“We’re very anti-medication,” Chiarelli is told at one of our final stops in Georgia, by a neurologist at Eisenhower Army Medical Center at Fort Gordon.
“I hear this everywhere I go,” the general replies. “ ‘We’re anti-medication, we’re anti-medication.’ But why do I get these sheets of paper”—profiles of suicides—“with twelve medications listed on them?” He mentions that he’s had two- and three-star generals confide in him that they were addicted to pain medication in the aftermath of their service, and that it took their wives to point it out to them. “Are you guys different?” asks Chiarelli. “Is this place a soda straw that no one else passes through?”
In fact, this residential facility that Chiarelli is visiting is different. It treats alcohol and substance abuse, PTSD, traumatic brain injuries, depression, and pain management all under one roof. Stephen N. Xenakis, a psychiatrist and former commander at Eisenhower, was an early proponent of this kind of integrated program. Like many doctors, he believes that one of American medicine’s greatest failings is its fragmentation into narrow-caliber silos, with doctors seeing ailments solely in the context of their own specialties. No population, says Xenakis, suffers more outrageously from this structural deficiency than returning soldiers. Doctors seldom take the totality of their extraordinary experiences into account. “Soldiers are in an environment that has dust particles and toxins we don’t even recognize,” Xenakis tells me. “There are pressure waves and blasts. They’re carrying packs, at altitude, that weigh 90 pounds. They’re in a different sleep cycle than normal. They’re in situations that are almost always stressful, if not traumatic.” Yet when they return home, he says, they’re shunted into all those individual silos, with each specialist seeing only what he or she is trained to see: A headache. Insomnia. Paranoia and irritability. A ruined knee. “So as doctors,” Xenakis continues, “we say, ‘Okay. We’re going to track this psychological problem, and we’re going to track this immunological problem, and we’re going to track their headaches and their musculoskeletal pain and their insomnia.’ ” He slowly breathes out. Though he retired in 1998, Xenakis has been urging the chairman of the Joint Chiefs to consider integrated medicine for quite some time. “When in fact it’s a system problem we’re dealing with,” he says. “And that’s how you get this poly-drug problem.”
Chiarelli’s not unsympathetic to this kind of logic. He’s a systems guy. “If the general were a doctor, he’d be a surgeon,” says Richard W. Thomas, the assistant surgeon general who frequently accompanies Chiarelli on his trips. “He’d be hot lights, cold steel.” The trouble is that mental-health questions don’t lend themselves to precise, technical fixes cost-engineered to reflect limited resources. In theater, the Army relies on a highly subjective psychological questionnaire that most of the experienced officers can ace, knowing just which boxes to check in order to avoid further observation by mental-health professionals. The Army is so short on mental-health personnel that Chiarelli is pushing telebehavioral therapy, whereby soldiers disembark from their tours abroad and debrief with psychotherapists via satellite. It’s not a very orthodox form of treatment, he knows, but his response to traditionalists is: As opposed to what? While few people are trying harder to make the Army a less psychologically destructive place than he is, Chiarelli has little patience for the kinds of open-ended, searching questions that are posed by doctors like Xenakis. “Psychiatrists—they’re the worst,” he blurts out at one point while we’re at Eisenhower, as his meeting with doctors there draws to a close. “I once had a meeting with a bunch of psychiatrists and psychologists where I had to kick every single one out of the room. Everybody had an opinion.”
“Potholes, lately. Those have been a big deal.” I caught up with David Booth two weeks ago—at his office, this time—where he is wearing a TENS Unit, or transcutaneous electrical nerve-stimulation device, in order to blunt some of his pain; the cold weather’s made his body even tenser than usual.
Potholes? I ask. “I got blown up, and my vehicle rolled,” he explains. “It’s the shake of the vehicle.”
Booth continues to lead a cloistered life. He still arrives at the office before the sun’s up, still stays in at midday, still hasn’t gone to the movies, still gets his groceries delivered, still isn’t seeing anyone. (“Someone said to me the other day that I’m ‘unapproachable,’ ” he says, “and I was like, ‘Yeah, I can see that.’ ”) But he was recently promoted to director of operations, and his workplace, a gleaming mini-NORAD that could double as a set for CSI, is filled with former policemen and servicemen. “My personal life … there isn’t one, and I’m not happy with it,” he says. “But my professional life is a different life. I’m busy, I’m working, I’m providing a service.”