FREDERICK DOWNS, JR., CHIEF PROSTHETICS AND CLINICAL LOGISTICS OFFICER: Well that’s because it’s my job to stay on top of the technology and what’s out there and we have our own process who, of course, are staying on top of what the technology is. And me, my staff, we have on trade all the research projects that are going so we need to be right there when that product is ready to go into the market.

LAMB: What do you do?

DOWNS: Well …

LAMB: What’s your job?

DOWNS: That’s a job is …

LAMB: Where though? Give us the background for those …

DOWNS: Oh, OK.

LAMB: … who don’t remember you.

DOWNS: Well I’m the Chief Prosthetic and Clinical Logistics Officer for the Veteran’s Health Administration for the VA. And I’ve been the chief in charge of prosthetics for 28 years. One of my jobs when I came in 28 years ago was to ensure that all American Veterans would be able to get state of the art prostate equipment. And so that, from the beginning, has been my task, my mission and since I use these devices and me and my friends use these device is why I have a personal interest in it but, of course, it’s the mission and it’s a mission that I love. And so what is going on out there? What is happening? And the world – for the Veterans of America, they deserve the best and Congress and – has ensured that they will provide them the best. It’s my job to make sure that we’re on top of that.

LAMB: Years ago we talked about your prosthetic and we just showed the audience that you are wearing an artificial arm. People can read the original interview on booknotes.org but give us the synopsis of how you lost your arm.

DOWNS: Well I was an infantry lieutenant for the U.S. Army in the fourth division, third brigade, first of the 14th infantry and I was in the northern part of South Vietnam, right south of Chug Lai and in January 11th, 1968, I stepped on a Bouncing Betty landmine, which came up out of the ground and exploded waist high and blew off my left arm right about there and I suffered grievous wounds over the rest of my body. And then I spent a year in an Army hospital, Fitzsimons Army Hospital in Denver, Colorado and then that’s when I was first introduced to the VA by the way. They came into the hospital and said when I got out of the Army, why they’re going to send me to college and help me get back on my feet again. And so that was a great revelation to me. Good news.

LAMB: I want to show our audience a little clip from the Booknotes discussion and we’re talking about this very same thing.

(BEGIN VIDEO CLIP):

UNIDENTIFIED PARTICIPANT: It was a catharsis for me. I want to talk about what had happened to me in the war rather than hold it inside. And I think that was a healthy thing to do because for one thing it was the most alive time, the most vivid time of my life and – this was the fourth time I’ve been wounded,. We were in a lot of combat. You’re a young man – I was the second oldest man in my company, I was 23. The commander was 24, so the men with us were 18, 19, 20 years old. And at 23, I was considered an old man. I wish I was 23 again. But just leading those men in combat, keeping them alive, fighting the enemy, the intense combat we were in, I found later we were in one of the five provinces in the south that was never pacified. And it was so intense that it’s going to be in my memory cells forever, very vividly parts of it, certainly. And you can’t get rid of it. You can’t hide it. You can’t deny it, it’s there, and so you must deal with it and go on with your life.

(END VIDEO CLIP)

LAMB: Well if you wanted to be 23 back in 1992, how does it feel today?

DOWNS: Well let’s see. I just had my 64th birthday late last week and 23 would be really nice on my body, all of these aches and pains. But it’s been a wonderful life. It’s been good.

LAMB: How many books have you written?

DOWNS: Three books. The first one was the ”Killing Zone: My Life in the Vietnam War” and that covered that period of time when I was in Vietnam in ’67 and a little bit in ’68. Then ”Aftermath,” that takes place that year in the hospital, what it was like to go through that process and recover and get adjusted to my new kind of life. And then about 20 years after that, General John Vessy (ph), Former Chief of Staff who was President Reagan’s presidential emissary to Vietnam on POW MIA affairs. Well he sent me over there to review the Vietnamese prosthetic program. And so I wrote a book about those experiences. I made about 13 trips and I wrote about the first four trips and it was called ”No Longer Enemies and Not Yet Friends.”

LAMB: Michael Weisskopf, a ”Time” magazine reporter lost his hand and he was here and showed us the hand, which is – what would you call if it rotated electronically? What are those called?

DOWNS: Those are MyoElectric. MyoElectric hands and their – I have what’s called a Body Power because mine is mechanical. It – well it’s – this was the model I was introduced to in 1968. They didn’t have MyoElectric in those days. And so I’ve been use to wearing this for 40 years now but it’s controlled by a harness behind my back and it’s two cables and that – I’m able to move the arm up and down and move this open and so that’s functional for me. But now with this generation they have the choice of using MyoElectric. And my residual limb, my stump fits inside a plastic socket. Well with the MyoElectric, that can have sensors on the inside of that socket, a little guide wire that goes down to the cervil (ph) mechanisms in the wrist or the hand and when you send a signal down your arm, that little sensor can pick up that signal and translates that to a mechanical, to a cervil (ph) mechanism, that’s what causes the gears to turn and the hand to open and close by flexing your bicep, your bicep or your tricep or one of your other muscles that they can cover with a sensor.

LAMB: How many – I’m not sure of the exact word of it – prostheses have been used since the Iraq war started?

DOWNS: Well since the Iraq war started, there’s been about – and this numbers pretty close – about 780 major amputations since the war started and, of those, all of the soldiers, men and women, are fitted with MyoElectric upper extremities and, for lower extremities, they’re fitted with computer knees, computer ankles and the – so everyone of them is fitted with it. And they also are fitted with the Body Powered and they’re also fitted with the non-functional, it’s a cosmetic arm. Just it looks nice. It’s a hand and it doesn’t really do much but – they have all three choices that they’re provided and then they can adjust to whichever one they want to use.

LAMB: How many folks who have lost limbs from Iraq have you met and, of those you’ve met, which one had the biggest impact on you?

DOWNS: Well I’ve met nearly, up until last year or so, I’ve met nearly all the amputees at Walter Reed and because I go out there on a regular basis to visit them both as a pure visitor in a professional manner – the ones I think – it’s hard to say. Tammy Duckworth certainly had an impact on me.

LAMB: Why?

DOWNS: Because she was a female, had a lot of spirit. She was a helicopter pilot. She had lost both her limbs when her helicopter was shot down and had that fierce determination. Same way with Dawn Halfacker, she had lost her arm. She was a West Point graduate and also the same kind of spirit. And I saw that with, of course, many. Some of them stick in my mind more than others but, to me, I would always go back in time to when I was in that bed and I would look at them and I would see that they had a whole future in front of them but they couldn’t really see that. And some of them affected me more than others. Sometimes when I go home I’d just be – I’d tell me wife I just emotionally was very difficult for me because to see their bodies all torn to shreds and – even though I knew they would heal, I knew that their future was in front of them, for that moment of time when I’m there visiting, some of the soldiers were such – in terrible condition it just had to affect me.

LAMB: Because – and I know you don’t we have this clip. We have – Connie Doebele, our producer on another program she’s doing, went out to Chicago to interview Tammy Duckworth and she ran for Congress. You see her there on the screen. You’ll see in this clip that her husband’s sitting right next to her and this is for a special that will run later. But let’s watch a little bit of this and maybe you can explain how the VA gets into this.

DOWNS: OK.

(BEGIN VIDEO CLIP)

TAMMY DUCKWORTH: I own I think four pairs of legs and they’re for different uses like – well this is my primary pair that I walk with, then I have a backup pair. I have a pair of swim legs that I use for going into the ocean for exercise, that sort of – you want to do water aerobic. I have a pair with just a power knee, which they were testing out on some of us coming out of Walter Reed. It’s actually the first truly bionic knee and it actually has a motor in it and I’m testing that out. It was meant for a person with a single leg amputee but they were – the amputees at Walter Reed are strong enough and were showing that bilaterals can do it and so I use that one mostly to walk on the treadmill because it actually improves my gait. But in terms of each of the legs, I’ve gone through many versions of the same leg. The knee stays the same. The component – the microprocessor stays the same but the rest of it where it fits on my body changes because (ph) my body changes shape as I heal and change.

CONNIE DOEBELE: And is that true for all amputees? Things change as their body changes?

DUCKWORTH: Yes. Things change as your body changes and also as you become more or less active over your lifetime and it’s expected that you will continually have to get new this part, this is called a socket. It’s like a sleeve made out of carbon fiber that your leg fits inside and so this part will need to be changed periodically throughout the rest of your life.

DOEBELE: Is it difficult to take that one on and off?

DUCKWORTH: No. No. It’s very easy to do.

DOEBELE: And on this leg, how do you move it at the knee?

DUCKWORTH: I actually put weight – when I’m standing, as I walk and that leg is behind me, as I’m starting to take a step, I push down on my hip and push down on the toe and then the leg actually propels itself. It’s got a microprocessor that calculates an algorithm 50 times a second and measures my pace, my stride length, my balance and it keeps me upright and if I start to stumble, it locks the knee up and prevents me from falling.

(END VIDEO CLIP)

LAMB: As you watch that, what do you think?

DOWNS: I think it’s great stuff. It’s wonderful. I – she’s getting to try all these new things. Those are provided to her by Walter Reed. The VA provides the same kinds of different devices to any of the Vets that want them. But to me it’s exciting to see that because 40 years ago, there psychologically there was – people wanted to hide their prosthetic device because their alien. Now time has passed over the 40 years and peoples’ attitudes have changed. The soldiers coming back are welcomed back, which is a big difference. And they’re being introduced to this high tech stuff. They’ve sort of been prepared for it through the movies and TV with the robotic cops and Terminator and that kind of thing. So they’re expecting – they’re expecting and have high expectations about high tech devices. They want them. They’re anxious to try them. They’re eager. And you can see her attitude there. She is very upbeat and she’s not afraid to show off those devices and explain how they work and it’s another evolution as prosthetics moves forward.

LAMB: What’s your budget for this year?

DOWNS: My total budget for this year is about $1.3 billion and that includes all prosthetics and the VA everything that goes to replace or supplement or aide bodily part or function is considered a prosthetic. And so I have what I call centralized funding so I get all the money that we need in the VA to provide these prosthetic appliances, whether they’re arms, legs, wheelchairs, surgical implants, whatever.

LAMB: Do you need more money?

DOWNS: No – well, no. I’m – we’re given all the money we need. Congress makes sure we’re funded. The secretary of the VA, the under secretary for health, that’s – they – that money comes off the top. That’s centralized funding for prosthetics. So before anything else is funded, that money is put aside so that there’s no shortage of dollars for prosthetics for the veterans.

LAMB: How many prosthetic devices will you give a soldier or someone that’s been wounded?

DOWNS: As many as they need. The idea is – in the old days, when I first took over, it was – you got like one and that was it for a while until you needed a replacement. But, of course, the devices weren’t as sophisticated then either. Now you have a wide range. So as you just saw Tammy. She has five legs, I think. So let’s say you want to run, you want to walk, you want to swim, you want to ride a bike, you need a different prosthetic limb for each one of those or different fittings. So you’re provided all of those. And so it depends on what you want to do. The idea of healthcare and the VA in the mid ’90’s went to a holistic sense of how they take care of people so that we want to make sure your quality of life is good, your quality of healthcare is the best it can be and how do we make that happen. We do it through our medicines, through our clinical applications of the technology that’s available and we need to make sure that that technology is there and it can be prescribed, then people are taught how to use it, taught how to take care of it and then we replace it whenever the person needs it replaced. Some people wear their stuff out real fast. Others are not as active; they don’t wear it out so fast. But whenever they need it replaced, it can get replaced.

LAMB: Why did you decide never to change yours?

DOWNS: Well there’s a couple of reasons. First, I’m use to this. But the other thing is the training required. The training required is that you got have a number of days and weeks to figure out where the sensor is and then they have to work with you and you have to train your muscles to move arm up and down, rotate, this, that and the other and I don’t have the time to do that. And I’m perfectly happy with what I’ve got. I’m use to it but I’m – as a matter of curiosity, someday I want to – if I ever get some time, I want to get fitted up with the MyoElectric so I can do a comparison myself but there’s no reason why I couldn’t except just habit.

LAMB: You hear two things about the Veteran’s Administration. One, it’s the greatest medical system in the world. And secondly, our callers who are veterans who call in and complain about just about everything you can imagine.

DOWNS: Yes.

LAMB: Which ones right?

DOWNS: Well …

LAMB: … people on the VA or the …

DOWNS: You got to look at the balance. Yes, we do provide the highest quality healthcare in the world and last year it was to 5.5 million veterans. Well – but we are like any system, we have our faults, our problems. What makes us unique is that we are responsive to those calls from those veterans that are complaining and we do our best to make sure we are responsive. I have a Web site. You can go into that Web site and send me messages. The VA is very receptive to whatever complaints we get, it’s our job to jump on top of it and human nature being what it is, we can’t solve all the problems and sometimes the problems aren’t entirely ours either but we are responsive.

LAMB: How many people work for the VA?

DOWNS: About 230,000 I believe.

LAMB: How many different medical facilities are there around the United States?

DOWNS: There are 154 medical facilities. We have about 800 – I’m not sure – about 830 outpatient clinics that are associated with those facilities. The idea is to outreach to those veterans in their area where they live.

LAMB: Two-hundred and thirty thousand, what – is there anyway to breakdown what they all do? And I know …

DOWNS: Oh, well, off the top of my head, probably 200,000 of them work in Veterans Health Administration and then I’m not sure how many thousands work in Veterans Benefits and then there’s the National Cemetery Service, those are the three administrations – those – we take care of the vet, the benefits, the hospital and then burial of the veteran. So we take care of that. And then we have an administration and that’s at our (INAUDIBLE) offices and at our central offices.

LAMB: What are the advantages – I use that term loosely – to an individual who’s gone to war in the United States and has lost a limb that say the other veterans don’t have? What kind of things can your – from an education standpoint, what provided for you for your whole life after what’s happen to you happened?

DOWNS: Well, first let me state it – if you’re going to be in the military anywhere in the world and get hurt, you want to be in the American military because we take care of our vets. They provide – I’m using myself as an example. They sent me back to college. I got an undergraduate degree. I got my graduate degree.

LAMB: Where did you get those from?

DOWNS: At the University of Denver. University of Denver in Denver, Colorado. Then they help me buy my first car. I got a stipend towards that. And now they provide a damp (ph) of equipment, levers, special – whatever special gears I need or special levers I need to adopt the car so I can drive it. And then they also helped me buy my first house and …

LAMB: In what way? VA loan?

DOWNS: … with a – a GI loan and – also I get a benefit check each month from the government. It’s tax free.

LAMB: Is it very big?

DOWNS: Yes, it’s – well it’s – you can’t – you can’t live totally on it but it’s a supplement to your life. So whatever else you make, that’s an addition to it. So you don’t – they don’t – the VA doesn’t look at your rank or anything else. They judge on your disability. What’s your disability and then they give you a rating based on that and then you receive that the rest of your life and you get a cost of living increase each year.

LAMB: What are you rated as far …

DOWNS: I’m rated as 100 percent. I got 70 percent for loss of my arm and then something like 50 percent for loss of use of this arm, which is severely damaged and then other percentages on the rest of my body and so they don’t add up to more than a 100 percent, they can’t do that but they have a form that they use so it comes out in my case to 100 percent. Now if I was spinal cord injured, if more grievously wounded then they have an A and a B and a C, so you have different categories so that your – the idea originally was to make sure that the veteran would not become destitute just because they were wounded.

LAMB: When you hear stories about vets, homeless vets, what’s your reaction when you hear that?

DOWNS: Well a reaction when I hear that is that’s a mental health issue in most cases and we do our best to reach out to those veterans. We have lots of folks that are working hard to outreach to those veterans, find out where they are, try to get them enrolled in our programs. There’s lots of activity going on in that area. A homeless vet is like the homeless folks you see here in the city. Sometimes they don’t want to – they don’t want to go into the institutions to be helped and so we have people who are out on the streets to try to outreach to them. So it’s a mental health problem. They are fellow veterans so we want to make sure we’re taking care of them and we do the best we can with those folks.

LAMB: What happens if a veteran doesn’t think he or she’s getting what she deserves? Where do they go?

DOWNS: They write their congressman and they write their senator. They write the President of the United States. The write the secretary of the VA. They write lots of letters. They contact – they have – and there are lots of conduits to get a hold of us. For instance, the Veterans’ Service Organization, American Legion, VFW, Disabled Veterans of America, Blind Veterans of America, they all have service officers who will take the case and will help work it through the VA. So there’s lots of conduits for a veteran who has a complaint to get the word to us.

LAMB: What if people watching saying he’s just an apologist for the place that he works, 28 years there and he’s drinking the Kool-Aid? I mean – do you feel that this country could do more for a veteran?

DOWNS: You know you can always think you can do more but you have to be rationale, realistic. You have to live within a budget. So we try to take care of all those veterans who enroll in our system and we try to make sure that all that care, they have good access. We try to make all that stuff happen but there are some days that – you know we have over 200,000 employees and all the – reach all over the United States and all over the world. So, yes, we make mistakes. Sometimes we have a bad attitude from an employee who had a bad effect on a veteran. Sometimes we have new employees who don’t know the rules and regulations. So that’s a constant miluse (ph) of issues we deal with every day. That’s part of our job is we’ve got to keep aware of the training. We have to keep aware of what are the issues, keep avenues open. That’s one thing about our system. Yes, we do have our problems but people can complain and we do respond. Now we don’t solve every problem. We can’t solve every problem. Sometimes problems are not solvable. Some people we just can’t make happy regards to what you do.

LAMB: So if somebody thinks that they need to appeal the decision, who makes the decision that you’re 100 percent disabled?

DOWNS: That decision is made first at a regional office and that’s the Veterans Benefits Administration. They look at your medical record. They make a decision. They adjudicate it. If I disagree with that, I can appeal it and then it goes back – further up the system and then the element is a board of Veterans Appeals, which is completely separate from the VA.

LAMB: How does that work?

DOWNS: Well that’s a – it’s – they have judges who make that decision.

LAMB: Who appoints the judges?

DOWNS: Those judges are appointed – I’m not sure I can answer that one. I think those are appointed by Congress. I’m not sure. You got me on that one.

LAMB: OK. So you don’t know whether they’re approved by – they have to be approved …

DOWNS: They have to be approved. Oh, yes. They’re bedded and they’re approved. I think Congress has to approve them. Yes.

LAMB: So the President would nominate them and then Congress would approve?

DOWNS: Well I can’t say that with confidence.

LAMB: What’s the difference in your attitude today? What’s happen in your own personal attitude about war and, again, if people want to read the description of how you were wounded, it’s a lot more extensive, they can go to booknotes.org, but what’s your attitude about your experience all these years later?

DOWNS: My experience …

LAMB: Have you changed at all? You’re …

DOWNS: I’m still gung-ho.

LAMB: You were Army.

DOWNS: I was Army and infantry. Army – when the war started and they had those news reporters who some had the ability to send pictures back of the tanks as we go down the road, like I wanted to be with them. I mean it was strange after all those years. Why would I want to go back into that mess? But – so there was that part of it. And then there was the realization after 40 years and working with these soldiers that I see come into the hospital, the tragedy of war but – and you hate it and now my daughter’s in the Marine Corp, she’s a lieutenant in the Marines and so I – my wife and I worry about that but my wife’s father, he was a Marine. He was killed at the end of World War II. And of course I’ve been through the war and so we understand the consequences of it. What you have to do is hope that your – we feel it’s a duty and obligation, my family, to serve your country. And what we hope is that our leaders are making the right decision so that if we go to war, we’re doing it for the right reasons and we have to trust that judgment.

LAMB: How did you get into the military in the first place?

DOWNS: I enlisted.

LAMB: You weren’t drafted?

DOWNS: No. I enlisted.

LAMB: Because the Vietnam War was a big draft war.

DOWNS: It was a big draft war but I was gung-ho and the fact that I was anxious to get into the war. I’d been brought up – my dad and all his friends were in World War II and I’ve been brought up listening to them tell their stories and, of course, I loved to read books and I read about all those things in war and I wanted to go to war. And I was a romantic about it before I went. I became quickly disabused that idea as soon as I got into war but that’s – I enlisted and then I went to OCS and then I was at Vietnam.

LAMB: When somebody loses a limb, what’s the different processes they go through?

DOWNS: First you go through, my God, it can’t be. It’s impossible. I want to go back in time five seconds. I want to change – you just reject the whole idea. I can’t tell you the depths of depression I went through immediately. As I was flying through the air and just a jagged bone, my arm was gone. And then fierce determination to survive long enough for the helicopter to get there and pick me up, I wanted to live and – as bad as I was. And then when I came to, after – then it’s the resignation of how bad is it and then you have to go through a period of adjustment. This is the way my life is now. Of course, I – you think so many what ifs during the time you’re laying in the bed and you’re in all that abject misery and pain. You hate people. You hate God. You just – you go through all kinds of stuff because you’re trying to get yourself back together.

LAMB: Were you married at the time?

DOWNS: I was. I was. And so you’ve got to think about your family and I worried about my job. And then you go through a period where you’re going to say, OK, this is the way I’m going to be so I’m going to get on with it now. You got to make that adjustment and then your spirit comes back to you.

LAMB: Are you still married to the same woman?

DOWNS: No. My wife at that time – in those days, I didn’t get to see her for a long time. So I got wounded in January and March, I think it was March, she came out to see me, walked into the hospital and there were thousands – over a thousand of us wounded in the hospital with all kinds of grievous wounds and I think the shock was great for her and so our – our marriage dissolved over – in a short period of time.

LAMB: Was it directly a result of losing your arm?

DOWNS: No. I think it contributed to it but, frankly, we were both young and that probably had a lot to do with it, immature. But – and then being in a war, being separated, those are all traumatic kinds of things for a person to go through.

LAMB: How soon after that divorce did you remarry?

DOWNS: Not too – let’s see. I got married in the same year, about five, six months later and we’ve been married 40 years now.

LAMB: And where did you meet her?

DOWNS: When I was in the hospital, I met her – one of my buddies who had lost his leg in a landmine was dating this lady who lost her leg to cancer, so we were at the Officer’s Club one night and he’s getting ready to go see his girlfriend and so we said why don’t you take us with, does she have any friends, they did and so we went down the street in downtown Denver there and walked into the house and met her and bingo that was it.

LAMB: The reason I’m asking this is I wonder what her reaction is. She met you with someone. Were you wearing …

DOWNS: I was wearing – yes, I was wearing my artificial arm and – because that was the question that you have. Are women going to be interested in me? What will people think of me? And as I tell new amputees, if you’re comfortable with yourself and then people will be comfortable with you and so I was comfortable with myself and so she just didn’t bother her at all. She was curious like anybody would be but …

LAMB: One of the toughest interviews I’ve ever done and one that I can remember the most was Lewis Polar, Jr. (ph).

DOWNS: Yes. I knew Lou (ph).

LAMB: He wrote a book called ”Fortune Sad (ph)” and his father was Chester (ph) poor but I remember him sitting across from me with only one limb left.

DOWNS: That’s right.

(CLIP OF PULLER FROM 1991 BOOKNOTES)

LAMB: He eventually committed suicide. And in the book he even talks about the relationship – their physical relationship after this is all over. How much does that impact the depression thing you’re talking about? The amputees you talk about coming back that you meet at Walter Reed.

DOWNS: The – it’s part of your building your psyche back up again. You wonder about job, sex, family, friends. How are they going to look at you when your bodies completely different? That’s when you have to come to a realization yourself that I’m still the person I was. I look different and my body’s torn up but my friends, I still value my friends, I still love life. You make that realization and you have lots of questions about well are people going to look at my hook, are women – if women are turned off by this, then that’s not the kind of person you want to be around anyway. And so was you find is human nature being what it is, people accept you for the way your are.

LAMB: How often during this Iraq war have you run into amputees that their personal life has gone bad because of what’s happened to them?

DOWNS: A couple of times but it’s – again, it’s – these folks are older than my generation. They’re professionals for one thing. Their professional Army so they’re older. They’re more mature for the most part. Their marriages are established. So I see lots of support. I don’t know, of course, all of them. I deal with amputees mostly. But, again, the soldier is older and his family is older and they have children that they have close connection to so they make the adjustment.

LAMB: You’re talking about the Army hospital, Walter Reed, and you work for the Veterans Administration. Is there good communication between the two and if you get prosthesis at the Walter Reed hospital, how does that transfer, once you get out of Walter Reed, out of the Army and you’re living under the Veterans Administration?

DOWNS: And that’s a good – the reason that’s a good question is at the begin – we have a good relationship, the VA and DOD both, all – we work very hard to try and make sure it’s seamless between when they come from active duty to veteran.

LAMB: DOD means the Department …

DOWNS: The Department of Defense and whether it’s Bethesda or wherever it is. We’re working hard. Well at the beginning of the war, we had our routine, both DOD and the VA, and we thought we were copasetic. Well it turned out we weren’t. There was a miscommunication. Soldiers would show up at the VA hospital when they were home on convalescent leave and the VA would say, well, you can’t – you’re active duty so you can’t come to our hospital. You have to be a veteran. Well soldiers didn’t have time to differentiate between DOD, appropriated dollars and VA appropriated dollars, so they just thought it was the VA that was turning them down or the Army or whatever. So we had lots of problems there. And, of course, in these days, if a veteran has a problem and he’s a young soldier, they put it on a blog or something and then at the speed of light it’s around the world, that the VA’s not providing good care. So we had our share of public relation issues at the beginning of the war and still somewhat bothers us but we’re working hard, seamless transition, trying to make sure that we get the names of all these soldiers, that they are discharged, then we have people assigned to – try to have a case manager signed to each one of them. So there’s lots of activity going on but it did catch us by surprise at first because we thought we had it set up. Well we worked hard in the last year, since the war, that corrected to make it work. And now when they’re providing a limb in the Army, many of them still like to go back to the Army but when they go home, they get use to being in their situation. They go to the VA hospital, we’ll provide them whatever replacement, new arm, new leg that they have, that they’re wearing so we make sure that whatever they have, they can get it through the VA.

LAMB: What’s the most expensive prosthesis?

DOWNS: The most expensive one? Well you’re looking at some of the – some of the electric arm, some of the combination of hands, 110, $120,000.

LAMB: You pay for it all?

DOWNS: Yes.

LAMB: Every penny.

DOWNS: And the VA.

LAMB: Veteran has no …

DOWNS: The veteran has no – doesn’t pay – pays for nothing. We pay for complete prosthesis, the repair, the service, replacement.

LAMB: How fast can you get a new arm?

DOWNS: As fast as it takes – let’s say – this arm here – for instance I’m getting ready to replace this one because it’s getting old and it’s …

LAMB: How old is it?

DOWNS: I think it’s about three years, about three years old. So I’ll call the VA hospital. They’ll have me come in for an amputee clinic team so they can schedule that within a week or two.

LAMB: What did you call it?

DOWNS: An amputee clinic team. It’s a team, a physician, a prosthetics, PT or OT prosthetic rep, you go before them and you say I want a new arm, I want to try a new MyoElectric arm. So they’ll write the prescription and then I take that prescription to my prosthetist and that can be a VA prosthetist or it can be a private prosthetist. They fabricate the limb for me and that fabrication period takes two, three, four, five weeks depending upon a lot of factors. They fabricate it. I’m fitted with it and when I’m happy with it, I go to the VA amputee clinic team, they say am I satisfied with it and if I am then they check it, OK, then they authorize payment to go through the process. So that period of time takes weeks, a month, two months, depending on what type of limb it is and the complexities of it and the backlog they may have.

LAMB: How many different places in the country can a veteran go for – to meet with a prosthetic team?

DOWNS: OK. We have amputee clinic teams at all 154 of our medical centers and then we have 21 special poly-trauma (ph) centers, which we also have our amputee centers – they’re not centers of excellence but they’re amputee centers of care, I’ll call them that, then we have 64 of our prosthetic labs associated with some of those facilities. Then we have 600 contracts but private contractors around the country. Now – so the veteran can go wherever he really wants to go. If, for instance, he wants to go to someone – his prosthetist who doesn’t have a VA contract, if that prosthetist agrees to the VA price well then we say fine, go ahead and fabricate it. Our job here is to make it as easy as possible for the amputee to be serviced and get that limb replaced.

LAMB: What about the rural people, people that are fair away from these centers?

DOWNS: Well that’s just it. They have – where’s their closest prosthetist. They’ve got to go where there’s a prosthetist. Now in Indiana, where I’m from, I would have to Indianapolis to the closest prosthetist and that’s about 70 miles.

LAMB: You’re from originally?

DOWNS: Around Crawfordsville, Turkey Run State Park on the western side of the state. So it’s about 70 miles to Indianapolis. And in Indianapolis there’s a VA hospital and there’s also a number of private prosthetist in that area that could fabricate that limb for me.

LAMB: I know there’s statistics, World War II, Korean War, Vietnam War and the Iraq War on the number of people wounded who survived. What’s changed? What’s the difference?

DOWNS: I don’t know the numbers of what’s changed but the survivor rate is much higher.

LAMB: I think I read you wrote somewhere 95 percent survived the Iraq War where 60 percent survived the World War II.

DOWNS: Somewhere like that. Sixty percent – in Vietnam it was 60 percent, 60 percent survived World War II, about 70 percent survived in Vietnam and about 95 percent are surviving in this current war and it’s because of the body armor. It’s because of the medics on the field; each person now is carrying first aid equipment that we didn’t dream of back then. Stop the blood – stop the bleeding to the bandages that they use now have chemicals in it and I don’t even know all the terms. It’s just fascinating what they’re able to do to stop the bleeding and control the trauma right there, then they quickly are able to transport them back to a hospital and they’re back here in the States within two days.

LAMB: Why did your daughter, who watched you all her life deal with only one arm in an era where there’s no draft, why did she decide to enlist in the Marine Corp?

DOWNS: That’s a question her mother and I ask too. But she’s explain – she said, dad, ever since I was in the fifth grade, I’ve wanted to go into the military and I guess I was some kind of a role model for her on that and she’s always been an adventurous person. So I ask her why didn’t you join the Army? But she finally – she graduated from college and then she informed us she was going to join the Marines.

LAMB: Where did she go to college?

DOWNS: University of Denver.

LAMB: So she did follow in your footsteps there.

DOWNS: She did. And my wife also graduated from the University of Denver. So we have a legacy there. The – both our girls are Kate and Abigail are fiercely independent and think for themselves, so – and are patriotic, got full blood of heart and spirit. Both our girls are of the nature that they’re going to do something for their country.

LAMB: You played a major roll in this network back in 1992 with your book, ”No Longer Enemies and Not Yet Friends” on Vietnam because we went to Vietnam and followed the John Kerry committee around looking for POW’s and MIA’s for a week. When you look back on your experience with General Messy in Vietnam and now we recognize Vietnam, we have relations and all that. Is that a good idea?

DOWNS: Oh yes.

LAMB: Why?

DOWNS: It’s a good idea because well they were our enemy then but there’s no need for them to carry on and be an enemy forever.

LAMB: How many times have you been back?

DOWNS: All together I believe it was 14 times.

LAMB: And how did they deal with – how many amputees did they have compared to the United States in Vietnam?

DOWNS: Well they reported 300,000 amputees at the time when I went over. And as far as I know how that was validated, we didn’t question it one way or the other. It seemed plausible considering how long the war had been going on and the combat that occurred in that country. And we kind of moved north and south Vietnamese. We wanted the South Vietnamese amputees also to be taken care of in addition to the North Vietnamese amputees so there were lots of politics involved there with that whole process.

LAMB: Do we spend any money today on the Vietnamese, the South Vietnamese that are here in this country on amputees?

DOWNS: No. No, we don’t do that.

LAMB: They don’t have any access to …

DOWNS: They have – no, they don’t have any access to – they were not American soldiers.

LAMB: So back to the original statement we talked about, America’s veterans receive the best prosthetic care in the world you wrote back in February. What did the rest of the countries do about this?

DOWNS: Well the rest of the countries they don’t do as good a job. You have your – I mean, in my opinion, they don’t do as good a job because they don’t have the same healthcare system that we have. I know they have socialized medicine in certain countries but, again, when you talk to those countries and how they provide artificial limbs, it’s not always top quality. It’s not always the number that they wish and many times they have to pay for it themselves. Russians, they are an example of a country that doesn’t provide state of the art limbs to their soldiers and so it’s spotty all around the world.

LAMB: How much money do we spend on the Veterans Administration on yearly basis total?

DOWNS: On a yearly basis, I’m not sure I’ve got the numbers – in the health area, which I’m familiar with, is $32 billion.

LAMB: Is it enough again?

DOWNS: That’s a – yes, it is enough. We have enough money to take care of the veterans. What is – what remains unclear is we have a number of veterans who are enrolled in our system, they have to be enrolled before we can take care of them and this was designed over a long period of time but how Congress wanted the VA to operate. So we have 7.5 million veterans enrolled of which we took care of 5.5 million last year. So we have enough money to take care of that. Those are not the issues. The issue is who’s not in. Which veterans are not allowed in the enrollment because originally after end of World War II the VA was to take care of service connected combat wounded individuals, of people who had been hurt when they were in the service. As time evolved over the decades, when more and more non-service connected were allowed to come into the system. For instance, when I first came into the system almost 37 years ago, the ratio of service connected and non-service connected was depending upon the type of medicine. It could be as many as in our area of prosthetics, 60 percent service connected and 40 percent non-service connected. In the last 28 years, that’s switched. So now the majority of our patients are non-service connected. And these are veterans who had something happen to them outside their service but they don’t have access to healthcare, many reasons that they would come into the VA and we want them to enroll and take care of them if we have the capacity. So that’s always an issue back and forth, do we have enough capacity taking care of those folks.

LAMB: You’ve been at the VA for 28 years?

DOWNS: I’ve been in the VA for 34 years, seven of those years were with the benefits administration and the other remaining have been with the Veterans Health Administration.

LAMB: And your job and you’re not a political appointee?

DOWNS: No.

LAMB: Sixty-four years old, what makes you mad and how often do you get mad and what do you do about it when you’re in the middle of this bureaucracy?

DOWNS: Well I’m tenacious and my belief is that we spend gazillions of dollars blowing things up and planes crashing, tanks getting destroyed, so it doesn’t take that much money to take care of a disabled veteran so we need to make sure we keep our priority in focus. So I’m very intense about making sure that all our veterans receive the prosthetic device they’re suppose to get, that we have the money for it, make the presentation to all the folks in our chain of command and they support our dollar. So when I get mad at the bureaucracy, I just hunker down and just start charging forward.

LAMB: But over the years who’s had the biggest impact, a President, secretary of the Veterans Administration, the Congress, individuals in Congress, what’s move – you say it’s dramatically different than it was when you lost your arm in Vietnam than today, what changed that?

DOWNS: You know you have – it kept taking – it’s a combination of all of that because its takes veterans who are advocates who are pushing forward.

LAMB: So that …

DOWNS: American Legion, DAV, they have legislative – they push legislation to help the – you’ve got the Congressman who want to support it and you have the President who wants to support the veterans but he wants to support everyone so their OMB represents him and so we work with OMB to try and get the budget to be where it needs to be. So it’s a combination. It’s really what makes the democratic process work. It certainly seems frustrating and slow and some – and bureaucratic but on the other hand we make progress because there is so much input from so many different sources and then a compromise is reached and we go forward and so more money is put into research to look at how we can improve prosthetic devices, how can we improve healthcare. More money is put into all the various clinic activities that we do. Issues come up. Today we’re dealing with mental health because of a dramatic brain injury coming out of the Iraqi/Afghani war. And more awareness of PTSD and other mental health issues, suicide and that’s in the minds of everyone right now. Are we doing enough? And so we have all this attention. And a while ago you mentioned, well we have veterans who call in who complain they’re not being taken care of. Well, as I said, we pay attention to that and Congress pays attention to them and are we doing enough or not? We don’t take the assumption that we’re doing OK so don’t bother us. No, that’s not the way we do things. We take the assumption; well maybe they have a point. Let’s look at it and see if they do.

LAMB: What do you do when you’re sitting at your desk and get a call from Congressman X and they say, Fred, you people down there aren’t moving on one of my constituents and you know that the constituent – it’s just hypothetical – really doesn’t deserve for you to move on. They’re just pulling your chain. I mean there’s got to be those in the system all the time. What do you do?

DOWNS: I tell the Congressman give me his name, number and we’ll contact him and we’ll review it. We’re review the case. And I treat every one of those cases like that because it’s true, this veteran may be pulling our chain, maybe he’s mentally just not going to be happy, just not going to work, he can’t be satisfied, you can’t solve his problem but we will go back and look at it again and we’ll contact our people at the local level and they will contact that individual. Now he may not get any further than he got before but we have reached out and try and respond to try and bring him into the system or at least try to explain to him one more time why we can’t do something.

LAMB: But what about …

DOWNS: … bound by rules and regulations.

LAMB: What if the congressperson doesn’t deserve the attention? That they’re demanding something that is not – you know them and you know this is strictly a political play, how do you deal with them?

DOWNS: Well the same way. You got to …

LAMB: If they – they threaten your appropriation.

DOWNS: Oh, no. They don’t do that. I mean they – from – I’m talking from a prosthetics point of view, what I work with, they don’t – the Congressman don’t threaten prosthetics. In fact they always want to make sure there’s more money there. So they’re all on accord there, if I understand the drift of what you’re trying to get to.

LAMB: Yes, I’m try – try to understand how the process moves. I mean it sounds all neat and in a package but you know everyday isn’t.

DOWNS: Oh, no and it’s like my whole day is filled with problems and problem solving and responding to congressman and veterans and to chain of command and to the GAO and the OIG and OMB and all the acronyms. It’ll just drive you nuts.

LAMB: But give us an example without naming names of a problem you’re dealing with.

DOWNS: Of a problem I’m dealing with right now …

LAMB: Or have dealt with, which is complicated and involves all this.

DOWNS: OK. One is service dogs. Service dog is different than a guide dog. A guide dog for the blind is very well defined. About five years ago an advocacy group convinced a congressman to put a law in place that the VA would provide service dogs to veterans and that’s about as big as it got and that’s – the law was passed. So then it comes over as a law and my job then, because it’s assigned to prosthetics, will have to know regulation, policy and procedures to carry this out. Well it turns out there were no real standards concerning service dogs. Now service dog, for folks who may not know, is – you often see them and they’ll have a saddle on their back and they’re with a disabled individual, sometimes in a wheelchair and they can put things in the saddle bags on the animal and sometimes the dog can do things like open doors and there are other functions that dogs are suppose to be able to perform and so there’s a large advocacy group out there pushing service dogs as being a solution for helping disabled folks get through life and be independent but there’s no – so we had – I had to put together a worker (ph) because there’s no standards and how to develop policy when – I mean do you have a Chihuahua and a German Shepherd, what kind of functions do they perform and who trains them and you have people in prisons that train them and you have people in their homes who train them and so there’s a Web site – you go to the Web site on service dogs, there’s dozens and dozens of them. And all these folks are well meaning but what are the standards? So we have to develop standards to ensure quality of care to the veteran because the dog – you got to make sure the dog is taken care of because then the humane folks want to make sure that the dogs not mistreated. So there’s training issues for who trains them, training issues for the veteran, how they use the animal, which kind of animals do you use and how are they trained, so we had to put all this together. While we were putting it all together, well the congressmen keep getting pushes from the advocate groups to why isn’t the VA providing service dogs yet. So it took – we had to research – there’s no research to support it so we had to hold them off while we did some research. So we did a couple of research projects to see what do dogs, do they really function the way they do, are they – what do they cost, what are they worth, what can they do, how long do they live and what are the vet bills going to be, what kind of harnessing do you have to pay for, all these kind of issues.

LAMB: By the way, how much do they cost?

DOWNS: It depends. You get them – non-profit gives you the dog. Other folks want to charge you 15, $20,000 and so it’s like – it’s all over the board. And who – and what are your standards for training and so that’s a big issue.

LAMB: Who pays in the end and how many service dogs …

DOWNS: Well I was supposed to figure all this out, see. This is what we do. The law is passed and now how do we make it work and so it took us about five years to come up with – getting the research project took a long time and research project and we had a group committee, meanwhile we’re getting a lot of pressure from certain congressmen who want this to be provided and so – but we can’t – we explained to the different congress folks why weren’t not making any quicker progress than we are and so they understand that. It’s a process.

LAMB: How long did it take to get the actual dog …

DOWNS: It’s taken about five years and we finally have a final draft in place and so what we’re going to do is we’ll provide service dogs on a case-by-case basis. We’ll accept dogs only from non-profit organization. And we’re developing standards – we have to develop the standards because there are no standards so we’re working with the service dog industry to develop standards in training and other …

LAMB: How much will VA pay of all this?

DOWNS: We’re not going to pay anything for the dog because we get the dog from non-profit. We will pay the veterinarian cost and we’ll pay for the harnessing. That’s what we do with the guide dogs.

LAMB: How many do you expect to have to provide?

DOWNS: Well that’s another thing. We don’t know. That is an unknown to us. We’re going to do it on a case-by-case basis because at this stage we have no idea which disability can use a service dog and those are unknowns for us.

LAMB: But just for case of this discussion, how much did it cost you to do those studies and how long did they take?

DOWNS: They cost hundreds of thousands of dollars to do the studies. Like I said it took – they were supposed to be 18 month studies. They turned into three-year studies because of the difficulties of putting together the research on it, the evaluation.

LAMB: Meanwhile are any of these veterans getting dogs?

DOWNS: No. No.

LAMB: And are the members of congress that pushed the hardest for it still in Congress?

DOWNS: Right.

LAMB: They’re still there?

DOWNS: They’re still there.

LAMB: Are they unhappy along the way because …

DOWNS: Well they’re unhappy, yes, because we haven’t been able to come up with the policy yet. We’re not providing the dogs and so there are some vets who want these dogs.

LAMB: What about the advocacy groups? Are they …

DOWNS: Advocacy groups want the dogs because they think the service dogs are good solution. So that’s part of that – what makes my job so interesting and so great is that we are responding – we have to respond to Congress. We have to respond to the veterans’ needs. We have to stay within the rules and how the government works. We have to be fiscally responsible, in other words pay attention to cost. We have to balance all of these in trying to meet the needs of all of these different constituencies; the veteran, the service dog industry, the Congress and then of course the budget people. We need to be able to give them information about how many of these dogs we’re going to provide and how much money would that cost. So this is an example of a sticky issue that came down the pike that you can’t ignore. It’s important. It has value to certain individuals and certain veterans.

LAMB: Speculate though? How many dogs do you think you’re going to have to deal with?

DOWNS: I even hate to say this, I can’t speculate. I don’t know.

LAMB: Will it be a thousand or will it be 500 or will it be 20,000?

DOWNS: I think it would 500 to 1,000. It won’t be 20,000. I don’t think so.

LAMB: Is it worth all this expense, all this time?

DOWNS: Well that’s always the crucial question, is it worth the expense? If the dog is able to perform what it’s supposed to do, then it would be worth it to the individual. And that’s where government is different than private industry. We, in the government, yes, we may spend more money to solve this particular problem but, over a period of time, we’ve increased the quality of life of the individual. We’ve put stability into the industry. We have responded to a law. So we’ve been able to stabilize what has been an unknown area and put some structure and form to it and begin to frame it. Now whether it’s worth it or not? When you’re dealing with the human body and a condition, is this arm worth $2,400 and is it worth it versus the MyoElectric arm, which is maybe worth $60,000, so which one of these is best for me? Cost wise, the bean counters will say, no, you go with this arm. Health wise, quality wise and just from a human standpoint of quality of life, you’ll go with MyoElectric. So that’s how you do this.

LAMB: Fred Downs, we’re out of time and those that want to read more can go back to booknotes.org where we have the 1992 discussion on your book and we thank you very much for joining us for the last hour.

DOWNS: Thank you.

END