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Wounds of War

By John Ketwig (reviewer)

Wounds of War: How the VA Delivers Health, Healing, and Hope to the Nation's Veterans
by Suzanne Gordon
(Cornell University Press, 2018)

Be forewarned: The rear of our family SUV sports a bumper sticker that says "If you can't afford to take care of the veterans, don't go to war.—Bernie Sanders." The following review may be colored by that pre-existing point of view.

Author Suzanne Gordon is a journalist who has written an awesome collection of books, mostly investigative in nature, about various aspects of healthcare and, a very different topic, the healthcare business, in America. Noting that there is a movement afoot to privatize the VA, she set out to investigate the facts and put together a book that would clarify what's really going on in the fields of healthcare and caring for the needs of America's veterans. "Wounds of War" is that book, just published in October. This book is a gold mine of information about the VA, or technically the US Department of Veterans Affairs.

Actually, this is a collection of numerous books in one. In his second inaugural address on March 4, 1865, nearing the end of the Civil War, President Abraham Lincoln pledged "to care for him who shall have borne the battle and for his widow and his orphan." "Wounds of War" offers a brief history of the federal government's efforts to make Lincoln's promise come true right up to present day. The Veterans Administration was first formed in 1930 by President Herbert Hoover and became the Department of Veterans Affairs in 1989. The history of veterans' benefits is colorful and fascinating, but it is far from the primary reason Ms. Gordon found it necessary to write this book.

Building from the foundation, "Wounds of War" defines the multiple missions of the VA, and its structure. The Department of Veterans Affairs is made up of three agencies. The Veterans Health Administration, or VHA, (commonly referred to as the VA), is the largest of the three. The others are the National Cemetery Administration which provides burial for eligible veterans, and the Veterans Benefits Administration which determines and administers a broad range of benefits to our vets, such as the GI Bill, housing benefits, vocational rehabilitation and employment, pensions, home loans, life insurance, and access to VHA care. The VHA is by far the largest of the three agencies, delivering care to nearly nine million eligible veterans in over 1,700 sites, including acute-care hospitals, outpatient clinics, rehabilitation facilities, nursing homes, inpatient residential programs, and campus and community-based centers. With a salaried staff of 314,000, the VHA is the nation's largest and only integrated healthcare system that has full public funding.

It is important to note that the VHA is not a hospital chain competing with the for-profit system to attract customers and achieve market share. Its doctors are salaried, unlike the corporate systems where physicians are incentivized to hurry patients through or overtreat them to maximize profits. (I am often concerned that VA doctors are incentivized by the pharmaceutical industry to overprescribe pills.) In theory, the VHA is a full-service healthcare system that uses taxpayer dollars to provide all types of care to its select group of patients.

The VHA has four primary missions. First, it delivers clinical care (medical, mental health, and rehabilitation) via 153 hospitals, 900 clinics, 300 mental health centers, and various other facilities that assist more than 230,000 people every day. I was surprised to learn that the second major mission is research. The VHA pioneered such advancements as the shingles vaccine, the nicotine patch, and the first implantable cardiac pacemaker. The current Million Veteran Program is exploring the impact of genetics on health and various medical treatments. Because the VHA has far more patients than any other healthcare system in America, and because it has established a universal communications system that allows tracking and sharing over a larger study group and area, the VHA is uniquely positioned to use its data for a wide range of research projects. In 2016 alone, VHA researchers published 9,480 papers. Today the VHA is researching the link between genes and suicide risk, prostate cancer, and the use of probiotics to treat veterans with traumatic brain injury. Because it is America's largest healthcare system, and treats more men suffering from prostate cancer, the opportunities to discover new treatments and drugs, and to communicate those findings, is unique. It must also be mentioned that the unique nature of the VHA system does not require any type of pre-authorization from the insurance industry, doctors are free to prescribe and treat their patients' needs freely and without second-guessing or denials. The third VHA mission, also a surprise, is teaching. The VHA is affiliated with the major academic medical centers throughout America, and it currently trains 70 percent of our medical residents and 40 percent of all other healthcare professionals, nurses, physicians, psychologists, social workers, physical therapists, and other specialties.

The fourth mission is emergency preparedness for veterans impacted by such disasters as fires or floods. In a disaster zone, teams of VHA employees are responsible for contacting veterans and making sure they are not hurt, that they are receiving medical care, and that they have housing, medications and medical services quicker and beyond the scope of what's available to the general population.

Is it any wonder that the VA, America's largest healthcare system, the second-largest branch of our federal government with an annual budget allocation of $164 billion is a tempting target of our country's most established and greedy profiteers? Corporate medicine and the insurance industry see all those dollar signs and are using every trick at their disposal to get their share.

Simply stated, and despite many of the reports we have seen in the media, the VA's health system works far better than the for-profit corporate healthcare industry that has been shaped by the profiteers. "Wounds of War" devotes many pages to describing the various VA programs in place all across the country, and comparing their results with those of the for-profit private industry. Obviously, the real purpose of this book by an investigative journalist with vast experience analyzing the medical profession is to combat the profit-oriented corporations and the politically-motivated conservative zealots like the Koch brothers and the puppet group they fund, the Concerned Veterans of America. The vast majority of American veterans receiving care from the VA feel strongly that those services should not be privatized or turned over to the for-profit medical industry. Kenneth Kizer was named by President Clinton to head the VHA in 1994, and is recognized for his enormous contributions. Harvard Business Review</span> called the transformations at the VA under Kizer the most successful turnaround in US history, and Businessweek recognized the VA for providing "the best medical care in the US" Kizer left the VA in 1999, noting that "conservatives" were provoked when the nation's premier business publications lavished such positive attention upon a government program that is essentially a successful example of socialized medicine located throughout the American hometown landscape. The Republican Bush administration began to undermine the basic organization and practices of the VA, and introduce incentive programs straight out of the corporate playbooks that would ultimately lead to the types of scheduling abuses at the Phoenix VA hospital, and numerous others, that created a nationwide outpouring of scandal. Gordon suggests that the kind of supportive working environment that Kizer and his team had created has been largely replaced by a punitive one. The threats of budget cutting and mass firings as portions of the VA's activities are handed off to the private for-profit sector have sent a devastating and discouraging message to the VA community.

But "Wounds of War" is far more than a history. It is also a user's guidebook to today's VA, with in-depth descriptions of the many programs and activities offered by the VA system, often with comparisons to corresponding programs in the private, or for-profit, healthcare field. My copy of the book bristles with fluorescent sticky notes like quills from a porcupine.

Assuming that many readers of this review will be concerned veterans, this book offers abundant information on programs that should enable many of our brothers and sisters to jot down some notes and approach the VA armed with specific information about what care should be available. In that respect, it succeeds as a guidebook, a road map through a very complex system of avenues that include programs to help returning vets return to civilian life, prevent suicide, overcome disabilities, deal with trauma, reduce homelessness, deal with the police and the justice system, and locate elder care for the aging veterans community, and end-of-life care. The good news is, the facts are all thoroughly documented, well-organized, understandable, and include insightful comments from veterans and their family members the author has interviewed along the way. The not-quite-so-good news is that many if not most of the programs the author describes are not available at the average hometown VA facility, or, if they are, "Wounds of War" does not tell us how to access them. The author visited a variety of VA facilities all across America, in big cities and small towns, but clearly the majority of her observations come from the VA's Fort Miley hospital in San Francisco. Did I mention an array of fluorescent sticky notes protruding from my book? An index, especially one listing symptoms, diseases, and common concerns with the page numbers where those problems are addressed might have made my sticky note reference system unnecessary.

I was bothered throughout the book by acronyms that were not included in the list at the front of the book. In some cases the acronym's true meaning was revealed, but when it reoccurred many pages later in the book it was assumed the reader would remember. As veterans, we are all too familiar with the government's and military's use of acronyms, but this book is intended to be a guidebook, and we could certainly use a bit more help here. Fifty years after leaving Vietnam, and never having visited the Fort Miley hospital in San Francisco, I am totally unfamiliar with a PDAT or a CIT. I have never encountered a HUD-VASH, or a PIM, OTP, CLC, ADRD, OECD, or REACH VA program, an ACE or a GECDAC. Is a BEST (Behavioral Education and Support Team), pioneered in San Francisco, in place elsewhere? Yes, there is a list of acronyms at the beginning of the book, but it is woefully incomplete. Perhaps I nitpick?

"Wounds of War" is a terrific book, and I would recommend that every veteran depending upon the VA for his or her healthcare buy it. It will be a valuable reference book, and it can provide a wealth of helpful information should you decide to contact your Senator or Congressman and convey your opinion about privatizing the VA. In these Times of Trump, it is going to take a lot of communication from the veterans community to prevent the Koch brothers and other crusaders from destroying the VA. Most of us, the nation's veterans, oppose privatization, but from any perspective there is an enormous amount of money guiding health care in the US today, and the right-wing community values money above all else. The VA is far from perfect, but "Wounds of War" will convince you that it is doing a pretty good job, and give you lots of material to help spread that message far and wide. I highly recommend this book.

John Ketwig is a lifetime member of VVAW, and the author of ...and a hard rain fell: A GI's True Story of the War in Vietnam.