The protracted wars in Iraq and Afghanistan have taken a major toll on the mental health of U.S. soldiers and on veterans’ health care system. While the Department of Veterans Affairs has been unable (or unwilling) to appreciate the shortcomings of its mental health programs for injured soldiers returning from the battlefields in Iraq and Afghanistan, the VA’s Office of Inspector General in its May 2008 report faulted the agency’s long-term case management of patients with traumatic brain injury, and a federal lawsuit by two veterans’ groups in San Francisco seeks to force the VA to improve care for veterans, particularly those with post traumatic stress disorder (PTSD).
Screening for mental health problems among returning soldiers has proved extremely difficult for VA and the Department of Defense, despite newly introduced screening instruments, including pre- and post- deployment health assessments and reassessments. The accuracy of these instruments – primarily self-evaluation questionnaires – has been hampered by cultural and practical factors. Soldiers returning from combat operations who are cared for at Walter Reed Army Medical Center may not know that they have mental health problems or, when suspecting that they do, may not want to report them for fear of stigmatization and discrimination and of being retained for treatment at the military medical facility rather than discharged home. Military and VA physicians who oversee their care have also been reluctant to refer patients to additional psychological evaluation for concerns over jeopardizing soldiers’ military careers. A pervasive military culture that tends to view mental illness as a weakness also contributes to the oversight of symptoms as precursors of PTSD. As a result, soldiers with severe anguish and depression have been lost to treatment and follow-up. And this may have contributed to the burgeoning of suicides and attempted suicides among returning soldiers and veterans.
What is disturbing is that the VA, which has made significant strides in improving its comprehensive health care programs, including spectacular advances in head trauma, behavioral health problems like PTSD, and substance abuse, and traumatic amputation, may founder under the weight of a dramatic increase of catastrophic but nonfatal physical injuries among soldiers. And resources may be lacking to satisfactorily address the increasing demand for VA services of both returning soldiers and aging veterans.
As two professionals who witnessed these changes in the VA, we are compelled to ask whether changes within VA and DOD must be considered to satisfactorily handle the health care needs of soldiers and veterans. Three options should be explored.
A first option is for the VA to retain its present structure and concentrate on significantly improving its relationship, communication, and cooperation with DOD. This option, which implies adjusting and even overcoming cultural and practical differences between the two departments, would help in the transition of service members from active duty to civilian life and back to active duty, if this is what service members decide. There should also be a change in the power imbalance that currently exists between DOD and the VA so as to promote the view that these departments are complementary and reciprocally equal. These changes would enhance the goal of achieving better overall care of soldiers as they transition from DOD to the VA.
A second option is for DOD and VA to merge, creating a new integrated entity responsible for serving soldiers from enlistment to death. This expanded entity could accommodate a large and largely independent health care division whose only mission would be to deal with health problems associated with military services, and which would be equipped to readily manage all care for service members, whether they fall ill during military service, are casualties from the battlefield, suffer from traumatic brain injury, battle post-traumatic stress or physical disabilities, or are elderly veterans requiring ongoing care for mental health problems and chronic diseases. This option would put the lifelong medical interests of service members in the hands of health care professionals, not the military command, and ideally, should put the best medical interests of service members first in all instances, whether they retire from the military or are being considered for a return to combat.
A third option is to transform the VA into a system that provides specialized care, in areas where it excels, to the types of patients that are produced by warfare. For all other health care needs, soldiers and veterans would be given the equivalent of a Medicare card, without deductibles or copayments. The major potential drawback of this option is that veterans may abandon the VA altogether. To keep up the scale necessary for first-rate care, and to attract top-tier health care professionals to provide that care, the “soldier care card” might have to be limited to illnesses not commonly or effectively dealt with by the VA.
As the national phase of the presidential election is about to begin, we believe that the care of those who serve our nation should be a critical part of the election debate, and we encourage the public and the press to demand that the presidential candidates offer their own specific solutions to care for our wounded warriors and all veterans.
The opinions expressed in this essay do not reflect the view of the Department of Veterans Affairs.
Evelyne Shuster is a philosopher and medical ethicist, and Peter M. Jucovy is chair of the Institutional Review Board, at the Philadelphia Veterans Affairs Medical Center.