Wounds of War

How the VA Delivers Health, Healing, and Hope to the Nation's Veterans

Suzanne Gordon

• Publisher: Cornell University Press
• Year: 2018
• Print ISBN: 9781501730825
• eBook ISBN: 9781501730832
• Topic: Medicine
• Subtopic: Military & Maritime History

U.S. military conflicts abroad have left nine million Americans dependent on the Veterans Health Administration (VHA) for medical care. Their "wounds of war" are treated by the largest hospital system in the country—one that has come under fire from critics in the White House, on Capitol Hill, and in the nation's media.

In Wounds of War, Suzanne Gordon draws on five years of observational research to describe how the VHA does a better job than private sector institutions offering primary and geriatric care, mental health and home care services, and support for patients nearing the end of life. In the unusual culture of solidarity between patients and providers that the VHA has fostered, Gordon finds a working model for higher-quality health care and a much-needed alternative to the practice of for-profit medicine.

1

PROMISES BROKEN AND KEPT

A Short History of the VHA

The Department of Veterans Affairs is now the second-largest department of our federal government, comprising three separate agencies with a total workforce of about 370,000 and an annual budget allocation of nearly $186 billion (of which 36 percent goes to health care). How that bureaucracy developed over time from its underfunded, fragmented, state or federal predecessors is worthy of note. If the multiple reorganizations, consolidations, and political battles over veterans’ benefits and services reflect any single historical thread, it’s our persistent societal ambivalence about the burden of caring for former military personnel or offering them income support.

Since its inception, the United States has celebrated the patriotism and sacrifice of its soldiers—while they were on active duty. But after hostilities ceased and troops were mustered out, former combatants have been forced to struggle, repeatedly, for recognition of their pressing postwar needs. In Wages of War: When American Soldiers Came Home—from Valley Forge to Vietnam, Richard Severo and Lewis Milford trace this sad pattern back to the 1780s.¹

Veterans of George Washington’s Continental army were paid in paper currency that was nearly worthless and not accepted by banks, merchants, or local governments demanding overdue property tax payments. Many citizens who had volunteered to liberate the colonies from British rule ended up impoverished as a result. Some suffered humiliating eviction from their small farms or postwar incarceration in debtors’ prisons.

Continental army officers fared better, of course. They received pensions and, under limited circumstances, so did their widows and orphans. But rank-and-file soldiers elicited little sympathy from the same business and political elites who had strongly encouraged them to enlist. When the financial desperation of some veterans led them to take up arms again—in Shays’ Rebellion in western Massachusetts in 1787—that uprising was quickly suppressed.²

A Pledge by Lincoln

Between our War of Independence and Civil War, any postwar assistance for former enlisted men and officers came primarily from their individual states, which operated homes for disabled veterans. In 1862 the US Sanitary Commission conducted a study of what national governments in Europe did for their veterans. Its findings led to congressional authorization of a National Home for Disabled Volunteer Soldiers shortly after Abraham Lincoln’s reelection as president. In his second inaugural address on March 4, 1865, with the Civil War nearing its end, Lincoln famously pledged “to care for him who shall have borne the battle and for his widow and his orphan.”³

Unfortunately, even the able-bodied among the hundreds of thousands of demobilized Union army veterans faced multiple postwar difficulties. In August 1865 one former volunteer asked readers of the New York Herald, “What are the returned soldiers who were mustered out honorably from the service to do for employment? Are our wives and children to starve? All are willing to work, I am sure, if they can find employment. If a soldier asks for a situation, the response generally is, ‘we are full’ … or ‘we engaged a clerk this morning.’”⁴

Such pleas for better treatment too often fell on deaf ears. Even a military publication like the Army and Navy Journal warned veterans not to “slump and become a dirty loafer” if they wanted to succeed in civilian life. Those who developed “new muscular habits,” rather than succumbing to personal despair and reliance on charity, would find postwar housing and employment; those who sought special help would simply become dependent on it.⁵

Nevertheless, the post–Civil War need for national homes for disabled veterans was so great that they grew from one facility to six around the country by 1887. Their mission, carried on today by the VHA, was to assist veterans seriously injured during military service and then left jobless and impoverished. Both the Army and the Navy had their own facilities for professional soldiers in need of such care, but admission required twenty years of military service. The National Homes were a critical place of refuge for those who volunteered or were conscripted for shorter tours of duty during the Civil War.

Residents received medical care, social support, and even employment opportunities. As VA historian Darlene Richardson explains, “These homes were like little towns, with churches, theaters, and post offices. They were self-sustaining communities” filled with veterans who raised vegetables, tended to cows, and worked in manufacturing shops that produced products, like shoes, for use by residents themselves.

In the late nineteenth century, of course, formal hospital care of any type was very limited, so most wounded Civil War veterans, from North and South, were dependent on family caregivers. To support their role, the federal government provided some funding for relatives assisting Union Army veterans. But, as Richardson notes, recent immigrants to the United States often lacked the family connections or resources necessary for in-home care.

In addition, one large cohort of disabled veterans—those who served in the Confederate army—was excluded from the National Homes. (Exceptions were former rebels who were captured, took an oath of allegiance to the Union, and changed sides until honorably discharged.) As the twentieth century approached, the volume of newly disabled soldiers—mainly from the Spanish-American War—was just a tiny fraction of the patient population produced by conscription and enlistment between 1861 and 1865. The National Home network continued to serve Union veterans who were aging and no longer able to support themselves. But when these old soldiers began to die off, federal policy makers considered closing the homes because they were now underused.

Expanded Federal Role

US involvement in World War I canceled those plans. Prior to joining that murderous fray, the Wilson administration created a Bureau of War Risk Insurance (BWRI) within the Treasury Department to insure cargo ships bound for Europe and threatened with German attack. In 1917 the bureau also began offering life and personal injury policies for active-duty military personnel, veterans, and families of servicemen.

Of the 4.7 million Americans who served in World War I, 116,000 died, and 240,000 were wounded, creating a burden of care that could not be met by either existing military hospitals or the National Homes (now numbering just ten). So the BWRI created a new two-track system of veterans’ health care. The National Homes continued to serve survivors of the Civil War, Spanish-American War, and other pre–World War I conflicts, and the newly wounded returning from Europe were moved into private and public facilities of their own.

In 1919 President Wilson transferred responsibility for all veterans’ care to the US Public Health Service, also then housed in the Treasury Department. The Health Service began building its own facilities for veterans and acquired several former Army hospitals, including Fort Miley in San Francisco and two similar sites in Virginia. Because new hospital construction took several years to complete, many World War I veterans were assigned, in the meantime, to the old National Homes. Adding to this makeshift mix, the federal government leased some private hospital space for veterans’ care.

In 1921 Congress merged all World War I veterans’ programs—the BWRI, the Public Health Service, and the Federal Bureau of Vocational Education—into a single Veterans Bureau. The Bureau of Pensions under the Interior Department and the post–Civil War National Homes were not initially included in this consolidation. Eight years later, however, the bureau took over the New York Soldiers and Sailors Home, the last surviving National Home.

Overall, veterans’ affairs were still handled by multiple federal bureaucracies throughout the 1920s. To access services, veterans had to fill out myriad forms and apply to different agencies. “If you wanted burial services, you had to go to the War Department, which administered the national cemeteries,” says Richardson. “Where you were buried depended not on where you lived, but what war you served in. If you needed prosthetics and had served before World War I, you went to the War Department. If you were a World War I veteran, then you went to the Bureau of Insurance and the Veterans Bureau. Vocational and rehabilitation training and compensation depended on a different agency. And pensions—or compensation, depending on the year a veteran was applying for funds—were a function of the Bureau of Pensions under the Interior Department.”

To make matters worse, the first director of the Veterans Bureau, Colonel Charles R. Forbes, was fired after just two years on the job, fined, and jailed for defrauding the government on hospital contracts. This Harding administration scandal in 1923 led to the appointment of Brigadier General Frank T. Hines in 1923. Hines began consolidating veterans’ services, establishing subdistrict offices of the bureau, and improving health care delivery. In 1924, eligibility rules were even “liberalized to cover disabilities that were not service related.”⁶

The Bonus Marchers Debacle

Nevertheless, six years later, veterans battered by the Depression were still so frustrated by bureaucratic red tape that the American Legion demanded further change from Congress and the Hoover administration. In 1930 President Herbert Hoover signed Executive Order 5398, which created a Veterans Administration to consolidate and coordinate all federal activities involving former military personnel, including pensions and health care (but, for another forty-three years, still not their burial places).

The newly formed VA worked with the American College of Surgeons on an overhaul of the hospital network created for World War I veterans. The facility mix that emerged included hospitals providing general medical and surgical services, plus specialized facilities devoted to the treatment of tuberculosis and mental health problems. Between 1931 and 1941, the number of VA hospitals increased from fifty-four to ninety-one, with the number of beds rising from 33,669 to 61,849.⁷

Meanwhile, in 1924, Congress passed the World War Adjusted Compensation Act, setting the stage for a major confrontation with veterans. This legislation provided veterans with service certificates guaranteeing them a bonus payment twenty years later. As the Great Depression deepened, impoverished veterans demanded that their bonuses be paid immediately, rather than in 1945. President Hoover, a fiscal conservative, rejected these pleas. In desperation, forty thousand destitute vets—dubbed the Bonus Army—rode the rails or marched to Washington, DC, to lobby his administration. They camped out near the Anacostia River in a protest mode adopted by Occupy Wall Street eighty years later. Although Hoover found time to give visiting Boy Scouts a warm White House welcome, he staunchly refused to meet with any delegation of veterans.

Instead, the president and his political allies dismissed the marchers as radical troublemakers who threatened to overthrow the government. To quell their protest and drive them from the capital, Hoover dispatched federal troops led by Army chief of staff General Douglas MacArthur. Officers, including Dwight D. Eisenhower and George S. Patton, organized an infantry and cavalry assault that used tear gas, fixed bayonets, and six tanks. At least two marchers were killed, their makeshift camp was burned, and the bonus marchers dispersed. Of those subjected to this brutal treatment, 94 percent were in fact veterans, 67 percent had served overseas, and about 20 percent suffered some sort of disability.⁸ But they left Washington empty-handed, for the time being.⁹

The federal government’s responsiveness to veterans’ needs did not initially improve under Hoover’s successor in the White House. In 1933 the Roosevelt administration actually reduced veterans’ allowances for service-related disabilities by 25 percent.¹⁰ Despite a second veterans’ march on Washington that year, it was not until 1936 that Congress finally authorized payment of veterans’ bonuses before their stipulated due date—action that required overriding a presidential veto.¹¹

Post–World War II Changes

During World War II, however, veterans’ benefits increased dramatically. “After the attack on Pearl Harbor, Congress liberalized service-connected disability policies,” Richardson notes. It also approved aid to families of servicemen who were killed or disabled before they had an opportunity to take out insurance. During the war, many of the VA’s physicians, dentists, nurses, and administrative staff were called to active duty or volunteered for military service. To replace these employees, the VA reduced minimum age and physical requirements for many jobs. Women were hired for positions previously filled only by men to address the rapid increase in the volume of VA patients.

The Disabled Veterans’ Rehabilitation Act of 1943 established a vocational rehabilitation program for disabled veterans who served after December 6, 1941. As a result of this law, the VA provided more than 620,000 of them with job training.¹² During World War II, Congress also authorized the provision of artificial limbs to amputees, paving the way for the VA to become a world leader in the development of prosthetic devices.

By 1946, when General Omar N. Bradley replaced Hines as VA administrator, the agency operated ninety-seven hospitals, capable of handling more than eighty thousand patients. Bradley recruited Major General Paul R. Hawley to lead the VA’s Department of Medicine and Surgery (rebranded forty-five years later as the Veterans Health Administration). Hawley created a separate outpatient treatment program for veterans whose disabilities were not service related. With the nation still facing an enormous burden of care for patients who served in World War II, Bradley ordered the construction of twenty-five new hospitals and additions to eleven existing facilities. By 1950 the VA had 151 hospitals nationwide—and needed that additional capacity after three years of military conflict in Korea.

Hawley pioneered what is today one of the VHA’s most important but lesser-known programs: providing medical resident and teaching fellowships at veterans’ hospitals throughout the country. In addition to developing these medical school ties, Hawley persuaded Congress to endow the VA with a research capacity greater than that of any other hospital chain in the United States. “After the 1940s research programs took off, nuclear medicine takes off, collaborative research with the National Institute of Health, Academy of Science—all of it exploded,” Richardson says. “The VA worked with [the Department of Defense] to do clinical trials to find out how to end [tuberculosis].”

The Vietnam Years

Changes in battlefield weaponry and resulting injuries, combined with the enhanced lifesaving ability of modern technology, have spawned different postwar challenges for veterans’ health care in every era. For example, the use of mustard gas during World War I created a whole host of debilitating health problems for former soldiers who survived their initial exposure to it. Fifty years later, much faster, helicopter-assisted evacuation of the wounded to field hospitals and naval vessels saved the lives of many soldiers who would have succumbed to their injuries in earlier conflicts. But these same higher survival rates taxed the veterans’ health care system in often unexpected ways, particularly after wars waged with many “citizen soldier” conscripts.

In Vietnam the United States suffered its first military casualty in 1959. Over the next sixteen years, 2.7 million draftees and enlisted personnel were deployed to Southeast Asia, 58,000 lost their lives, and 153,000 were wounded.¹³ By 1972 more than 300,000 veterans had physical or mental disabilities they could prove were connected to their Vietnam-era military service. Hundreds of thousands more had yet to establish their eligibility for care based on PTSD symptoms or their exposure to Agent Orange, a toxic herbicide sprayed throughout Vietnam as a counterinsurgency measure.¹⁴

It is not su...

Table of contents

• Acknowledgments
• List of Abbreviations
• Introduction: What Kind of Care for Veterans?
• 1. Promises Broken and Kept: A Short History of the VHA
• 2. Those Who Have Borne the Battle: The VHA’s Patient Population
• Profile—What It Means to Be a VA Volunteer
• 3. Primary Care the Way It Should Be
• 4. Healing Minds and Bodies: Integrated Mental Health Care and Primary Care
• 5. Dealing with a World of Hurt: VHA Treatment of Chronic Pain
• 6. When Wounded Warriors Are Women: Caring for Female Veterans
• 7. Mental Health the Way It Should Be
• 8. Unpacking PTSD: From Diagnosis to Effective Treatment
• Profile—Karen Parko: A Special Kind of Professional Development at the VA
• 9. Returning to Civilian Life: Veterans on Campus
• 10. Suicide Prevention: VHA Programs That Save Lives
• 11. Overcoming Disability: VA Rehabilitation Services
• Profile—Mark Smith: No Ordinary Bike Shop
• 12. Transcending Trauma: The Martinez Cognitive Rehabilitation Program
• 13. Off the Streets: Reducing Veteran Homelessness
• 14. Alternatives to Jail: Veterans’ Justice Programs
• Profile—Cops and Vets: The Memphis Crisis Intervention Model
• 15. Specializing in Elder Care: The VA and Geriatrics
• 16. Knocking on Heaven’s Door: The VA and End-of-Life Care
• 17. Better Care Where? The VHA Compared to the Private Sector
• Conclusion: A System Worth Saving—and Making Even Better
• Epilogue: Thank You for Your Service?
• Notes
• Index
• About the Author