Long Campaign to Change

There has been a long standing campaign to get the President to change the previous policy, led by families who had soldiers die by suicide. Various veteran groups, members of Congress and  mental health professions, including myself have been publicly advocating that the President change the policy.

The Keesling  Family

I first wrote about this issue in my blog (Psychiatry Talk.com in December 2009) after reading a NY Times piece the previous month about the tragic loss which the Keesling family suffered when their 25 year old son Chance killed himself in Iraq in June of that year. He was in his second tour of duty when the stresses of combat combined with an argument with his girl friend over the phone led to hopelessness and suicide. Hours before his self-inflicted fatal gunshot wound the Keesling family received a rambling despondent email message from their son.

Chance Keesling (Photo from the Keesling family)

His father Gregg commented on my blog and we began a correspondence about this issue. He and his wife had decided to share some of their grief with the public in order to try to bring about a change in the Presidential policy, which was so hurtful to his, and other families who suffered similar losses.  They would receive a folded flag, a letter from the Army praising their son, a rifle salute at his burial and financial death benefits. But the letter of condolence from the President of the United States, which is the symbol of the voice of the people of our country, which is sent to every other fallen soldier in war since the presidency of Abraham Lincoln, was conspicuously absent. There was an increasing frequency of articles touching on this subject in the media. I wrote about it again in my blog and in the Huffington Post and received more comments than any other pieces that I have written. The House of Representatives voted in May 2010 to add an amendment sponsored by Representatives Burton and Napolitano to the Defense Authorization (HR 5136) that urged that the policy be overturned. The only response from the President was that this policy was being evaluated.

Why There Was Resistance to Change ?

It was difficult to say exactly why there was resistance to changing this policy. It appeared to come from certain factions within the military who had the misguided idea that such recognition would encourage suicide or would be rewarding those who were “weak” and couldn’t deal with stresses compared to those who did. These ideas were antithetical to the fact that there were so many accounts of the comrades of these soldiers who did die from suicide who were quite devastated by these losses and very supportive to the families of their fallen comrades and to their memories. There also was no psychological basis for such theories. I could not help but feel this was another example of the stigmatization of mental illness.

American Psychiatric Association Weighs In

As a Past Speaker of the Assembly of the American Psychiatric Association (APA) I believed that it was important that American Psychiatry speak out on this issue. I wrote an Action Paper (a resolution) with Dr. Roger Peele of Washington D.C. which was also co-authored by Drs. Catherine May, Eliot Sorel, Hind Benjelloun and Joseph Napoli which was voted upon and approved by the APA Assembly in May of 2010. The Board of Trustees of the American Psychiatric Association then approved it. In July 2010 James H. Scully Jr. M.D., CEO and Medical Director of the American Psychiatric Association wrote to President Obama representing the 37,000 psychiatric physicians. He called upon the President to eliminate the stigma and shame associated with suicide for families and survivors by reversing current policy and forwarding Presidential condolence messages to families of individuals who complete suicide while in military service. In October of 2010  the APA issued a public statement urging President Obama to reverse the policy of barring such letters. A number of other mental health groups including the American Foundation for Suicide Prevention and the Mental Health America had officially come out in favor of this policy change. APA President Carol Bernstein, M.D. issued a statement in which she noted, “ The contributions of these men and women to their country are not less for having suffered a mental illness. A reversal of this policy to allow condolence letters to family members will not only help to honor the contributions and lives of the service men of women, but will also send a message that discriminating against those with mental illness is not acceptable.”

The Long Awaited Change

The number of suicides in the military continued to go up either approaching or in some analyses exceeding the number of combat deaths. The problem of PTSD and the mental health of our combat troops became a high priority of the military but there was still no change in the Presidential policy.

Last month (June 2010) I met with Gregg Keesling for breakfast as he was in Los Angeles for a business meeting. He had received some indication that the President was reconsidering his policy but nothing had come down yet. Senator Barbara Boxer had just sent a letter to the President, which was made public.  We reflected in our discussion whether this issue might come to a head sooner if fate had led to a high profile family to lose a military family member to suicide rather than unknown but valiant people such as Gregg and his wife. It was clear that he and others like them in memory of their lost loved ones were not giving up the fight and were continuing to push for a change in the Presidential policy.

The Keeslings were notified in advance of the official announcement that henceforth the families of soldiers who die in a combat zone by suicide will receive a Presidential letter of Condolence. They understood that this would not be retroactive but were nevertheless overjoyed that the battle that they had fought in memory of their son was won. While there is nothing that relieves the pain of the loss of a child, hopefully the significance of this accomplishment will help in a small way.

I certainly am very pleased that the President has seen fit to make this change in his policy. I imagine that it was not an easy thing to do since there apparently was strong resistance in the military.

Still Unfair Discrimination

Coming Home (Photo from the Keesling family)

However, it should also be pointed out that there is still something inherently unfair and discriminatory about the new policy. As I understand it, letters of condolence will only be sent to families of troops who have killed themselves in a war zone. I am certain that if a soldier is critically injured by an explosive device but does not die until he or she is back in the United States receiving treatment, his family would not be denied a letter of condolence from the President. Similarly what if a soldier develops a mental disorder related to the stresses which he or she is experiencing in a combat zone and is transferred to the US to be treated but unfortunately succumbs to this condition and commits suicide? Shouldn’t this soldier also be considered to be a combat victim and shouldn’t his or her family also receive a letter of condolence.  Sometimes changes come in small increments and perhaps this important step and the attention to this issue will help the destigmatization of all mental disorders.

Mental Health Experts will Offer Help

Edited by M. Blumenfield & R. Ursano

I am sure that there will be mental health specialists from the United States and elsewhere offering their assistance to our colleagues in Japan as has been the case with other major catastrophes. During the Kobe earthquake in Japan in 1995, I was a member of the Committee on Disasters of the American Psychiatric Association and we arranged to translate a good part of our mental health written materials for disaster into Japanese so I am sure they will be made available again  at this time. In that event and during subsequent events, American psychiatrists held conference calls with mental health professionals in impacted areas to offer the benefit of experience which we had from working in various events including plane crashes, The World Trade Center bombing, Oklahoma City, Katrina, 9/11 and other events. An organization called Disaster Psychiatry Outreach was formed by a group of young psychiatrists from New York who trained many psychiatrists who then participated in the mental health efforts in various locations throughout the world. For several years I participated with my colleagues in  teaching courses at the annual meeting of the American Psychiatric Association about disaster psychiatry. I am sure there will be many mental health professionals joining other volunteers  to assist the Japanese in dealing with this traumatic event.

I would like to briefly review some of the anticipated mental health issues in a disaster such as this one.

Psychological First Aid

Needless to say – the first effort is always rescue and attempt to save as many as lives as possible. All resources will be directed  towards  searching and finding the victims of this tragedy. First Aid to the victims should always have priority over mental health support but it should be given with Psychological First Aid.   this means that  food, water and shelter should be provided in a compassionate manner. An essential part of this effort is to communicate in efficiently and humanely  with families and loved ones who have survived.   Another part of this psychological first aid is going to be some kind of continued support to those who have suffered so many losses personal and material loses. The role of insurance, government support and foreign aid along with that of friends and family will be very meaningful and psychologically supportive.

Not Just Grieving But Complicated Grieving

Edited by Fred Stoddard, Jr., Craig Katz, and Joseph Merlino

Whenever there is loss of life there is grieving by family, friends and I am sure by the entire country. Grieving is a universal process and while it is influenced by culture and religion, there are certain physical and emotional components of it that are well know by physicians, ministers, mental health professionals and anyone who has been around long enough to see such responses in themselves and others. There will be waves of emotions whenever anything reminds them of the loss, tears and depressive symptoms. While the lost person may never be forgotten, the severity of the symptoms and inability to function as before will usually improve over time with normal grieving. However a situation like this is one which falls into a different category usually named complicated grieving. Such a designation  is made when there is the death of large numbers of people especially when children are killed or large numbers of children are grieving, unexpected death often of horrible and bizarre circumstances. ( This designation also applies when there is murder or suicide which doesn’t apply here ).It is more likely to occur when the body has not been located and given a ceremonial funeral.  Complicated grieving usually is prolonged for at least a few years, sometimes longer. It is complicated by symptoms of severe depression and may lead to substance abuse and suicidal behavior. There is often a need of the  bereaved to to find an explanation for the event or seek some type of restitution. This may lead to tremendous anger directed towards the government and public officials even in a situation where there was a natural disaster. These feelings can  also get directed towards God and towards one’s religion. It becomes very meaningful for the government, and society to recognize the loss of lives. Memorial and commemorative services at anniversaries of the event as well as monuments and dedicated rebuilding becomes part of the healing process.

Acute Psychological Stress

By Robert Ursano, Carol S. Fullerton, Lars Weisaeth and Beverly Raphael

There are acute psychological stress symptoms which will occur in huge numbers of people in the days and weeks after the event.These will consist of extreme anxiety, depression, insomnia, bad dreams, flashbacks of the horrible events which they experienced, helplessness, numbing, detachment, feelings of unreality, depersonalization dissociative amnesia where a person can’t recall important aspects of the trauma, tendency to avoid anything or any thoughts to do with the trauma and a tendency to have an increased startle reaction or tendency to jump very easily. At this stage people are susceptible to abusing alcohol and drugs. It had been very common for peer groups and mental health professionals to organize debriefing group meetings where people who recently had been through a trauma would be encouraged to review  their experiences as well as their emotional responses including the personal meaning to them. It was thought that this approach could diminish the possibility of long term psychological symptoms. Subsequent research did not establish this as a valid approach and raised questions whether at times the group discussions created more anxiety in some individuals. While each situation is different and there are often limited psychological resources, the best psychological approach appears to be psychological first aid with warm supportive environment where the victims basic needs are met, valid information is supplied by caring people, efforts are made to connect with families, intermediate and long term planning is established and the victims are counseled about what type of psychological feelings they might be expected to have . People should be cautioned about tendency to abuse alcohol and drugs. During group meeting where information and other necessities are being provided, there should be screening for individuals who may need individual counseling, therapy with or without psychiatric medication.  People with pre-existing mental disorders may have an exacerbation of their condition although in some cases such people faced with an external catastrophic event may actually fare fairly well as they put aside their “personal demons” and actually cope better than usual. People with underlying mental conditions may need adjustment of their medication. In addition there can be an important role for the use of administering sleep medication , anti- anxiety medication of other psychotropic medication to some people during the acute phase of a trauma.

Post Traumatic Stress

By V. Alex Kehayan & Joseph C. Napoli

It is invariably that a certain number of people will go on to develop a post traumatic stress disorder where they can have persistent symptoms as described above. This can be quite distressing and incapacitating  for some people . There are several  psychological treatment techniques which may or may not include medication While the percentage is variable perhaps between 10-50% can have significant symptoms in months and years to come. We have learned that the majority of people in such situations have shown great resiliency and have a good psychological recovery over time . People closest to the areas of destruction are more likely to suffer although this is not invariably the case. Children are particularly vulnerable and should not be neglected in screening for emotional problems. Today with mass media, people watching the events can identify with their fellow countrymen and women and suffer symptoms. We now also know that there are psychological causalities among the police, fire, emergency personnel, hospital workers, morgue workers government officials and especially members of the working press who go out of their way to witness a great deal of the death and destruction.

Risk Communication

Mental health professionals can provide assistance and consultation in all phases of a disaster. There are also mental health experts who have studied the field of risk communication which is how public officials and the media provide information about potential danger. It has been shown that it is both essential for there to be a spokesperson who is trusted to deliver honest information to the public at the same time to do it in a manner to minimize fear and panic. This has been studied and there are techniques which this can be done in the most effective manner.

Psychologcial Impact of Radiation Threat

One additional thought related to the above issue of risk communication is the situation where there is the potential of radiation fallout to the communities surrounding nuclear plants which is the situation occurring as I am writing this. There was a similar situation in the United States with the Three Mile Island incident where there was a question of the accidental release of radioactive vapor into the air. Subsequent studies have shown that while there actually was no  physical danger many people suffered psychological symptoms especially women of child bearing age  and mother of small children who were highly anxious about the potential danger of radiation.

There are some excellent books on psychological issues in disasters which can be easily accessed. I have pictured  some of them in this blog. I welcome your thoughts on this very important current issue.

There is very little reason that I should have to mention this in a psychiatry blog. After all homosexuality is not a mental disorder. Except perhaps for the fact that Don’t Ask Don’t Tell has caused a great deal of psychological pain to those who have had to hide their identify for fear of being kicked out of the military or  suffering other repercussions. This should not be minimized, but overall it is a discrimination issue and one of social justice but not a significant psychiatric one.

However, it was not always this way. Up until 1973, the psychiatric profession considered homosexuality a mental disorder. There was a DSM code for it. The predominant official psychiatric thinking included various theories how certain types of child rearing may have brought about this sexual orientation. Many psychiatrists believed that therapy could change homosexuality and bring about “normal heterosexuality.”

Obviously there were many psychiatrists and other mental health professionals who did not hold this view. There was an increasing amount of research which did not support it . In fact, some experts believed  that homosexuality was founded on genetic and  biological determinants. There was also a great deal of clinical experience which supported the idea that sexual orientation could not be altered by therapy.

There was an historic meeting of the American Psychiatric Association in 1973 where the APA Assembly debated and passed a position paper stating that homosexuality was not a disorder and an equally historic debate within the Board of Trustees which took this position. It then became the official position of the American Psychiatric Association which has been reflected in subsequent DSM publications.

A few years ago I was broadcasting a podcast on the Internet and I interviewed Alfred M. Freedman who was the President of the American Psychiatric Association in 1973. I asked him about the background and the details of this famous debate. It was a very revealing interview in which he shared with me the behind the scenes activities involved with this event. A transcript of this interview was reproduced in theJournal of Gay & Lesbian Mental Health 13(1) 2009.

Alfred M. Freedman, M.D.

Dr. Freedman was Chairman of the Department of Psychiatry of New York Medical College and hired me on the faculty there in 1980. He is now in his 90s living in Manhattan and still attends meetings of the APA.

I am pleased to be able to provide the links to this video interview which can be seen on You Tube in three sections or heard on Shrinkpod in it’s entity.

I thought that this might be a good time to report some follow-up on various blogs which I have written .

The first blog that I wrote on October 12, 2009 was Review of Fox TV Show Mental. It was a critique of a new television show  which was about a psychiatrist. In my opinion, the program lacked authenticity and missed the opportunity to depict psychiatry and mental illness in a realistic manner.The show was not renewed. There is an excellent program about a psychotherapist on  HBO titled In Treatment which  just began it’s third season. It stars Gabriel Byrne as Dr. Paul Weston who has weekly sessions with patients , including one with his own therapist. This is a scripted show and although the writing is quite good, it is fiction based on a similar Israeli TV show.  I believe that it  would be possible to develop a high quality reality tv show of an actual ongoing therapy which could not only show real therapy sessions but also allow for interesting discussion by experts. There would be some ethical considerations in doing it which but I believe could be overcome and it  could be done in a thoughtful manner.

The second blog on October 19^th was titled When a Mother Kills Her Children. It was about post partum psychosis with a discussion of the Proposed bill before the US Congress tiltled the Melanie Stokes Mothers Act . I am pleased to say that in March of 2010 it was passed and signed by the President. This  legislation will establish a comprehensive federal commitment to combating postpartum depression through new research, education initiatives and voluntary support service programs.

In December 2009 I first wrote a blog Condolence for Soldier Suicide where I made the case that it was wrong for the President of the United States not to write a letter of condolence to the families of American soldiers who have died by suicide. Another blog was written on this subject in August  2010 titled We Can’t Avoid PTSD and Suicides . While the President has still not changed his policy, the Secretary of the Army has recently written to some of the families and expressed his regret on the death of the soldiers. Perhaps this may be a sign of things to come. I authored an Action Paper with Dr. Roger Peele of Washington D.C. requesting the Assembly of the American Psychiatric Association to ask the President to reconsider his policy on this issue. It was passed by the APA Assembly and also endorsed by the Board of Trustees of the APA . This makes it the policy of our 38,000 psychiatrists organization. In addition Mental Health America and the American Foundation for the  Prevention of Suicide has passed similar resolutions and also are in the process of gathering signature for a petition to  President Obama. I believe we are getting closer to this long over due recognition to the families of these soldiers .

Another important military issue  and human rights issue was discussed in the February 2010 blog titled Abolishing Don’t Ask Don’t Tell (DADT).  Polls have consistently shown a majority of the public supports letting gays serve, and Defense Secretary Robert Gates and top military commanders such as Admiral Mike Mullen have recently endorsed it. In September 56 Democratic senators voted for the defense authorization bill, which included DADT repeal, but the measure failed to achieve the 60 votes needed to overcome a Republican filibuster.  A recent study conducted by the Pentagon concluded that ” …while a repeal of DADT will likely in the short term bring out some limited and isolated disruption to unit cohesion and retention, we do not believe this disruption will be widespread or long-lasting, and can be adequately addressed. The report, based on responses from 115,000 service members and 44,266 spouses, includes interviews with former gay or lesbian service members, some of whom were discharged from the military under the “don’t ask, don’t tell” policy. Of those surveyed, 69 percent said they had served with a gay service member and 92 percent of those respondents said they were able to work together.Fifty to 55 percent of those surveyed said the repeal won’t have any effect, 15 to 20 percent said it would have a positive effect and 30 percent said the effect would be negative.The report went on to say that  “The reality is that there are gay men and lesbians already serving in today’s U.S. military and most service members recognize this,” the report states. “Much of the concern about open service is driven by misperceptions and stereotypes about what it would mean.”I still like the words of Barry Goldwater on this issue who said, ” It is not important if your are straight , just that you can shoot straight.”

When there was a proposal for a 39% hike in healthcare rates purposed in California by private insurance companies, I raised the question in a March 2010 blog titled  Stockholders Must Vote CEO Pay whether  there should be  law where stockholders,not Board of Directors of Compensation Committees, should be required to approve any compensation packages more than 200 times the minimum wage in the US. That controversy seems to have been revived just this past month when compensation at Wall Street firms was reported to be  expected to hit $144 million . A column in the Wall ll Street Journal raised the question I brought up that since the 2008 financial crisis profits remain 20% below the 2006 level while the pay at these firms rose an astonishing 23 % over that time frame,  shouldn’t the owners of these firms be the ones to decide if they want to spend their money raising the compensation of their executives. ?

The May 12^th 2010  blog titled Autism & FragileX- New Treatment has become the most looked at blog of PsychiatryTalk of the year so far. In it,  two new research projects concerning Autism Spectrum Disorder and Fragile X Syndrome are briefly reviewed. In the first, a random controlled study of children with Autism Spectrum showed that the Early Start Denver Model showed statistically improvement over a control group in regard to intellectual development and adaptive behavior. In the second study, preliminary research showed that a new medication improved behavior associated with Fragile X Syndrome compared to the control group. There is also some belief that such medication would be effective with children with Autism Spectrum.  As a followup I don’t find any announcements of new breakthrough research. However, there is  a $211 million HHS-wide initiative that would invest an additional $1 billion over the next eight years in autism related activities, the NIH budget includes $141 million in FY 2010 for research into the causes of and treatments for autism spectrum disorders (ASD). The funded research will  include identifying biomarkers; improving ASD screening; establishing ASD registries; understanding genetic and environmental risk factors, as well as interactions between the immune and central nervous systems; and enhancing services that can help people with ASD across the lifespan.

Also in May I wrote two blogs addressing financial issues in the  American Psychiatric Association and they were Impact of APA Budget Cuts and  Increase APA Budget $1.5 Miilion. In the the former I discussed the expected impact of the cuts on the APA Assembly and APA Components particularly the Communications Committee and the Disaster Committee. In the second blog I outlined several specific suggestions how I felt that the APA could gain this large increase in it’s budget. Certainly the APA continues as a very vigorous organization representing 38,000 psychiatrist and speaking out on important issues concerning mental health. It is still too early to determine if the cutbacks will seriously hinder it in it’s effectiveness. I understand that some of my suggestions are being considered by some of the leadership but as far as I know no steps have been taken to implement any of them

In a July 14^th blog titled I would Like to Thank My Psychiatrist It was stated that Los Angeles Laker Ron Artest after his team won the NBA Championship thanked his psychiatrist on national television. This is was noted to be  example how an increasing number celebrities are comfortable publicly discussing their psychiatric history. Television programs, movies, the Internet and the new media have all contributed to the reduction of stigma about mental health problems and treatment. My colleague Bill Arroyo informed me that Artest was mistaken in that his therapist was not a psychiatrist but another mental health professional. While I appreciate the correction, the changing attitudes towards discussing therapy still  holds and is a good trend.

Last month I wrote my first blog on Miners in Chile anticipating any psychological issues that people who have gone through  a traumatic event may experience. As the miners began to emerge from the successful rescue efforts asecond blog was written in conjunction with a blog that I wrote for  CNN.com which I suggest that in this situation I believe that resiliency will be the default and most if not all of these miners will not have any long lasting psychological effects. In fact this brush with death may end up being a positive experience for them . It is obviously too early to tell  but it is very gratifying to see the good feeling around the world for these miners. However, just recently  29 miners  died in an explosion in New Zealand and we are reminded how such tragedies occur all the time and so cause great mental anguish for so many people. In this regard still another report of a recent tragedy caught my eye and that was the traumatic event in Cambodia where more  more than 378 people died and hundreds more were injured in a stampede at the end of the annual Water Festival late Monday in Phnom Penh. So many of these victims  were young people , many in their teens. I hope that there are mental health professionals and others available to help the survivors, families and friends deal with their grief.

Needless to say, I am still enthused about continuing this blog. I do appreciate the growing readership and I would want to encourage each of you to feel free to comment directly on the blog with your own views are particular topics. Whenever I have had occasion to give a talk whether it has been at a national meeting, a Grand Rounds or even a local group, I am always very pleased if there are 25 people in the audience, as it is privilege to share my interest with others. So it becomes a special opportunity to use the Internet to reach much larger numbers throughout the world through this wonderful medium. Thank you all for your continued interest.

APA Budget Cuts Hit Assembly and Components

This week in New Orleans the Assembly of the American Psychiatric Association will be in session just preceding the annual meeting of the APA. In certain ways this will be a momentous meeting  in that the APA  may be taking the first steps in a restructuring process which may significantly change how it functions.

Assembly

During the last Assembly Meeting which I attended in my capacity as Distant Past Speaker, the Assembly had a mandate from the Board of Trustees to cut it’s budget by $200,000.  This was due to a of  loss advertising revenue and  diminished income from the annual meeting. In addition changes made several years ago left  the APA unable to  utilize income from APPI publishing and the APA Foundation which are required to function independently of the APA.

Assembly of the APA In Session

After discussion and debate, the Assembly accomplished this task. The Board rescinded a request of another major cut. The result of the cuts that were made is that there are less representatives and alternative representatives will not have financial support to attend meetings. There are other cuts in staff and activities of the Assembly. Many are concerned about the diminution of alternate and younger representatives, as the Assembly is often the training grounds for APA leadership. There is also the question of whether these cuts are taking away the voice of under represented minorities as well as that of various sub-specialty groups which have been traditionally represented in the Assembly. These and future cuts are viewed by many as leading  to a less democratic process with increased executive functioning.

Components

The Assembly was not the only part of the APA to be cut. The Fall Components Meeting was essentially eliminated, as were most of the Components. This doesn’t mean that activities in the areas previously covered by the Components were destroyed. In some cases an individual was appointed as representative to a Council charged with the responsibility of an area previously handled by a Component. Some committees might meet at the annual meeting in reduced size or have conference call and in other cases staff were assigned duties previously handled by Components.

It is not clear how these changes will impact the APA. However, I would like to express my concern about two Components upon which I have been very active in the past.

Communications Committee

APA Public Affairs Broadcasting Live From APA New Orleans Meeting 2001

In the past each Area had a representative on what previously was called the  Joint Commission on  Public Affairs which also had s several knowledgeable members who were consultants. This was a vibrant vehicle of communication and exchange which brought back ideas and activities to the various Areas and local DBs, each of which had their own PA Committee. In addition, this APA Component arranged biannual Institutes where there were exhibits, demonstrations of programs and exchange of ideas. I learned about a clergy dinner that Kentucky was holding which I brought to my then DB in Westchester which now has  been running such a program  for more than 15 years. I participated in an education program about how to approach newspaper editorial boards, which led me to start a local newspaper column that ended up being syndicated for Gannett Newspapers. Training which occurred at these institutes in radio and television provided many others and myself with the confidence to pursue projects in these media . At these meeting we also were introduced to ideas how to establish our Area and DB web sites which were in a nascent stage. I can see reverberations in many public affairs activities of psychiatrists throughout the country, which can be traced to the interaction, and exchanges which came from this Component. I understand from some initial inquires that most of these activities have not been occurring recently and certainly not at the level which they occurred in the past.

Disaster Committee

Most psychiatrists (except those the military) become involved with this aspect of psychiatry because of some incident which occurs in their locale. That was the case with myself and I ultimately found myself on this committee with a group of remarkably experienced and dedicated psychiatrists. There were creative projects which  emerged from this group which included, awards and recognition for psychiatrists working in disasters, an emergency funding mechanism for district branches at the time of disaster, development of a manual for use in disasters which was translated into Japanese after a request during the Kobe earthquake, a special place on the APA website for disaster information, the development of disaster workshops for the DBs (in conjunction with the Assembly), the development of courses for the annual meeting which were conceived , discussed and developed at these meeting as well as  many other things. Last time I looked there was no Disaster Component and disaster activities are under the oversight of one very capable member) and staff. – Addendum- Since writing this I have learned that a Committee of the Board led by Dr. Sullivan and Bernstein have reinstated the Disaster Committee. I don’t know if it will meet in person and what resources it will have but that is a good piece of news. There still needs to be some indication what will happen to all the other activities of the Components.

Where Do We Go From Here

Realistic financial restrictions can’t be overlooked. A vibrant organization has to constantly reinvent itself. Some people have advocated cutting back the Assembly even further. It has been questioned whether APA  members want governance by a representative group. After all less than 25 % of APA members even vote in national elections. Utilizing members to be an active part of the governance is more expensive than just having paid full timestaff run the whole show.  Even though members donate their time, the fact is that travel and hotel are expensive and the deliberate process takes more time. On the other hand, there are other potential revenue streams and the  creativeness of members in the past has been very productive in finding new ways to do things. Some believe rather than limit participation, we should increase it, which could also expand APA membership.

APA Will Continue to Be Vibrant But Different

I have a confidence and optimism about the APA. We are fortunate in having a very talented Medical Director and have always been able to attract outstanding staff. However I believe that the he APA 10 years from now will be quite different than the APA of 10 years ago. What that difference will look like, will depend on the  priorities and values which we hold and what kind of governance we will choose .

I welcome comments on this topic . In next week’s blog I will offer some suggestions as to how I believe that  the APA can increase it’s income more than $1 million / year  and continue to support the Assembly, Components and new programs.

American Psychiatric Association - 2020

The Vaginal vs. Clitoral Orgasm Debate

It was the early 1970s and it was one of the first annual meetings of the American Psychiatric Association which I attended. I don’t recall the city but remember that there was one particular program that I decided I would not miss. It was debate between a well known psychoanalyst (or perhaps a group of analysts) and William Masters and Virginia Johnson- two psychologists who were doing research into human sexuality. The topic was “Vaginal vs Clitoral Orgasm”

Freudian Point of View

The concept of vaginal orgasm as a separate phenomenon was first postulated by Sigmund Freud. Psychoanalysis was not far from it’s prime and Freud’s theories were still highly respected although certainly questioned and modified by various schools of thought. In 1905, Freud stated that clitoral orgasm was purely an adolescent phenomenon, and upon reaching puberty the proper response of mature women was a changeover to vaginal orgasms, meaning orgasms without any clitoral stimulation. While Freud provided no evidence for this basic assumption, the consequences of this theory were considerable. Many women felt inadequate when they could not achieve orgasm via vaginal intercourse alone or involving little or no clitoral stimulation.  Many psychiatrists trained in psychoanalytic theory, or influenced by some of their teachers who were primarily Freudian analysts, were influenced by these writings. Therefore, they would focus on a patient’s report of orgasm  mainly by clitoral stimulation as being indicative of early conflicts and failure to mature properly. This might lead to deeper psychoanalytic treatment. In other situations, the nature of current relationships might be questioned. Still another approach was to consider this a sexual inhibition which might respond to a  cognitive therapy where corrective suggestions were offered to  women to achieve orgasm with “proper masturbation.”

Masters & Johnson

In 1966, Masters and Johnson published their work  about the phases of sexual stimulation. Their work included women and men, and unlike Alfred Kinsey earlier (in 1948 and 1953), they tried to determine the physiological stages before and after orgasm. Masters and Johnson observed that both clitoral and vaginal orgasms had the same stages of physical response. They argued that clitoral stimulation is the primary source of both kinds of orgasms. Physicians trained prior to this time had little instruction in human sexuality. Therefore the work of Masters and Johnson was viewed with great interest by many psychiatrists especially those training at this time.

The second wave of the Women’s Movement often called women’s Liberation was also at it’s peak. Jane Gerhard had published “The Myth of the Vaginal Orgasm” in 1968. Freudian thinking was a lightening rod for women to reject psychoanalytic theory in particular and male psychiatrists in general. Many women would only agree to see a woman psychiatrist. Some women expressed great anger towards the psychoanalytic theories about female sexuality. The concept of the vaginal orgasm was not far from the center of this hostility.

Time Marches On

I wish I could remember the details of the this debate (one does repress these sexual things). If  there is  transcript of it I would think it be worth publishing. I do recall that they moved the venue several times prior to starting it because the crowds were getting larger and outgrew the seating capacity. I know that on the basis of that meeting and  from subsequent reading of the growing literature about human sexuality  as well as talking to patients, I understood that vaginal vs. clitoral orgasm was not the to key successful sexual function. Our understanding has progressed greatly and the previous point of contention has little relevance although some people still hold on to the dichotomy.

In 1974 Helen Singer Kaplan reported that stimulation of the clitoris is usually experienced in the vagina. This made sense and closer anatomical and neurological advances confirmed this observation. Recent discoveries about the size of the clitoris show that clitoral tissue extends some considerable distance inside the body, around the vagina. This discovery may possibly invalidate any attempt to claim that clitoral orgasm and vaginal orgasm are two different things. Clitoral tissue is more widespread than the small visible part most people associate with the word. It is possible that some women have more extensive clitoral tissues and nerves than others, and therefore whereas many women can only achieve orgasm by direct stimulation of the external parts of the clitoris, for others the stimulation of the more generalized tissues of the clitoris via intercourse may be sufficient.

The Gräfenberg spot, or G-spot, although first identified in the 1940s still has not been scientifically identified. However discussion about it has added a new  dimension to understanding the location of an orgasm. More recently.it has been an area of discussion among experts in human sexuality. It  is a small area behind the female pubic bone surrounding the urethra and accessible through the anterior wall of the vagina. The size of this spot appears to vary considerably from person to person. A recent theory receiving some publicity is that the female body can achieve orgasm both from stimulation of the clitoris and of the G-spot. Such orgasm is sometimes referred to as “vaginal,” because it results from stimulation inside the vagina, including during sexual intercourse.

Conclusion

A great deal has changed in the past 50 years , not only in our understanding of human sexuality but also in the comfort of patients and their  doctors in discussing sexual functioning. Most psychiatrists are not only comfortable in talking about it but are well trained in treatment approaches to complaints about sexuality.  We understand that there are a number of medical conditions which need to be ruled out from the onset. A full evaluation of patients psychological functioning is obviously also essential. For example depressed patients often have sexual problems. Drug and alcohol definitely effect sexual functioning. We also know that sexuality should not be viewed in a vacuum. The nature of relationships certainly effects sexual functioning.

Treatment approaches have a wide range of possibilities, which I hope we can examine in future blogs. Most psychiatrists and other mental health specialists today  do agree that we are now past the clitoral vs. vaginal debate.

President Obama in his State of the Union Address stated that he wanted to abolish policies that prohibited gays from openly serving in the military.  I am also glad to see that just this past month the American Psychiatric Association finally got around to supporting this position. “The U.S. should repeal Don’t Ask, Don’t Tell and allow capable men and women to serve without regard to sexual orientation,” said APA President Alan F. Schatzberg, M.D. Even more important a few days ago Admiral Mike Mullen, Chairman of the Joint Chief of Staff said it was his personal belief that “allowing gays and lesbians to serve openly would be the right things to do.”

I thought this would be a good time to consider the history of this issue and what if any psychiatric implications would there be to such a change.

Early 20th Century – Gays Not Welcome in Military

There is evidence that the US military had a policy dating back at least as far back as pre World War II that recruits were not welcome in the military service if they were homosexual.  There were indications as early as the 1940s that some psychiatrists (in this case Harry Stack Sullivan) tried unsuccessfully to get the US military to accepts gays into military service .

Harry Stack Sullivan

No doubt there were gays in the military but it would have to be hidden and secret. The identification of homosexuality would be grounds for discharge. I believe in the earlier years that would have been a dishonorable discharge. During my time serving as a psychiatrist in the Air Force during the Viet Nam War it would have an administrative discharge.

Psychiatrists in the military were in an ethical bind. If they put information about sexual orientation into the  chart the patient could be removed from the military. Should military psychiatrists ask and should they write it in the psychiatric record? Of course during about the first ¾ of the 20^th century homosexuality was officially considered a psychiatric disorder that in many cases was thought to be a condition that deserved treatment. Therefore one could understand if military leaders and even a compassionate military medical establishment would not want soldiers who were considered to be ill, to be in the military. Even though there was an increasing amount of understanding that this was a misconception and in fact the overwhelming majority of such soldiers did not feel in conflict and were not in need of therapy.

APA Eliminates Homosexuality from DSM

Alfred M. Freedman

In 1973 the American Psychiatric Association eliminated homosexuality from the official diagnostic manual. The history of how this came about and the implications of it for American psychiatry are quite significant. I had the opportunity to interview Alfred M. Freedman who was President of the APA at that time and he shared with me the behind the scenes activities which can be seen on You Tube in three sections or heard on Shrinkpod in it’s entity.

This acknowledged the changes that were taking place in most of the psychiatric community. It would still be some time before openly gay psychiatrists were accepted into the psychiatric establishment and were allowed to become professors of psychiatry or candidates at psychoanalytic institutes. Things were evolving…but not very much in the military.

President Clinton Officially Establishes Don’t Ask Don’t Tell

In 1993 President Clinton officially established the Don’t Ask Don’t Tell policy which essentially was saying that a gay person was welcome in the military as long as nobody knew about it. It did mean that recruiters were not allowed to ask nor were  military superiors allowed to do so.

It may not be so easy to picture the dilemma that a gay soldier who wanted to serve in the military would still have. They would be forced to lead a secret life and accept that the people around them would view them as a criminal worthy of punishment or at least banishment, should their true identify be known. It reminds me of the Muranos, the secret Jews who lived during the Spanish Inquisition. They had to pretend that they were someone else and would always have the fears of the dire consequences that would occur if they were discovered.

This policy has hit women in the military especially hard. Statistics on members of the military discharged under the ban showed that, though women accounted for just 14 percent of the armed forces in 2007, they made up more than 46% discharges for sexual orientation in 2007. Over all, the number of gay men and lesbians discharged from the military in 2007 rose to 627 from 612 a year before, according to Pentagon statistics.This is all occurring at a time when the military is having difficulty recruiting personnel , especially those with specialized language skills.

What Are the Concerns About Letting Gays Serve Openly in the Military ?

As with any piece of human behavior there can be conscious and unconscious determinants. No doubt some of the opposition to allowing gays into the military comes from underlying homophobia where there is a fear of close proximity to people who are gay. This can very well be based on unconscious latent homosexual impulses. Utilizing this line of reasoning to try to bring about change in US policy would not be very productive and most likely would only harden the resistance to reexamination of it.

However it may be useful to look at some of the rational arguments that have been raised. These concern the idea that soldiers, particularly in combat zones or where there are close quarters would be uncomfortable if they knew their comrades might have sexual attraction to them. This might lead to anxiety, poor morale and less military effectiveness. The same question was raised in regard to women in the military and as far as I know it has not been a problem.

More important there are many other countries which have gays serving openly in the military with no such problems reported. In one report 4 countries were studied in depth and they were Israel, Germany, Canada and Sweden. Military officials in each of these countries stated on the basis of their experience, the inclusion of homosexuals in their military has not adversely affected unit readiness, effectiveness, cohesion or morale. For example Israeli officials said that homosexuals have performed as well as heterosexuals and have served successfully in all branches of the military since 1948. Canada where problems in these areas were predicted said none had materialized

John M. Shalikashvili, a retired army general, who was Chairman of the Joint Chiefs of Staff from 1993 to 1997, spoke out on this issue. He described having  a number of meetings with gay soldiers and marines, including some with combat experience in Iraq, and an openly gay senior sailor who was serving effectively as a member of a nuclear submarine crew. He said that these conversations showed him just how much the military has changed, and that gays and lesbians can be accepted by their peers. He also quoted a Zogby poll of more than 500 service members returning from Afghanistan and Iraq, three quarters of whom said they were comfortable interacting with gay people.

One interesting question has been raised and that is whether or not such soldiers if they acknowledge their sexual orientation while on leave in certain Moslem countries could be subject to criminal prosecution there as some places have quite harsh laws against homosexuality. That reminds me that female military personnel in Saudi Arabia at one point were suppose  must wear black head- to-foot robes called abayas and ride in the back seat when off base. They could only leave base if a man accompanied them. The Air Force’s highest-ranking female fighter pilot sued to overturn this policy.  That is another story and such issues should not determine how the US decides to constitute our military forces. Good judgment obviously needs to be used when visiting  potentially hostile environments.

Conclusion

I do believe that we can take President Obama at his word and expect the Don’t Ask, Don’t Tell policy to be lifted. His Secretary of Defense stated recently that that the President and he can take this process only so far, as the ultimate decision rests with Congress. I believe we will see a change in policy this year and it will go smoothly. We will look back on previous policies as we look back on the history of other prejudices and discrimination, which have existed, in our history.

Barry Goldwater

I don’t find myself in agreement with Senator Lieberman from Connecticut too much these days, but I thought he put it very well when he echoed the words of  Barry Goldwater who said, “It’s not important if you are straight, just that you can shoot straight.”

Your Comments Are Welcome

If an American soldier is wounded and then dies or is killed immediately in Iraq or Afghanistan,  the President of the United States and The Secretary of Defense write a condolence letter to the family. However, if an American soldier is wounded physically and /or psychologically during his action in Iraq or Afghanistan and then commits suicide there is no letter of condolence written to his or her family by the President and the Secretary of Defense.

There are now more suicides among our combat troops than all those killed by enemy fire in Iraq and Afghanistan together according to a recent CNN Report on this topic. There have been 354 suicides thus far in the year 2009 which is more than the 335 total of combat deaths which occurred in Iraq and Afghanistan combined . While most of the suicides don’t occur until the soldiers have returned to the states at least one third have taken place in Iraq and Afghanistan. The US Army and the National Institute of Mental Health are partnering to assess risk and resilience in service members in an epidemiologic study of mental health, psychological resilience, suicide risk, suicide-related behaviors, and suicide deaths. While this is quite important, it does not address the failure of our leaders to knowledge the sacrifice of those psychologically injured soldiers who commit  suicide. This is a serious defect in our moral fabric.

While Presidents since Lincoln have been writing letters of condolence to families, there is apparently unwritten policy that this does not include families of soldiers who have committed suicide. It is easy to imagine how hurtful that must be to a family who is burying a son or daughter who came back from war with psychological problems and then committed suicide or perhaps killed themselves while still overseas. The New York Times recently wrote a story about one such family. After Gregg and Janet Keesling’s son, Chancellor, killed himself in Iraq in June, the family received a folded flag, a letter from the Army praising their son, a 21-gun salute at his burial and financial death benefits, but not a letter of condolence from President Obama.

A spokesperson for President Obama said that the policy in regard to who should receive a letter of condolence is currently undergoing a review.

What is Going on Here?

I heard one report state that many soldiers would feel that their comrades combat death would be somehow demeaned if the families of soldiers who suicided were given an equal letter of condolence. Another view is that treating suicide the same as other war deaths might encourage mentally frail soldiers to take their lives by making the act seem honorable. These ideas may be influencing the thinking of some our military leaders and perhaps the President. I hope not.

If this is the case it is misguided thinking which resurrects the stigmatization of mental illness. These conditions are not something that anyone chooses to have. This includes depression, post traumatic stress disorder and traumatic brain injury all of which can be secondary to combat experiences. Soldiers cannot will themselves to avoid these conditions anymore than a soldier can avoid a bullet aimed at their head or an explosive device that goes off under their vehicle.  While training and good support can reduce the odds somewhat but once you are in a combat zone you are vulnerable to injury. I also know of no evidence that people on the verge of suicide would be driven to do it because their family would get a letter of condolence.

There is a famous cartoon which shows a therapist giving a patient a large slap in the face while saying “Snap out of it”  and the title of the cartoon is “One Session Therapy”. If there is humor in this, it is because some people have the phantasy that it is that easy to put aside psychological injury. Anyone with knowledge about mental illness and clinical experience knows that it is not true.

A soldier who suffers to the point of  ending his or her own life, has to be recognized as someone who has suffered as much as anyone can imagine.

As far as the idea that some deaths deserve a letter of condolence and some don’t, consider this. If a soldier in Iraq is working in the kitchen and the stove catches fire leading to his demise, would this death be any less deserving of a letter of condolence than a soldier who was caught in an enemy ambush? Would the loss be any less deserving of the latter soldier if it turned out that he made a foolish tactical error leading to his being killed as compared to someone who was brave enough to fall on a grenade to save others lives? Of course not. Similarly, would you compare a soldier who faced many horrific combat situations and developed PTSD with another soldier who became severely depressed shortly after his  plane just  touched down in the combat zone if both ended up having intolerable suicidal feelings which led to their death? Would one family be deserving of a letter of condolence and another not? I don’t believe that we judge some soldiers deaths as being more worthy than others.

Yes, we do give out special medals and recognition  for unusual acts of bravery but these in no way diminish the sacrifice that others have made.

They Are All Heroes

All of the soldiers that we have discussed above would have volunteered to serve in the military and today everyone knows that this most likely could mean exposure to combat. For this they deserve our thanks and when they and their families have made the supreme sacrifice they deserve at least a letter of condolence.

Action to Fix This Situation

What can we do to see that the families of soldiers who have suicided be given the same letter of condolence as families of other soldiers who have died in the military?

We can a write a letter to the President of the United States, Secretary of Defense and our Congressperson and US Senator. Those of you who are mental health professionals should clearly state this in such correspondence and explain how you feel about this situation especially based on your understanding of mental illness. The email address to write to the President is :       president@whitehouse.gov       There is every indication your email would be read by his staff and a sample of them are often shown to the President.  If many of the readers of this blog were to write him a note it is bound to make an impression as this issue is under consideration by the President at present. If you would like some tips on how to write to the President I found this brief article .

We should also ask our professional organizations if they have not done so already to weigh in on this matter. I am writing a letter to my colleague Dr. Alan Schatzberg, President of the American Psychiatric Association (APA), requesting him to consider asking the Board of Trustees to pass such a resolution if this has already not been done. This last November I finished my term as Past Speaker of the Assembly of the American Psychiatric Association and left the Assembly. So while I cannot sponsor such a resolution myself anymore,  I will ask my former colleagues there to also consider doing so . Both the Board of Trustees and the Assembly must approve position statements in the APA. I would hope that once this organization takes it on they will be able enlist the support of our colleagues in the American Medical Association as well as other professional groups.

By all indications President Obama is a compassionate person and I believe that once he has the facts and has heard from the public including mental health professionals, he will do the right thing.

I welcome your comments on this issue.

About a year ago my wife and I relocated from New York to Southern California. After many months of remodeling our new home , building a home office and setting up my practice I thought we were  settled and I  was now a Californian. Then I experienced my first earthquake. It was a relatively mild one I am told. But for 15-20 seconds it was a little rock and roll in our new house. We had lived in San Francisco many years ago during my internship but I had forgotten what these shakes feel like and how helpless you actually are during these occasions.

Sorry Your Insurance Won’t Pay For Extra Medication

So not surprisingly, I was mobilized to action as people often are when they experience an episode of helplessness. I ran out and  bought flashlights , a crankable radio, picked up a months supply of water and a first aid kit. I even bought “museum putty”  a product I never heard of before which fastens objects on bookcases and shelves to prevent damage during a shake.  Then I went to my local pharmacy to be sure we had at least an extra  month supply of our prescription medications for our emergency kit.  By this I mean an extra month that would be in place even if the usual month supply or 90 day supply was running down. My pharmacist says sorry you are not authorized for such . Well of course I could get my physician to write it for me or being a licensed physician I could write the prescription myself. However the pharmacist informed me, of what I should have realized, that even if I had a prescription for an emergency supply of medication, my insurance prescription coverage wouldn’t pay for it. The same rules apply to online purchases.

People Can Run Out of Medication  During A Disaster

I am not a newcomer to the study  of disasters. I  had served on the Dimensions of Disasters Committee of the American Psychiatric Association.  For the past several years I have taught a course for psychiatrists at the annual meeting of the American Psychiatric Association  with a New Jersey psychiatrist Dr. Joe Napoli . I also edited a book in this area with Dr. Bob Ursano Chair of the Department of Psychiatry of the Uniformed Services School of Medicine . We taught the participants of our course about the common knowledge among disaster experts that the most frequently dispensed medication to people in the aftermath of a disaster is not a tranquilizer or a sleep medication but rather prescriptions for the everyday medications, which they take and now no longer have access to or have run out of them.

Just recently I read the position statement of the American Association for Geriatric Psychiatry about Disaster Preparedness  sent to me by Dr. Morty Potash, a psychiatrist from New Orleans . In it was mentioned the fact that during Hurricane  Katrina  more than 56% of the persons who went to the Astrodome for shelter, 5,846 persons, were older than  65 year of age. Similarly, access to needed prescription medications represented a significant problem. Obviously, it can also be a problem for people of every age. Furthermore, the most common visits to Houston  Texas Emergency Rooms by people displaced by Katrina were for refills of existing medications suggesting that the usual resources for refills were absent. It stands to reason that there is a possibility of medical offices  being made unavailable by the disaster, physician and staff being injured or predisposed caring for other victims.

A Reserve Supply of Medication is Needed

Patients will need to have at least a month supply of their medications. We are talking about  the common heart medications, blood pressure medications, thyroid , insulin and other hormonal treatment , antibiotics, medication for prostate and urinary  problems as well as cancer therapies and many less common types of treatment

Psychiatric patients will need access to their medications of course. Patients taking medication for panic disorder would be likely to have an exacerbation of attacks should they run out of medication and certainly the stress of an emergency situation would make this even more likely. Patients taking medication to stabilize a mood condition such as one of the bipolar mood disorders could decompensate as could a person with schizophrenia who no longer has access to antipsychotic medication . While it can take a few weeks, depression can reoccur after cessation of antidepressants.  The result of the return of serious depressive symptoms can be suicidal behavior . Research demonstrated that psychiatric medication among Manhattan residents following the World Trade Center Disaster increased.

As I mentioned, many people do get a 90 day supply of medication and may even have a prescription for three renewals .The ability of physicians to write prescriptions is regulated by the states with federal laws governing certain type of controlled medications. There may be some variations in different parts of the country . It appears to me that most states will not allow a full month supply of medication to be held on a continued basis ( with rotation if meds become outdated.) Also most if not all  insurance  plans do not allow or will not pay for  a renewal until a short time before the drugs run out which means that you can’t guarantee that you can put away a supply of medications for emergency planning.

It would seem logical that a physician should have the ability to write a prescription for an extra month supply of medication and provide instructions for rotations of the drug if there is concern about it being outdated. It also seems appropriate that insurance companies should pay for this extra supply of medication even though in most cases it won’t be used and will just be out there being rotated. ( I am sure the pharmaceutical companies won’t mind this situation.)

There Can Be Exceptions

It also is true that under some circumstances a physician may not want the patient to have more than a limited supply of a particular drug. This could be because the effects need to be evaluated before more meds are prescribed or perhaps because the physician may be concerned about potential addiction problems or even suicidal tendencies. In such situations the physician  properly might not write a prescription for extra medication  even if he or she were authorized to do so.

Can We Change the Regulations and Laws?

As a recent Past Speaker and therefore a member of the Assembly of the American Psychiatric Association I co-authored with several other psychiatrist including Dr. Napoli, mentioned above and Dr. Arshad Hussain from  Missouri who is  past Chair of the APA Committee on Dimensions of Disaster, a resolution to have the American Psychiatric Association to investigate this situation and advocate with other groups such the American Medical Association on the national level and State Medical Associations on the local level  so legislative regulations are altered to facilitate this aspect of disaster planning. This was approved by the Assembly in November in Washington D.C and I am hopeful that this organization will take up the advocacy with other interested parties mentioned above as well as with government agencies and.  insurance companies. I also spoke with my California State Assemblyman ( who happens to be my son ) who will look into this issue further in my state. These types of changes don’t occur quickly or easily.

Can You Survey Your Local Situation  ?

Although this weekly blog has only been up for a little more than two months we know that we are read in many states throughout the US as well as many countries. Can those of you who are iinterested in this issue check it out and determine if the average person can get an extra supply of medication for emergency preparedness where you live and would most insurance companies pay for it? Please send a comment on your findings to this blog ( below ). We will put it on within 12-24 hours. Perhaps we can get the data that will motivate those who make the laws and regulations. The power of the Internet can also help us get such information to the people who can make differences on  this issue both in the US and elsewhere. Lives could even be saved in the next disaster event.

Your Comments and Data on this Topic is Welcome