Books reviewed in this essay:
War is brutal and the battlefield deadly. Soldiers en route to deployment are required to write and sign their wills before departure—a humanizing/dehumanizing duality. The public keeps track of the awful toll with the chyrons of numbers of killed and missing in action scrolling below newscast images of carnage and destruction. These numbers, however, are related to military actions and usually do not include the nonbattle injuries that have always plagued armies, threatening their operational readiness. At least 20% of troop casualties in Vietnam did not arise from enemy action but from soldiers succumbing to infections and other noncombat injuries (Shanks 2023). Medical techniques have greatly increased the ability to keep wounded troops alive, and we now have large numbers of disabled veterans who survive injuries from which they would have died in Vietnam. Most disabled veterans will be treated within the Veterans Health Administration (VHA) system, which is also now caring for a large number of elderly surviving Vietnam veterans who meet criteria of having a service-related condition or who are indigent enough to meet VHA eligibility criteria.
While on active duty a soldier's health is the purview of the highly skilled Department of Defense (DOD) Army, Navy, and Air Force Medical and Nurse Corps. Preventive medicine is a priority, particularly when troops are deployed to areas with endemic diseases to which most Americans have no immunity. Indeed, the civilian population has profited immensely from this aspect of military medicine. The precautionary medical regime that most travelers to such endemic regions must undergo today was, to a great extent, developed during US military conflicts in such stricken areas. DOD medical teams also provide battlefield triage to the seriously wounded as well as subsequent surgical treatment and recovery in military hospitals. Their skills have preserved the lives of many soldiers. They are in charge of the health of the US president. Once a soldier is discharged and becomes a veteran, his or her health care may be the purview of the VHA, depending on the disorder, the type of discharge from the service, and financial status.
A sizable fraction of soldiers, particularly those deployed to combat zones, are at high risk for posttraumatic stress disorder (PTSD). Most veterans with PTSD related to their service will be eligible for treatment at the VHA, but unfortunately this has not always been the case. Throughout its history, the United States has often done a dismal job of caring for wounded veterans, particularly those suffering with mental health problems. One would imagine that PTSD sufferers or those with its associated chronic diseases would have been greeted with open arms at the VHA after Vietnam, but it took an uphill battle spanning many years for veterans to gain eligibility for treatment. Even today, many sick veterans whose ailments are very likely to be related to their service cannot receive care from the US Department of Veterans Affairs (VA) because their afflictions are not yet “recognized” as service-related, such as the many chronic physical ailments linked to PTSD (Stellman and Stellman 2019). Those with subsyndromal PTSD (i.e., those who have many symptoms but not enough to meet strict PTSD diagnostic criteria) are not eligible for treatment unless they have another qualifying disease or economic circumstance (APA 2022; Mota et al. 2016).
The US military is now composed entirely of volunteers. In the years following 9/11 the United States engaged in many years of combat, and, without conscription, the number of active-duty troops is relatively small. The low number of troops has led to multiple war zone deployments for many of them, putting them at even greater risk for developing PTSD. Modern weaponry has also increased risks for traumatic brain injury. The need to maintain mentally healthy troops to reduce family dysfunction and to prevent suicide among this population has thus became a DOD priority, particularly as awareness of mental health issues within the services and in the public square has grown.
The two books reviewed in this essay deal with health care programs within the US Army for active duty soldiers and within the VHA for veterans.
Helping Soldiers Heal: How the US Army Created a Learning Mental Health Care System relates the experience of a Massachusetts Institute of Technology (MIT) team contracted to develop a systems approach to behavioral health for active duty soldiers. A little more than a decade ago, some in DOD leadership recognized that the DOD approach to mental health was in serious need of repair. Outside consultants were brought in for assistance. After some brutal initial experiences in trying to work effectively within the vast DOD health system, the MIT team gained appropriate sponsorship and support within the army, the largest DOD branch of service, and undertook systematic analysis and redesign of its mental health care systems. Srinivasan (MIT) and Ivany (US Army) have written an excellent book describing the process. Much of their approach is based on theoretical underpinnings of a learning health system similar to those set forth by an Institute of Medicine workshop (IOM 2007). The book is well written and illustrated with clear schematics. I found the historical background on the army's approaches to maintaining troop mental well-being and its appraisal of the inconsistency of treatment they observed throughout the huge system to be very informative.
Much of the text is devoted to explicating how the embedded behavioral health (EBH) model and the Behavioral Health Data Portal for standardizing data collection were developed and implemented (Aker 2024). The descriptions of the ups and downs they faced in creating the EBH model are particularly informative. While there are no nongovernmental civilian hospital systems that even come close in complexity and size to that of the army, the chapter “Translating Learning from the Army” could be particularly useful for those seeking to create or improve their own learning health system.
The final chapter of the book brings into focus the huge organizational barriers that exist for adoption of the EBH across the DOD. Barriers include major differences in structure and leadership between the service branches as well as a good deal of interservice rivalry. Implementation of any mental health program is also burdened by the stigma that many soldiers perceive to be attached to seeking treatment and the reality that “stress-free” alternative assignments for a soldier with PTSD may not be available. A diagnosis of PTSD may thus prematurely end a military career for a soldier who had envisioned at least 20 years of active service. The US Army has taken some important strides in easing the path for its soldiers. More remains to be done. In addition to informing the process of creating a learning health system, the Srinivasan and Ivany book could serve as a useful text for those teaching courses on the process.
Moving from active service to postservice, we turn to the world of the VHA, which is the largest integrated health system in the United States, comprising 171 VA Medical Centers and 1,113 outpatient clinics of varying complexities, with more than nine million veterans enrolled in its program. The VHA is also the largest US provider of graduate medical education, with 113,000 health professional trainees and nearly 16,000 affiliated medical faculty (VA 2023).
Unfortunately, the pathway to using the VHA is not always simple, as Suzanne Gordon, a seasoned and talented reporter and policy analyst, makes clear in Wounds of War: How the VA Delivers Health, Healing, and Hope to the Nation's Veterans: “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” (19). She cites the excellent Wages of War by Richard Severo, the former New York Times reporter who was instrumental in bringing Agent Orange into public discourse, and Lewis Milford, an attorney and environmental activist who played an important role representing veterans in their fight to have adverse effects of Agent Orange and nuclear radiation exposures recognized (Severo and Milford 1990).
PTSD is a good example. The last combat troops departed from Vietnam in 1973, but PTSD did not officially enter the panoply of “recognized” mental health diagnoses until 1980. This recognition, although delayed, was in part related to the activism of Vietnam veteran organizations like the American Legion. It took many more years for the rigorous clinical guidelines that exist today at the VHA to be put in place (Friedman, Keane, and Resick 2007). Scott (2004) thoroughly details the problems for Vietnam vets in a book that may be two decades old but is still relevant.
Wounds of War is an important read for the many in the academic community involved in researching, assessing, and advising on the organization and delivery of health care but who have never set foot in a VHA facility and are not likely to have family or friends interact with the system. Gordon makes clear that there are two driving forces behind this book. The first is that the VA is a successful example of how the federal government can deliver large-scale health care over a wide range of specialties, and she wants people to know more about how that has been accomplished. She uses her admirable reportorial and analytic skills in a series of interviews to show how the VHA is effectively providing care in each of the major areas of health care, each of which is covered in a separate chapter. These include primary care, integrated mental health and primary care, treatment of chronic pain, care for female warriors, specific areas of mental health care (PTSD, suicide prevention, and various approaches to “transcending trauma”), geriatric services, and end-of-life care. Gordon spent five years working with VA administrators, veteran groups, and politicians interested in preserving and strengthening veteran health care as background. Each chapter is, in essence, a case study.
The second driving force behind the book is Gordon's dedication to countering the powerful ongoing efforts to privatize the VHA system. Her concluding chapter, “A System Worth Saving,” provides details of efforts to privatize veteran services and close facilities. For the millions of veterans and their families who rely on the service, this chapter would likely be a hair-raising read. She does a good job of describing congressional actions, and inaction, that have hampered the VA's ability to deliver high-quality care. One example is the failure to offer competitive salaries in high-wage areas of the country, an important reason why many jobs are unfilled. Gordon describes some of the bureaucratic bungling—or, perhaps, purposeful obstruction (it is not clear which)—that has kept VA accomplishments out of the news, or worse, have portrayed it as a bungling system (375–76).
The VA system's future is far from clear. It should serve as a shining example of how a governmental health care system can function very well in delivering care and training. Unfortunately, the numbers are not in its favor. Warfare—which clearly is never likely to end—involves fewer and fewer soldiers, thereby tilting the economics against the current system. The private sector is eager to step in. Perhaps adding a semiconductor-care function for damaged drones and other incapacitated artificial intelligence tools of war might work? Sarcasm aside, the system is worth saving—and certainly worth learning from. Let us hope it is not too late.
