Veterans’ healthcare still falls far short

In the eight years that America has been at war, over 2.1 million men and women have been deployed to Iraq and Afghanistan. Not since Vietnam have so many Americans fought under such unforgiving conditions, and their bodies and minds reveal agonizing new and different wounds of war.

The typical combat veteran has sustained orthopedic injuries, concussions from blasts, emotional trauma, and the untold stresses of a harsh environment. The periodic surveys of deploying soldiers indicate that roughly 25 percent suffer with various medical complaints. A RAND study from 2007 estimated that 300,000 service members bear identifiable, albeit invisible, wounds from mild traumatic brain injury and psychological trauma.

But, treatment is not keeping pace with injuries even as the numbers have been rising. The lives of returning soldiers and Marines have become more difficult with serial deployments. Divorce rates are increasing, and there have been record numbers of suicides. The VA counts more than 100,000 homeless veterans on any given night. One senior physician, who has treated many soldiers from WWII, Korea, and Vietnam, observes that patients from Iraq and Afghanistan have shown up with the worst mix of conditions that he has ever seen.

The soldiers in Iraq and Afghanistan are engaged in 21st century combat, but the social and medical support systems back home are bogged down by the legacies of the Cold War. These systems are not integrated in any way, so they are unable to respond effectively. Instead the soldier is shuttled from one medical or institutional silo to another, with each specialist attempting to help, but sometimes making things worse.

The compensation system has changed little since the 1950s, while the nature of the illnesses and injuries, not to mention the mentality of the country, has radically shifted. Pilot programs have been started to unify the disability ratings of the DoD and Veterans Affairs, but they are sporadic, and have not advanced in philosophy or policy. They are stuck on “fair payments” and offer little help to the disabled veterans as they try to cobble together a future that has been unimaginably altered. 

Much remains to be done. Returning veterans long to “normalize” their lives and get on a trajectory that is as productive as possible. Compensation helps, but falls short of meeting real needs — good education, training, rewarding employment, family and friends. 

The implementation of 21st century rehabilitation and support services has lagged. Basic coordination among the VA facilities, DoD hospitals and clinics, and local communities services is almost non-existent.

Where to start? The Dole-Shalala Commission recommended “fundamental changes” in healthcare for veterans and active-duty personnel in July 2007, but essential corrective measures have only been only inching along. The DoD and VA are still prisoners of the traditional specialties. Not enough time and energy is devoted to promoting, in a holistic fashion, the health and wellness of the veteran, not just treating the diseases. Too few clinics and hospitals have set up integrative teams. Funding for research and hiring of clinicians rigidly follows lines of specialty practices and ignores the realities of the patients’ lives. Wounded soldiers and disabled veterans have to navigate a dizzying array of clinics in the often futile hope that finally a care coordinator will be able to direct them to the right appointments.

The research for developing better treatments is stifled by the tyranny of the “gold standard” randomized controlled trial. Newer statistical tools and methodologies have been ignored. When seeking treatment, soldiers and veterans get the usual diagnostic tests that were introduced decades ago. Even though the veterans face life-changing emergencies, the traditional institutions of healthcare proceed at the same stately old pace. 

Just like 21st century warfare needs to be coordinated and integrated, so does healthcare and rehabilitation. The burden of caring for the 2 million souls who have seen repeated combat is a public health problem, far beyond the “disease model” that dominates currently. It requires the classical “paradigm shift” to focusing on the optimal health and welfare of the individual and immediate social network. Making the shift imposes a challenge on the national leadership, and for them to direct a bold and energetic campaign.

We may be a nation at war, but it only seems to apply to those brave few men and women in uniform in far-off places. The missing link for modern warfare in the 21st century — prolonged and uncertain — is the changes in institutions and policies that support its armed forces at home. 

The ghosts of the Vietnam War still haunt us. Let’s hope we do better this time and not let current domestic political and social pressures sweep aside the very real needs, and lives, of our veterans. Because in the end, if we are unwilling or unable to confront these very real problems, the consequences on soldiers, and on their families and friends, will trouble us for future generations.

Xenakis is a psychiatrist who has advised the Pentagon on psychological health and traumatic brain injury issues. He is currently conducting research in this field.