrate professional excellence in promoting, 
protecting, and restoring the health of all entrusted to our 
care anytime and anywhere.
    I would like to address five specific areas.
    Number one, as our Surgeon General addressed, is readiness. 
In this area, Navy medicine's first priority, Navy nurses 
remarkably deliver superb medical care throughout the 
battlefield continuum. We have recorded over 125,000 mission 
days in operational and training exercises. Navy nurses have 
deployed this past year throughout the world to Kuwait, Iraq, 
Djibouti, Afghanistan, Bahrain, the Philippines, Thailand, and 
Guantanamo Bay. As you know, humanitarian efforts have been 
provided to tsunami and Haitian relief countries, as well as in 
our homeland in Pensacola after Hurricane Ivan.
    Some examples of our readiness training are the following. 
Through the Navy trauma training course with LA County/
University of Southern California Medical Center in Los 
Angeles, our Navy nurse instructors provide participants real-
life exposure while integrating with the hospital's trauma 
staff to provide specialized care. Our nurses who are training 
there are part of a team of physicians and corpsmen who soon 
will go in harm's way. The newly established Navy EnRoute Care 
Corps has trained 22 Navy nurses at Camp Lejeune, North 
Carolina prior to their deployment to Iraq. This course 
includes a training pipeline involving the Air Force critical 
care air transport course, Navy trauma training course, and 
helicopter egress and water survival training. We also continue 
to contract with civilian trauma centers in close proximity to 
our medical treatment facilities for additional training and 
real-life experiences in trauma.
    To optimize the readiness capability of our sailors and 
marines, we have placed nurse practitioners on board our 
aircraft carriers Nimitz, Kennedy, and Enterprise. In addition 
to rendering traditional episodic care on those carriers, our 
nurse practitioners promote wellness through post-deployment 
health assessments, tobacco cessation, and medical exams. A 
nurse practitioner with two other health care team members was 
recently deployed to the Nimitz to assist 6,000 of our sailors, 
who were just coming back from the Middle East, which resulted 
in the most efficient completion of the post-deployment health 
assessment evolution known to any vessel.
    The second area I want to address is quality health 
services. In sync with Navy medicine's second priority of 
delivering quality and cost-effective health care, our Navy 
nurses span the continuum of care from promoting wellness to 
maintaining the patient's optimal performance. Innovative 
examples include the mental health nurse outreach program with 
the Marine Corps School of Infantry at Camp Lejeune, the 
Partnership for In-Garrison Health and Readiness in Camp 
Pendleton, and the Nurse Managed Welcome Center at Pearl 
Harbor. Through a comprehensive referral network with the VA 
transition program, our nurse case managers are right in there 
assessing rehab specialists in collaboration with other 
specialties for our returning casualties to get the best care 
possible.
    Other initiatives include the Nurse Run Medevac Transport 
Team at Bethesda and our specialized wound care clinics 
throughout our medical treatment facilities (MTF).
    In an age of cost containment, our nurses are savvy in 
business planning and continuously evaluate best health care 
business practices. Nurses in the ambulatory care setting have 
implemented clinical business rules and performance goals to 
guide their daily practice. Disease management programs for 
asthma, diabetes, breast cancer, and cardiac care have improved 
the patient screening rates. They have recaptured network costs 
and they have maximized provider productivity and guaranteed 
exceptional continuity of care, which is what it is all about.
    To enhance our quality of care, a sample of research topics 
includes clinical knowledge development from care of the 
wounded during Operation Iraqi Freedom, retention of recalled 
Nurse Corps Reservists, the effects of oxidative stress on 
pulmonary injury in our Navy divers, and factors associated 
with post partum fatigue in our Active duty women in the 
military. Several of these studies are funded by the TriService 
Nursing Research Program, which fosters military nursing 
excellence and promotes collaboration between not only military 
nurse researchers but with academia as well.
    In support of One Navy Medicine concept, which Admiral 
Arthur spoke to, the integration of our Active, Reserve, and 
civilian nurses renders a more efficient, effective, and fully 
mission-ready nursing force. With the deployment of over 400 of 
our Active duty Navy nurses, along with the mobilization of our 
reserve Navy nurses to support our military treatment 
facilities, there has been neither a reduction of inpatient bed 
capacity nor an increase of disengagements to the network.
    Together, as an example, we have also optimized joint 
training opportunities such as the chem-bio-radiological 
Defense training program between Navy Health Care New England, 
the Rhode Island National Guard and the marines at their local 
Reserve center. In addition, while our Active duty nurses 
attend the EnRoute Care course, our Reserve nurse officers 
participated in a pilot program of the Joint EnRoute Care 
course in the U.S. Army School of Aviation at Fort Rucker.
    Never have opportunities been greater for all of our corps 
to be in executive positions. To meet the mission in all care 
environments through Navy medicine's fourth priority of shaping 
our force, it is critical we specifically shape Navy nursing 
with the right number of nurses with the right education and 
training in the right assignments at the right time. Our Active 
duty component is presently 96 percent manned, with 2,979 of 
our almost 3,100 positions filled. However, for the first time 
in over 10 years, we only attained 68 percent of our fiscal 
year 2004 Active duty recruitment goal, acquiring 63 out of 92 
nurses.
    Of note, though, we recently increased our nurse accession 
bonus to $15,000 to be competitive with the other services. In 
addition, since the inception of the Nurse Candidate Program, 
this is the first year we were able to essentially double the 
accession bonus from $5,000 to $10,000 and their monthly 
stipends doubled as well from $500 to $1,000.
    Regarding our Reserve recruiting goal, we may experience 
challenges in attaining specific specialties. Of particular 
note, the hospital corpsmen professional development option was 
initiated last year for Reserves as part of a 3-year pilot 
program. In this scenario, our Reservists are provided drill 
credits while attending a bachelor of science in nursing 
curriculum. This upward mobility program will serve as an 
accession source for junior Nurse Corps officers.
    We also, in five of our military treatment facilities, are 
doing a pilot program where nurses are paid similar to VA 
nurses for on-call, holiday, weekend, and shift differential, 
and that is registered nurses (RNs) and in the future our 
licensed practical nurses (LPNs).
    Promoting retention, we have several initiatives to retain 
our talented professional nursing force. Our graduate education 
scholarship program is our number one retention tool. We give 
about 90 of those scholarships every year. We carefully 
identify our graduate education programs and we are trying to 
take the specialties that are most used in wartime and train to 
them. We strongly support our nurses to attend USUHS.
    Another significant first-time accomplishment. We were able 
to increase the certified registered nurse anesthetist 
incentive special pay to a multiyear contract this year. As 
part of a 1-year pilot program, we also have initiated special 
pays similar to the VA hospitals, as stated. After 1 year, we 
will evaluate these programs to see what that does for our 
retention and increasing salaries.
    To maximize our joint medical capabilities, as our final 
priority, we collaborate and integrate with the other services, 
as well as with local, State, and Federal agencies. As nurses 
function in significant roles in homeland security within Navy 
medicine, we also participate in joint programs for chemical 
and biological defense, and in many of our treatment 
facilities, nurses are at the forefront for emergency 
preparedness.
    In conclusion, the Navy Nurse Corps has been consistently 
dynamic in this ever-changing world. Our Navy nurses are using 
the latest technology, as you well know. We are conducting 
cutting-edge research and creating health policies across 
military medicine to advance our practice and improve all of 
our delivery systems.
    It has been an honor to serve as the 20th Director of the 
Navy Nurse Corps. I am very proud of our distinguished corps 
and of our great history. The Nurse Corps this Friday on May 13 
turns 97 years old. As I move on to a new assignment as 
Director of TRICARE Regional Office West in San Diego, I remain 
committed to the Navy Nurse Corps, our great Navy, and the 
Marine Corps team, and the Department of Defense. Like many of 
our Navy nurses and my professional colleagues who function in 
pivotal executive roles, I will continue to support our efforts 
to impact legislation, health care policy, and medical delivery 
systems. I hand the Navy Nurse Corps over to the very capable 
leadership of my successor, Rear Admiral (Select) Christine 
Bruzek-Kohler.
    My greatest gift every day lies in working with the fine 
officers and civilians who support our military and in 
collaborating with my splendid colleagues, not only in the 
armed forces, but across academia and in our Federal and 
international governments. I want you to know we give our best 
always to the heroes, past and present, who keep this country 
free and our best to their families who support them so well.
    Thank you. As always, we appreciate your great support.
    Senator Stevens. Thank you, Admiral.
    Admiral Lescavage. You are welcome, Senator.
    [The statement follows:]Lescavage.txt

         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 indeed an honor and privilege to 
speak before you about our outstanding 5,000 Active and Reserve Navy 
Nurses who continue to provide preeminent health care in all 
operational, humanitarian and conventional settings.
    As key members of the Navy Medicine team, our military and civilian 
nurses proudly demonstrate operational readiness and personal 
excellence in promoting, protecting and restoring the health of all 
entrusted to our care anytime, anywhere. Aligned with our Surgeon 
General's five priorities, we continuously monitor our capabilities and 
embrace innovations to meet challenges head-on during these rapidly 
changing times. I will address each priority and illustrate how Navy 
Nursing meets our unique dual mission in the support and protection of 
our operational forces, while at the same time providing health care to 
family members and retirees.

                               READINESS

    In the area of readiness, Navy Medicine's first priority, Navy 
Nurses continue to readily adapt and remarkably deliver superb medical 
care throughout the battlefield continuum in support of our operational 
and humanitarian mission via Surgical Companies, Surgical Teams, Shock 
Trauma Platoons, the Forward Resuscitative System, Fleet Hospitals, 
Expeditionary Medical Facilities, on Navy and Hospital Ships, and our 
Military Treatment Facilities at home and abroad. In addition to the 
services provided by our nurses assigned to operational billets, we 
have recorded more than 125,000 mission days in operational and 
training exercises. Operational platform and intensive trauma training 
formulate the framework for our nurses to capably provide immediate and 
emergent interventions and perform safely in any situation or austere 
environment.
    In meeting our mission requirements, we continuously shape our 
Force Structure with emphasis on critical care, emergency, trauma, 
perioperative, medical-surgical, anesthesia and mental health nursing 
specialties. Navy Nurses have deployed this past year throughout the 
world to Kuwait, Iraq, Djibouti, Afghanistan, Bahrain, the Philippines, 
Thailand and Guantanamo Bay, Cuba. Humanitarian efforts have been 
provided to Tsunami and Haitian relief countries, as well as Pensacola 
after Hurricane Ivan. Together with our Canadian and British active and 
reserve colleagues, we have also been involved in several large 
combined joint task force exercises. To achieve all of this and more, 
our mobilized Reserve Nurses have spectacularly integrated with our 
military and civilian staff and have dedicated themselves to providing 
exceptional care to our service members and beneficiaries on the 
homefront.
    To enhance our mission-ready capabilities, joint training 
opportunities have been maximized with our military and civilian 
medical communities which involves hands-on skills training, the use of 
innovative state-of-the-art equipment, and the proliferation of web-
based programs for multi-system trauma casualties. Through the Navy 
Trauma Training Course (NTTC) with the LA County/University of Southern 
California Medical Center in Los Angeles, Navy Nurse instructors 
provide participants ``real life'' exposure while integrating with the 
hospital's trauma staff to provide specialized care. Our 46 nurses who 
rotated through the program this past year have stated that they were 
better prepared to treat our trauma casualties. The newly established 
Navy EnRoute Care Course recently trained 22 Navy Nurses at Camp 
Lejeune, North Carolina, prior to deploying them to Iraq. This course 
includes a training pipeline involving the Air Force Critical Care Air 
Transport Course, Navy Trauma Training Course, and Helicopter Egress/
Water Survival training. This highly specialized care is essential to 
our Forward Resuscitative Surgery System in order to transport and 
provide required medical care to patients who are at risk of sudden, 
life threatening changes prior to their transport to a higher echelon 
level of care. Through the Tri-service Combat Casualty Course, our 
nurses train in simulated combat conditions. For specific nursing 
specialty needs, the Services have supported each other. One fine 
example is the coordination of intensive care unit training with 
Landstuhl Medical Center for our nurses in Naples, Italy. We also 
continue to contract with civilian trauma centers in close proximity to 
our Military Treatment Facilities for didactic training and ``hands-
on'' care. In addition, our Nurse Internship Programs at several of our 
teaching facilities continue to facilitate the transition of our new 
nurses into the Navy.
    To optimize the readiness capability of our Sailors and Marines, we 
have placed nurse practitioners onboard the aircraft carriers NIMITZ, 
KENNEDY, and ENTERPRISE. In addition to rendering traditional episodic 
care, they promote wellness through post-deployment health assessments, 
tobacco cessation, and medical exams. Additionally, the nurse 
practitioners conduct medical training (e.g. Basic Life Support and 
Deckplate Health Promotion Courses). They also update medical supplies, 
equipment and practice guidelines while underway. A nurse practitioner 
with two other health care team members was deployed to the aircraft 
carrier NIMITZ to assist 6,000 sailors returning from Iraq, resulting 
in the most efficient completion of the Post Deployment Health 
Assessment Evolution of any vessel as hallmarked by the Commander of 
the Naval Air Force, United States Pacific Fleet.

                        QUALITY HEALTH SERVICES

    In sync with Navy Medicine's second priority of delivering quality 
and cost-effective health care, our Navy Nurses span the continuum of 
care from promoting wellness to maintaining the optimal performance of 
the entire patient.
    Innovative health services programs and joint partnerships across 
our military treatment facilities help us to maintain a readiness focus 
for our patient population. Examples include the Mental Health Nurse 
Outreach Program with the Marine Corps School of Infantry at Camp 
Lejeune; the Partnership for In-Garrison Health and Readiness in Camp 
Pendleton; and the Nurse-Managed Welcome Center at Pearl Harbor, 
Hawaii. Nurses in the Case Management Department at the National Naval 
Medical Center have programs supporting the continuum of care for our 
returning casualties. Through a comprehensive referral network with the 
Veteran Affairs' Transition Program, our nurses can access 
collaboratively-developed clinical practice models such as traumatic 
brain injury and post traumatic stress guidelines. They additionally 
utilize rehabilitation specialists and are now able to identify the 
best available health care while the patient is on convalescent leave 
or is between rehabilitation stays. There are many other military 
member initiatives, such as the Nurse Run Medevac Transport Team at 
Bethesda, Maryland that cares for returning casualties. We have 
specialized Wound Care Clinics throughout our military treatment 
facilities and we, now more than ever, utilize our mental health 
nurses.
    The Nurse Call Center at Jacksonville, Florida is the benchmark for 
other military treatment facilities and provides 24/7 triage and advice 
coverage, emergency room follow-up calls, and a direct link to the 
patient's primary care manager or specialist. Disease Management 
Programs for asthma, diabetes, breast cancer, and cardiac care have 
improved screening rates; recaptured network costs; maximized provider 
productivity; and guarantee exceptional continuity of care at Patuxent 
River, San Diego, and Cherry Point. Other innovative programs include 
the Health Lifestyle Choice Program for children and teens at San Diego 
and the Post Partum Clinics in Bremerton, Pensacola, Guam, Twenty-Nine 
Palms, and Yokosuka. In concert with the Armed Forces Center for Child 
Protection, the Shaken Baby Syndrome Prevention Program is now being 
piloted at six of our hospitals with additional emphasis on parent 
training.
    In an age of cost containment while promoting high quality of 
patient care, it is essential that nurses are trained in business 
planning and continuously evaluate best health care business practices. 
For example, one of our nurses developed a survey to evaluate disease 
(asthma and diabetes) and condition management measures as part of a 
Navy-wide ``Disease and Condition Management Report Card'' which is 
comprised of clinical and financial metrics. At Bethesda, nurses in the 
ambulatory care setting have implemented clinic business rules and 
performance goals to guide daily practice. At Naval Hospital 
Jacksonville and the Naval Medical Center Portsmouth, nurses have 
collaboratively developed an electronic patient tracking system which 
integrates the Emergency Department with Ancillary Services. Through 
the use of information technology, patient status and movement within 
the facility are closely monitored; clinical data is more expeditiously 
recalled; and personnel resources can be adjusted for well-justified 
reasons.
    Research priorities are focused on workforce retention, clinical 
practice, deployment experiences, outcomes management, and the gaining 
of specific competencies. A sample of research topics includes: 
clinical knowledge development from care of the wounded during 
Operation Iraqi Freedom; the perinatal depression screening program; 
retention of recalled Navy Nurse Corps Reservists; the effects of 
oxidative stress on pulmonary injury in Navy divers; retention criteria 
for military health system nurses; and factors associated with post 
partum fatigue in Active Duty military women. Several of these studies 
are funded by the TriService Nursing Research Program, which fosters 
military nursing excellence and promotes collaboration between not only 
military nurse researchers but with academia as well.
    Our nursing research has been disseminated through countless 
professional forums worldwide, such as at distinguished conferences 
sponsored by the National Nursing Honor Society Sigma Theta Tau, the 
Association of Military Surgeons of the United States (AMSUS), TRICARE, 
Royal College of Nursing of the United Kingdom, and the Micronesian 
Medical Symposium. Numerous publications by Navy Nurses can be found in 
prestigious professional journals, such as the Journal of Trauma, 
Critical Care Nurse, Journal of the American Association of Nurse 
Anesthetists, Military Medicine, Geriatric Nursing and many more. In 
addition, many of our nurses have received esteemed awards at 
University Annual Research Day presentations, as well as at the Phyllis 
J. Verhonick Army Research Conference which acknowledged a joint 
service study called, ``A TriService Integrated Approach to Evidence 
Based Practice.''

                           ONE NAVY MEDICINE

    In support of the One Navy Medicine concept as a third priority, 
the integration of active, reserve and civilian nurses renders a more 
effective, efficient and fully mission-ready nursing force both at home 
and abroad. With the deployment of over 400 Active Duty Navy Nurses 
along with the mobilization of Reserve Nurses to support our Military 
Treatment Facilities, there has been neither a reduction of inpatient 
bed capacity nor an increase of network disengagements.
    Together, we have also optimized joint training opportunities, such 
as the Chemical, Biological and Radiological Defense (CTR-D) Program 
training between the New England Naval Health Care Ambulatory Clinics, 
the Rhode Island Air National Guard, and the Marines at their local 
Reserve Center. Expert instructors deliver both classroom and 
confidence chamber training, including exercises involving the use of 
gas masks and chemical suits. While our Active Duty Nurses attend the 
Navy EnRoute Care Course, our Reserve Nurse Corps Officers recently 
participated in a pilot program of the Joint Medical EnRoute Care 
Course at the U.S Army School of Aviation Medicine at Fort Rucker, 
Alabama. This program combines medical skills and rotary wing training 
to create a cadre of joint service, multidisciplinary team members to 
provide an advance level of care during transport.

                        SHAPING TOMORROW'S FORCE

    To meet the mission in all care environments through Navy 
Medicine's fourth priority of shaping tomorrow's force, it is critical 
that we continuously focus on our human capital strategy. Our goal here 
is to specifically shape Navy Nursing with the right number of nurses 
with the right training in the right assignments at the right time, and 
become the premier employer of choice for active, reserve and civilian 
nurses. We accomplish this through several interdependent processes. 
With nurse executive leadership, we have identified specific nursing 
specialties for each deployable assignment to meet operational 
requirements. Personnel with the right clinical expertise are assigned 
to deployable platforms. When not deployed, these nurses serve in our 
Military Treatment Facilities to meet our peacetime mission. We 
carefully identify graduate education programs that best meet our 
specific requirements, such as our wartime specialties in critical 
care, emergency, trauma, perioperative, anesthesia, medical-surgical 
and mental health. Finally, while closely monitoring the national 
nursing shortage, we continue to pursue available authorities to 
recruit and retain our exceptionally talented nurses.
    Our Active Duty component is presently 96 percent manned with 2,979 
of our 3,094 positions filled. As a result, our recruitment efforts are 
focused on maintaining adequate staffing to continue to meet our 
mission, particularly in our critical wartime specialties. Our pipeline 
scholarship programs help contain our annual recruiting goals. However, 
for the first time in over 10 years, we only attained 68 percent of our 
fiscal year 2004 Active Duty recruitment goal, acquiring 63 out of 92 
nurses. We recently met with success in increasing our Nurse Accession 
Bonus to $15,000; we continue to maintain our presence at national 
nursing conferences and tap Navy Nurses at all levels to market our 
career opportunities to their professional associations. Since the 
inception of the Nurse Candidate Program, this is the first year we 
have essentially doubled the Accession Bonus from $5,000 to $10,000 and 
the monthly stipend from $500 to $1,000.
    Regarding our reserve recruiting goal, we may experience challenges 
in attaining our specific specialty in some areas. Of particular note, 
the Hospital Corpsman/Dental Technician Professional Development Option 
was initiated last year for the Reserves as part of a 3-year pilot 
program. Reservists are being provided drill credits while attending a 
Bachelor of Science in Nursing curriculum. This upward mobility program 
will serve as an accession source for junior Nurse Corps Officers.
    Promoting retention, we have several initiatives to retain our 
talented professional nursing force. As mentioned earlier, our graduate 
education scholarship program is a primary motivator for recruitment 
and our number one retention tool. Within our education plan, we 
strongly support nurses who choose to attend the Graduate School of 
Nursing at the Uniformed Services University of Health Sciences. At 
present we have sixteen students in the Nurse Anesthesia, Family Nurse 
Practitioner, Perioperative Clinical Nurse Specialist, and Doctoral 
Programs with an additional eleven students slated to begin in the 
coming academic year. As we continue to collaborate and identify our 
mission requirements, the faculty leadership has refined their 
curricula to meet our needs. Two classic examples include the 
development of the Military Contingency Medicine/Bushmaster Program to 
optimize mission readiness and the focus of research efforts towards 
relevant military nursing topics.
    Another significant first-time accomplishment to assist in our 
retention efforts, we were able to increase the Certified Registered 
Nurse Anesthetist Incentive Special Pay or ISP to a multi-year contract 
program. For all Nurses, we continue to focus on quality of 
professional life by granting appropriate scopes of practice and giving 
them challenging leadership positions.
    To recruit civil service nurses, we continue to use Special Hire 
Authority to expeditiously hire nurses into the federal system. We 
sometimes can supplement these new hires with recruitment, retention 
and/or relocation bonuses depending on staffing requirements and 
available funds. As part of a 1-year pilot program, we have initiated 
Special Pays for registered nurses at five of our Military Treatment 
Facilities for such things as on-call, weekend, holiday, and shift 
differential with increased compensations. We will soon pilot the 
program for Licensed Vocational Nurses at the same sites. After 1 year, 
we will evaluate the effectiveness of these programs in retaining these 
clinical experts.

                       JOINT MEDICAL CAPABILITIES

    In continuously shaping our human capital work force of nurses, we 
are better able to collaborate and integrate with the other Services, 
as well as local, state and federal agencies to maximize our joint 
medical capabilities within our final priority of working jointly. 
Nurses now function in significant roles in Homeland Security within 
Navy Medicine by developing policy, plans and a concept of operations 
and then managing programs that focus on the security of our customers 
and our bases. The challenges of today have created a need to evolve 
the nursing role into a greater perspective that crosses the joint 
service and interagency world at all levels. As one example, a Navy 
Nurse is one of two medical representatives working with the Joint 
Program Executive Office for Chemical and Biological Defense to assess 
and analyze installations to identify appropriate levels of CBRN 
(chemical, biological, radiological, nuclear) equipment distribution 
and support for 59 Navy installations. Nurses at Bethesda, Maryland 
have been at the forefront with the first collaborative emergency 
preparedness exercise involving military, federal and civilian health 
care facilities in the National Capitol Region. In addition, in many of 
our Military Treatment Facilities, nurses are assigned disaster 
preparedness and homeland security responsibilities. Noted for our 
clinical expertise, operational experiences and solid leadership 
qualities, I can assure you that our Navy Nurses are collaborating at 
all levels.

                               CONCLUSION

    The Navy Nurse Corps has been consistently dynamic in this ever-
changing world, remaining versatile as visionary leaders, innovative 
change agents and clinical experts in all settings. Our Navy Nurses are 
at the forefront using the latest technology in the operational setting 
and in our Military Treatment Facilities; conducting cutting edge 
research; performing as independent practitioners; and creating health 
care policies across Military Medicine to advance nursing practice and 
to improve delivery systems.
    I appreciate the opportunity to share the accomplishments and 
issues that face Navy Nursing. It has been an honor to serve as the 
20th Director of the Navy Nurse Corps. I am very proud of our 
distinguished Corps and of our great history. As I move on to a new 
assignment as Director of TRICARE Region West in San Diego, I remain 
committed to the Navy Nurse Corps, our great Navy and Marine Corps 
Team, and the Department of Defense. Like many of our other Navy Nurses 
and my professional colleagues who function in pivotal executive roles, 
I will continue to support our efforts to impact legislation, health 
care policy and medical delivery systems. I hand the Navy Nurse Corps 
over to the very capable leadership of my successor, Rear Admiral 
(Select) Christine Bruzek-Kohler.
    My greatest gift everyday lies in working with these fine Officers 
and Civilians and in collaborating with my splendid colleagues across 
the services, across academia and in our federal and international 
governments. I want you to know we give our best always to those heroes 
and families who keep this country free. There is no greater honor than 
to serve. Thank you.

    Senator Stevens. General Brannon.

STATEMENT OF MAJOR GENERAL BARBARA C. BRANNON, 
            ASSISTANT AIR FORCE SURGEON GENERAL FOR 
            NURSING SERVICES, DEPARTMENT OF THE AIR 
            FORCE
    General Brannon. Chairman Stevens, Senator Inouye, and 
Senator Mikulski, I am delighted to once again represent your 
Air Force nursing team. This year marks my sixth report to you, 
and it is amazing how quickly the years pass by.
    Our Air Force Medical Service has persevered in providing 
outstanding health care in a very dangerous world. Air Force 
nurses and aerospace medical technicians are trained, equipped, 
and ready to deploy anywhere anytime at our Nation's call. It 
has been an honor to care for so many heroes.
    In support of Operations Enduring Freedom and Iraqi 
Freedom, 2,160 Air Force nurses and technicians deployed this 
past year. Our aeromedical evacuation (AE) system has proven to 
be the critical link in the chain of care from battlefield to 
home station.
    In 2004, Air Force nursing AE crews completed 2,866 
missions supporting 28,689 patient movement requests around the 
world. Critical care air transport teams (CCATT) were used in 
486 of the AE operations.

                 CRITICAL CARE AIR TRANSPORTATION TEAMS

    The synergy of combining our AE crews with these critical 
care air transportation teams has enabled us to transport more 
critically ill patients than ever before. Additionally, 
advances in technology and in pain management have greatly 
enhanced patient comfort and patient safety.

                          SPECIALTY PROVIDERS

    The success of deployed medical care depends on having 
specialty providers available when needed. Certified registered 
nurse anesthetists fulfilled 100 percent of their deployment 
taskings, plus 47 percent of the anesthesiologist taskings. 
They have ably met all mission requirements and patient care 
needs.
    Lieutenant Colonel Bonnie Mack and Major Virginia Johnson 
deployed to Tallil Air Base in Iraq as the only anesthesia 
providers for 20,000 United States and coalition forces. On one 
occasion Colonel Mack and Major Greg Lowe provided 24 hours of 
anesthesia for six Italian soldiers who were severely wounded 
in a terrorist bombing. These men survived only because expert 
anesthesia and emergency surgery was close at hand.
    Air Force mental health nurses have also played an 
important role in caring for our wounded and for our health 
care teams. Sixteen mental health nurses were deployed to the 
Ramstein Air Base contingency air staging facility to support 
patients from all services. They provide early intervention to 
ameliorate long-term emotional effects and in some cases even 
facilitate return to duty in theater. We recently incorporated 
mental health nurse practitioners into our provider teams, and 
they can also substitute for psychiatrists and psychologists in 
the deployed setting.

                   332ND EXPEDITIONARY MEDICAL GROUP

    Our largest group of Air Force medical ``boots on the 
ground'' is at the 332nd Expeditionary Medical Group at Balad, 
which transitioned from Army to Air Force staffing last 
September. Its multinational team currently includes 148 Active 
duty Air Force nursing personnel, and they have many stories to 
tell. They provided lifesaving surgery for a 65-year-old Iraqi 
woman who triggered an explosive device as she answered her 
front door. Her daughter was a translator for the U.S. forces. 
They cared for the wife of an Iraqi policeman and her two 
children, all badly burned, when a grenade was thrown into 
their home. Since September, this team has supported 10 mass 
casualties, 3,800 patient visits, and 1,550 surgeries.
    Air Force nurses are outstanding commanders in both the 
expeditionary environment and at home station. This past year, 
3 nurses have deployed as commanders of expeditionary medical 
units, and at home there are 16 nurses commanding Air Force 
medical groups, 45 nurses command squadrons and 1, Colonel 
Laura Alvarado, is serving as a Vice Wing Commander.
    The nurse shortage does continue to pose an enormous 
challenge and we need to maintain robust recruiting to sustain 
our Nurse Corps. This year we have brought 110 new nurses on to 
Active duty, which is slightly more than at this same point 
last year.

                            NURSE RETENTION

    Retention, of course, is the other key dimension of force 
sustainment, and while monetary incentives play the key role in 
recruiting, quality of life issues become important as career 
decisions are being made. We continue to enjoy excellent 
retention in the Air Force and we ended fiscal year 2004 close 
to our authorized end strength.
    In 2004, the services were directed to identify non-wartime 
essential positions for conversion to civilian jobs. Initially 
we targeted almost 400 nursing positions for conversion over 
the next 3 years, primarily in our outpatient areas. This 
allows us to concentrate our Active duty nursing personnel in 
areas that will sustain their wartime skills. As force shaping 
continues, we will identify additional positions, but recognize 
that the nursing shortage may present hiring challenges.

                  TRISERVICE NURSING RESEARCH PROGRAM

    The TriService Nursing Research program continues to 
support major contributions to the science of nursing. This 
year 25 Air Force nurses are engaged in studies covering topics 
from expeditionary clinical practice to retention. For example, 
Reserve nurse Colonel Candace Ross is the principal 
investigator for a study on the impact of deployment on 
military nurse retention. Her findings should provide a road 
map for more effective retention strategies.
    The Graduate School of Nursing at the Uniformed Services 
University is very responsive to developing programs to meet 
our military nursing requirements. The school graduates its 
first class of perioperative clinical nurse specialists in May 
and the inaugural Ph.D. class will complete its very successful 
second year. Our certified registered nurse anesthetists 
(CRNAs) program at USUHS continues to graduate top-notch 
providers who score well above the national average on their 
certification exam. In 2004, 9 out of the 13 graduates earned a 
perfect score on the examination. This program is also unique 
in that it provides hands-on experience in field anesthesia.

                           PREPARED STATEMENT

    Mr. Chairman and distinguished members of the subcommittee, 
it has certainly been a tremendous honor to serve our Nation 
and to lead the more than 19,000 men and women of our Active, 
Guard, and Reserve total Air Force nursing force. I have 
increasingly treasured your support and your advocacy during 
this very challenging time for nursing and for our Nation.
    Thank you for inviting me once again to tell our Air Force 
nursing story. No one comes close.
    [The statement follows:]

         Prepared Statement of Major General Barbara C. Brannon

    Mr. Chairman and distinguished members of the committee, it is an 
honor and great privilege to again represent your Air Force nursing 
team. This year marks my sixth report to you and I am amazed how 
quickly the years pass by. It has been an honor to support and care for 
so many heroes--military men and women ready to sacrifice their lives 
for the cause of freedom, national security and a safer world.
    Our Air Force Medical Service has persevered in providing 
outstanding healthcare in a very dangerous world. Terrorist 
organizations continue to challenge our peace and security and natural 
disasters have taken a huge toll in death and devastation. Air Force 
Nurses and Aerospace Medical Technicians are trained, equipped and 
ready to respond anytime, anywhere at our nation's call.

                         EXPEDITIONARY NURSING

    In support of Operations ENDURING FREEDOM and IRAQI FREEDOM, 2,160 
nurses, and technicians deployed this past year as members of 10 
Expeditionary Medical Support Units, two Contingency Aeromedical 
Staging Facilities (CASF), and five Aeromedical Evacuation (AE) 
locations. Three nurses commanded expeditionary medical facilities and 
provided outstanding leadership. Today, Air Force nursing personnel are 
serving in a large theater hospital in Balad, smaller hospitals at 
Kirkuk and Baghdad International Airport, and in other deployed 
locations.
    The 332nd Expeditionary Medical Group at Balad is currently home to 
70 nurses, 6 licensed practical nurses and 99 medical technicians. This 
multi-national group includes 148 nursing personnel from the Air Force 
active duty team. During this current rotation, they have already 
supported 3,800 patient visits with 1,600 hospital admissions and 1,550 
surgeries. Some patients with massive trauma require surgical teams 
that include up to seven different surgical specialties simultaneously. 
They have responded to at least 10 mass casualty surges and have many 
stories to tell. They provided lifesaving surgery and cared for a 65-
year-old Iraqi woman who triggered an explosive device when she 
answered her front door. Her daughter was a translator for U.S. Forces. 
They cared for a young mother, her two-year old child, and her two-
month old baby, all badly burned when a grenade was thrown into their 
home. Her husband is an Iraqi policeman. The team in Balad is our 
largest group of Air Force medical ``boots on the ground,'' providing 
life-saving surgery, intensive care and preparation for aeromedical 
evacuation.
    I have had the opportunity to watch our tremendous Air Force 
nursing team in action as they provide world-class healthcare to 
wounded soldiers, sailors, marines and airmen. Military medics are 
saving the lives of people with injuries that would have been fatal in 
other wars. During World War I, 8.1 percent of the wounded died of 
their wounds. Today, lifesaving medical capability is closer to the 
battlefield than ever before, and in Iraq only 1.4 percent of the 
wounded have died.
    Aeromedical Evacuation has proven to be the critical link in the 
chain of care from the battlefield to home station. The availability of 
aircraft for patient movement is fundamental to the Aeromedical 
Evacuation system. Patient support pallets and additional C-17 litter 
stanchions have increased the number of airframes that can be used for 
aeromedical evacuation.
    In 2004, our Air Force nursing AE crews have flown 2,866 missions 
supporting 28,689 patient movement requests around the world. The 
majority of our AE missions are crewed by members of the Air National 
Guard and Air Force Reserve; it is a seamless, total nursing force 
capability.
    The synergy of combining aeromedical evacuation crews with critical 
care air transport teams (CCATT), additional high-technology equipment, 
advances in pain management and more extensive crew training has 
enabled us to transport more critically-ill patients than ever before. 
In 2004, CCATT teams were used in 486 patient movement operations. For 
example, Major Gregory Smith from Wright-Patterson Air Force Base was 
deployed as the nurse on a three-person CCATT. The team cared for nine 
casualties who required intensive care and were wounded during the 
Battle for Fallujah. Six of these patients had lifesaving surgery 
within six hours of injury and were evacuated from the field hospital 
within 48 hours of injury. Eight of the nine patients required 
mechanical ventilation during the flight. CCATT capability makes early 
air transport possible, reducing the requirement for in-theater beds 
and delivering injured troops to definitive care within hours rather 
than days.
    There are many, many examples of the tremendous capability and 
endurance of the AE crews. In one instance, Major Marianne Korn, a 
reserve flight nurse from the 452nd Aeromedical Evacuation Squadron, 
March Air Force Reserve Base, and her AE crew transported 82 patients 
from Ramstein Air Base to Andrews Air Force Base in response to 
Operation PHANTOM FURY. Overall, during this time the squadron surged 
to support a 35 percent mission increase and transported more than 
1,400 patients between the CENTCOM, EUCOM and NORTHCOM theaters.
    Another integral part of the aeromedical evacuation system is the 
Aeromedical Staging Facility (ASF) that serves as both an inpatient 
nursing unit and passenger terminal for patients in transit. They are 
staffed primarily by nursing personnel from the reserve, guard and 
active component of the Air Force. The level of activity is tied 
closely to the intensity of the conflict. ASF nurse Lieutenant Karen 
Johnson and her team cared for 296 patients from 13 separate missions 
within a three-day period following fierce fighting in Operation 
PHANTOM FURY.
    About that same time, Colonel Art Nilsen, Chief Nurse of the Air 
Force Squadron at Landstuhl Regional Medical Center, wrote to me and 
highlighted the tremendous accomplishments of the Army and Air Force 
team working together in that hospital. He invited me to visit and, in 
early December, barely three weeks later, I landed at Ramstein Air Base 
in Germany. My first stop was the 435th CASF at Ramstein, celebrating 
its first anniversary. Major Todd Miller, Chief Nurse, shared the 
amazing successes of the CASF over the past year. Deployed personnel 
have staffed the CASF on a rotational basis; a total of 391 nursing 
personnel from 55 Air National Guard, Air Force Reserve and active duty 
units. The team cares for every patient that transits Ramstein, a total 
of more than 22,000 in 2004. In the CASF, an empty bed is a welcome 
sight and means another patient is a step closer to home.
    It was already dark when I went out to the aircraft with the CASF 
team. I had a chance to talk with each patient as they were transferred 
from the aircraft to the waiting ambulance bus. It had been a long and 
uncomfortable flight, but it was obvious that they had been well cared 
for and were anxious to continue their journey home. Many talked about 
the wonderful medical care they had received and gave special praise to 
the Air Force team at the theater hospital at Balad Air Base and to the 
AE crews.
    I met many of these young men again when I visited Landstuhl 
Regional Medical Center. My visit was shortly after the battles in 
Fallujah, and the hospital and AE system were at surge capacity, as 
busy as in the early months of war. I will never forget the wounded 
marines and soldiers at Landstuhl. I was humbled by their acts of 
courage, their unwavering loyalty and sense of duty to their buddies. 
The nursing team on the units looked tired but energized. Everyone was 
working long hours and extra days. But when word came that an aircraft 
was arriving from Iraq, they came in to help--on days off and even 
after finishing a long shift. Many said they thought this would be the 
sentinel experience of their lives and careers. Those who had worked in 
large civilian trauma centers said they had never before cared for 
patients with injuries as severe.
    Two days later, I was headed home on a C-17 with eighteen litter 
patients, another twenty who were ambulatory and an AE crew from the 
315th Reserve Squadron at Charleston, SC and the 94th Reserve Squadron 
at Dobbins, GA. The medical crew director was Major Joyce Rosenstrom, a 
reserve nurse with the 315th. There was also a critically wounded 
marine on board who was accompanied by an active duty CCATT from the 
medical center at Keesler Air Force Base, MS., led by pulmonologist, 
Col Bradley Rust. The other team members were critical care nurse, Capt 
Erskine Cook and cardio-pulmonary technician SrA Laarni San-Agustin. 
The ten-hour flight was relatively uneventful with the medics working 
non-stop to ensure each patient received great care with particular 
attention to pain management. At the Andrews Air Force Base flight 
line, medical personnel from the Air Force hospital, Walter Reed Army 
Medical Center and Bethesda Naval Medical Center transferred patients 
to waiting ambulance buses. The patients' journey from the battlefield 
back to the United States was complete.
    The success of deployed medical care depends on having specialty 
providers available when needed. Anesthesiologists are key members of 
surgical teams, but significant shortages on active duty have left gaps 
on deployment packages. Certified Registered Nurse Anesthetists (CRNAs) 
have filled deployment requirements for anesthesia providers forty-
seven percent of the time and have ably met all mission and patient 
care requirements.
    Lieutenant Colonel Bonnie Mack and Major Virginia Johnson are CRNAs 
deployed to Tallil Air Base in Iraq as the only anesthesia providers 
for over 20,000 U.S. and coalition forces, and civilian contract 
personnel. During their deployment, a terrorist bomb ignited an Italian 
police compound just 10 kilometers from their facility. Colonel Mack 
and Major Greg Lowe provided anesthesia during the surgeries of six 
severely wounded Italian soldiers, working continuously for almost 24 
hours. These men survived because emergency surgical intervention and 
anesthesia were there to support them.
    During her deployment, Colonel Mack also served on a Critical Care 
Expedient Recovery Team assembled at Tallil to provide medical care on 
combat search and rescue missions when a para-rescue team is not 
available. Their role is to provide care during transport of recovered 
crew members to a medical facility. A mission can take the team into 
dangerous territory, but she willingly volunteered. In her words ``it 
is a great honor to be involved in the safe return of even one 
airman.'' Her team flew training missions and launched in response to a 
bombing in Karbala, but fortunately did not have to respond to a downed 
airman.
    Major Delia Zorrilla, a perioperative nurse, was awarded the Bronze 
Star in recognition of her tremendous service while deployed to Manas 
Air Base, Kyrgyzstan in support of Operation MOUNTAIN STORM. She served 
as the Chief Nurse of the facility and established a resupply system 
that ensured critical surgical supplies were available 24/7.
    Our mental health nurses have played an important role in caring 
for patients during Operation IRAQI FREEDOM and Operation ENDURING 
FREEDOM. Sixteen mental health nurses deployed to Ramstein Air Base to 
support Army troops returning from Iraq. They first interact with 
patients in the CASF and screen for Post-Traumatic Stress Disorder. 
They also provide patient education and strategies for coping with 
emotional distress and life-altering injury. Having this capability far 
forward enables early intervention and can ameliorate long-term 
emotional effects and, in some cases, even facilitate return to duty in 
theater.
    In the last sixteen months we have recognized the importance of 
mental health nurse practitioners and inserted the capability into 
deployment packages. They can also substitute for psychiatrists and 
psychologists in the deployed setting. We currently have five working 
in our facilities and five more will begin their practitioner programs 
this summer.
    In addition to providing service in Operation IRAQI FREEDOM, Air 
Force Nursing supports humanitarian relief around the world. Lieutenant 
Colonel Diana Atwell from Beale Air Force Base, CA led a team of 14 Air 
Force and 30 Salvadorian military and Ministry of Health medics in a 
humanitarian mission to San Salvador. The team planned and set up 
healthcare at five sites in impoverished districts within the city. 
They provided primary care, internal medicine, pediatric, optometry and 
dental services to more than 8,000 patients. Patients lined up for 
hours and more than 11,000 patient care services were provided, double 
what the team had anticipated. General Carlos Soto Hernandez, military 
Chief of Staff, visited one of the sites and praised them for their 
dedication and commitment.
    In another humanitarian effort, Major Tina Cueller, a reservist and 
Professor at the University of Texas, launched an initiative to assist 
Iraqi nurses. During her annual tour at Ramstein AB, Maj Cueller 
learned that over the years, looting in Iraq had stripped nursing 
schools of all textbooks. When she returned to the University of Texas, 
she arranged a book drive, collecting over 3,000 nursing textbooks. 
They were delivered through the aerovac system from Lackland AFB, 
Texas, to Ramstein Air Base Germany, to their final destination, Kuwait 
City. Major Cheryl Allen, an Army nurse, received the books in Kuwait 
and forwarded them to Baghdad where Colonel Linda McHale, deployed to 
work with the Iraqi Ministry of Health, coordinated their distribution.
    Humanitarian relief is not confined to far-away places, and the Air 
Force has been called to lend a hand in support of Homeland Medical 
Operations. Capt Ron Leczner from the 81st Aeromedical Staging Facility 
(ASF) at Kessler, MS coordinated the transfer of 47 local nursing home 
patients after the governor of Mississippi declared a mandatory 
evacuation of the Gulf Coast in anticipation of Hurricane Ivan. A 
skeleton crew at the ASF, including medical technician students, moved 
41 non-ambulatory and six ambulatory geriatric patients to Keesler 
Medical Center during 69 mile per hour winds. The nursing home 
residents were returned to their facilities by ASF staff and local 
ambulances within 12 hours after the hurricane passed.

Skills Sustainment
    Lessons learned from the field and after-action reports have led us 
to reevaluate clinical currency and sustainment training for our 
nursing personnel. Our Readiness Skills Verification Program has been 
refined and is web-based with embedded links to specific training 
materials. Units are encouraged ``to think outside the box'' and 
establish training agreements as needed with Army, Navy, VA or civilian 
institutions to keep their members clinically current.
    Air Force nurse and medical readiness officer Major Lisa Corso from 
the 704th Medical Squadron at Kirtland, NM, found new ways to improve 
the readiness skills of her reserve unit. For their annual field 
training and mass casualty exercise, Major Corso invited the local Army 
reserve unit to participate. Both groups were part of the planning 
process and the Army medics had a wealth of first-hand experience from 
members previously deployed. They provided expert instruction on skills 
that were identified for refresher training. The exercise was a huge 
success, and both units look forward to more joint training exercises 
in the future.

Recruiting and Retention
    The nurse shortage continues to pose an enormous challenge 
nationally and internationally. This year, the Bureau of Labor 
Statistics projected registered nursing would have the largest job 
growth of any occupation through the year 2012, and it is now estimated 
that job openings will exceed the available nurse pool by 800,000 
positions. The crisis is complicated by an increasing shortage of 
masters and doctoral-prepared nursing faculty across the country. 
Although the number of enrollments in entry-level baccalaureate 
programs rose 10.6 percent last year, the National League for Nursing 
reported that more than 36,000 qualified students were 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.
    A robust recruiting program is essential to sustain the Nurse 
Corps; our fiscal year 2005 recruiting goal is 357 nurses. As of March 
22, 2005, we have brought 110 new nurses onto active duty, 31 percent 
of our goal and more than at the same point last year. The Air Force 
continues to fund targeted incentive programs to help us attract top 
quality nurses. We have increased our new accession bonuses from 
$10,000 to $15,000 for a four-year commitment and our highly successful 
loan repayment program was again available this year. Last year we 
awarded 134 loan repayments, and this year funds were available for 26. 
Both of these programs have been very successful in attracting novice 
nurses but not as successful in attracting experienced nurses, 
particularly in critical deployment specialties. To further support 
recruiting, we have increased nursing Air Force ROTC quotas for the 
last two years and filled 100 percent of our quotas. We added 
additional ROTC scholarships for fiscal year 2005, increasing our quota 
from 35 in fiscal year 2004 to 2041.
    We continue to advertise our great quality of life, career 
opportunities and strong position on the healthcare team. I also take 
advantage of any 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. Our slogan, 
``we are all recruiters'' continues to reverberate, and active duty 
nurses enthusiastically tell our story and encourage others to ``cross 
into the blue''. We have also expanded media coverage of Air Force 
Nursing activities and accomplishments to attract interest in the 
civilian nurse community. The cover of the December 2004 Journal of 
Emergency Nursing featured Air Force nurse Major Patricia Bradshaw and 
Technical Sergeant Patricia Riordan, respiratory therapist. They 
deployed to the 379th Expeditionary Aeromedical Evacuation Squadron and 
were shown caring for a wounded IRAQI FREEDOM soldier. The article 
showcased the unique role of critical care nurses in the aeromedical 
evacuation environment. Nursing Spectrum magazine honored Lieutenant 
Colonel Cassandra Salvatore as the Greater Philadelphia/Tri-State Nurse 
of the Year and Capt Cherron Galluzzo, Florida Nurse of the Year for 
2004 and Air Force Company Grade Nurse of the Year.
    Retention is the other key dimension of force sustainment. While 
monetary incentives play a key role in recruiting, quality of life 
issues become very important considerations when making career 
decisions. We continue to enjoy excellent retention in Air Force nurses 
and ended fiscal year 2004 close to our authorized end strength of 
3,760.
    We conducted a survey in 2004 to identify positive and negative 
influences on nurse corps retention. The top two factors influencing 
nurses to remain in the Air Force were a sense of duty and professional 
military satisfaction. Our nurses clearly enjoy the unique opportunity 
to serve our country and to care for our troops. Local leadership and 
inadequate staffing were the two primary detractors identified. We are 
clarifying their concerns and are providing better leadership 
development programs. We are also putting senior, experienced nurses 
back at the bedside to guide and mentor our junior nurses and support 
their professional development and satisfaction.
    It has been three years since we initiated our Top Down Grade 
Review to correct our imbalance of novice and expert nurses. We have 
identified a number of company grade authorizations for conversion to 
field grade based on requirements and continue to pursue adjustments of 
authorizations among other career fields. We also identified the 
significant positive impact civilianizing a larger percentage of 
company grade positions would have on grade structure and career 
progression. Serendipitously, the services were directed by the Office 
of the Secretary of Defense to identify military positions not wartime 
essential that could be converted to civilian jobs. In our initial 
evaluation we identified 305 Nurse Corps and 75 enlisted Aerospace 
Medical/Surgical Technician billets to convert to civilian 
authorizations over the next three years. These changes will primarily 
be in the outpatient setting, concentrating our military personnel in 
our more robust patient care areas to maintain clinical currency in 
wartime skills. We will continue to identify nurse positions which do 
not provide expeditionary capability or support our wartime training 
platforms for civilian conversion.

Research
    Air Force nurse researchers continue to excel at expanding the 
science of military nursing practice thanks to the strong support from 
the TriService Nursing Research Program (TSNRP). This year, Air Force 
nurses are again leading the way in advancing our understanding of the 
effects of wartime deployment on today's military force. Twenty-five 
Air Force nurses are currently engaged in research covering priorities 
from clinical practice and training to recruitment and retention 
issues.
    Colonel Penny Pierce is an Air Force Reserve Individual 
Mobilization Augmentee assigned to the Uniformed Services University of 
the Health Sciences (USUHS) Graduate School of Nursing (GSN). She is 
conducting research to determine the effects of deployment experiences 
and stressors on women's physical and mental health, and their 
likelihood to remain in military service. Colonel Pierce received the 
2004 Federal Nursing Services Award at the 110th Annual Meeting of the 
Association of Military Surgeons of the United States for her 
pioneering research on factors that influence the health of military 
women.
    Colonel Candace Ross, a reserve nurse at Keesler Air Force Base in 
Biloxi, Mississippi is heading up a TSNRP-funded study on the Impact of 
Deployment on Nursing Retention. The study is designed to identify 
factors associated with retention of nursing personnel in the military 
service in hopes of identifying actionable areas for retention efforts.
    Colonel Laura Talbot, an Air Force reservist with the 440th Medical 
Operations Squadron at General Mitchell Air Reserve Station in 
Milwaukee, Wisconsin, and nursing faculty member at USUHS, is 
conducting research to test two different approaches to prosthetic 
rehabilitation for soldiers with below-the-knee amputations. This 
research is vital because 2.4 percent of all wounded-in-action during 
Operation IRAQI FREEDOM and ENDURING FREEDOM have suffered traumatic 
amputations. This is almost double the 1.4 percent during the Korean 
Conflict. Her research may promote accelerated rehabilitation for 
amputees and facilitate return to active duty for those who are able.

Education
    The Graduate School of Nursing at the Uniformed Services University 
(USUHS) supports military clinical practice and research during war, 
peace, disaster, and other contingencies. The PeriOperative Clinical 
Nurse Specialist program will graduate its first class of six in May 
2005. The students are conducting research to identifying 
organizational characteristics that promote or impede medication errors 
across the surgical continuum of care. Fewer medication errors will 
save lives and shorten hospital stays. They will be presenting their 
work at the National Patient Safety Foundation Conference later this 
spring.
    The graduates of the Nurse Anesthesia Program in 2004 once again 
scored significantly higher than the national average on their 
certification examination. Nine of the 13 CRNA graduates scored the 
maximum score of 600 and three scored 595 or higher, well above the 
national average of 551.5.
    In addition, the Air Force is currently funding two full-time 
students and another Air Force nurse is enrolled part time in the USUHS 
PhD program.

Nursing Force Development
    The USAF Nurse Transition Program (NTP) marked its 27th year in 
2004. The NTP is an 11-week, 440-hour course designed to facilitate the 
transition of novice registered nurses to clinically competent Nurse 
Corps officers. The program provides clinical nursing experience under 
the supervision of nurse preceptors and training in officership and 
leadership. There were several key changes this year, among them the 
addition of our first overseas NTP training site at the 3rd Medical 
Group, Elmendorf Air Force Base, Alaska. Last November, under the 
guidance of NTP Coordinator, Major Deidre Zabokrtsky, we successfully 
graduated our inaugural class of four nurses from the program.
    Our nurses provide outstanding leadership in the expeditionary 
environment, in military treatment facilities, and in positions not 
traditionally held by Nurse Corps officers. We currently have 16 nurses 
commanding Medical Treatment Facilities and 45 nurse Squadron 
Commanders. Col Laura Alvarado is the first nurse to serve as a Vice 
Wing Commander, and is at the 311th Human Systems Wing, Brooks City 
Base, TX. Maj Kari Howie is a CRNA and the first nurse to serve as the 
Deputy Chief of Clinical Services for a major command headquarters.
    This year, for the first time in history, two active duty nurses 
are serving concurrently as general officers in the Air Force. 
Brigadier General Melissa Rank joins me, and was promoted to her 
current grade on January 1, 2005.
    Colonel John Murray was the first military nurse to be appointed 
full professor at the Uniformed Services University of the Health 
Sciences. Colonel Murray was also selected by the Assistant Secretary 
of Defense for Health Affairs to serve on the National Advisory Council 
for Nursing Research.
    Mister Chairman and distinguished members of the Committee, it has 
been my tremendous honor to serve our nation and to lead the more than 
19,000 men and women of our active, guard and reserve total Air Force 
Nursing team for the last five years. I have increasingly treasured 
your support and advocacy during this challenging time for nursing and 
for our Air Force. Thank you for inviting me to tell our story once 
again. No one comes close!

    Senator Stevens. Well, thank each of you very much. It is 
delightful to have you back with us again this year.
    I only have one question, and I am going to usurp Senator 
Mikulski's role. You have heard her suggestion. Would that 
suggestion have any role in the nursing corps, Colonel?
    Colonel Bruno. Yes, sir, I think it certainly would. We 
currently have a program in place to loan repay, but it is a 
short-term, funded-this-year program to loan repay up to 
$30,000 for Nurse Corps officers, one time. It has been a 
useful tool in our recruiting. It was implemented at a time 
when we also increased the accessions bonus for those nurses. 
So they could come on to active duty and get a longer 
obligation if they took the accessions bonus and the loan 
repayment. So it has been useful, and we think that a continued 
use of that would be great.
    Senator Stevens. Admiral.

                       RECRUITMENT AND RETENTION

    Admiral Lescavage. I believe it is a great idea. As I 
observe recruiting and retention in the Navy Nurse Corps and 
all across military medicine, as the Surgeons General stated, 
it is not necessarily about monetary resources. We stay in for 
certainly greater reasons. However, monetary resources help and 
I believe that we need to be equitable.
    And as I watch recruiting, I can tell you it is difficult 
to be at a recruiting booth where either our sister services or 
other Federal entities or in the civilian arena are all 
offering different options. We all have different programs, and 
perhaps it is time that we all get aligned and we are on the 
same song sheet.
    The idea that Senator Mikulski had is a very good one. As I 
stated, we are doing a pilot program in five of our military 
treatment facilities for the civilian nurses and trying to 
retain them. But as mentioned, you go to the VA, and there are 
different options down that road too. So we are looking for 
anything out there, any ideas. So thank you.
    Senator Stevens. General.
    General Brannon. I would like to make two points. First of 
all, our loan repayments have been the most successful tool to 
bring new graduates into our Nurse Corps.
    Senator Stevens. How much can you repay the debt?
    General Brannon. This year we were repaying $29,000. Last 
year it was $28,000, a one-time thing. We gave 134 loan 
repayments. This year we had 26 to offer, and they went very 
quickly. The $15,000 accession bonus is helpful, but the loan 
repayment is more popular. People come out with a tremendous 
amount of debt from nursing school.
    The one point I would like to make, however, as our 
accession bonus and loan repayment is successful, we do have 
problems attracting experienced nurses in some of the critical 
specialties. Both of these incentives tend to bring people who 
are brand new out of school. So we do spend time molding and 
shaping them.
    Senator Stevens. Thank you very much.
    Senator Inouye.
    Senator Inouye. If I may, I would like to follow up on that 
without getting into Senator Mikulski's territory.
    According to the Department of Labor Statistics of the 
United States, by the year 2012, there will be a demand for 
over 1 million new and replacement nurses, and it appears that 
we will not be able to meet that demand. So obviously it is not 
just in the services but throughout this Nation. I do not know 
what the solution is, but it is a very critical one and 
something has to be done, otherwise we will have great problems 
not in just recruiting nurses but in recruiting military 
personnel.
    I would like to ask a couple of questions. Most Americans 
look upon nurses as being female, but I know that in the 
military there are a lot of men. What proportion of the Nurse 
Corps in the Army is male?

                          MALES IN NURSE CORPS

    Colonel Bruno. About 34 percent.
    Senator Stevens. And in the Navy?
    Admiral Lescavage. One-third.
    General Brannon. We are about the same, sir, about 32 to 33 
percent.
    Senator Stevens. Do you make a special effort to recruit 
men or it is the same?
    General Brannon. It really is the same in the Air Force, 
sir.
    Admiral Lescavage. They seem more than interested in 
joining the military services. Many, I notice, do go on to be 
nurse anesthetists or critical care nurses and operating room 
nurses.
    General Brannon. You know, I do notice that probably a 
larger percentage of the men do have prior service, and I think 
they see nursing as a wonderful career opportunity, they get 
their education, and then they join the Nurse Corps.
    Senator Inouye. General Brannon, what is this air 
expeditionary force concept that you employ in your recruiting?
    General Brannon. You mean as far as----
    Senator Inouye. Deployment.
    General Brannon. In deployment. Well, really the Air 
Force's air expeditionary forces consist of essential teams 
that are on call to deploy and manage our medical facilities in 
the case of medical and to provide patient care for a period of 
time. We have five teams that are in what are called the Air 
Expeditionary Force (AEF) window. So we have one team that is 
deployed at any time.
    We use that combined with our expeditionary medical system 
which is our very capable, small facilities, up to the size of 
a theater hospital that we deploy far forward in kind of a hub 
and spoke arrangement. So we have teams of people that come 
into these areas, take over for the crew that is ready to 
rotate back home, and provide that in-theater care. So it is a 
great system.
    I think now we have all developed the mind set that as 
medics, we are expeditionary. Deployment is no longer something 
that you might be called to do. It is a part of your service 
and you can anticipate and look forward to your opportunity to 
serve. It has created a lot of enthusiasm, I think, for that 
military aspect of service.

                               VA NURSES

    Senator Inouye. Admiral Lescavage, in your presentation I 
got the impression that VA nurses are paid better than Navy 
nurses. Is that correct?
    Admiral Lescavage. Yes, sir, and the VA doctors in many 
cases.
    Senator Inouye. I thought it was the other way around.
    Admiral Lescavage. Well, if you add our retirement, perhaps 
that may change the numbers a bit, but as you know, not 
everyone stays to retirement.
    Senator Inouye. At this moment, the pay of VA nurses is 
higher than military nurses?
    Admiral Lescavage. It depends on the grade level, but many 
times, yes.
    Senator Inouye. Is that the situation in the Army?
    Colonel Bruno. Yes, sir, it certainly is. We can use 
special pay rates that equal what the VA is if the VA is in the 
area, but they are difficult to implement. You have to do 
studies, but we do utilize them effectively.
    Senator Inouye. Is that the situation in the Air Force?
    General Brannon. Well, sir, I do not think there is a 
significant discrepancy in our Active force and the VA nurses. 
What becomes of great concern is the VA nurses and our civilian 
Air Force nursing force. As we look to increase our number of 
civilian nurses, the competition with the VA will be 
significant. So we are seeking to establish pay rates that are 
comparable with VA nursing pay.

                           DEPLOYMENT POLICY

    Senator Inouye. Is the deployment policy among the services 
the same or do they differ in every service?
    Colonel Bruno. I think they are different, sir. In the 
Army, if you deploy, you deploy for 1 year, and you are 
stabilized for as long as possible afterwards, but the 
deployment is 1 year.
    Senator Inouye. What about the Navy?
    Admiral Lescavage. We are about 6 months, depending on the 
mission.
    General Brannon. We have 16 months at home and then a 4-
month deployment, then 16 months at home, 4-month deployment, 
for the most part.
    Senator Inouye. What would happen if the Army adopted the 
Air Force plan?
    Colonel Bruno. Well, I think it might be helpful with our 
retention of some nurses. We have an exit poll that we conduct 
when nurses leave, and one of the issues that has come forward 
in the last 2 years has been the length of deployment. It is 
very difficult to be away from home for that length of time.
    Senator Inouye. What about the Navy?
    Admiral Lescavage. Well, I think our people are pretty 
happy with the 3 to 6 months. We support the marines, as you 
know, and we are sending mostly operating room nurses, critical 
care, and nurse anesthetists. So up to 6 months seems to do the 
trick.
    Senator Inouye. Have your problems increased now that 
sailors are doing ground duty in Iraq?
    Admiral Lescavage. I'm sorry.
    Senator Inouye. The sailors are now doing infantry work in 
Iraq.
    Admiral Lescavage. Yes, sir.
    Senator Inouye. Has that complicated your problems in Iraq?
    Admiral Lescavage. No, sir. We are there to support the 
sailors and the marines and any others.
    Senator Inouye. Thank you, Mr. Chairman.
    Senator Stevens. Thank you.
    Senator Mikulski.
    Senator Mikulski. Thank you very much, Mr. Chairman.
    We are very much on your side. In addition to being on this 
excellent subcommittee, I have a civilian life both on the 
Labor/HHS Committee, and working with Senator Sue Collins, we 
have been working on the civilian nursing shortage. So we know 
that you are in a war for talent with community-based hospitals 
and academic centers of excellence where the nurses themselves 
are being trained. As you know as nurses, you tend to stay 
where you get your training. It is just part of the culture. So 
we understand that. And then VA is competing with them, and now 
we have got all this competition. So we understand the 
challenges that you face.
    One of my first questions is the retention issue and what 
does it take to be able to retain. Now, Senator Inouye raised 
the issue of the OPTEMPO which you are facing, and I think we 
would encourage an evaluation of that. Also, how we could be 
supportive in that evaluation as you have to go up with your 
brass. So you are not functioning by yourself here as 
independent agents.
    Second, I was fascinated, General Brannon, where on page 16 
of your testimony you said two things affected them. It was not 
only money and OPTEMPO, but it was local leadership and 
inadequate staffing. What does local leadership mean? Is that 
the general over the base? Is this the nurse on the floor that 
the young nurse reports to?
    General Brannon. Well, that is a very good question and one 
I have asked myself. We need to go back and survey that. 
Anecdotally when I talk to some of the junior nurses, we tend 
to have a pretty junior staff, and we have very junior folks 
often working together. I think they lack that closer contact 
with the more seasoned, experienced nurses who provide the 
professional development, the support, and really the nurturing 
that every nurse needs. We are looking at changing our system a 
bit to put some of the more senior experienced nurses back into 
direct patient care so they can be the mentors and leaders to 
our promising young officers.

                          INADEQUATE STAFFING

    Senator Mikulski. Also, what about the inadequate staffing? 
It seems like one goes against the other.
    General Brannon. Sure, and I think inadequate staffing 
derives from--our staffing ratios are pretty good, and I know 
you are familiar with that, knowing what is going on in nursing 
around the Nation, but when you have people who are deployed 
off the units or out of the facility, everybody picks up a 
little bit additional duty.
    Senator Mikulski. So there is a lot of stress.
    General Brannon. There is a lot of stress.
    Senator Mikulski. So your nurses, male and female, are 
saying, number one, there is the pay issue.
    Second, there is the deployment, but when you are in the 
military, you know you are going to be deployed, but there are 
different deployment schedules within the services. The 
question is should we have a uniform deployment policy. I do 
not know that. I would look to you and your wise heads.
    And then the other, though, is the staffing. There is the 
staffing in battlefield conditions, or in your riveting story 
about traveling from Iraq all the way back to Andrews, this was 
a very poignant story that you tell in your testimony.
    But the question is what about the use of other kinds of 
nurses. At the hospitals, does everyone have to be a bachelors 
degree nurse to be with you? Can you use community college 
nurses? Can you look at medical corpsmen who have a background 
and perhaps use that medical background, a military background, 
but get an associate of arts of degree in nursing and move them 
quicker into the field? Because if they are enlisted, they tend 
to be older and, quite frankly, cannot take time off while they 
are in school.

                           EDUCATIONAL LEVEL

    General Brannon. Well, frankly, Senator Mikulski, I think 
one of the things that makes our military nursing force so 
strong is our educational level. As you know, we are across the 
services an all-baccalaureate force on Active duty, with about 
one-third having masters degrees.
    It is very difficult to present evidence that says that 
makes a difference. However, this past year in the Journal of 
the American Medical Association there was a great study by 
Professor Linda Aiken in Pennsylvania actually showing that in 
surgical patients, the higher percentage of the baccalaureate 
prepared nurses, the fewer complications and the lower the 
incidence of morbidity and mortality. So I think we are 
beginning to see some substantive evidence that education does 
make a difference----
    Senator Mikulski. I am in no way minimizing the bachelor of 
science (B.S.) or whatever, but we are facing a crisis here. 
And what we are looking at is, in some ways, subsets of who 
does what where. I think I am confused between your use of the 
terms ``military nurses'' and ``civilian nurses.'' Do you have 
civilian nurses?
    General Brannon. We do, indeed, and they are not all 
baccalaureate.
    Senator Mikulski. What do they do?
    General Brannon. They provide nursing care in many of our 
areas, and, as I mentioned, primarily in some of the areas 
where there are critical specialties where experience makes a 
big difference.
    Senator Mikulski. I am going to jump in. I know our time is 
short, but I do not think we understand it. I am new to this 
subcommittee. It is a spectacular subcommittee with astounding 
leadership, and on the 60th anniversary of the Victory in 
Europe (VE) Day, we know we want to salute these guys here, one 
who will forever remember the battle of Monte Cassino.
    But what we are seeing is different pay, and even among all 
of you, different deployment schedules. Then the use of nurses, 
both the military nurses and the civilian nurses. I wonder if 
you could submit to me and to the subcommittee kind of a chart 
on some of these issues as we look at it and then maybe perhaps 
a comparison to VA and other Federal counterparts so we can 
work with you on what we need to do to help you and also then 
to sort out where other talent could be used in the military 
but not at this highly unsophisticated level.
    [The information follows:]

                         Pay Scale Comparisons

    The chart below compares the civilian pay grades assigned 
to inpatient registered nurses at a representative sample of 
our medical treatment facilities (MTFs). The MTFs queried all 
Bachelor of Science in Nursing requirements for their civilian 
nursing staff. Contract employees may hold an Associate Degree 
in Nursing if it is written into the contract. Eglin AFB and 
Wilford Hall Medical Center pay the standard General Schedule 
(GS) rate while other locations are authorized locality pay. 
The civilian pay rates were obtained from Salary.com and are 
current as of June 1, 2005.
    The grade for our nursing positions is predetermined; 
however, the VA does not advertise positions in the same 
manner. Each successful applicant is reviewed by a Nursing 
Professional Standards Board to determine grade and salary 
based on the individual's education and experience. Once the 
grade is determined, the pay scale for that particular locality 
is used. As a result, the VA rates could not be included.

----------------------------------------------------------------------------------------------------------------
                                                                                                 Civilian--Local
            Location                           Facility                      GS Level/Pay              Pay
----------------------------------------------------------------------------------------------------------------
Anchorage, AK..................  Elmendorf AFB......................  GS 9 ($50,476)...........          $67,757
Dayton, OH.....................  Wright-Patterson AFB...............  GS 11 ($54,389)..........          $57,299
Pensacola, FL..................  Eglin AFB..........................  GS 11 ($57,000)..........          $51,694
San Antonio, TX................  Wilford Hall Medical Center........  GS 11 ($53,841)..........          $53,306
San Francisco, CA..............  David Grant Medical Center.........  GS 9 ($49,841)...........          $66,352
                                 ...................................  GS 10 ($54,886)..........  ...............
Washington DC..................  Malcolm Grow Medical Center........  GS 11 ($55,652)..........          $59,941
----------------------------------------------------------------------------------------------------------------

    Senator Mikulski. I just say to my colleagues and to 
everyone listening, starting on page 4 is Major General 
Brannon's story about these thousands of flights that you have 
made and how they made a difference. So let us just kind of 
work together, but we have got a very big job.
    Good luck to you, Admiral. So you are going to be running 
TRICARE.
    Admiral Lescavage. Yes, ma'am.
    Senator Mikulski. Well, that is called jumping out of the 
fat and into the fire.
    Thank you.

                     ADDITIONAL COMMITTEE QUESTIONS

    Senator Stevens. Thank you very much, Senator.
    I thank you very much for your testimony. Senator Mikulski 
is right. We all remember your services very well from our days 
in World War II. It is a few days after the 60th anniversary. 
So none of you were there, but we thank you anyway for being 
part of the group that helped us so much. We look forward to 
working with you in trying to find additional ways to give 
incentives for your recruitment. Thank you very much.
    Colonel Bruno. Thank you, sir.
    Admiral Lescavage. Thank you, sir.
    General Brannon. Thank you, sir.
    [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 Kevin C. Kiley
               Questions Submitted by Senator Ted Stevens

                       SUPPORTING TRANSFORMATION

    Question. Would each of you please describe some of the new 
technologies and tactics that have proven most effective in caring for 
our front line troops?
    Answer. The adoption of new trauma doctrine, called Tactical Combat 
Casualty Care (TC\3\), has incorporated additional emphasis on care far 
forward, be it self aid, buddy aid, or medic aid. With an emphasis on 
early intervention, this doctrinal change has had a significant effect 
in reducing deaths and limiting subsequent necessary treatment and 
rehabilitation. This doctrine is empowered through the use of new 
products, such as tourniquets, hemostatic bandages, and the newly 
reconfigured first aid kit.
    Another doctrinal change over the past several years has been the 
speedy removal of patients through evacuation chains to definitive care 
within our medical centers and hospital in Europe and the United 
States. There are definitive benefits to the patient who can begin 
treatment routines sooner, but it also reduces the medical footprint in 
theater and thereby medical Soldiers at risk. This doctrinal change 
could not have occurred without a broader scope of evacuation support 
medical devices, such as Codman neurological monitors, Chillbuster 
patient warmers, Belmont fluid warmers, or KCI wound vacuums.
    Question. What tools and equipment are still required to improve 
the care provided to combat casualties?
    Answer. A recent study of all available resuscitative fluids and 
volume expanders was concluded, and the study found the use of hextend 
as the most efficacious in clinical outcomes. This product is being 
worked into our Rapid Equipping Force Initiative for quick fielding to 
the theater for full scale adoption.
    The use of recombinant factor VII as a clotting agent for surgical 
patients as well as internal bleeding from blunt trauma could have an 
incredible effect. This product, which is approved in Europe, is in a 
Phase III clinical trial for a trauma indication and if successful, it 
will be rushed to full scale use. Because it does not have FDA 
approval, it is only used in an off-label, compassionate manner which 
limits its potential value.
    Oxygen remains a consistent treatment component of combat casualty 
care, and many actions are being taken to reduce the need for cylinders 
in theater. Today, oxygen is the largest logistical burden for the 
medics. In an adaptation of industrial oxygen generators, used for 
welding and manufacturing processes, new medical generators are being 
developed in smaller scale and greater oxygen content. This downsizing 
has gotten to the point that wards and operating room tables can be 
supported through these ambient air oxygen generators. Continued 
development is ongoing to reduce them to individual patient sizes that 
will support evacuation patients.
                                 ______
                                 
             Question Submitted by Senator Pete V. Domenici

                    ACCESS TO MENTAL HEALTH SERVICES

    Question. I understand from your statements that you are diligently 
pursuing incidences of mental health issues such as depression, anxiety 
and post-traumatic stress disorder. I commend you for that. It is my 
understanding that to date the Department of Defense has done a good 
job reaching out to soldiers upon their return.
    My concern is for mental health services for rural Guard and Air 
Guard members in particular. Those Guardsmen in places like Springer, 
New Mexico are far from metropolitan areas and do not have access 
following demobilization to military mental treatment facilities with 
mental health services.
    I understand that this rural demographic is a small portion of your 
total population, but do you share my concerns about mental health 
access for rural Guard and Reserve members and if so can you give me 
your thoughts on how we might best address this issue?
    Answer. Providing mental health services for rural Guard and Air 
Guard members is a recognized challenge. Reserve component Soldiers, 
who have been activated, are entitled to all of the behavioral health 
services offered to active duty personnel. After demobilization, 
reserve component Soldiers are entitled to the TRICARE benefit for six 
months. Veterans who have served in OEF/OIF are entitled to care at the 
Veterans' Administration for two years. However, rural Reserve 
component soldiers may not live near military or VA providers. The 
Military One Source program was developed in October 2003 for Soldiers 
and Army civilians redeploying from combat. It includes a 24-hour, 
seven-days-a-week toll-free phone information and referral telephone 
service and a website with links to information and assistance. 
Initially developed by the Army for both active and reserve component 
Soldiers and family members worldwide, it has now been adopted by the 
Department of Defense for all service members, families, and civilian 
employees. In January 2005, the Department of Defense announced a Post-
Deployment Health Reassessment to screen all Soldiers 90 to 180 days 
after deployment. One of the reasons for this additional screening is 
that many Soldiers will not recognize or report mental health symptoms 
at the time they return home, but may later. These reassessments are 
scheduled to begin on September 1, 2005.
                                 ______
                                 
            Questions Submitted by Senator Richard C. Shelby

                          ANTHRAX VACCINATIONS

    Question. Pursuant to the order of a federal district court, the 
anthrax vaccination program has been suspended. However, this past 
December Secretary Wolfowitz requested an emergency authorization to 
resume use of the anthrax vaccine. Considering all the documented 
health risks, does the panel feel it is in the best interest of the 
military to resume vaccinating our troops? And why?
    Answer. Anthrax spores can kill or incapacitate American troops if 
used against us as a weapon. It is clearly in the best interests of our 
troops to use the only round-the-clock protection available against 
this lethal threat. The sudden deaths from inhalation anthrax among 
U.S. Postal Workers and other Americans during the fall 2001 anthrax 
attacks on Senator Daschle and Senator Leahy and other targets 
demonstrate how easy it is for people to breath in anthrax spores 
without realizing they have been exposed. In April 2002, the National 
Academy of Sciences released a Congressionally commissioned report that 
reviewed all available scientific evidence and heard from people 
concerned about anthrax vaccine. The National Academy of Sciences then 
concluded that the anthrax vaccine licensed by the Food and Drug 
Administration protects against all forms of anthrax and is as safe as 
other vaccines.

                      COMBAT STRESS CONTROL TEAMS

    Question. General Kiley, in your testimony you state there are a 
wide array of mental health assets in theater including Combat Stress 
Control teams and other personnel assigned to units and hospitals. Can 
you provide some numbers and tell us how many teams and personnel make 
up this program? Are there any current plans to increase your numbers 
of mental health assets in theater?
    Answer. Since the beginning of Operation Iraqi Freedom, combat 
stress units and other mental health assets have been deployed into 
theater. Personnel include psychiatrists, psychologists, social 
workers, psychiatric nurses, occupational therapists and enlisted 
technicians. As well as the combat stress control teams, there are 
mental health assets organic to the division and combat surgical 
hospitals. They work in close conjunction with the chaplains. The 
combat stress teams work closely with leaders and Soldiers to help them 
cope with both the stresses of combat and the challenges of being away 
from families for long periods of time. Their role is to provide 
education, preventive services, and restoration and treatment services. 
Typical educational activities include combat and operational stress 
control and suicide prevention classes, and preparation for reunion 
with their families. Clinical work includes individual and group 
evaluation and treatment. There are 10 combat stress control teams in 
theater, with a total of 224 mental health personnel. This number is 
appropriate for the number of U.S. forces deployed in the CENTCOM 
Theater. To add more to the theater would not add significant benefit 
and would detract from the staff available in CONUS and OCONUS 
providing care to other Soldiers and their families.

                        RECRUITING AND RETENTION

    Question. In your testimony, General Kiley, you note that you are 
concerned about the retention of health care professionals and that you 
are working with the Commander of Army Recruiting to reverse the 
current trends. How far from your desired retention and recruiting rate 
are you currently? What steps are you taking to address the situation?
    Answer. The Global War on Terrorism and Army transformation make 
recruitment and retention of Army Medical Department personnel 
challenging. Transformation has provided a new set of requirements 
which, given the long training tail for medical personnel, cannot be 
immediately met through recruitment and student programs. The only way 
to meet this need, in the near term, is to retain individuals to fill 
these positions. At the same time, members of the Army Medical 
Department have some of the most ``exportable'' skills in the Army and 
some skills, like the Nurse, are in short supply and high demand in the 
civilian market place. The lure of lucrative employment coupled with no 
deployments is having its effect on retention. A comparison of three 
year average continuation rates for 1999 to 2001 (pre 9/11) against 
2002 to 2004 shows significant changes. At the 7th year of service, 
Nurses are down from 87 percent to 84 percent and at the 5th year, 93 
percent to 90 percent; Physician Assistants have demonstrated a 
remarkable drop in the 12th, 13th and 14th year of service (92 percent 
to 76 percent, 85 percent to 77 percent and 88 percent to 72 percent 
respectively).
    Direct accessions of medical personnel have also proved to be 
challenging. The chart below shows current fiscal year 2005 recruitment 
for both Active and Reserve component medical personnel.

----------------------------------------------------------------------------------------------------------------
                                  Active Duty     Percent     Army Reserve    Percent   National Guard   Percent
----------------------------------------------------------------------------------------------------------------
Medical Corps................  18 of 40.........       45  64 of 201........       32  12 of 104.......       12
Dental Corps.................  10 of 30.........       33  7 of 48..........       15  0 of 32.........  .......
Nurse Corps..................  75 of 170........       40  225 of 485.......       46  13 of 55........       24
----------------------------------------------------------------------------------------------------------------

    The backbone of medical recruiting is our student programs 
(scholarships and stipends). Recruitment for these student programs is 
more difficult than expected. The Army has requested additional Health 
Professions Scholarship Program allocations. We believe that these 
additional scholarships are needed and as individual influencers learn 
that more scholarships are available, they will be filled by quality 
individuals who will shape the medical department of the future.
    Increases in Incentive Special Pays, Accession Bonuses, Loan 
Repayment Programs and other incentive pays are all tools which can be 
utilized by the recruiters and Commanders to influence recruitment and 
retention decisions. In February 2005, the Army increased Incentive 
Special Pays for Certified Registered Nurse Anesthetists retroactive to 
January 1, 2005. As of June 2005, 88 percent of the eligible Nurse 
Anesthetists elected to sign a new Incentive Special Pay contract. 
Twenty-two percent of these nurses opted for 1-year contracts and 78 
percent opted for multi-year contracts.
    The Surgeon General approved the utilization of Active Duty Health 
Professions Loan Repayment as an accession tool to assist U.S. Army 
Recruiting Command (USAREC) in meeting their recruitment mission for 
Physician's Assistants in fiscal year 2006. This will be the first year 
that USAREC has been tasked to directly recruit Physician's Assistants. 
Anecdotal evidence suggests that the ability to offer recent graduates 
from civilian Physician's Assistants programs the opportunity to have 
the Army assist in the repayment of their educational loans will make a 
difference in their propensity to serve. This is a new program for this 
group; however it has proven to be very successful with Pharmacy 
officers and Registered Nurses in the past.
    Finally, USAREC signed a contract with Merritt Hawkins in June 2005 
for a 6-month trial period to recruit Army Reserve Physicians. Merritt 
Hawkins is the top-ranked civilian Healthcare Professional recruiting 
firm in the country. The trial period is to run from July to December 
2005.

                          ANTHRAX VACCINATIONS

    Question. During the height of the Iraq invasion, concern, and more 
specifically controversy, surrounded vaccinating our armed forces for 
anthrax. This debate has not died down. The FDA has reported that there 
are over 50 side effects to the anthrax vaccination, and this is taking 
into account that former FDA Director David Kessler has stated that 
only 10 percent of reactions ever get reported. In 1998 the former 
Secretary of the Army Luis Caldera acknowledged the anthrax vaccine was 
linked to ``unusually hazardous risks.'' There have been documented 
cases of DOD continuing shots after major reactions, which violates 
vaccine instruction and documented cases of DOD administering shots 
from expired lots. Further, Senate Report 103-97 stated that the 
vaccine has still not been eliminated as a cause of the Gulf War 
Syndrome. In the past 5 years, thousands of cases of adverse reactions, 
causing serious health problems, have been linked to the anthrax 
vaccine. Several soldiers have even died from the shots. In light of 
the inherent risks in the program, I would appreciate hearing the 
panels' views as to why are we still mandating that our servicemembers 
receive these shots?
    Answer. Anthrax spores can kill or incapacitate American troops if 
used against us as a weapon. It is clearly in the best interests of our 
troops to use the only round-the-clock protection available against 
this lethal threat. The sudden deaths from inhalation anthrax among 
U.S. Postal Workers and other Americans during the fall 2001 anthrax 
attacks on Senator Daschle and Senator Leahy and other targets 
demonstrate how easy it is for people to breath in anthrax spores 
without realizing they have been exposed.
    In April 2002, the National Academy of Sciences (NAS) released a 
Congressionally commissioned report that reviewed all available 
scientific evidence and heard from people concerned about anthrax 
vaccine. The National Academy of Sciences then concluded that the 
anthrax vaccine licensed by the Food and Drug Administration protects 
against all forms of anthrax and is as safe as other vaccines.
    While some individuals have expressed concern about anthrax 
vaccine, a detailed analysis of 34 peer-reviewed medical journal 
articles shows that people vaccinated or unvaccinated against anthrax 
have the same health experiences. It is well recognized that minor 
temporary side effects are underreported (which is the point Dr. 
Kessler was making); however, serious adverse events are reported, 
especially in a well-monitored integrated health system, such as the 
Military Health System.
    With reference to adverse events, Defense policy requires anyone 
who presents to medical personnel with a significant adverse health 
condition after receiving any vaccination (e.g., anthrax, smallpox, 
typhoid) to be evaluated by a physician to provide all necessary care 
for that event. The physician must determine whether further doses of 
that vaccine should be given, delayed, or a medical exemption--either 
temporary or permanent--be granted. Military medical personnel are 
trained how to manage perceived or actual adverse events after 
vaccination with any vaccine.
    As of July 2005, anthrax vaccinations are voluntary, under an 
Emergency Use Authorization issued by the Food and Drug Administration.
    As for links between anthrax vaccinations and illnesses among Gulf 
War veterans, two publications by the civilian Anthrax Vaccine Expert 
Committee concluded that multi-symptom syndromes among some veterans of 
the Persian Gulf War were not reported more often among anthrax 
vaccines than expected by chance. As explained in these articles, the 
vast majority of adverse-event reports involve temporary symptoms that 
resolve on their own. While one death has been classified as 
``possibly'' related to a set of vaccinations, these civilian 
physicians did not attribute other reported deaths to anthrax 
vaccination.
    Secretary Caldera's actions are quoted out of context. His finding 
related to the risks to the manufacturing enterprise (the only 
manufacturer licensed by the Food and Drug Administration to produce 
anthrax vaccine) if the manufacturer was subjected to multiple 
lawsuits. He was not referring to the risks of the vaccine itself. In a 
Congressionally commissioned report, the National Academy of Sciences 
concluded in April 2002 that anthrax vaccine is as safe as other 
vaccines.
                                 ______
                                 
            Questions Submitted by Senator Daniel K. Inouye

                           SUICIDE PREVENTION

    Question. What is the process for assuring our troops and their 
leadership are well trained in suicide prevention and intervention 
protocols as they relate to both the peacetime and wartime missions?
    Answer. Suicide prevention is a Commander's program. The proponent 
for the program to include training is Army G-1. In general, Army units 
typically have an annual requirement to conduct suicide prevention 
training. This is usually conducted by installation Chaplains or 
Behavioral Health personnel. Many units and installations sponsor 
Applied Suicide Intervention Training (ASIST) that provides specific 
intervention skills to noncommissioned officer leadership and selected 
Soldiers. Formal investigations are done after every active duty 
suicide focusing on lessons learned and prevention. Additional training 
is also provided to support agency staff, including Chaplains and 
healthcare providers, on how to identify signs of suicide and how to 
effectively screen and intervene with service members who are having 
suicidal thoughts. Leaders, both officer and non-commissioned officers, 
receive training on how to take care of their troops in the area of 
suicide.

                           HEALTH ASSESSMENTS

    Question. How does the AMEDD determine if soldiers are both 
psychologically and physically healthy enough to be deployed? What 
improvements should be made in the current pre-deployment evaluation?
    Answer. The Pre-Deployment Health Assessments (DD 2795) falls 
within the overall framework of Force Health Protection, which provides 
comprehensive health surveillance. All Soldiers identified as having 
psychological and/or physical health related concerns are screened by 
medical personnel for further evaluation. Medical personnel make 
recommendations to Commanders concerning whether or not Soldiers are 
healthy enough for deployment. Identifying Soldiers who are at risk for 
physical injury before deployment is an area for improvement in pre-
deployment evaluation. In addition, an annual preventive health 
assessment has been developed and will be fielded in the coming year. 
This annual requirement specifically includes assessment of domains 
relevant to medical readiness, both physical and psychological. The 
implementation of this annual assessment will help to maintain the 
health of our troops across the deployment cycle, not just immediately 
before.
                                 ______
                                 
            Questions Submitted by Senator Patrick J. Leahy

    Question. You have been working for four years with congressional 
support to develop a robust, mobile hospital solution to replace the 
Deployable Medical Systems you've had in place for nearly thirty years 
now. With the research and development phase of this work now near its 
end, is it not time to move this effort to the next stage and develop a 
procurement program for these hard-shelled, mobile hospital units?
    Answer. The research and development phase has not been completed 
for hard wall shelters. In fact, the Army only recently received just 
one set of first prototype shelters with the most recent being provide 
in the spring of this year. Though the shelters exhibit promise, there 
are some shortcomings from our initial review and have yet to gather 
the most meaningful data, operational user tests. At this moment, there 
are two competing designs at work with an expected down select in the 
late fiscal year 2006, early fiscal year 2007 timeframe. We anticipate 
that the Army will find separate technologies within each prototype 
system that has value and will compete a requirement that builds upon 
combined characteristics. At present, the further developmental and 
procurement quantities have been programmed as requirements into our 
budget, but higher priority requirements preclude its funding at this 
point in time.

                      COMPOSITE HEALTH CARE SYSTEM

    Question. I have followed the evolution of CHCS II and Tricare 
Online with interest, and it strikes me that there is a confluence of 
maturing technologies that can be leveraged to empower the patient to 
improve health care quality while reducing health care costs. If 
Department of Defense servicemembers and beneficiaries are given the 
ability to securely enter data about themselves and their medical 
problems into CHCS II via Tricare Online, it will solve a huge problem 
facing the military health system, namely how to get standardized 
clinical information into the medical record without using expensive 
and scarce medical personnel. Physicians would get better information 
about their patients, and patients would get immediate guidance from 
the tools mounted on Tricare Online to help them with their problems. I 
know there are knowledge tools in CHCS II, but I would like each of you 
to comment on any plans your service has to offer them to beneficiaries 
on Tricare Online. What are your thoughts about using Tricare Online to 
help populate subjective clinical information into CHCS II?
    Answer. The Health Assessment Review Tool (HART) and Personal 
Health Record (PHR) are two such tools that are projected for a TOL 
interface with CHCS II. A web-enabled HART is by far the most effective 
and efficient method of making HART available to all populations 
(TRICARE Standard, TRICARE Prime, Reserve/National Guard, civilian 
employees of DOD activities). The successful implementation of this 
web-enabled functionality is a positive step toward empowering the 
patient to participate in his or her own heath care.
    The E-Health Personal Health Record (PHR), accessible via TOL, 
addresses the Military Health System's (MHS) need for a secure portal 
for beneficiaries to access their electronic medical record. The MHS is 
working with commercial organizations and the Veterans Health 
Administration to define optimal business processes and to develop 
industry leading functional and technical requirements. This structured 
response capability is scheduled for deployment in fiscal year 2008, 
capabilities will allow the patient to review or enter allergies, past 
medical history and to review test results and other information that 
must be either posted or verified by the medical staff. This will help 
to ensure that the information was received by the patient and prevent 
unnecessary visits to check lab results that were normal.
                                 ______
                                 
           Questions Submitted by Senator Barbara A. Mikulski

                     POST TRAUMATIC STRESS DISORDER

    Question. The New York Times recently reported that an Army study 
shows that about one in six soldiers in Iraq report symptoms of major 
depression, serious anxiety or post-traumatic stress disorder, a 
proportion that some experts believe could eventually climb to one in 
three, the rate ultimately found in Vietnam veterans. (NY Times, Dec. 
16, 2004). (Reference for the above Army study is: New England Journal 
of Medicine, Vol. 351, No. 1, pg. 13).
    According to the Times and the Army report, ``through the end of 
September, the Army had evacuated 885 troops from Iraq for psychiatric 
reasons, including some who had threatened or tried suicide. But those 
are only the most extreme cases. Often, the symptoms of post-traumatic 
stress disorder do not emerge until months after discharge''. (NY 
Times, Dec. 16, 2004).
    The Times also referenced a report by the GAO that found similarly 
alarming results: ``A September report by the Government Accountability 
Office found that officials at six of seven Veterans Affairs medical 
facilities surveyed said they `may not be able to meet' increased 
demand for treatment of post-traumatic stress disorder.'' (NY Times, 
Dec. 16, 2004).
    However, despite this well-documented crisis, I am concerned that 
we are not doing enough to combat PTSD.
    In light of these very serious concerns, what is the Department of 
Defense doing to address well-documented examples of PTSD in our men 
and women returning from the battlefields of Iraq, Afghanistan and 
elsewhere?
    Answer. The Department of the Army complies with a series of 
Department of Defense policies which govern the Pre- and Post-
Deployment Health Assessment process. A February 2002 Joint Staff 
Policy details the procedures for Deployment Health Surveillance and 
Readiness. The Pre- and Post-Deployment Health Assessments (DD 2795 and 
DD 2796) are designed to provide comprehensive health surveillance for 
service members affected by deployments. The overarching goal of the 
Army is to provide countermeasures against potential health and 
environmental hazards to include Post Traumatic Stress Disorder (PTSD) 
for optimal protection to our troops. Early detection and management of 
all deployment-related health concerns, including PTSD, can reduce 
long-term negative health consequences and improve the quality of life 
for those with deployment concerns. All Soldier's identified with PTSD 
and/or other mental health symptoms are referred to mental health 
providers for further evaluation and follow-up. The Post-Deployment 
Health Assessment provides ongoing identification and management of 
later emerging deployment health concerns. Copies of all Pre- and Post-
Deployment forms are kept in a central database at the U.S. Army 
Medical Surveillance Activity.
    This system of identification and treatment is being further 
enhanced through implementation of a Post-Deployment Health 
Reassessment to be conducted at the 3-6 month period after service 
members return from an operational deployment. This program will 
provide an opportunity for identification and treatment of health 
concerns, including mental health concerns, that emerge over time. In 
addition, DOD and VA have also collaborated in the development and 
dissemination of an evidence-based clinical practice guideline for 
identification and treatment of acute stress and PTSD in both primary 
care and specialty mental health care settings.The guideline supports 
the Post Deployment Health Evaluation and Management Clinical Practice 
Guideline that was fielded for mandatory implementation in every 
military primary care clinic in 2003. Because PTSD is not the only 
mental health concern resulting from deployment and because PTSD is 
often related to physical health symptoms, additional guidelines have 
been developed and disseminated throughout the military health system 
to include a DOD/VA Clinical Practice Guideline for Major Depression, 
Substance Use Disorder, and Ill-defined conditions and concerns.
    Question. Are clinical trials being conducted in conjunction with 
our nation's pharmaceutical industry?
    Answer. The Army Medical Department is not currently conducting 
clinical trials in conjunction with the pharmaceutical industry.
    Question. Is the Department aware that there exists a not-for-
profit organization in Maryland that is committed to pulling together 
all developing new technologies for the treatment of PTSD?
    Answer. The Army is aware that the Department of Defense, in 
collaboration with the Department of Veteran's Affairs, has contracted 
with the Samueli Institute for Information Biology (SIIB) to conduct 
the program entitled Integrative Healing Practices for Veterans (VET 
HEAL). SIIB is a non-profit, non-affiliated medical research 
organization, based in Maryland, supporting the scientific 
investigation of healing processes with Information Biology and its 
application in health and disease.
    Question. What is the Department doing to identify these and other 
innovative approaches to the treatment of PTSD?
    Answer. The Army Medical Department, in conjunction with the 
Department of Defense and the members of the National Center for PTSD 
partnered to develop The Iraq War Clinician Guide, which is now in its 
second edition (June 2004). This guide was developed specifically for 
clinicians and addresses the unique needs of veterans of the Iraq war. 
Topics include information about the management of PTSD in the primary 
care setting, caring for veterans who have been sexually assaulted, and 
the unique psychological needs of the amputee patient. Similarly, the 
Veterans Health Administration and the military services developed the 
VA/DOD clinical practice guideline for the management of post-traumatic 
stress. In addition, the Department of Defense has partnered with the 
Department of Veterans Affairs to conduct two randomized clinical 
trials, including one focused on effective treatment for military women 
and one focused on prevention and education for early intervention 
through a technology enhanced program called DESTRESS. These studies 
aid us in ensuring our treatments are the most effective they can be 
and they are provided at the appropriate time. DOD and VA have also 
collaborated in the development and dissemination of an evidence-based 
clinical practice guideline for identification and treatment of acute 
stress and PTSD in both primary care and specialty mental health care 
settings.The guideline supports the Post Deployment Health Evaluation 
and Management Clinical Practice Guideline that was fielded for 
mandatory implementation in every military primary care clinic in 2003.
                                 ______
                                 
          Questions Submitted to Vice Admiral Donald C. Arthur

               Questions Submitted by Senator Ted Stevens

                       SUPPORTING TRANSFORMATION

    Question. Would each of you please describe some of the new 
technologies and tactics that have proven most effective in caring for 
our front line troops?
    Answer. The Navy is involved in the following projects and programs 
to care for our front line troops:
  --The introduction of Body Armor, the Forward Resuscitative Surgical 
        System, and reduced evacuation times has had a substantial 
        impact in reducing members killed in action (KIA) compared to 
        prior conflicts.
  --The introduction of Quikclot for controlling hemorrhage.
  --Fielding of a Patient Tracking Device in OIF and OEF, the Tactical 
        Medical Coordination System (TacMedCS).
  --Combat Trauma Registry (CTR). This registry has made a major 
        contribution to understanding of casualties. Data summarized 
        from the CTR forms have been used in theater to provide medical 
        situation updates. The CTR is being used for ongoing studies 
        and analyses which include: head, neck and face injury study, 
        extremity injury study, and shunt efficacy study.
  --Field Oxygen Concentration Units, reducing need for cylinders.
  --EnRoute Care System--the supplies, equipment and personnel 
        available to use any mobility platform to transport critically 
        injured casualties.
  --Improved Medical Diagnostic Capabilities in Field of Operations: 
        Digital Radiography.
  --Individual First Aid Kit (IFAK), (including tourniquets and 
        advanced compression dressings for self and buddy aid).
  --Improved First Responder Aid Bag.
  --OSCAR (Operational Stress Control and Relief) to Reduce Combat 
        Stress.
  --New Seats Installed in the Small Special Operations Boats (should 
        reduce injuries to operating personnel through greater shock 
        absorption).
  --Use of a Centralized Computer System to Collect Heat Stress Data on 
        Ships (should reduce the incidence of heat injury and reduce 
        work load. Also has land-based applications).
  --Improved Methods of Rapidly Gathering and Assessing Lessons Learned 
        Data from ongoing experiences linkage to off-the-shelf 
        solutions/ideas for providing care to front line troops.
    The Marine Corps has introduced new technologies and tactics to 
improve first responder care, resuscitative surgery, and patient 
evacuation with enroute care.
  --First responder care. Marines from I MEF and II MEF have received 
        Combat Lifesaver Training to enhance their ability to provide 
        self-aid and buddy aid. These Marines also received a new 
        Individual First Aid Kit (IFAK) to improve their ability to 
        stop life-threatening bleeding. The new IFAK includes a 
        hemostatic agent (QuikClot), a new tourniquet, and improved 
        battle dressings.
  --Resuscitative Surgery. The Marine Corps has successfully used the 
        Forward Resuscitative Surgery System (FRSS) to provide life-
        saving surgery far forward on the battlefield. The FRSS has 
        demonstrated the potential of far forward resuscitative surgery 
        to reduce battlefield mortality among the most seriously 
        wounded.
  --Patient evacuation with Enroute Care. The Marine Corps has also 
        successfully used specially trained nurses and hospital 
        corpsmen to provide enroute care during the evacuation of 
        critically injured casualties onboard its helicopters. 
        Providing enroute care for these critically injured casualties 
        has contributed to reducing battlefield mortality.
    Question. What tools and equipment are still required to improve 
the care provide to combat casualties?
    Answer. While the number of Killed in Action has been greatly 
reduced by the aforementioned capabilities. Much work is need now for 
those who are wounded in action.
  --Improved Body Armor for extremities.
  --Treatments to prevent/treat blast trauma and long term neurological 
        deficits resulting from exposure to blast.
  --Research on Combat and Operational Stress to include enhanced 
        research on Mental Health and Post Traumatic Stress (PTSD).
  --Blood substitutes and improved resuscitation strategies.
  --Technologies to stop internal hemorrhage.
  --Technologies to sustain life support and reduce logistical burden 
        during delayed/prolonged evacuation.
  --Technologies to treat brain injury.
  --Technologies to improve limb and organ viability from trauma.
  --Microbiology of blast and bullet injuries in returning troops.
  --Research on Musculoskeletal Injuries (including epidemiology, 
        prevention, and footwear).
  --Research on Effectiveness of Current Body Armor (i.e., how many 
        casualties prevented).
  --Research on the Causes and Prevention of Motor Vehicle Accidents 
        (almost 10 percent of casualties resulting from hostile enemy 
        action were due to motor vehicle accidents).
  --Improved Medical Diagnostic Capabilities in Field of operations.
  --Improved Bioenvironmental Tools for Operational Risk Management and 
        Deployment of Medical Resources and Identification of Routes of 
        Evacuation.
  --Research on the Impact of Multiple Stressors (Noise, Heat, Chemical 
        Exposure, etc.) on Recuperation of Casualties.
  --Development of Antioxidant Treatment Protocols for Laser Eye 
        Injuries.
  --The Submarine Force Needs Better Casualty Movement and Evacuation 
        Equipment for casualty transfer and MEDEVAC. Currently 
        available stretchers and evacuation equipment do not permit 
        rapid movement of casualties in and out of the tight confines 
        of submarines.
  --Anti-Hypothermia Warming Blankets.
  --Improved Non-Performance Degrading Analgesia.
  --Improved Means for Combat Medic Training.
  --Easy to Use Vascular Shunts for Limb Salvage.
  --Research on Use of Antioxidant Supplementation for Performance 
        Enhancement and Rehabilitation.
  --Research on Development of Back Packs to Transfer Load Carriage 
        From the Shoulders to the Hips to Reduce Injuries.
  --Research to Reduce Concussive Injury from Blast and Bullet Strikes 
        to the Head.
                                 ______
                                 
            Question Submitted by Senator Richard C. Shelby

                            ANTHRAX VACCINE

    Question. During the height of the Iraq invasion, concern, and more 
specifically controversy, surrounded vaccinating our armed forces for 
Anthrax. This debate has not died down. The FDA has reported that there 
are over 50 side effects to the Anthrax vaccination, and this is taking 
into account that former FDA Director David Kessler has stated that 
only 10 percent of reactions ever get reported. In 1998 the former 
Secretary of the Army Luis Caldera acknowledged the Anthrax vaccine was 
linked to ``unusually hazardous risks.'' There have been documented 
cases of DOD continuing shots after major reactions, which violates 
vaccine instruction and documented cases of DOD administering shots 
from expired lots. Further, Senate Report 103-97 stated that the 
vaccine has still not been eliminated as a cause of the Gulf War 
Syndrome. In the past 5 years, thousands of cases of adverse reactions, 
causing serious health problems, have been linked to the Anthrax 
vaccine. Several soldiers have even died from the shots. In light of 
the inherent risks in the program, I would appreciate hearing the 
panels' views as to why are we still mandating that our service members 
receive these shots?
    Answer. DOD's mandatory Anthrax Vaccine Immunization Program is 
currently on a court-ordered pause. We are offering the Anthrax vaccine 
to personnel in high threat areas under an Emergency Use Authorization.
    Anthrax is the #1 threat on the Joint Chiefs bioweapon threat list. 
Anthrax spores make lethal weapons that can be easily disseminated 
through non-traditional means. This was demonstrated in the 2001 
Anthrax attacks, which killed several U.S. Postal Employees. Reports 
continue to be published in newspapers about the attack's infected 
survivors and their persistent health consequences. During the Anthrax 
attacks, city hospitals had only one or two patients requiring 
extensive and lengthy treatment for their illness. In a widespread 
attack, the number of patients requiring hospitalization would 
overwhelm the medical infrastructure. The Department of Defense uses 
Anthrax vaccine to ensure service members are protected against an 
attack using Anthrax.
    Over 1.3 million service members have been protected against 
Anthrax spores since March 1998. While some individuals have expressed 
concern about Anthrax vaccine, a detailed review of 34 peer-reviewed 
medical journal articles shows that people vaccinated or unvaccinated 
against Anthrax have similar health experiences. In 2002, the National 
Academy of Sciences published a congressionally commissioned report 
that concluded Anthrax vaccine has a side-effect profile similar to 
that of other vaccines licensed by the Food and Drug Administration 
[www.iom.edu/Object.File/Master/4/150/0.pdf]. DOD policy requires that 
anyone who develops adverse health conditions after any vaccination be 
evaluated by a physician. This policy also specifies that all necessary 
care be provided and that a determination be made as to whether further 
doses of that vaccine are indicated. It is well recognized that minor 
temporary side effects are underreported, which is the point Dr. 
Kessler was making. Serious adverse events are much more likely to be 
reported, especially in a well-monitored integrated health system, such 
as the Military Health System.
    The civilian Anthrax Vaccine Expert Committee (AVEC) issued two 
publications regarding adverse vaccine events that occurred from 1998-
2001 with respect to multi-symptom syndrome (MSS) described by some 
veterans of the Persian Gulf war. The panel found no evidence of a 
pattern of MSS after Anthrax vaccination. As explained in these 
publications, the vast majority of vaccine adverse-event reports 
involve temporary symptoms that resolve on their own.
    DOD reviews death reports after any vaccination very carefully. One 
death of a DOD service member has been classified as ``possibly'' 
related to the receipt of multiple (Anthrax, Smallpox and others) 
immunizations. The civilian physicians on AVEC evaluated other deaths 
and did not attribute them to Anthrax vaccination.
    The question for the record misstates the former Secretary of the 
Army's position, which was the business situation posed an unusually 
hazardous risk for BioPort Corporation as a small vaccine manufacturer.
    At no time has anyone shipped expired lots or vials of Anthrax 
vaccine to any military facilities. However in an isolated case, 
Anthrax vaccine from vials a few weeks beyond their potency dating was 
inadvertently administered. This 1999 incident was thoroughly 
investigated and correct vaccine management procedures were re-
emphasized to prevent future incidents.
                                 ______
                                 
             Question Submitted by Senator Patrick J. Leahy

                                CHCS II

    Question. I have followed the evolution of CHCS II and TRICARE 
Online with interest, and it strikes me that there is a confluence of 
maturing technologies that can be leveraged to empower the patient to 
improve health care quality while reducing health care costs. If 
Department of Defense service members and beneficiaries are given the 
ability to securely enter data about themselves and their medical 
problems into CHCS II via TRICARE Online, it will solve a huge problem 
facing the military health system, namely how to get standardized 
clinical information into the medical record without using expensive 
and scarce medical personnel. Physicians would get better information 
about their patients, and patients would get immediate guidance from 
the tools mounted on TRICARE Online to help them with their problems. I 
know there are knowledge tools in CHCS II, but I would like each of you 
to comment on any plans your service has to offer them to beneficiaries 
on TRICARE Online. What are your thoughts about using TRICARE Online to 
help populate subjective clinical information into CHCS II?
    Answer. TRICARE Online (TOL) has the potential to provide our 
beneficiaries the ability to convey information about their health 
status and concerns to providers. Our vision is in line with this goal, 
a clinical intervention tool informing beneficiaries, Primary Care 
Managers (PCMs), and Military Treatment Facility (MTF) administrators 
about required preventive services, health risk factors, chronic 
disease history, and health status. This tool assists the MHS at the 
Enterprise, Service, TRICARE Region and MTF level with population 
health management by providing estimates of the health needs and health 
status of the enrolled and non-enrolled TRICARE populations. Currently 
in development are the appropriate screening tools and alert 
functionality to mitigate the medical-legal risk of not being able to 
respond to a concern ``real-time'' while empowering beneficiaries to 
enter historical and screening information at their own pace. This 
information will be saved to the Clinical Data Repository making the 
data accessible via CHCS II.
                                 ______
                                 
           Questions Submitted by Senator Barbara A. Mikulski

            MENTAL HEALTH AND POST TRAUMATIC STRESS DISORDER

    Question. The major mental health problem being faced by the 
returning veteran is Post Traumatic Stress Disorder (PTSD).
    The New York Times recently reported that an Army study shows that 
about one in six soldiers in Iraq reports symptoms of major depression, 
serious anxiety or post-traumatic stress disorder, a proportion that 
some experts believe could eventually climb to one in three, the rate 
ultimately found in Vietnam veterans (NY Times, Dec. 16, 2004) 
(Reference for the above Army study is: New England Journal of 
Medicine, Vol. 351, No. 1, pg. 13).
    According to the Times and the Army report, ``through the end of 
September, the Army had evacuated 885 troops from Iraq for psychiatric 
reasons, including some who had threatened or tried suicide. But those 
are only the most extreme cases. Often, the symptoms of post-traumatic 
stress disorder do not emerge until months after discharge.'' (NY 
Times, Dec. 16, 2004).
    The Times also referenced a report by the GAO that found similarly 
alarming results: ``A September report by the Government Accountability 
Office found that officials at six of seven Veterans Affairs medical 
facilities surveyed said they `may not be able to meet' increased 
demand for treatment of post-traumatic stress disorder.'' (NY Times, 
Dec. 16, 2004).
    However, despite this well-documented crisis, I am concerned that 
we are not doing enough to combat PTSD.
    In light of these very serious concerns, what is the Department of 
Defense doing to address well-documented examples of PTSD in our men 
and women returning from the battlefields of Iraq, Afghanistan and 
elsewhere?
    Answer. Navy medicine is directly involved in the management of 
PTSD both on the battlefield and at home. Last year, we initiated our 
Operational Stress Control and Readiness (OSCAR) Project with the U.S. 
Marine Corps. This project places mental health assets directly with 
Marine Corps fighting units, and those mental health providers stay 
with the unit both during the period of deployment and in garrison. 
Thus, our Marine Corps mental health providers are truly organic assets 
to the Marine divisions. Likewise, we have psychologists stationed 
aboard each aircraft carrier in the Navy to provide direct services to 
deployed service members. Following on the highly successful example of 
our shipboard psychologists, we have deployed psychologists and 
psychiatrists with Expeditionary Strike Groups (ESGs) to provide 
similar services to detachments of Marines and other service members 
being transported via ESGs.
    Question. Are clinical trials being conducted in conjunction with 
our nation's pharmaceutical industry?
    Answer. Medical Departments of the uniformed services do not work 
directly with pharmaceutical manufacturers as we are legally proscribed 
from doing so. However, under the auspices of the Henry M. Jackson 
Foundation, military researchers may participate as investigators in 
clinical trials with various sources of funding. Military medical 
personnel, both at the Uniformed Services University and at our 
teaching hospitals, may devise and submit for approval through 
appropriate institutional review boards clinical studies that involve 
post-traumatic stress disorder and other conditions. Several joint 
projects with the VA are presently ongoing, including a study at Naval 
Medical Center San Diego of virtual reality technology to assist 
patients with PTSD.
    Question. Is the Department aware that there exists a not-for-
profit organization in Maryland that is committed to pulling together 
all developing new technologies for the treatment of PTSD?
    Answer. Yes. Several not-for-profit organizations exist in the 
State of Maryland that can and have in the past provided expert 
assistance to the DOD in its efforts to understand PTSD and ameliorate 
its effects. For instance, trainers from the International Critical 
Incident Stress Foundation, in Ellicott City, routinely provide 
training in critical incident stress debriefing gratis to military 
mental health providers and military first responders. The Maryland 
Psychological Association has offered the services of its members to 
family members of servicemen and women who may be suffering from the 
effects of combat stress or related disorders. Additionally, the 
Maryland Psychological Association partners with the American Red Cross 
to train its members in disaster response. The services take advantage 
of the expertise of faculty at the Uniformed Services University in 
Bethesda who are world renowned experts in the study of combat stress 
and related disorders, we apply their research findings in our clinical 
practice to better serve active duty members and their families. We 
also work closely with other agencies, both in the federal and private 
sector, such as the VA's National Centers for PTSD, to identify sources 
of expertise in the management of stress and apply findings to our 
service members.
    Question. What is the Department doing to identify these and other 
innovative approaches to the treatment of PTSD?
    Answer. Navy medical resources are intensely involved in the study 
of innovative treatment strategies for PTSD. We work closely with our 
colleagues in the VA and at the Uniformed Services University, as well 
as various private and publicly funded institutions of higher 
education, to educate our providers regarding most effective 
treatments. In addition to collaboration in research endeavors as 
mentioned above, we have jointly produced with the VA a number of 
Clinical Practice Guidelines, including guidelines for the management 
of acute and chronic stress, depression, and other disorders. We co-
sponsor conferences for our clinicians and decision makers regarding 
the management of PTSD, and are involved in a number of joint working 
groups designed to create a true continuum of mental health care for 
our active duty, disabled, and retired service members.
                                 ______
                                 
   Questions Submitted to Lieutenant General George Peach Taylor, Jr.

               Questions Submitted by Senator Ted Stevens

                       SUPPORTING TRANSFORMATION

    Question. Would each of you please describe some of the new 
technologies and tactics that have proven most effective in caring for 
our front line troops?
    Answer. The Air Force Medical Service has clearly played a 
tremendous role in the delivery of health care to our front line 
troops. To open, let me say that prevention has proven to be enormously 
successful in preventing injury and providing superb safe environments 
for our personnel. Our deployed Preventive Medicine Teams have provided 
direct preventive medicine support to military personnel throughout 
Operation Iraqi Freedom, providing such resources as occupational and 
environmental health surveillance, environmental health programs, field 
sanitation training, disease and non-battle injury prevention, health 
risk assessments, and medical force protection.
    The lighter, leaner footprint of Air Force medical resources has 
been extremely effective in providing a consistent clinical capability 
to the Combatant Commander and warfighter. The hard work accomplished 
with focus on interoperability in capability was proven a success 
during the transition from the Army Combat Support Hospital to the Air 
Force Expeditionary Medical System this past fall. Shortly after that 
transition, the vast majority of casualties from the battle of Fallujah 
were received and cared for at that very same facility. The dedication 
and teamwork of our Army and Air Force medics ensured seamless medical 
care, timely evacuation, and lifesaving care to the injured warfighter.
    In December of 2004, the Assistant Secretary of Defense (Health 
Affairs) directed the Services to implement the Joint Theater Trauma 
Registry. Air Force clinicians played a tremendous role in the 
development of the first Joint Theater Trauma System (JTTS). Modeled 
after the successes of the civilian sector, the JTTS keeps us at the 
cutting edge, bringing the skills of trauma centers to the battlefield. 
The goal is to provide a system for routing casualties to destinations 
that are best able to provide the required care: ``The Right patient, 
to the Right place, at the Right time.''
    The employment of critical care capability during aeromedical 
transport and the role of evidence-based medical innovations have also 
been important. Our community has been aggressive in meeting the needs 
of the aeromedically evacuated critical care patients through 
implementation of new technology for intra-cranial pressure monitoring 
ensuring the safe transport of patients with head trauma, as well as 
the latest in pain management using the non-electronic Stryker Pain 
Pump. Additionally, the move to universally qualify aeromedical 
evacuation crew has further ensured the safe passage of our sick and 
injured.
    The Air Force Medical Service clearly plays a critical role in the 
delivery of health care to our front line troops. It has only been 
through the collaborative efforts between the medical and operations 
communities, multi-service and multi-national forces abroad that our 
delivery of health care during the most challenging of contingencies 
has become the best in the world.
    Question. What tools and equipment are still required to improve 
the care provided to combat casualties?
    Answer. Our medical forces are doing tremendous work in the 
delivery of health care to our front line troops and their experience 
provides us with valuable lessons learned. These lessons learned deal 
primarily with the tools and equipment still required to improve the 
care provided to combat casualties. Based on lessons learned, we still 
need solutions for the following requirements to provide the best 
combat casualty care possible. I would be happy to discuss these with 
you at your convenience in greater detail.
    Rapid diagnostics capabilities for deployed and homeland stationed 
medics: This shortfall includes deployment of systems similar to 
Epidemiology Outbreak Surveillance to rapidly diagnose emerging 
threats, as they happen to give commanders the information they need to 
preserve the fighting force through prevention and prophylaxis.
    Near real-time medical surveillance or environmental factors to 
include water sources: This capability enables monitoring of sources to 
allay the damage or illness from weapons of mass destruction.
    Water and Intravenous purification: Exploitation of current 
technology trends to allow on-site water purification to two standards, 
potable and infusion quality. This capability dramatically decreases 
the pallet space and logistical footprint needed to provide water to 
troops.
    Oxygenation capabilities integrated with Aeromedical Evacuation and 
Expeditionary Medical Support: There is an increasing need for deployed 
medical personnel to provide their own oxygen.
    Acute care and local extracorporeal membrane oxygenation to 
facilitate stabilization for transport of critically injured patients.
    Instant reach-back communications for facilitation of inter-service 
patient care coordination: There are considerable shortfalls in 
interoperability for rapid communication leading to delays in 
treatment, transport and communication of care rendered.
    Blood substitutes are needed to not only expand the fluid volume of 
injured patients but to also include increased oxygen carrying 
capability that standard volume expanders lack.
    Medical Scancorder development must be accomplished so that 
Soldiers and Airmen can be monitored for instability of vital signs/
hemodynamics before they experience symptoms.
    Portable anesthesia is now limited by respirator availability or 
intravenous access; stable, simple and effective anesthesia devices are 
needed to allow humane and safe anesthesia to injured patients.
    Patient controlled anesthesia is the standard of care: This 
standard is not currently met by most equipment/personnel medical 
support packages deployed and on modes of transportation available for 
evacuation.
    Trauma registry information as required by DOD Health Affairs 
Policy #04-031: Non-technological solutions are being used, which 
hinders the evacuation and medical care of injured Soldiers and Airmen.
    Despite the challenges we face, it is my privilege to share 
successes of improved combat casualty. The proud men and women of the 
Air Force Medical Service have recently fielded Telehealth initiatives 
within the CENTCOM Area of Responsibility (AOR), which provide reach-
back via Telehealth consultations and Teleradiology. We have also 
provided telephonic FAX capabilities for asynchronous reach-back 
consultations. Pumpless extra-corporeal lung assist has been used to 
evacuate critically ill patients that formerly would have been too 
unstable to transport. And, based on the most recent recommendations 
from our surgeons who have seen large numbers of severe orthopedic 
injuries, the addition of pneumatic tourniquet systems for extremity 
surgery, and compartment pressure monitors to diagnose limb-threatening 
compartment syndrome are examples of improve combat care to our front 
line troops. However, there are more tools needed to achieve improved 
treatment outcomes based largely on lessons learned from the AOR.
    The management of shock is probably the most basic element of 
trauma care. The replacement of fluid, administration of blood 
products, and maintenance of the body at normal temperature are all key 
to this lifesaving process. The thromboelastography (TEG) analyzer is 
a powerful clinical monitor to evaluate the interaction of platelets 
and plasma factors, plus any additional effects of other cellular 
elements (e.g., WBCs, RBCs). To guide administration of blood products, 
TEG has been recommended by our trauma surgeons, as the analysis 
provided by this tool would clearly benefit the management of our 
critically injured casualties. Forced-air warming therapy has become 
the standard choice for preventing hypothermia. Maintaining patient 
normothermia is proven to reduce increased complications for the post-
operative patient as well as the massive trauma patient. The Bair 
Hugger temperature management devices, such as the warming blanket and 
warming units, are those being specifically recommended for addition to 
the deployed inventory.
    There is currently discussion underway about having basic 
diagnostic cardiology in theater, such as a treadmill and 
echocardiogram capability. We are working with the Army and Navy, 
analyzing the benefits of accomplishing basic stress testing in 
theater, prior to evacuation, with the increased chance of returning 
more troops back to their unit rather than being evacuated to 
Landstuhl, Germany.
    Also critical to the effective management of patients is the 
continuity of information transfer. As casualties travel from the 
battlefield and through the military health care system, clinicians are 
known for writing on the dressings of casualties to ensure critical 
information goes with the patient and is readily accessible by all that 
will care for the casualty along the way. Use of the Battlefield 
Medical Information System, ``BMIST,'' has been initiated. This 
wireless electronic information carrier has been successful; however, 
the challenge has been to ensure that every field medic is issued the 
hand-held element so they can complete the casualty's electronic record 
on-site and be able to ``beam'' or give it on a memory chip to the air 
ambulance or aeromedical evacuation crew who can take it with the 
casualty on to their final destination.
    Finally, the challenges of communication between the multiple 
Service medical assets have unfortunately continued through the years. 
There is a wide array of communications tools and equipment among the 
different Services, each fulfilling their own requirements, but 
unfortunately most often not linking with the sister Services. While 
there are numerous initiatives underway addressing this very issue at 
the Joint and individual Service level, the critical key, as with every 
initiative regarding the management and care of our forces, is to 
ensure integration of these efforts.
                                 ______
                                 
             Question Submitted by Senator Pete V. Domenici

                    ACCESS TO MENTAL HEALTH SERVICES

    Question. I understand from your statements that you are diligently 
pursuing incidences of mental health issues such as depression, anxiety 
and post-traumatic stress disorder. I commend you for that. It is my 
understanding that to date the Department of Defense has done a good 
job reaching out to soldiers upon their return.
    My concern is for mental health services for rural Guard and Air 
Guard members in particular. Those Guardsmen in places like Springer, 
New Mexico are far from metropolitan areas and do not have access 
following demobilization to military mental treatment facilities with 
mental health services.
    I understand that this rural demographic is a small portion of your 
total population, but do you share my concerns about mental health 
access for rural Guard and Reserve members and if so can you give me 
your thoughts on how we might best address this issue?
    Answer. Our best efforts address the concern by requiring all 
redeploying members to receive a medical screening to include mental 
health conditions by completing DD Form 2796, Post-Deployment Health 
Assessment prior to theater departure or within five days upon return 
to home station. This screening provides the first sign of the need for 
additional health care and prompt access to care within our Military 
Healthcare System.
    To aid continuity of care and address health conditions frequently 
identified several months following redeployment, Assistant Secretary 
of Defense (Health Affairs) recently announced an extension of the 
deployment health screening process projected to start June 10, 2005. 
Post-Deployment Health Reassessment will involve each member completing 
an additional health screening form three to six months following 
redeployment to specifically address mental and other health concerns. 
The member's responses in coordination with a healthcare provider's 
review will determine the need for additional care, which may then be 
obtained through TRICARE health system referral or through the Veterans 
Health Administration. Additional sources of care for mental health 
concerns in rural areas may include the local department of public 
health and safety and military Family Assistance Centers. In the 
National Guard, the Adjutant General determines the need and location 
of the Family Assistance Center in support of deployment activities, 
and the State Family Program Coordinator is the point of contact.
    Of note, Veterans who serve in a theater of combat operations 
during war are eligible for care for two years from their date of 
active duty discharge provided they first enroll in the Veterans Health 
Administration. Access to Veterans Health Administration-sponsored care 
is visible at: http://www1.va.gov/directory/guide/home.asp?isFlash=1.
                                 ______
                                 
            Question Submitted by Senator Richard C. Shelby

                          ANTHRAX VACCINATION

    Question. During the height of the Iraq invasion, concern, and more 
specifically controversy, surrounded vaccinating our armed forces for 
anthrax. This debate has not died down. The FDA has reported that there 
are over 50 side effects to the anthrax vaccination, and this is taking 
into account that former FDA Director David Kessler has stated that 
only 10 percent of reactions ever get reported. In 1998 the former 
Secretary of the Army Luis Caldera acknowledged the anthrax vaccine was 
linked to ``unusually hazardous risks.'' There have been documented 
cases of DOD continuing shots after major reactions, which violates 
vaccine instruction and documented cases of DOD administering shots 
from expired lots. Further, Senate Report 103-97 stated that the 
vaccine has still not been eliminated as a cause of the Gulf War 
Syndrome. In the past 5 years, thousands of cases of adverse reactions, 
causing serious health problems, have been linked to the anthrax 
vaccine. Several soldiers have even died from the shots. In light of 
the inherent risks in the program, I would appreciate hearing the 
panels' views as to why are we still mandating that our service members 
receive these shots?
    Answer. From the Air Force perspective, the use of anthrax as a 
bio-weapon poses a significant threat to military operations. The 
anthrax vaccine is the most effective means available today to protect 
our forces. Although antibiotics were used following the anthrax 
attacks in 2001, they provide effective treatment only if exposure is 
known before symptoms appear. Unfortunately, we do not always have the 
necessary warning time necessary for antibiotics to work alone. 
Although we will continue to work to increase warning time of pending/
existing attacks, our men and women must be prepared to carry out their 
duties in defense of this country regardless of circumstances. To that 
end, the best currently available round-the-clock protection to prepare 
our forces to counter the threat of anthrax is vaccination. The vaccine 
provides a critical layer of protection that may be augmented by 
antibiotics and other measures.
    Since March 1998, over 1.3 million DOD personnel have been 
protected against anthrax exposure. Over 150,000 Air Force personnel--
Active, Guard and Reserve--in service today have received the anthrax 
vaccination. While some individuals have expressed concern about 
anthrax vaccine, a detailed analysis of 34 peer-reviewed medical 
journal articles shows that people vaccinated or unvaccinated against 
anthrax have the same health experiences. In 2002, the National Academy 
of Sciences published a Congressionally commissioned report that 
concluded anthrax vaccine has a side-effect profile similar to that of 
other vaccines licensed by the FDA (www.iom.edu/Object.File/Master/4/
150/0.pdf). It is well recognized that minor temporary side effects are 
underreported (the point Dr. Kessler makes); however, serious adverse 
events are reported, especially in a well-monitored integrated health 
system, such as the Military Health System.
    In addition, the Air Force--along with the other Services--utilizes 
the Vaccine Adverse Event Reporting System (VAERS), a national vaccine 
safety surveillance program co-sponsored by the FDA and the Centers for 
Disease Control and Prevention. This system collects and analyzes 
information from reports of adverse events that occur after the 
administration of all U.S. licensed vaccines. Reports are encouraged 
from all concerned individuals: patients, parents, health care 
providers, pharmacists and vaccine manufacturers. All anthrax vaccine 
recipients receive information via the Anthrax Vaccination Immunization 
Program trifold brochure and other means on how to access VAERS.
    With reference to adverse events, Air Force policy requires anyone 
who presents to medical personnel with a significant adverse health 
condition after receiving any vaccination (e.g., anthrax, smallpox, 
typhoid) to be evaluated by a physician to provide all necessary care 
for that event. The physician must determine whether further doses of 
that vaccine should be given, delayed, or a medical exemption--either 
temporary or permanent--be granted. Air Force medical personnel are 
trained how to manage perceived or actual adverse events after 
vaccination with any vaccine (i.e., how to assess, treat and report).
    As for links between anthrax vaccinations and Gulf War Syndrome, 
two publications by the civilian Anthrax Vaccine Expert Committee 
concluded that multi-symptom syndromes among some veterans of the 
Persian Gulf War were not reported more often among anthrax vaccinees 
than expected by chance. As explained in these articles, the vast 
majority of adverse-event reports involve temporary symptoms that 
resolve on their own. While one death has been classified as 
``possibly'' related to a set of vaccinations, these civilian 
physicians did not attribute other reported deaths to anthrax 
vaccination in particular.
    With respect to expired lots, at no time has anyone shipped expired 
anthrax vaccine to any military facility. We are, however, aware of one 
incident involving vaccine from expired vials being administered to 
approximately 59 Marines at a military Medical Treatment Facility (MTF) 
in April 1999. That incident involved vaccine that expired after it had 
been stored on site at the medical treatment facility--it was not 
expired at the time of shipment. Corrective measures have been 
implemented to prevent a reoccurrence. For example, the handling 
procedures for vaccines were changed to ensure that, upon receipt by 
the MTF, the lot number and expiration of all vials of vaccine in the 
shipment are recorded. Also, the Distribution Operation Center at the 
United States Army Medical Materiel Agency issues a message to all 
Service Logistic Centers to pre-alert them to when any anthrax vaccine 
lot is about to expire. This message ensures all anthrax vaccine is 
used prior to expiration, and aids in the prevention of a reoccurrence 
of the situation encountered by the Marines.
    All information concerning this expired-vaccine incident was 
forwarded to the Armed Forces Epidemiological Board (AFEB), an 
independent, nationally recognized group of civilian scientific experts 
that advises the DOD on the prevention of disease and injury and the 
promotion of health.
    After reviewing the details of the incident, the AFEB concluded 
that the expired vaccine administered to the Marines posed little or no 
safety risk and any decrement in potency of the expired vaccine would 
be minimal and clinically irrelevant.
                                 ______
                                 
             Question Submitted by Senator Patrick J. Leahy

                       CHCSII AND TRICARE ONLINE

    Question. I have followed the evolution of CHCS II and TRICARE 
Online with interest, and it strikes me that there is a confluence of 
maturing technologies that can be leveraged to empower the patient to 
improve health care quality while reducing health care costs. If 
Department of Defense servicemembers and beneficiaries are given the 
ability to securely enter data about themselves and their medical 
problems into CHCS II via TRICARE Online, it will solve a huge problem 
facing the military health system, namely how to get standardized 
clinical information into the medical record without using expensive 
and scarce medical personnel. Physicians would get better information 
about their patients, and patients would get immediate guidance from 
the tools mounted on TRICARE Online to help them with their problems. I 
know there are knowledge tools in CHCS II, but I would like each of you 
to comment on any plans your service has to offer them to beneficiaries 
on Tricare Online. What are your thoughts about using Tricare Online to 
help populate subjective clinical information into CHCS II?
    Answer. Any technology that helps our providers take better care of 
our patients is worth exploring. As a matter of fact, the TRICARE 
Medical Authority (TMA) is already working on expanding the ability of 
beneficiaries to input data directly into CHCS II. The technology is 
not quite there yet, but TMA has a short-term solution that uses the 
internet and e-mail to allow patients to communicate directly with 
their providers. TMA is also working on an internet based Health 
Insurance Portability and Accountability Act compliant solution 
involving the movement of patient data from TRICARE Online to the 
provider via e-mail.
                                 ______
                                 
           Questions Submitted by Senator Barbara A. Mikulski

                     POST-TRAUMATIC STRESS DISORDER

    Question. The major mental health problem being faced by the 
returning veteran is Post Traumatic Stress Disorder (PTSD). The New 
York Times recently reported that an Army study shows that about one in 
six soldiers in Iraq report symptoms of major depression, serious 
anxiety or post-traumatic stress disorder, a proportion that some 
experts believe could eventually climb to one in three, the rate 
ultimately found in Vietnam veterans. (NY Times, Dec. 16, 2004). 
(Reference for the above Army study is: New England Journal of 
Medicine, Vol. 351, No. 1, pg. 13).
    According to the Times and the Army report, ``through the end of 
September, the Army had evacuated 885 troops from Iraq for psychiatric 
reasons, including some who had threatened or tried suicide. But those 
are only the most extreme cases. Often, the symptoms of post-traumatic 
stress disorder do not emerge until months after discharge''. (NY 
Times, Dec. 16, 2004).
    The Times also referenced a report by the GAO that found similarly 
alarming results: ``A September report by the Government Accountability 
Office found that officials at six of seven Veterans Affairs medical 
facilities surveyed said they ``may not be able to meet'' increased 
demand for treatment of post-traumatic stress disorder.'' (NY Times, 
Dec. 16, 2004).
    However, despite this well-documented crisis, I am concerned that 
we are not doing enough to combat PTSD.''
    In light of these very serious concerns, what is the Department of 
Defense doing to address well-documented examples of PTSD in our men 
and women returning from the battlefields of Iraq, Afghanistan and 
elsewhere?
    Answer. The Air Force currently screens all Airmen for PTSD 
symptoms upon redeployment. Because PTSD symptoms often emerge over 
time, the Air Force will begin reassessing Airmen 90-180 days after 
return from deployment, starting in June 2005. This reassessment 
screens for PTSD as well as other common mental health related 
concerns. Any deployer, whether active duty or reserve component, who 
endorses any psychological symptoms will receive a full evaluation be a 
healthcare provider, and referred for care when indicated.
    While review of post-deployment health assessment data indicate 
that Air Force deployers face significantly less exposure to traumatic 
stress than Army and Marine ground combat, the Air Force is nonetheless 
committed to identifying and treating all deployment related health 
concerns in an expeditious and thorough manner.
    Question. Are clinical trials being conducted in conjunction with 
our nation's pharmaceutical industry?
    Answer. The Air Force is not currently involved in clinical drug 
trials for the treatment of Post Traumatic Stress Disorder (PTSD) due 
to the very low incidence rate of PTSD within the Air Force.
    Question. Is the Department aware that there exists a not-for-
profit organization in Maryland that is committed to pulling together 
all developing new technologies for the treatment of PTSD?
    Answer. The Air Force relies on the VA/DOD Clinical Practice 
Guidelines for Post Traumatic Stress Disorder (PTSD) management. We are 
open and interested in any and all technologies and innovations in the 
area of PTSD treatment that meet clinical standards of care.
    Question. What is the Department doing to identify these and other 
innovative approaches to the treatment of PTSD?
    Answer. The Air Force has joined a working group with the other 
services, the Department of Veterans Affairs, and the National Center 
for Post Traumatic Stress Disorder (PTSD) to identify state-of-the-art, 
empirically validated treatment approaches to PTSD.
    Our goals are to identify and treat PTSD symptoms as soon as 
possible, and to ensure continuity of care as Airmen move to new 
assignments or separate from the Air Force.
                                 ______
                                 
            Questions Submitted to Colonel Barbara J. Bruno

               Questions Submitted by Senator Ted Stevens

                        RECRUITING AND RETENTION

    Question. How does the Uniformed Services University of the Health 
Sciences support military nursing?
    Answer. The Uniformed Services University of the Health Sciences 
(USUHS) supports military nursing by providing a ``signature 
curriculum'' designed to prepare nurses for practice and research in 
federal health care and military systems. The USUHS Graduate School of 
Nursing is dedicated to quality education that prepares both advanced 
practice nurses and nurse scientists with a Ph.D. to deliver care, 
conduct research and improve services to all military beneficiaries. 
Programs that are currently offered at USUHS include three Masters 
level programs; Perioperative Certified Nurse Specialist, Certified 
Nurse Anesthetist and Family Nurse Practitioner and a Ph.D. program in 
Nursing Science.
    Question. With the current nursing shortage nationwide, and 
continued need for medical support at home and overseas, what is the 
status of your recruiting and retention efforts?
    Answer. The Active Component (AC) Army Nurse Corps (ANC) has a 
requirement of 365 new officers for fiscal year 2005. As of June 30, 
2005, 187 new officers have been commissions and reported for active 
duty. It is projected that the AC ANC will meet 88 percent (322 of 365) 
of its accession requirements this year. The Reserve Component (RC) ANC 
has a requirement of 485 new officers for fiscal year 2005. As of June 
30, 2005, 236 new RC ANC officers have been commissioned. U.S. Army 
Recruiting Command projects that they will achieve 75 percent (366/485) 
of the RC ANC accession requirements this year.
    The ANC recruiting and retention programs are critical to our 
competitiveness in a tight nursing market. Active and Reserve programs 
are detailed below. Program gaps include funding a second baccalaureate 
degree for commissioned officers interested in becoming an Army Nurse 
and a scholarship program to fund enlisted Reserve Soldiers interested 
in obtaining a Bachelors of Science in nursing and pursuing a 
commission as a Reserve ANC officer.
Active Component
    The Health Professions Loan Repayment Program (HPLRP) is a 
successful recruiting and retention tool for the ANC. HPLRP provides 
payment of up to $29,323 toward qualifying educational loans incurred 
from undergraduate nursing education. Currently, all eligible Active 
Component ANC officers have been offered the opportunity to participate 
in HPLRP, either at the time of accession or as a retention incentive, 
or both. Since its inception in 2003, 272 officers have participated in 
this program. Thus far in fiscal year 2005, 17 new direct accession AC 
officers have received HPLRP.
    The ANC offers a $15,000 accession bonus in exchange for a four-
year active duty service obligation. This bonus is projected to 
increase to $20,000 in fiscal year 2006. Thus far in fiscal year 2005, 
15 new AC AN officers have elected this incentive. Officers may also 
choose to receive an accession bonus and participate in HPLRP. They 
receive an $8,000 accession bonus combined with the HPLRP of up to 
$29,323 for a six-year active duty service obligation. Thus far in 
fiscal year 2005, 37 new AC officers have elected to take this option. 
Nursing scholarships are offered through ROTC, the Army Nurse Candidate 
Program, and the Enlisted Commissioning Program. Scholarships vary in 
length from two, three, or four years depending on the program with at 
least a three year active duty service obligation. ROTC nursing cadets 
may participate in the Nurse Summer Training Program (NSTP), a three-
week internship in which they work with an ANC officer caring for 
patients. While ROTC has struggled in recent years to meet nurse 
mission, projections indicate that ROTC will commission the required 
175 nurses by fiscal year 2007. This year's projection is for 131 
nurses.
    The ANC has robust programs for training nurses in specialty areas, 
which also serve as excellent recruiting and retention tools. Under the 
Generic Course Guarantee program new officers can choose critical care, 
perioperative, psychiatric/mental health, or obstetrical/gynecological 
training. All company grade officers are also eligible to apply to 
those courses, as well as courses in emergency and community health 
nursing.
    The Long Term Health Education and Training program is a highly 
successful retention tool for mid-level officers. This program offers 
the opportunity to obtain a fully funded Masters degree or Doctoral 
degree. Officers who participate in the program incur at least a four-
year active duty service obligation depending on the length of the 
program. This past year, the U.S. Army Graduate Program in Nurse 
Anesthesia was ranked second in the nation by U.S. News and World 
Report.
    The ANC also offers specialty pay to nurse anesthetists, nurse 
practitioners, and certified nurse midwives. This year, the ANC 
successfully increased the specialty pay for nurse anesthetists for the 
first time in 10 years. Incentive specialty pay (ISP) is now $15,000 to 
$40,000, depending on their status and length of service agreement. 
Family nurse practitioners and certified nurse-midwives may also 
qualify for special pay that ranges from $2,000 to $5,000 annually.
    The AC ANC centrally manages the deployments of its officers in an 
effort to ensure equity throughout the organization. In terms of 
routine assignments, the ANC works aggressively to meet the personal 
and professional needs of its officers while ensuring both the needs of 
the Army and the officer are met as much as possible. Direct accessions 
usually receive one of their top three choices for their first 
assignment. Additionally, 98 percent of ANC officers married to other 
Army officers and enrolled in the Army Married Couples Program are co-
assigned with their spouse.
Reserve Component
    The HPLRP is available for all for Reserve ANC officers. It 
provides up to $50,000 over a three-year period for repayment of 
educational loans for nurse anesthetists, critical care, psychiatric/
mental health, medical-surgical, and perioperative nurses who agree to 
serve in the Selected Reserve. The Reserve ANC also offers an accession 
bonus of $5,000 per year for up to three years of Selective Reserve 
duty. This year, 283 officers have received this incentive. New Reserve 
ANC officers may take advantage of both of these programs sequentially, 
but not in combination. The Specialized Training Assistance Program 
(STRAP), which provides a monthly stipend of $1,279, is available only 
to officers enrolled in nurse anesthesia and critical care masters of 
science in nursing programs. Currently, there are 120 officers 
receiving STRAP. All are nurse anesthesia students. STRAP for bachelors 
of science in nursing programs is currently being staffed at Department 
of the Army. It is anticipated that it will be available in fiscal year 
2006.
    Question. Can you describe the effects continued deployments have 
had on staffing for Medical Treatment Facilities?
    Answer. The effects continued deployments have had on staffing for 
Medical Treatment Facilities are numerous. Military hospitals are not 
receiving nursing replacements at the same ratio as those nurses 
deploying and overtime for government service employees is not 
mandatory. Therefore, military nurses are required to work additional 
and many times erratic hours to maintain the same level of healthcare 
services offered to our beneficiary population. Army Nurse Corps exit 
surveys reveal lack of compensation for extra hours, not enough time 
spent with family and likelihood of deployment as ``extremely 
important'' reasons for leaving active service. In a recent report 
commissioned by the United States Army Accession Command, reducing the 
length/frequency of overseas deployments has the greatest impact on 
nurse accessions.
                                 ______
                                 
           Questions Submitted by Senator Barbara A. Mikulski

                            NURSING SHORTAGE

    Question. How many military nurses do you have on active duty? How 
many civilian nurses are employed by your service? How many nurses in 
the Guard and Reserves?
    Answer. The Army Nurse Corps currently has 3,105 nurses on active 
duty; the Army Medical Department had 3,025 civilian registered nurses 
employed; the Army National Guard had 651 nurses, and; the Army 
Selective Reserve had 5,554 nurses.
    Question. What is the deficit/shortage for each, between number on 
duty compared with the number you have authority to hire?
    Answer. The Army Nurse Corps deficit for the Active Component is 
301 nurses. This figure is derived from subtracting current active duty 
nurse inventory from 3,406 authorizations. As of March 31, 2005, there 
were 337 open recruitment actions for civilian registered nurse 
positions with the Army Medical Command. The Army National Guard 
deficit is 26 nurses. This figure represents the difference between 
reported inventory and 677 authorizations. Army Nurse Corps Selective 
Reserves deficit is 270 nurses, the difference between current 
inventory and authorizations.
    Question. What is the average number of years of service for active 
duty nurses? Guard and Reserve nurses?
    Answer. The average number of years of service for an active duty 
nurse is 8 years. The average number of years of service for National 
Guard is 18.0 and for the Reserves is 15.3 years.

                           NURSING EDUCATION

    Question. What percent of your nurses get a graduate degree at 
USUHS? What percent of your nurses get a graduate degree somewhere 
other than USUHS?
    Answer. As of May 31, 2005, 880 Army Nurse Corps officers possess a 
Master's degree, of those 8 percent hold a Master's degree from USUHS. 
Ninety-two percent possess a Master's Degree from an institution other 
than USUHS. The Army Nurse Corps is allotted a set number of seats in 
each of the three graduate nursing programs offered at USUHS. Officers 
interested in obtaining a Masters degree in a field offered through 
USUHS must attend USUHS and may not attend a civilian institution 
through the Long Term Health Education and Training (LTHET) program. 
The Army consistently fills the seats it is allotted at USUHS. In 2004, 
the Army Nurse Corps requested and was granted an expansion to double 
the number of seats in the Family Nurse Practitioner Program from 7 to 
14.
    Question. Does the military pay for advanced degrees for military 
nurses (at USUHS or elsewhere)?
    Answer. Each year the Army Nurse Corps sends 70-90 officers to 
complete graduate studies at USUHS or at a civilian institution through 
LTHET.
    Question. What is the average level of education for Military 
nurses? Civilian nurses?
    Answer. The average level of education for the Active Component 
Army Nurse Corps is a Bachelor's of Science in Nursing degree or 
Bachelor's of Science degree with a major in nursing. The average level 
of education for Civilian nurses is an Associate Degree in Nursing.

                           NURSING EXPERIENCE

    Question. What percent of your nurses come directly from nursing 
school, and what percent are experienced in nursing when they join the 
military? What percent of your nurses are prior service (in any 
specialty)? What percent are prior service and from another service 
(e.g., former Army nurses now working for the Navy)?
    Answer. All active duty officers complete college or university 
prior to their accession. Over the past five years, seventy-six percent 
of newly assessed Army Nurse Corps officers are new college/university 
graduates and twenty-four percent have at least one year of nursing 
experience. Forty-five percent of Active Component Army Nurse Corps 
officers have prior service experience. Eight percent of Active 
Component Army Nurse Corps officers served in another service prior to 
becoming an Army Nurse Corps officer.

                          NURSING DEPLOYMENTS

    Question. Where/how are your nurses currently deployed?
    Answer. In the interest of answering this question thoroughly and 
as succinctly as possible the word ``deployed'' is defined as a nurse 
drawing hazardous fire pay in a theater of operations. Army Nurse Corps 
officers are deployed in support of both Operation Enduring Freedom in 
Afghanistan and Operation Iraqi Freedom in Iraq/Kuwait. These officers 
deploy as nurses in Brigade and Division Support Medical Companies; in 
Corps-level Area Medical Support Companies; in Forward Surgical Teams; 
in Combat Support Hospitals, and; as Chief Nurse in a Corps/Theater-
level Medical Brigade/Medical Command and Control unit.
    Question. How often are Reserve/NG nurses activated?
    Answer. The current rotation policy for Army Reserve and Army 
National Guard units, specified in the Personnel Policy Guidance (PPG) 
of the Army, is a 1 year mobilization followed by 3 years of 
stabilization. The objective set by the Chief, Army Reserve and the 
Department of Defense is a 6 year rotation, 1 year mobilization and 5 
years dwell time. Certified Registered Nurse Anesthetists deploy under 
the Army's 90-Day Boots-on-the-Ground policy--a 120-day mobilization 
(no more than 90-days deployed) followed by at least 12 months 
stabilization. This policy was introduced to help retain critical 
wartime surgical specialties. According to information from the Army 
Reserve 1,272 nurses have been mobilized since November 2001.

                            CIVILIAN NURSES

    Question. Are civilian nurses used any differently than military 
nurses?
    Answer. Civilian nurses are utilized based on the job description 
and scope of practice. Unlike military nurses they do not deploy or 
have additional military training requirements. Civilian registered 
nurses (Civil Service Employees) are available to pull on-call 
schedules, work weekends, holidays and perform overtime within 
budgetary feasibility.
    Question. Do they fall under the same pay scale as military nurses? 
What about retirement benefits?
    Answer. Civilian nurses do not fall under the same pay scale as 
military nurses. Civilian nurses are paid based on the Department of 
Defense General Schedule pay system. Civilian nurses receive the same 
retirement benefits as all other Title 5 Federal civilian employees.
    Question. What is the relationship between AC military and civilian 
nurses, and their counterparts in the Guard and Reserves?
    Answer. Active component military and civilian nurses and their 
counterparts in the Guard and Reserves are invaluable members of the 
healthcare team. Overall a very good working relationship exists 
between our Active and Reserve Components and civilian nurses. The 
Guard, Selective Reserve, and civilian nurses support our ability to 
provide quality nursing care.
    Question. What is the average number of years a civilian nurse is 
employed by the military health care system (is there a high turnover?)
    Answer. The average number of years a civilian nurse is employed by 
the military health care system is 9.9 years. The U.S. Army Medical 
Command Civilian Personnel Office defines turnover rate as losses/prior 
year-end strength. The turnover rate for civilian registered nurses is 
17-20 percent. The replacement rate is calculated as the number of 
fiscal year fills divided by prior year-end strength. The fiscal year 
2004 Replacement Rate was 34 percent.
                                 ______
                                 
         Questions Submitted to Rear Admiral Nancy J. Lescavage

               Questions Submitted by Senator Ted Stevens

                        RECRUITING AND RETENTION

    Question. How does the Uniformed Services University of the Health 
Sciences support military nursing?
    Answer. Programs within the Uniformed Services University of the 
Health Sciences Graduate School of Nursing (USUHS GSN) have been 
successful in meeting our Navy Nursing specialty requirements. In fact, 
the Navy Nurse Corps requires all applicants for Family Nurse 
Practitioner, Perioperative Nursing, and Nurse Anesthesia Master's 
Degree Programs to seek admission to USUHS GSN as one of their two 
schools of choice.
    Our graduating nurses have reported that the graduate level 
education and clinical experiences obtained at the USUHS GSN are of the 
highest caliber, enhancing their medical readiness. During their 
program, our students report extreme satisfaction with the advanced 
professional clinical competencies they attain and the incorporation of 
military relevant practice and mission requirements into the curriculum 
(not available in civilian university programs). In addition, gaining 
commands report that these graduates meet credentialing requirements 
quickly and demonstrate the highest levels of clinical competencies.
    Of particular note, our first two Navy Nurses began the newly 
established Nursing Ph.D. Program this past fall on a full-time basis. 
In our vision, these graduates will take on the ultimate executive 
positions to create health policies, advance research and improve 
delivery systems. Their valued experience will be critical to advance 
and disseminate scientific knowledge, foster nursing excellence, and 
improve clinical outcomes across Navy Medicine and Federal agencies.
    Question. With the current nursing shortage nationwide, and 
continued need for medical support at home and overseas, what is the 
status of your recruiting and retention efforts?
    Answer. Navy Nurse Corps' recruitment efforts include a blend of 
diverse accession sources. Our successful pipeline scholarship programs 
(Nurse Candidate Program, Medical Enlisted Commission Program, Reserve 
Officer Training Corps, and Seaman to Admiral Program) account for 65 
percent of our active duty staffing requirements. The remainder (35 
percent) is acquired through direct accession and reserve recalls.
    For the first time in ten years, we only attained 68 percent of our 
fiscal year 2004 recruitment goal, acquiring 63 out of 92 nurses. As of 
March 2005, we have attained 21 percent of our fiscal year 2005 
recruitment goal, which is 6 percent less than our recorded status 
during the same month of last year. As a result, we carefully monitor 
our progress on a weekly basis.
    Our overall retention rate remains stable at 91 percent. Various 
retention initiatives include: graduate education and training 
programs, pay incentives, operational experiences, and quality of life 
issues (mentorship, leadership roles, promotion opportunities, job 
satisfaction, and full scope of practice). By the end of fiscal year 
2005, based on projected gains and losses, we anticipate a deficit of 
137 with a billet authorization of 3098 (96 percent end strength).
    Question. Can you describe the effects continued deployments have 
had on staffing for Medical Treatment Facilities?
    Answer. In sync with Navy Medicine's priority of delivering quality 
and cost-effective health care, our Navy Nurses span the continuum of 
care from promoting wellness to maintaining the optimal performance of 
the entire patient. With the deployment of over 400 Active Duty Navy 
Nurses along with the mobilization of Reserve Nurses to support our 
Military Treatment Facilities (MTFs), there has been neither a 
reduction of inpatient bed capacity nor an increase of network 
disengagements. Military (active and mobilized reserve components) and 
civilian nurses who remained at the homefront continued to be the 
backbone and structure in promoting, protecting and restoring the 
health of all entrusted to our care. Our success is attributed to 
innovative health services programs and joint partnerships across our 
MTFs. Ultimately, all MTFs do everything possible to conserve and best 
utilize the remaining medical department personnel through appropriate 
resource management practices (i.e. leave control, overtime 
compensation, streamlined hiring practices).
    Through an active Patient Safety Program, our military, civil 
service and contract personnel constantly monitor the safe delivery of 
patient care. In maintaining consistent superior quality of services, 
we utilize research-based clinical practices with a customized 
population health approach across the entire health care team. In 
addition, we maximize our innovative health services programs and joint 
partnerships across our military treatment facilities.
                                 ______
                                 
           Questions Submitted by Senator Barbara A. Mikulski

                           NURSING SHORTAGES

    Question. How many military nurses do you have on Active Duty?
    Answer. As of March 2005, there were 2,948 Active Duty Navy Nurse 
Corps Officers.
    Question. How many civilian nurses are employed by your service?
    Answer. Currently Navy Medicine employs 1,210 Registered Nurses 
(GS-610); 305 Practical Nurses (GS-620); and 12 Nursing Assistants (GS-
621).
    Question. How many nurses in the Guard and Reserves?
    Answer. The Navy is not organized like the Air Force or Army, and 
does not have a Guard Component. The Reserve Component of the Navy 
Nurse Corps, as of the end of March 2005, had a total end-strength of 
1,718 officers.
    Question. What is the deficit/shortage for each, between number on 
duty compared with the number you have authority to hire?
    Answer. We have 3,098 authorized Active Duty Nurse Corps Billets. 
As of March 2005, we had 2,948 billets filled for a deficit of 150 
Nurse Corps Officers. As of March 2005, the authorized number of 
billets for the Reserve Nurse Corps is 1,370. There are 1,718 Reserve 
Nurse Corps Officers for a total of 348 over our end strength.
    Question. What is the average number of years of service for Active 
Duty nurses? Guard and Reserve nurses?
    Answer. The average number of years of commissioned service for 
Active Duty nurses is 9 years. The average number of years of total 
Active Duty service (commissioned and enlisted years) is 12 years. The 
average number of total years served (enlisted and commissioned) for 
Reserve Nurse Corps officers is 16.13 years.

                               EDUCATION

    Question. What percent of your nurses get a graduate degree at 
USUHS?
    Answer. In calendar year 2004, there were 5 nursing graduates from 
USUHS or 7.0 percent of the total (71) Active Duty Navy Nurse Corps 
graduates in 2004. In 2005, the number of Navy students graduating from 
USUHS is also 5 or 7.0 percent of the total (70) Active Duty Navy 
Nurses expected to graduate. This year we are increasing the number of 
students attending USUHS. There will be a total of 24 students 
attending USUHS beginning fiscal year 2006.
    Question. What percent of your nurses get a graduate degree 
somewhere other than USUHS?
    Answer. In the calendar year 2004, 66 Active Duty Navy Nurse Corps 
Officers received graduate degrees outside of USUHS. This is 93 percent 
of the total (71) Active Duty Navy Nurse Corps graduates in 2004. For 
2005, we anticipate 65 graduates from universities outside of USUHS. 
This is 93 percent of the total (70) Active Duty Navy Nurse Corps 
graduates.
    Question. Does the military pay for advanced degrees for military 
nurses (at USUHS or elsewhere)?
    Answer. Although a few nurses join the Navy with advanced degrees, 
the Navy Medical Education and Training Command is budgeted to fund 
approximately 75 graduate nursing students each year. This ``Duty Under 
Instruction'' scholarship program allows the Navy Nurse Corps to 
prepare Advanced Practice Nurses (APN), Clinical Nurse Specialists 
(CNS) and Certified Registered Nurse Anesthetists (CRNA). These 
scholarships pay for the advanced training needed to support caring for 
those in harm's way.
    Question. What is the average level of education for Military 
nurses? Civilian nurses?
    Answer. Beginning fiscal year 2005, the level of education for 
Active Duty military nurses was 64 percent BSN, 30 percent MSN, 0.6 
percent Doctorate and 5 percent in graduate school. While aggregate 
data is not available on the education levels of our civilian nurses, 
they are graduates of two year community college programs, three year 
hospital based diploma programs, and the majority are four year college 
graduates.

                               EXPERIENCE

    Question. What percent of your nurses come directly from nursing 
school, and what percent are experienced in nursing when they join the 
military?
    Answer. In fiscal year 2004 we had 223 accessions to Active Duty. 
Of these, 38 had some experience (17 percent) and the remainder (185) 
were new graduates directly from school (83 percent).
    Question. What percent of your nurses are prior service (in any 
specialty)?
    Answer. Approximately 45 percent of the 2,948 Nurse Corps Officers 
on Active Duty as of March 2005 have at least 12 months or more of 
prior service. This is a result of the excellent pipeline (enlisted to 
officer) programs in the form of scholarships, that add stability to 
our numbers. This is particularly evident in readiness essential 
specialties such as the Certified Registered Nurse Anesthetist (CRNA) 
community. In this specialty, 68 of 146 CRNA's (47 percent) are prior 
service.
    Question. What percent are prior service and from another service 
(e.g., former Army nurses now working for the Navy)?
    Answer. Of the 2,948 Navy Nurses on Active Duty as of March 2005, 
six (0.2 percent) are inter-service transfers. Since the year 2000, the 
Navy Reserve has had a total of 37 inter-service transfers which 
represents about 2 percent of our total reserve end-strength.

                              DEPLOYMENTS

    Question. Where/how are your nurses currently deployed?
    Answer. Navy Nurses have deployed this past year throughout the 
world to Kuwait, Iraq, Djibouti, Afghanistan, Bahrain, the Philippines, 
Thailand and Guantanamo Bay, Cuba. During these deployments they 
support our operational and humanitarian mission via Surgical 
Companies, Surgical Teams, Shock Trauma Platoons, the Forward 
Resuscitative Surgical System, Fleet Hospitals, Expeditionary Medical 
Facilities, on both Navy and Hospital Ships, and our Medical Treatment 
Facilities abroad.
    Question. How often are Reserve/NG nurses activated?
    Answer. As of December 2004, a total of 385 nurses have been 
activated for Operation Iraqi Freedom. This represents a total of 23 
percent of the Reserve Nurse Corps End-Strength. Current Secretary of 
the Navy policy allows for a non-voluntary recall for up to 24 months. 
Most officers are recalled for a period of one year, with an option to 
serve a second year as needed.

                            CIVILIAN NURSES

    Question. Are civilian nurses used any differently than military 
nurses?
    Answer. Essentially, civilian nurses are hired primarily for their 
clinical expertise. All civilian nurses are hired with a minimum three 
years clinical experience, so they supply an immediate clinical support 
for all of our specialty areas. However, since we have a greater 
deployment requirement for some specialties such as perioperative, 
critical care, anesthesia, emergency/trauma, psychiatric/mental health 
and surgical nursing, there are often more military nurses in these 
specialties. Consequently, there are often more civilian nurses working 
in clinical areas such as obstetrical, maternal-infant, pediatrics and 
newborn nursery.
    Question. Do they fall under the same pay scale as military nurses?
    Answer. Civilian nurses are paid under separate pay scales based on 
the General Schedule or special salary rates established by the Office 
of Personnel Management (OPM) or the Department of Defense under an 
agreement with OPM to use certain pay flexibilities granted to the 
Veterans Administration. For the most part, civil service Registered 
Nurses are paid in the range of $64,000 to $80,000 for base salary.
    Question. What about retirement benefits?
    Answer. Civil service nurses are covered by two retirement plans 
based on when they entered the federal service. Both are contributory 
plans and require the employee to make contributions from pay toward 
their retirement.
  --Civil Service Retirement System--is basically a single 
        contributory, self-insured program supplemented by the non-
        matched Thrift Saving Plan.
  --Federal Employees Retirement System--is a combination of social 
        security, small basic annuity and the Thrift Saving Plan (with 
        some matching contributions).
    Question. What is the relationship between AC military and civilian 
nurses, and their counterparts in the Guard and Reserves?
    Answer. In support of the One Navy Medicine concept, the 
integration of active, reserve and civilian nurses renders a more 
effective, efficient and fully mission-ready nursing force both at home 
and abroad. With the deployment of over 400 Active Duty Nurses along 
with the mobilization of Reserve Nurses to support our Military 
Treatment Facilities, this concept of integration has allowed our 
civilian staff, reserve backfill and Active Duty nurses to work 
seamlessly to care for all of our beneficiaries.
    Question. What is the average number of years a civilian nurse is 
employed by the military health care system (is there a high turnover?)
    Answer. With the keen competition for nurses in many of the more 
populated areas, nurses will move from hospital to hospital based on 
salary. Turnover is a continuing challenge, but with the flexibilities 
in hiring and compensation, we seem to be competitive. At any one point 
in time, there are approximately 50 civilian nurse vacancies, or 4.0 
percent of the 1,210 total Registered Nurse positions.
                                 ______
                                 
        Questions Submitted to Major General Barbara C. Brannon

               Questions Submitted by Senator Ted Stevens

                        RECRUITING AND RETENTION

    Question. How does the Uniformed Services University of the Health 
Sciences support military nursing?
    Answer. The Uniformed Services University of the Health Sciences 
(USUHS) is committed to providing excellence in graduate nursing 
education to prepare advanced practice nurses for the delivery of 
healthcare during peace, disaster response, homeland security threats 
and war. The Graduate School of Nursing (GSN) faculty and staff have an 
exceptional blend of experience in the military and/or the federal 
health care systems, and are prepared to provide a distinctly unique 
educational experience that cannot be found at other universities. The 
GSN signature curriculum is specifically designed to prepare nurses for 
advanced practice and research roles in support of Active Duty members 
of the uniformed services, their families and all other eligible 
beneficiaries. This curriculum for graduate students includes 
operational readiness, evidence-based practice, population health 
outcomes, force health protection, federal health care systems, as well 
as leadership.
    The Perioperative Clinical Nurse Specialist (PCNS) Program (the 
newest Master's program) prepares graduate nurses for clinical 
practice, management, leadership, research, teaching and consultation 
in advanced practice roles within the perioperative environment. This 
is the only program of its kind in the United States focused totally on 
perioperative practice and administration. Military unique aspects of 
the curriculum stresses concepts directed toward delivering 
perioperative care in both the military and federal health care system 
with a strong focus on patient safety research and care in austere 
environments. USUHS graduates are uniquely qualified to provide quality 
care in a variety of settings to include peacetime and wartime 
environments.
    The Registered Nurse Anesthesia (RNA) Program is dedicated to 
providing highly qualified nurse anesthetists for the uniformed 
services. The uniformed services require graduates independently 
provide quality anesthesia care in diverse settings. The military 
unique curriculum is specifically designed to integrate scientific 
principles of anesthesia theory and practice, stressing the unique 
features of operational readiness throughout the curriculum to prepare 
nurse anesthetists ready to deploy immediately upon graduation. USUHS 
Graduate School of Nursing students deploy up to six months earlier 
than graduates from other RNA programs.
    The rigorous curriculum of the Family Nurse Practitioner (FNP) 
Program at USUHS prepares graduate nurses for advanced practice roles 
in the federal sector. Their curriculum is more heavily weighted in 
diagnostic reasoning and clinical decision-making since they practice 
more autonomously in remote settings. In addition, the military unique 
program includes field training to prepare nurses to support combat 
casualties in deployed environment. Like the PCNS and RNA students, FNP 
students graduate with a full compliment of operational readiness 
skills and can deploy immediately upon graduation.
    The Uniformed Services University also prepares military and 
federal health nurses through doctoral education to research subjects 
from operational readiness and deployment health to patient safety and 
population health and outcomes management. This operational plan for 
research has been lauded by the Federal Nursing Service Chiefs, members 
of the USUHS Board of Regents, as well as the Assistant Secretary of 
Defense/Health Affairs.
    Operational readiness research areas at both the master's and 
doctoral level include Active Duty, Reserve and Guard fitness, health 
systems readiness, chemical, biological, radiological, nuclear and 
high-yield explosives (CBRNE) defense, decision support and validation 
of readiness training. Research also focuses on war injuries, care of 
amputees, women's health in the deployed environment and stress and 
coping in military families. Patient safety research is aimed at 
addressing scientific inquiry in the areas of health literacy and 
safety in the emergency room and/or operating room. Finally, research 
in the domain of genetics examines the latest in genetic testing and 
newborn screening.
    The Uniformed Services University provides the nation with premier 
nurses dedicated to career service in the Department of Defense and the 
United States Public and Federal Health Services. The curriculum 
includes military unique content that is not presented at civilian 
universities.
    Question. With the current nursing shortage nationwide, and 
continued need for medical support at home and overseas, what is the 
status of your recruiting and retention efforts?
    Answer. The nursing shortage continues to pose enormous challenges 
in supplying our demand for military nurse accessions and sourcing 
civilian nursing workforce. A robust recruiting program is essential to 
sustain the Air Force Nurse Corps. We have consistently been below our 
goals: 78 percent in fiscal year 2001, 67 percent in fiscal year 2002, 
79 percent in fiscal year 2003, and 71 percent in fiscal year 2004. Our 
fiscal year 2005 recruiting goal is 357 nurses and it appears we will 
end the year around 70 percent of that goal. We use the Health 
Professions Loan Repayment Program (HPLRP), accession bonuses and ROTC 
scholarships to recruit top quality nurses.
    Our most successful tool for recruiting novice nurses has been the 
HPLRP. In fiscal year 2004, we filled 118 quotas of up to $28,000 each. 
For fiscal year 2005, we could only fund 26 HPLRPs, leaving the 
accession bonus as the only financial incentive available. We increased 
the accession bonus from $10,000 to $15,000 for a four-year commitment. 
This has been moderately successful. We are currently formulating 
programs to use the National Defense Authorization Act 2005 authority 
to offer an accession bonus with a three-year commitment.
    We have increased nursing Air Force ROTC quotas for the last two 
years and filled 100 percent of our quotas. We added additional ROTC 
scholarships for fiscal year 2005, increasing our quota from 35 in 
fiscal year 2004 to 41. We are also enhancing our ``grow our own'' 
nurses from our enlisted corps. We revised the eligibility requirements 
for the Airmen Enlisted Commissioning Program (AECP) to increase the 
pool of enlisted to complete a Bachelor of Science in Nursing while on 
active duty. Following graduation they commission into the Air Force 
Nurse Corps. We have accessed 24 nurses through this program since its 
inception in fiscal year 2001.
    Advanced practice nurses are difficult to recruit. We primarily 
meet our requirements by training our active duty nurses in advanced 
specialties. We offer financial incentives to retain board certified 
nurse practitioners, certified nurse midwives and certified registered 
nurse anesthetists (CRNAs) consistent with our sister services. 
Advanced practice nurses earn an additional $2,000 per year for less 
than ten years of experience. In fiscal year 2000 we increased the CRNA 
special pay to $6,000 per year while they complete any time commitment 
for training. For those without a training commitment we increased the 
rate in fiscal year 2005 up to $25,000 per year for a three-year 
commitment. As a result, retention rates for CRNAs have increased from 
a low of 81 percent for fiscal year 2000 to 88 percent for fiscal year 
2004.
    The nationwide nursing shortage has also affected our ability to 
recruit civilian nurses. While the direct hire authority has 
significantly improved the hiring process for nurses, numerous 
positions remain unfilled in select areas of the country. The retention 
of these nurses has also proven to be a challenge. We have difficulty 
competing with civilian facilities that continue to offer more 
attractive incentive packages.
    While this continues to be a challenging time for recruiting, our 
retention has been excellent. We have averaged a loss rate of just over 
eight percent in the last ten years. Our nurses enjoy the opportunity 
for professional development including the opportunity to apply for 
advanced degree programs. They also recognize the promotion and 
leadership opportunities available in the Air Force that are not as 
common in the civilian sector. Our nurses are some of our best 
recruiters as they tell their stories and share their experiences. We 
continue to advertise our great quality of life and career 
opportunities, as we remain focused on attracting top quality 
baccalaureate nurses and nurturing them into tomorrow's nursing 
leaders.
    Question. Can you describe the effects continued deployments have 
had on staffing for Medical Treatment Facilities?
    Answer. The Air Force Medical Service has been faced with the 
challenge of providing consistent medical support to each Air 
Expeditionary Force (AEF) while at the same time maintaining critical 
home station medical support and formal medical education programs. The 
solution has been to optimize use of medical center and large hospital 
staffing to meet most AEF requirements. This has multiple benefits 
including the ability to provide a constant, predictable, measurable 
level of support (same hit for medical treatment facility in every 
bucket). This also allows for better programmatic adjustments as well 
as increased ability to capitalize on resourcing investments and 
enhancement of medical education and training.
    While this process has been successful in anticipating the 
requirements for deployment, several additional challenges have come to 
light. These include tasking for already stressed medical Air Force 
specialties, e.g., Critical Care, Surgical Specialties, Mental Health, 
and Independent Duty Medical Technicians. Also, the Air Force has been 
asked to fill some billets, e.g., Combat Stress Teams, Preventive 
Medicine Teams, Detainee Health Team and others. These additional 
taskings are met within the AEF cycle when possible to maintain a 
predictable level of support. When this cannot be accomplished, 
additional deployable assets may be tasked. Another solution has been 
to use Air Force medics that have not previously been considered 
deployable for medical reasons to fill assignments such as staff 
positions to backfill personnel at either Air Force facilities that 
deploy personnel or to deploy forward. Air Force medics who might not 
be able to deploy forward have also been tasked to fill slots at Army 
facilities such as Landstuhl in Germany and Tripler Army Medical Center 
in Hawaii.
                                 ______
                                 
           Questions Submitted by Senator Barbara A. Mikulski

                           NURSING SHORTAGES

    Question. How many military nurses do you have on active duty?
    Answer. There are 3,673 nurses on active duty as of April 30, 2005.
    Question. How many civilian nurses are employed by your service?
    Answer. The number of civilian nurses currently employed by Air 
Force is 740.
    Question. How many nurses in the Guard and Reserves?
    Answer. There are currently 797 nurses in the Air National Guard 
and 2,062 in the Air Force Reserve.
    Question. What is the deficit/shortage for each, between number on 
duty compared with the number you have authority to hire?
    Answer. The deficit/shortage between number of nurses on duty 
compared to the number we have the authority to hire for Active, Guard, 
Reserve, and Civilian is as follows:
    Active Duty deficit/shortage equals 277 out of 3,673.
    Guard deficit/shortage equals 120 out of 797.
    Reserve deficit/shortage equals 106 out of 2,062.
    Civilian deficit/shortage equals 28 out of 740.
    Question. What is the average number of years of service for active 
duty nurses? Guard and Reserve nurses?
    Answer. The average number of years of service for Active Duty 
nurses is 11 years, while the average number of years of service for 
Air National Guard and Air Force Reserve nurses is 15 years.

                               EDUCATION

    Question. What percent of your nurses get a graduate degree at 
USUHS?
    Answer. Currently, 2 percent (92) of all nurses on active duty 
(3,675) have a graduate degree from the USUHS. On average, 45.6 percent 
(26) of all nurses are selected each year for Air Force-sponsored 
education opportunities to attend the USUHS in the following programs: 
Masters of Science in Nursing (MSN): Family Nurse Practitioner MSN; 
Perioperative Clinical Nurse Specialist; MSN Nurse Anesthesia; 
Doctorate (PhD), and Nursing Science.
    Question. What percent of your nurses get a graduate degree 
somewhere other than at USUHS?
    Answer. We currently have 1,443 Nurses with Masters Degrees in the 
Air Force. The breakdown is as follows: 915 Other (on their own)--63.4 
percent; 407 AFIT (Air Force Institute of Technology) sponsored--27.0 
percent; 92 USUHS--7.6 percent; 21 Tuition Assistance--1.4 percent; 6 
HPSP (Health Professions Scholarship Program)--0.4 percent; 1 VEAP 
(Veterans Education Assistance Program)--0.06 percent; and 1 Education 
Delay--0.06 percent.
    We currently have 14 Nurses with Ph.D.s in the Air Force. The 
breakdown is as follows: 6 AFIT sponsored; and 8 Other (on their own).
    There are currently three Air Force students enrolled in the Ph.D. 
program at the USUHS.
    Question. Does the military pay for advanced degrees for military 
nurses (at USUHS or elsewhere)?
    Answer. The Air Force has several programs to assist nurses in 
pursuing advanced degrees. In fiscal year 2004 we selected 57 nurses 
for education opportunities. Of these, 31 attended civilian 
institutions for programs not offered at the USUHS. These students are 
sponsored by the Air Force Institute of Technology. The remaining 26 
nurses selected attended the USUHS. The Air Force also offers tuition 
assistance for Airmen that choose to pursue programs during off-duty 
time. Officers can receive up to $4,500 per fiscal year for courses 
that lead to an advanced degree. We also offer scholarships for nurses 
interested in nurse anesthesia and women's health through the Health 
Professions Scholarship Program.
    Question. What is the average level of education for Military 
nurses? Civilian nurses?
    Answer. All nurses in the Air Force Nurse Corps hold a bachelors 
degree in nursing. Of these, 39.3 percent (1,443) also hold a masters 
degree and 0.4 percent (14) hold a Ph.D.
    According to the most recent data from the American Association of 
Colleges of Nursing, in the year 2000, 34 percent of nurses in the 
civilian sector hold an associates degree in nursing (ADN), 22 percent 
practice with a diploma, and 43 percent hold a bachelors degree in 
nursing. Only 9.6 percent hold a masters degree and 0.6 percent hold a 
Ph.D. According to the U.S. Department of Health and Human Services, 
only 16 percent of ADNs obtain a post-RN nursing or nursing-related 
degree.

                               EXPERIENCE

    Question. What percent of your nurses come directly from nursing 
school, and what percent are experienced in nursing when they join the 
military?
    Answer. Nurses are considered inexperienced until they have 
practiced for one year. Experienced nurses, on the other hand, have 
worked in clinical nursing for more than one year or have trained in a 
specialized area. Over the last four years, the percentage of 
inexperienced nurses recruited has steadily increased. In fiscal year 
2001, these nurses comprised 22.8 percent of all new accessions with 
experienced nurses constituting the remaining 77.2 percent. By the end 
of fiscal year 2004 the percentage of inexperienced nurses increased to 
39.3 percent of all nurses recruited, bringing the four-year average to 
30.9 percent. The four-year average for experienced nurses fell to 69.1 
percent.
    Question. What percent of your nurses are prior service (in any 
specialty)?
    Answer. Officers in the Air Force Nurse Corps come from a variety 
of backgrounds. Nurses with prior service in any specialty comprise 
25.6 percent of the Air Force Nurse Corps. Of these, one percent are 
officers commissioned in the Air Force that later transferred to the 
Nurse Corps. Nurses with prior enlisted service make up 24.6 percent of 
the Air Force Nurse Corps. From this category, eight percent were prior 
enlisted in the Air Force and 16.6 percent were prior enlisted in other 
services, including the Air Force Reserve and Air National Guard.
    Question. What percent are prior service and from another service 
(e.g., former Army nurses now working for the Navy)?
    Answer. At the end of calendar year 2004, the Air Force Nurse Corps 
included 392 nurses (10.8 percent) who had been commissioned in a 
different branch of the military and then transferred to the Air Force. 
This includes nurses who transferred from the Air Force Reserve and the 
Air National Guard.

                              DEPLOYMENTS

    Question. Where/how are your nurses currently deployed?
    Answer. The following data is obtained from Deliberate Crisis 
Action Planning Execution Segments (DCAPES) and is as of May 24, 2005. 
The data reflects personnel deployed on Contingency/Exercise Deployment 
(CED) orders at SECRET level and below and includes the type of nurse 
currently deployed by the area of responsibility of deployment.

----------------------------------------------------------------------------------------------------------------
                                                                       TDY--AOR
                    AFSC5D                     -------------------------------------------------------   Total
                                                 CENTCOM     EUCOM     NORTHCOM    PACOM     SOUTHCOM
----------------------------------------------------------------------------------------------------------------
CLINICAL NURSE................................         40         11         13          1          3         68
CN CRITICAL CARE..............................         30         15          7  .........  .........         52
CN Womens Health Care Nurse Prac..............          1  .........          1  .........  .........          2
FLIGHT NURSE..................................         40         28         45  .........  .........        113
MENTAL HEALTH NURSE...........................          2          4          6  .........  .........         12
NURSE-ANESTHETIST.............................          7  .........  .........  .........          1          8
NURSING ADMINISTRATOR.........................          5  .........          3  .........  .........          8
OPERATING ROOM NURSE..........................         19  .........          1  .........  .........         20
NURSE-MIDWIFE.................................  .........  .........  .........  .........          1          1
                                               -----------------------------------------------------------------
      Grand Total.............................        144         58         76          1          5        284
----------------------------------------------------------------------------------------------------------------

    Question. How often are Reserve/NG nurses activated?
    Answer. Based on personnel currently assigned to the Selected 
Reserve (SelRes), there are 2,876 nurses in the SelRes. Of this number, 
733 individuals have been mobilized 845 times since September 11, 2001. 
Specifically, one was mobilized four times; five were mobilized three 
times; 99 were mobilized two times; and 628 were mobilized one time. 
The average number of mobilizations per month since September 11, 2001 
is approximately 19 (about 11 mobilizations a month during the past 12 
months). The peak mobilizations were in February-April, 2003 (490 
total; with 232 in March 2003)--of those mobilized, 475 individuals 
were deployed one or more times. Note: The mobilization data are per 
the Military Personnel Data System (MilPDS) and the deployment data are 
per the Deliberate Crisis Action Planning Execution Segments (DCAPES) 
deployed history file, May, 2005.

                            CIVILIAN NURSES

    Question. Are civilian nurses used any differently than military 
nurses?
    Answer. During peacetime, civilian nurses are used much the same as 
military nurses. One stumbling block to fully integrating civilian 
nurses into our nursing teams is the requirement for overtime pay for 
time worked beyond forty hours. On Air Force hospital inpatient units, 
nurses are scheduled on 12-hour shifts. The rotation requires the 
nurses to work four shifts one week and three shifts on the opposite 
weeks. Civilian nurses would regularly exceed forty hours in a seven-
day period and have fewer than forty hours in others. This would 
increase civilian pay bills. Additionally, when a civilian has a short 
notice absence, the extra coverage usually falls to the military 
nurses. This is manageable with a small civilian force; however, 
scheduling is much more complicated and taxing with a larger civilian 
force. Civilian nurses are currently assigned to all settings, but in 
the future will be concentrated in the outpatient clinics. We need to 
assign military nurses to most of our inpatient and critical care 
authorizations for currency in wartime clinical skills.
    Question. Do they fall under the same pay scale as military nurses?
    Answer. Civilian and military nurses do not fall under the same pay 
scale. Civilian nurses currently receive their pay based on the General 
Schedule (GS) for federal employees or a contractual agreement. Pay 
rates may be adjusted based on locality. The GS rating for nurses may 
vary due to kind of work (inpatient versus outpatient), specialized 
skills necessary (intensive care versus inpatient ward), and management 
responsibilities.
    Basic Pay is the fundamental component of military pay. All members 
receive it and typically it is the largest component of a member's pay. 
A member's grade (usually the same as rank) and years of service 
determines the amount of basic pay received. Their basic pay is not 
affected by the their duty location. The military does offer 
certification pay for our advanced practice nurses and incentive 
special pay for our Certified Registered Nurse Anesthetists.
    Question. What about retirement benefits?
    Answer. The retirement benefits would be computed using the general 
formula for the retirement system the employee is covered under the 
Civil Service Retirement System (CSRS) or the Federal Employees 
Retirement System (FERS). The formulas for the computation of 
retirement benefits can be found in the U.S. Office of Personnel 
Management CSRS and FERS Handbook For Personnel and Payroll Offices 
available on line at http://www.opm.gov/asd/hod/pdf/C050.pdf.
    Question. What is the relationship between AC military and civilian 
nurses, and their counterparts in the Guard and Reserves?
    Answer. Nurses in the Air National Guard (ANG) and in the Air 
Reserve Component (ARC) are utilized several ways once activated. Some 
of the nurses are used to backfill positions vacated by active duty 
nurses deploying. This role has enabled some facilities to continue to 
meet their peacetime mission requirements. Other nurses are deployed 
along with their units. They have manned contingency air staging 
facilities overseas and stateside. They are also responsible for 88 
percent of aeromedical evacuation flights.
    While on active duty, ANG and ARC nurses receive the same pay and 
benefits as their full-time Active Duty counterparts. Civilian nurses 
receive their pay based on the General Schedule (GS) for federal 
employees or a contractual agreement.
    Question. What is the average number of years a civilian nurse is 
employed by the military health care system (is there a high turnover?)
    Answer. The civilian nurses currently employed by the Air Force 
through the military health care system have worked for the Air Force 
for an average of 8.26 years. The nurses who left Air Force employment 
between January 1, 2004 and May 1, 2005 had an average of 7.81 years of 
civilian service some of which may have been performed for other 
governmental agencies.

                          SUBCOMMITTEE RECESS

    Senator Stevens. The subcommittee will reconvene tomorrow 
at 10 a.m., in this room to review the Missile Defense Program 
for 2006. We stand in recess until that time.
    [Whereupon, at 11:59 a.m., Tuesday, May 10, the 
subcommittee was recessed, to reconvene at 10 a.m., Wednesday, 
May 11.]
