Rajiv shah has strict but different systems but they have numerous projects that go around the world, with contractors that are overseeing these things. Its a process that seems to take some time get under control. The idea is to make a number of recommendations on how they can do that. Again, it has been a problem for usaid for some time. Can we speak about the alan gross story, and whether or not the end restrictions efforts are constant. His family have been quite disappointed by the administration. Chris the efforts of the administration. Is it tied up in cuba politics . I think it is tied up in cuban politics. They have not been forthcoming on what these efforts are. That is beyond the diplomatic channels, which we dont have a lot of diplomatic relationships with cuba. His family is not being told what is being done. Final question, going back to what did heard ministration spoke about. From your independent reporting, has a been a turn in the crisis . I think there is has been a slowing. Using contained might be a little premature. They are definitely making progress. There have been smaller outbreaks that have been quickly contained. That is a sign of how effective the responses gotten. Mentioned before, it is putting a strain on the agency because theyre having to pull people and resources from other places to deal with that. It is an packing their work in other places like syria and south sudan. You know, sustainability is the question. How long can they sustain this in the absence of not having the necessary funding to carry on with his mission of trying to eradicate this outbreak . Isa follow on issue that going to impact other health , it willike malaria impact those countries could those will be come greater hallenges less attention to them. Thanks to you for your questions. We appreciate your time. Thank you. X happy thanksgiving. Happy thanksgiving. We will have it live at 2 00 p. M. On cspan3. Later in the day, we would hear ,rom u. S. Gregory trevor about Emergency National security challenges. Theyll be an on a cart eastern on cspan three. A look at efforts to treat posttraumatic stress this order and soldiers. Dickinson college and puns obeying your hosted this event. It is a little bit less than one hour and a half. Good evening. My name is virginia. Im a student project manager for contemporary issues. And aalf of the form consent college. I would like to welcome you to tonights event. Ptsd, a pound discussion. In the past decade, poster mastic stress disorder has come to the forefront of national discussion. Ptsd is not a new medical condition. It was observed and soldiers from the world wars, then called shell shock. Ptsd does not only affect soldiers. Anyone who has endured her to manic event can experience those ,ightmares, anxiety, flashbacks and difficulty sleeping. Tonight we have experts from different films fields. She was severely injured in a car bombing. The two members of her crew and military escort. David wood is a senior military correspondent for the Huffington Post. He has worked extensively with American Military units, including a company that went into combat during the iraq and afghanistan wars. In 2012, he won a Pulitzer Prize for the wounded veterans. At this time, i would like to ask that you silence cell phones and electronic devices. Tonights event will be live tweeted. You can follow along by using the hashtags clarkforum and ptsd. A question and answer session will follow the Panel Discussion so please hold all questions until then. Because tonights event is televised and available for live streaming, it is imperative that you wait for the microphone before speaking. And now, please join me in welcoming our moderator and Panel Discussion, wendy moffat. [applause] good evening, thank you for coming on this veterans day. Im going to be talking about one of two of my subjects, dr. Thomas w salmon, who was the first psychiatrist in any American Army and then early discover and treater of war trauma, particularly Mental Illness amongst the allied American Expeditionary forces in the First World War between 1914 in 1918. He was born in 1876 and died quite young in 1927. His work is very important and in the history of understanding this disorder. Even though he was a prescient figure, ptsd would have been an elocution that would have been bewildering. He came at psychiatry from a Public Health perspective, and he began as somebody who was an advocate for Mental Health and the prevention of Mental Illness. Also for training doctors to understand that this is a legitimate form of medicine. This is at a time when people who were incarcerated in institutions were there for reasons that were not medical illness. Many people who had tertiary syphilis had Mental Illness kinds of symptoms. Many people that chronic alcoholism, people who we would think of is to build mentally disabled, people with cerebral palsy. A great range of disabilities that made people be marked as subnormal and warehoused away. Initially his work was in the National Community for Mental Hygiene trying to differentiate between the kind of Mental Illness he was confident that could be cured and the kinds that were caused i again it brain injury. Organic brain injury. This is not easy in the premri time. The u. S. Entered the war rather late compared to the other allies. That offered him a chance to see not only what was called shell shock, this terrible sent set of mental disabilities but also the ways in which the allies screwed up the treatment of people who have those problems. He became almost incandescent with anxiety about what was going to happen to the American Expeditionary force. He studied canada, he studied france, he went to great britain. We see him here at the headquarters at his office in 1918. Salmon was a person with a really intense, beautiful, clinical mind. He was quite sympathetic as a doctor of individual people, but he also had a systematic mind and he understood that treating the soldiers was going to be an important and complex matter. This is one of the hospitals in the battle line. You can see that if you sneezed, you could probably knock them down. It says ambulance here on the righthand side. This is some of his doctors. They built these on the fly. Here is the doctor on the side, he sort of towers over people. He was dubbed the nut picker by the rest of the very skeptical u. S. Army medical corps and he was shoehorned into this because he came from a Public Health and private sector place. He literally forced his way and became the only psychiatrist in the army to run this whole enormous setup. What he discovered about traumatic injury, mental injury in particular, was that it was mitigated by treating it immediately. It was mitigated by the process of believing that people could get well. That sounds sort of silly, but it is very true. And it was mitigated by intense activity to help patients right away. What you see is that core of trauma psychiatry now. We call it proximity. He devised treatment on his own with other people thinking it through. This is a map from the american front here. This is where the headquarters was. And what he discovered is if you put advance hospitals in the field and train doctors to see people who have these mental symptoms, that you could filter out in a triage system very quickly and get to people when they needed help. If you look here, you can see, here is headquarters. This line, roughly speaking, this is an active front. You see here, 1, 2, 3 advanced neurological hospitals. These are within five or six miles off the front. A very dangerous place to be. Sometimes no more than a tent where the soldiers were taken when they exhibited the signs we associate with ptsd. What is interesting as he going back and forth not only from this headquarters here were we saw him but also to the only dedicated Psychiatric Hospital in the entire army. That is what you are looking at earlier. He is spending a huge amount of time going back and forth and he is bringing the soldiers back who are up at these advanced hospitals if they do not get well within 72 hours. It was a very civil protocol but it ismitive, quite remarkable. The men who come in who were unable to hold a gun, unable to stand up, shaking so hard they cannot stop, catatonic, various other kinds of symptoms, gives them a hot drink and a bed they can lie on by themselves. He is an empiricist, so he watches. They sleep in average of 32 hours after they drink the hot drink. So we may not be talking about ptsd. We may be talking about simple exhaustion, combat fatigue. This is the view from the top of the chateau. The 12th century chateau in france where this was set. They commandeered a ruined chateau and built a hospital which started in the summer of 1918 with three patients and by january 1919, had more than 600. He treated more than 2500 people at that hospital. These are people who got brought back. This is a monastery in the middle of Argonne Forest where some of the tents was set up. Is the one that was the furthest up on that map. You can see that the chateau, the old chateau is sort of norman, and the officers were billeted down at the mayors house down the road. Were looking through the portcullis. Very primitive conditions they lived in. Salmon was a remarkable sketch artist. He was ambidextrous and he did a lot of beautiful sketching of things. This is not very clear. You can see that he is sketching the line. In the left hand side, it says balloon in flames as it goes up and down. We have stood exactly where this is, towards the end of the war. As the allies and americans are pushing up. This is a photograph from the 18th of november, 1918. He was touring around a great deal and he moved around a great deal. At the end of his life, he became very worried and concerned about the treatment of veterans and he advocated for a Veterans Bureau, which is the forerunner in the early 1920s of the v. A. He viewed it as a signal failure of his life that he was unable to get some things that we now think of as absolutely central for Mental Health. Mental Health Parity for veterans, that is that their Mental Health should be treated on a par with their physical health. De stigmatizing people with Mental Illness, the belief that people with Mental Illness, particularly from more trauma could get better, and probably most importantly, that we have to pay for what our veterans need. He was very upset and he was caught in a huge rats nest of political problems including fighting privatization of military health care. So he feels like a very prescient person to me. I will leave it there. Im sure we will have questions. Thank you. The panelists should come up and sit now. Im the last of the av. This is where we ask you a couple of questions. You do. Im automatically taking the moderator role. [laughter] as i was watching the pictures and thinking, ok, this has always been a problem that is with us. With the work that he was able to do you went to france and had to dig this out of archives. How widespread were the Lessons Learned across the military . There was a lot of resistance within the army at the time, but there is a huge reckoning in the immediate aftermath. In 1920, 1921, and there is a an interest in all the lessons that one could get. There was a huge set of volumes in which they put all their insight and a lot of what he has written is in those. There is a lot of anxiety as the army goes down after the war and there is a lot of disinterest in continuing to fund veterans and military health. It gets dismantled. One of the final ironies was a great deal of his patient records were poked during the vietnam war. They were in san antonio. At the army medical archives. He said we knew we had better weapons so we would never have ptsd again and i said youre joking, right . He said not about the pulping. That underscores this is a perennial problem. He would want us to build on the knowledge that we have and not dismantle it in peace time in the hopes we did not have to pay for it. Can you tell us can you hear me . We all need to talk loud. We will all project. I want to know more about the mechanism of moving. There was a lot of befuddlement among military doctors about what caused shellshock. They believed that somehow it was the reverberation of exploding shells that caused this jitteriness. They noticed that a lot of patients who were jittery had never been around shells. What was his understanding . His locution was a war neurosis. He is picking up the most advanced of the british doctors. I never heard that word used in that context. What do you mean by his locution . They are trying to frame what is this new iteration of behavior that they are saying and soldiers. Youre right. Many of them have never been subjected to artillery. They are aware that there are mood changes that have been with brain injuries that might not be the same thing as what we would call ptsd. And so he viewed war neurosis, as a perfectly rational, curable response to the conditions of combat. He remarks that it is a surprise that more soldiers do not have it. He understands it as an unconscious phenomenon. He is aware of for it but uninterested in freudian apparatus of individual ways of developing and psychosexual behavior. He is a pragmatist. He has this idea that the mechanical qualities of the First World War were somehow the instigator of this. It is probable we have had Something Like this in the civil war as well. He saw it as something that was emerging out of modern conditions. We can go way back in history even to see evidence of what we now call ptsd. Even before the First World War. You look at jonathan shays work and the idea that if you read homer you can see some of this. Salmon was interested in making sure that the people are injured get treated and get better. He is not a philosopher of the longterm, but he does notice that they have a huge incidents of this. It is hard to know whether statistics actually bear out but there was a quite low incidence of suicide amongst the people he treated. There was a quite low incidence relative to the brits and the french. He thought that he was empirically getting better. Its a debate whether p. I. E. Still works. We still use it. Treating people right at the front and working them back as they need more treatment. Any military person, the idea of curing soldiers is to get them back in fighting shape. Were not talking about trying to get them out of the army or out of fighting. Were trying to get them so they are whole enough so they can continue combat. Did he have a hierarchy of what caused the worst shellshock . Was it everything from being too close to the explosion to moral injury . He does not differentiate it that way. It may be that the american pressed inwas so time that he did not the experience to play these things out. What he does do that is interesting is he insists on longitudinal studies of the people who were affected. So there is a survey and a study in 1920 and another in 1924 and if he had not died a boating accident in 1927, that would have gone straight through. He wanted to followup. He followed them back in the states. He fought hard for nonprivatization of medical facilities and he was furious that the first thing that the Veterans Bureau did to save money was ask all of them, which you like to be in a Mental Hospital or would you like to go home . Theyll said we would like to go home. They said problem evaporated, no need for this. His speeches in the early 1920s are unbelievable, but you will have to read my book to know more. [laughter] what i want to know is what did he find out in those longitudinal studies . The last one was in 1924. Six years after the war. He found that people get better with treatment. That is what he found out. Which means that is what we find in army medicine. We estimate that 80 of soldiers who are treated for ptsd do recover, if they complete the treatment. So many of them do not complete treatment. What ive seen the reason are not looking you is because [indiscernible] what we have seen is 5 to 10 of soldiers will meet the diagnostic criteria for posttraumatic stress disorder. That is a sizable number. As many as 10 to 15 will have other Behavioral Health conditions that require some kind of treatment. What the army has done since 2007 is with some appropriated money from congress, has developed the Behavioral Health service line that coordinates and synchronizes Behavioral Health care delivery into a system that really builds on p. I. E. Proximity, immediacy, an expectation that people will get better. Soldiers, specifically will get better. We have embedded Behavioral Health teams that are right in the brigade combat teams and those are primarily in the garrison. Before they deploy. There are other Behavioral Health aspects that are part of the organization when they deploy. Even in garrison we have these Behavioral Health clinics, specialty clinics that are in the brigade footprint. What we found is that makes it more likely that a soldier will come in and get help. He does not have to get as much time off work. He does not have to get a right a ride to the hospital. He or she can come right in and see a Behavioral Health professional. What we have done is we aligned those professionals with a specific battalion and brigade, so that if there is a unit that has an exercise coming up or more pointedly, if they had certain experiences while they were deployed, the Behavioral Health professional kno