TIME Veterans

Top Veterans Affairs Official Resigns

VA Secretary Shinseki Testifies Before Senate On State Of VA Health Care
U.S. Veterans Affairs Secretary Eric Shinseki and Veterans Affairs Undersecretary for Health Robert Petzel testify before the Senate Veterans' Affairs Committee about wait times veterans face to get medical care May 15, 2014 in Washington, DC. Chip Somodevilla—Getty Images

The Department's Undersecretary for Health Robert Petzel steps down amid scandal involving an alleged cover up of long wait times for patients

Amid a scandal over delays in care for veterans and forged records at veterans’ hospitals, the top official for veterans’ health care resigned on Friday.

Veterans Affairs Secretary Eric Shinseki accepted the resignation of Robert Petzel, the department’s undersecretary for health care. Shinseki asked for the resignation, the Associated Press reports, quoting an anonymous source. Petzel was already set to retire this year. The resignation comes one day after Shinseki and Petzel came under fire during a four-hour hearing of the Senate Committee on Veterans’ Affairs, in which senators said they were enraged by the problems plaguing the department, including long waits for appointments, a backlog of benefit applications and reports of unnecessary deaths.

“As the President has said, America has a sacred trust with the men and women who have served our country in uniform, and he is committed to doing all we can to ensure our veterans have access to timely, quality health care,” the White House said in a statement provided to TIME. “He has asked Secretary Shinseki to conduct a review of Veterans Health Administration practices and procedures at its facilities nationwide to ensure better access to care, and that review is ongoing.”

“If these allegations are true people should be going to jail, not just resigning their positions,” Senator John McCain said on Fox News Thursday Night. He added that the Justice Department will likely conduct a criminal investigation.

[AP]

TIME Veterans

Top Veterans Affairs Health Care Official Resigns

Veterans Affairs Secretary Eric Shinseki Testifies Before Senate Robert Petzal
Eric Shinseki, U.S. secretary of Veterans Affairs (VA), left, and Robert Petzel, U.S. VA undersecretary for health, swear in to a Senate Veterans' Affairs Committee hearing in Washington, May 15, 2014. Andrew Harrer—Bloomberg/Getty Images

Undersecretary for Health Dr. Robert Petzel has stepped down a day after being grilled in Congress amid uproar over alleged malfeasance and cover-ups at the Department of Veterans Affairs. Petzel said in September that he planned to retire this year

Updated 7:18 p.m. ET

Secretary for Veterans Affairs Eric Shinseki announced Friday he accepted the resignation of the official in charge of the VA’s healthcare services.

Undersecretary for Health Dr. Robert Petzel offered his resignation a day after sitting aside Shinseki while both men were grilled on Capitol Hill. Shinseki and Petzel faced questions Thursday about long-standing inefficiencies in the VA’s healthcare system, as well as allegations that VA officials covered up evidence of delays at a Phoenix, Arizona, clinic that may have led to the deaths of 40 veterans.

“As we know from the Veteran community, most Veterans are satisfied with the quality of their VA health care, but we must do more to improve timely access to that care,” Shinseki said in a Friday statement. “I thank Dr. Petzel for his four decades of service to Veterans.”

Petzel said in September that he planned to retire this year, according to the Associated Press.

“As the President has said, America has a sacred trust with the men and women who have served our country in uniform, and he is committed to doing all we can to ensure our veterans have access to timely, quality health care,” the White House said in a statement. “He has asked Secretary Shinseki to conduct a review of Veterans Health Administration practices and procedures at its facilities nationwide to ensure better access to care, and that review is ongoing.”

This post was updated with a statement from the White House.

TIME Veterans

VA Day of Reckoning: Head Could Roll Over ‘Secret Lists’

Obama Welcomes Wounded Warrior Project's Soldier Ride To White House
VA Secretary Eric Shinseki and President Obama at a veterans' event last year. Win McNamee / Getty Images

Secretary Eric Shinseki faces Congress, and trouble, if woes are widespread

There’s a sword of Damocles hanging by a hair over Veterans Administration chief Eric Shinseki as he heads to Capitol Hill on Thursday to testify on the VA’s expanding secret wait-list mess. It’s an apt place for the retired four-star Army general, himself a veteran wounded in Vietnam. He finds himself in the tightest spot in his five years as secretary of the Department of Veterans Affairs, dealing with the downstream costs of two of the nation’s longest wars.

Charges—and confirmations—about VA double bookkeeping when measuring how long veterans have to wait for appointments are nothing new. But what has given the latest stories more impact are the deaths allegedly linked to the delays, the secret lists designed to hide them, and charges that the secret lists were a way for VA executives to mask shortcomings and thereby maximize their cash bonuses.

Those bonuses come from an annual $150 billion VA budget, triple 2001’s spending.

Congressional Research Service

Whether the sword falls won’t depend so much on what Shinseki tells the Senate Veterans Affairs Committee. He has already said he won’t resign. What’s critical is how Congress and veterans react to what he says, and what a VA-wide inspector general’s probe into the problem turns up. Shinseki will survive if he convinces them he was ignorant of such wrongdoing—he has denounced it as “absolutely unacceptable”—and shouldn’t have been expected to detect it on his own.

But anyone who has paid attention to VA data is aware that there have been persistent efforts inside the agency to make vets’ wait times seem shorter than they actually are. One 14-day limit for getting an appointment was ripe for abuse, and critics say such abuse should have been anticipated and eliminated. Shinseki’s defense becomes weaker with every corroborated story of his subordinates gaming the system. If there’s evidence that the problems are systemic, Shinseki’s days are numbered.

“This is an accountability moment for the VA,” says Phil Carter, who served as an Army officer in Iraq and now champions veterans issues at the nonprofit Center for a New American Security. “The key question is where within the organization to fix accountability: at the secretarial level, the regional level, the hospital level, or some other place.” Only after the IG’s inquiry, Carter says, can the government “decide who should be held accountable for these issues.”

“This is not a new problem,” Paul Rieckhoff, head of the Iraq and Afghanistan Veterans of America, conceded last week. “Veterans have been dying in line for care for decades.” IAVA, like most veterans’ groups, has not called for Shinseki’s ouster.

But others have already made up their minds. “General Eric Shinseki has served his country well,” Daniel Dellinger, the commander of the American Legion, said May 5, when he and his 2.4-million-member organization called on Shinseki to step down. “However, his record as the head of the Department of Veterans Affairs tells a different story. The existing leadership has exhibited a pattern of bureaucratic incompetence and failed leadership that has been amplified in recent weeks.”

There is a baby-bathwater issue, too. “Surveys suggest that patient satisfaction is high among the 6.5 million veterans who get care each year from the VA,” Senator Bernie Sanders, I-Vt., who chairs the veterans committee, said Wednesday. “And while the American Customer Satisfaction Index said VA patients rank their care among the best in the nation, it is clear to me that there are problems within the VA and that the VA has got to do better.”

The VA is the country’s single largest health-care system, with its 300,000 employees spread among 151 medical centers, 820 clinics, and other sites tending to the needs of 230,000 vets a day. “While of course Shinseki is responsible for everything that happens at VA, he’s been fixing serious problems and overall the system is improving,” says Ron Capps, an Army veteran who has sought help from the VA. “So we should give him some more time and space to continue with his plan.”

Whether or not the fudged wait lists are widespread, warning lights highlighting them have been flashing for years:

  • The VA’s “method of calculating the waiting times of new patients understates the actual waiting times,” the agency’s inspector general said in a 2007 report on outpatient visits. “Because of past problems associated with schedulers not entering the correct desired date when creating appointments, [the VA] uses the appointment creation date as the starting point for measuring the waiting times for new appointments.”
  • In 2012, the IG said that when it came to getting a mental-health appointment within the VA goal of 14 days, the agency claimed it met that target 95% of the time. But after drilling deeper into VA data, the IG concluded only 49% got their appointments within two weeks.
  • That same year, the IG reported that patients at a VA facility in Temple, Texas, had “prolonged wait times for GI [gastroenterology] care [that] lead to delays in diagnosis of colorectal and other cancers…staff indicated that appointments were routinely made incorrectly by using the next available appointment date instead of the patient’s desired date.”
  • Not surprisingly, the longer the wait for care, the worse the result. “Long-term outcomes, such as death and preventable hospitalizations, are more common for veterans who seek care at facilities that have longer wait times than for veterans at facilities that have shorter wait times,” the federal Institute of Medicine said last year.

 

 

TIME U.K.

British Charity Sees Rise in Afghanistan Vets Seeking Mental Health Help

A U.K. veterans mental health charity reported a 57% increase over one year in Afghanistan veterans seeking support

The number of British veterans of the war in Afghanistan seeking help for mental health issues increased sharply from 2012 to 2013, a charity group said Monday, warning that need would continue to rise as the country ends its involvement in the war.

Combat Stress, a U.K. veterans mental health charity, said the number of veterans seeking its help went up 57% in the course of a year. The group received referrals for 358 veterans last year, compared to 228 in 2012. Its caseload now includes more than 660 veterans. The increase is linked to the withdrawal of British troops in Afghanistan from all but two bases in Helmand province.

The charity said it found that veterans wait an average of 13 years after serving before seeking help, but the average time has now fallen to 18 months for Afghanistan veterans. Combat Stress also reported that their total caseload of 5,400 veterans across the country was the highest number in its 95-year history.

“We have had great support from the Government and the public over recent years and we simply could not operate without the generosity we have experienced, ” said Commodore Andrew Cameron, chief executive of Combat Stress. “We cannot allow the ex-Service men and women who suffer from the invisible injuries of war to go unnoticed and untreated.”

TIME Veterans

This Woman Is the Last Civil War Pensioner Alive

The last living child of a Civil War veteran, Irene Triplett still receives a monthly pension from the federal government

Irene Triplett, 84, receives a $73.13 monthly pension payment from the Department of Veteran Affairs every month. It’s for her father’s military service—in the American Civil War.

Triplett is the last child of any Civil War veteran to still receive benefits for the conflict that ended a century-and-a-half ago, the Wall Street Journal reports. Triplett’s father, Mose Triplett, was born in 1846 and joined the Confederate forces in 1862 before deserting and signing up with the Union. In the 1920s, he married a women 50 years his junior, who later gave birth to Irene.

16 widows and children of veterans from the 1898 Spanish-American War still receive benefits from the VA. While the last World War I veteran died in 2011, 4,038 widows and children still get monthly payments for their family members’ service in that conflict.

[WSJ]

 

TIME politics

Veteran Affairs Secretary: I Won’t Resign

Secretary of Veterans Affairs, Eric K. Shinseki Tours VA Medical Center-Hampton, in Hampton, Virginia
Secretary of Veterans Affairs, Eric K. Shinseki exits a shuttle while being given a tour of the VA Medical Center-Hampton, in Hampton, Virginia. The Washington Post/Getty Images

Secretary Eric Shinseki rejected calls from veterans advocacy groups for his resignation Tuesday, after allegations of systematic neglect at veteran care facilities

Embattled Veterans Affairs Secretary Eric Shinseki rejected calls for his resignation Tuesday, amid allegations that veteran care facilities had neglected to treat patients in need of urgent care.

Shinseki told the Wall Street Journal that he would work toward improving communications with the American Legion, the nation’s largest veterans advocacy group, which called for Shinseki’s resignation on Monday.

The Legion accused Shinseki of “poor oversight” after whistleblowers came forward with reports of a care facility in Phoenix shunting patients onto a secret waitlist, obscuring prolonged wait times that may have contributed to patient deaths.

“I’m very sensitive to the allegations,” Shinseki told the Journal, promising that he would react to the conclusions of an independent investigation.

[WSJ]

TIME Military

TBIs MIA: An Estimated 30,000 Undocumented Bruised Brains

Army Explosives Team Destroys Roadside Bombs In Iraq
Captured explosives used in roadside bombs are detonated by an Army bomb-disposal unit in Baghdad in 2005. John Moore / Getty Images

The Pentagon recorded only half of the wars' traumatic brain injuries, a new study estimates

Despite its vaunted intelligence-gathering capability, the U.S. military was surprised when enemies in Iraq and Afghanistan began building and deploying roadside bombs to kill and maim U.S. troops.

It got so bad that a soldier asked Defense Secretary Donald Rumsfeld nearly two years into the Iraq war why U.S. troops were forced to defend themselves against such improvised explosive devices with homemade “hillbilly armor.”

“You go to war with the Army you have,” Rumsfeld told the soldier, “not the Army you might want or wish to have at a later time.” It took the Pentagon three more years before Mine-Resistant Ambush Protected vehicles finally began trickling into Iraq.

While the troops were waiting for that armor, the Pentagon was also neglecting to track the traumatic brain injuries caused by such blasts, a new medical study says. TBIs—the “signature wound” of the post-9/11 wars—are tough to diagnose and treat. Without a good accounting of those who experienced a TBI, those challenges multiply.

The report’s authors, using amputations as a proxy for TBIs, conclude that the military documented only one in five TBIs estimated to have affected U.S. troops between 2003 and 2006. Responding to legislation, the Pentagon began tracking TBIs more closely beginning in 2007.

Overall, during the eight years spanning 2003 to 2010, the study estimates that 32,822 active-duty troops suffered undocumented TBI wounds. That’s more than the 32,176 documented by the Pentagon over the same period of time. “This analysis provides the first estimate of undocumented incident TBIs among US military personnel serving in Iraq and Afghanistan” before Congress demanded the improved counting, the report says.

Such missing diagnoses are important, says the study, conducted by a pair of Johns Hopkins University health experts. Undocumented TBIs could lead to troops being booted from the military as malingerers or for personality disorders—discharges that could restrict their access to care from the Department of Veterans Affairs.

For those remaining in uniform, it could lead to additional combat tours, boosting their chances of a second TBI and the “visual and auditory deficits, posttraumatic epilepsy, headaches, major depression, and suicide risk” that accompany multiple TBIs, according to the study. Even a so-called “mild” TBI can rattle the (helmeted) brain inside the skull, leading to a host of maladies including memory loss, cognitive deficits, mood volatility, substance-abuse disorders, personality changes, sleep difficulties and possibly post-traumatic stress disorder.

“In recent years, the U.S. military has generally been reactive, rather than proactive, in responding to public health crises, including suicide, psychotropic drug misuse, and gaps in wounded warrior care,” says Remington Nevin, a co-author of the study. “Public-health leaders within the Department of Defense have a troubling history of having epidemics and programmatic deficiencies identified only by outsiders long after the time to act has passed, rather than having these identified internally in time to mount an optimally effective response.”

A top Army psychiatrist at the time says troops minimized the issue, and their leaders weren’t seeking it out. “Soldiers did not want to come forward, for fear that would be taken out of the fight, or thought to be malingerers,” says retired Army colonel Elspeth Ritchie. “And we — the medics and the line [officers] — were not looking for it.”

The authors used an interesting yardstick to estimate the number of undocumented TBIs: they calculated them by developing a mathematic formula that established a relationship between amputations and TBIs, based on the wars’ later years when the Pentagon was more rigorously tracking TBIs. Unlike TBIs—the so-called “invisible wounds” of the nation’s post 9/11 wars—amputations are visible and easily counted.

IED blasts cause most TBIs and amputations, making missing limbs a good tool to estimate the missing TBIs, says the paper, by Rachel Chase and Nevin of Hopkins’ Bloomberg School of Public Health. “Including amputation counts in the model as a proxy for injury causing events is appropriate, given strong clinical and ecological evidence of common mechanisms of injury” for amputations and TBIs, they write in an article in the Journal of Head Trauma Rehabilitation slated to be posted next week.

Too often, wars’ impacts aren’t gleaned until years later. Mustard gas experiments poisoned thousands during World War II. Cold War nuclear-weapons tests are suspected of causing cancer. Agent Orange was the ticking time bomb in Vietnam—the Department of Veterans Affairs is still adding to its list of medical consequences. Gulf War Syndrome stemming from the first war with Iraq, in 1991, remains a mystery. Traumatic brain injury is simply the latest in the list of war’s unintended repercussions.

The authors put together two Pentagon charts and circled the missing TBIs. Nevin
TIME health

Almost Half of Homeless Men Had a Previous Brain Injury

Homeless people and TBI
Past traumatic brain injuries were correlated with homelessness Getty Images

A new study of homeless men found that 45% of the subjects surveyed had experienced traumatic brain injuries in the past. Brain injuries can cause both cognitive and personality problems that researchers don't yet fully understand

Traumatic brain injuries (TBIs) happen in a moment: a jarring collision while playing sports, an accidental fall, a sudden bomb blast. But their effects can last for a lifetime. Cognition and decisionmaking abilities can be damaged. Mood and behavior can shift suddenly, sometimes resulting in increased aggression or reduced motivation. While most people who suffer a TBI will be able to continue on with their lives unchanged, a subset of victims are never the same. The trajectory of their life is altered permanently.

Just how altered isn’t clear, but a new study published in the journal CMAJ Open offers some sobering data about a possible connection between TBI and homelessness. Jane Topolovec-Vranic, a researcher in trauma and neurosurgery at St. Michael’s Hospital in Toronto, surveyed 111 homeless men recruited from a city shelter to see whether they had suffered a TBI sometime in their past. She found that 45% of them had experienced a traumatic brain injury at some point in their life. (Sadly, most of her subjects’ TBIs resulted from assault.)

“You could see how it would happen,” she says. “You have a concussion, and you can’t concentrate or focus. Their thinking abilities and personalities change. They can’t manage at work, and they may lose their job, and eventually lose their families. And then it’s a negative spiral” — a spiral that, for the men in Topolovec-Vranic’s study, ends up in a homeless shelter. There’s no clear data on how prevalent TBI is in the general population, which makes it difficult to say for sure whether the homeless men in Topolovec-Vranic’s study were injured at an unusually high rate. Hers was also a small study, which limits any larger conclusions about the connection between TBI and homelessness.

But the more we learn about the long-term effects of TBI, the more worrying such injuries become. Another study recently published in the Journal of Adolescent Health found that nearly half of all newly admitted adolescents to the New York penal system had a history of TBI. Studies have also shown that military veterans who suffered a TBI are more likely to commit suicide than those who didn’t.

Our brains are extraordinary machines, and we now know that they continue to change throughout our lives — for the better and, sometimes in the case of TBI, for the worse. Homelessness is sad enough in its own right, but the thought that a single traumatic brain injury could make that fate more likely is truly tragic.

TIME

This Doctor Volunteers to Help Suffering Soldiers

The trauma war brings can become part of veterans, their families and communities

Though her practice specializes in treating children, clinical psychologist Barbara Van Dahlen’s greatest influence may be getting fellow doctors to give their time and expertise to help soldiers returning from war.

Concerned about the mental health consequences of the wars in Afghanistan and Iraq, she founded in 2005 Give an Hour, a national network of mental-health professionals like herself who provide free services for American veterans, their loved ones and their communities.

TIME honored Dr. Van Dahlen as one of the 100 Most Influential People in the World in 2012. Former Chairman of the Joint Chiefs of Staff Admiral Mike Mullen said of Dahlen: “Barbara has tenaciously attacked the epidemic of post-traumatic stress disorder, helping break through the stigma that prevents many from seeking help. She has also created an opportunity for many who have not served in uniform to make a difference.”

TIME Military

‘Busting My Ass, Defending Yours': Everyday, the Cost of War at Fort Hood

U.S. flags are pictured in front of the Central Christian Church in Killeen, Texas
U.S. flags are pictured in front of the Central Christian Church in Killeen, Texas, April 3, 2014. Erich Schlegel—Reuters

March was the first month without a U.S. casualty in Iraq or Afghanistan in over a decade. But the cost of war is still being borne on the home front.

On April 2, a junior enlisted soldier, Specialist Ivan Lopez, went on a shooting spree at the U.S. Army’s Fort Hood, next to the city of Killeen in central Texas. He killed three people and injured 16 others before taking his own life. Some of the first things we learned about Lopez were that he had apparently served for several months in Iraq in 2011, that his violence may have been motivated by a dispute with some fellow soldiers, that he was being treated for depression and anxiety (including with medication), and that he had legally purchased his weapon, a .45 caliber Smith and Wesson semiautomatic handgun, but violated Army rules when he brought it onto the post without registering it.

These scant details — the military status, the deployment, the diagnosis — seem to tell a familiar story: a soldier gone to war returns home mentally unhinged by what he has seen and done and unleashes that violence like a contagion on his family, his neighbors, his homeland.

This story is dangerous, though. Not because it gets any of the substance of this most recent tragic violence wrong, necessarily. Rather, its focus on isolated and dramatic violence distracts from the subtle, chronic, and widespread effects of war on the people who fight it. It draws crude links between experiences of war, mental anguish, and violence that stigmatize mental illness in general and soldiers in particular.

At best, it risks overlooking the routine, ongoing experiences of the community most directly affected by Wednesday’s events. At worst, it callously misrepresents the members of that same community and lets civilians off the hook for the effects of wars waged in our name.

‘My Other Car Is a Tank’

Americans are accustomed to thinking of war as a literally foreign entity, something that takes place on a distant battlefield on the other side of the world. Decades of an all-volunteer military have enabled this fantasy. The wars in Iraq and Afghanistan represent a major commitment of national purpose and resources, but less than one percent of the U.S. population has served in them. For those who have, though — people at Fort Hood and places like it — war isn’t confined to one time and place. Instead it’s ongoing and ubiquitous, its effects finding their way into the most mundane and intimate aspects of life. In the process war becomes “normal,” but not necessarily any easier to live with.

These slogans emphasize a mix of fierce purpose, wry self-awareness, and mild unease toward the broader civilian public.I spent 12 months at and around Fort Hood in 2007 and 2008, living near the base and learning about the everyday lives of soldiers and those close to them in the midst of ongoing war. Fort Hood is one of the biggest military bases in the world. Its population of around 50,000 soldiers and tens of thousands more military family members, civilian workers and contractors, and retiree veterans demographically and economically dominates the city of Killeen and the other towns neighboring the post.

Motels and chain restaurants run off the constant traffic of a military kept busy by war. Used car dealers, pawnshops, and payday lenders thrive amidst a captive market of young soldiers. The bumper stickers you see on cars sitting in traffic announce that “Half My Heart Is In Iraq” or that “My Other Car Is A Tank”; they declare “Busting My Ass, Defending Yours” or indicate with a wordless configuration of blue stars on a white background that the driver’s family members are deployed. These slogans emphasize the mix of fierce purpose, wry self-awareness, and mild unease toward the broader civilian public that many people I met there shared. Bars, dry cleaners, and big box stores are all adorned with yellow ribbons, “Support the Troops” banners, and the insignia of the 1st Cavalry Division, 3rd Armored Cavalry Regiment, 13th Sustainment Command, and the other units that call the base home.

The base itself is massive, spread out across 150,000 acres mostly devoted to ranges and training areas. Its main built-up area features classically bland, modernist government architecture, like the campus of a giant, sleepy state university, but decorated here and there with decommissioned war machines, old tanks, and helicopters. But just a few blocks away stretches its famous “ten miles of tanks” — the world’s biggest concentration of armored military vehicles (when they are not dispersed across the Middle East) in the form of a nearly 10-miles-long row of chain-link pens full of Abrams tanks, Bradley and Stryker fighting vehicles, and Humvees. They are all painted a uniform desert tan, and look just as at home parked on arid central Texas asphalt and limestone as they do in the deserts of Iraq.

Gate Ticker
Dana DeLoca/Courtesy of Kenneth T. MacLeish

There are other uncanny reminders of the nearness of violence too: On the way into town from the south, next to a billboard advertising a local lingerie shop changes with the seasons, the firearms store Guns Galore invites you to “CHOOSE FROM 1,200 GUNS ON DISPLAY” (news reports say both Lopez and Nidal Hasan, who killed 13 people and injured more than 30 at Fort Hood in a 2009 shooting spree, bought their guns there). Just inside the exit lanes of each gate of the post, giant signs enjoin drivers, “YOU SURVIVED THE WAR, NOW SURVIVE THE ROAD—DRIVE CAREFULLY.” Big red digital numerals indicate “[X] DAYS SINCE THE LAST TRAFFIC FATALITY” beside a blinking light that goes from red to amber to green as the number of safe days rises. I rarely saw the number of days go higher than 10 when I was there in ’07 and ’08 (though when I visited most recently in 2010, a few months after the first Fort Hood mass shooting, it was well into the green).

Jumping at Loud Noises

Fort Hood is the single largest point of departure and return for US forces deployed overseas, a central node in the U.S. wars in Iraq and Afghanistan. At the time of my research, Fort Hood was home to the 1st Cav and Fourth Infantry Divisions — brigades from each saw especially heavy combat as part of the 2006 Iraq War surge — as well as numerous smaller expeditionary units. The tremendous personnel demands of the wars necessitated a grueling rotational schedule that most of these units followed: 12-month tours frequently extended to 15 months and separated by 12 months or less of “dwell time” back in Texas.

She didn’t want to know what had instilled in her husband that lingering, disruptive sensitivity to signs of violence and danger.All this meant that going off to war was often less a one-time event than a repeated shuttling between home and Iraq, giving rise to a sense of both inevitability and uncertainty that loomed over the entire community. I remember my surprise when a friend who was waiting impatiently to learn when her husband, a career infantry noncommissioned officer (NCO), would return from his third deployment casually mentioned that he already expected orders to deploy again a year later. Decisions about policy and tactics may seem like abstract matters, but in such tiny but profound ways as this they show up in people’s everyday lives: The nation going to war means that some one, some person goes. Staying at war means they go again, and again.

I asked a friend I’ll call Jessica if her husband, I’ll call him Cal, a logistics NCO, seemed changed by his time in Iraq (I use pseudonyms to protect the privacy of the people who spoke with me). Cal had just finished a 15-month tour. When Jessica and I first met in 2007, his tour had just been extended, meaning he’d be home by Christmas instead of by Labor Day. She said she could tell that certain things bothered him more, that certain things stressed him out, even though he hid it well and didn’t talk about it. He could be pretty quiet anyway, so she didn’t worry about it much. She would sometimes notice how uncomfortable he seemed around crowds or loud noises — tense, jumpy, and extra quiet. She would ask him if a loud noise had bothered him, he would say yes, and she would leave it at that. I asked her what it made her think. She said she just didn’t want to think about what he might be being reminded of. She didn’t want to know what had instilled in him that lingering, disruptive sensitivity to signs of violence and danger.

People had different ways of responding to such things, though. Jessica told me about a close friend, also a spouse of a frequently deployed NCO. Every time this woman returned home from work or running errands when her husband was gone, as she rounded the carefully planned curve of her street in an Army housing subdivision, she would picture in her mind a car with government plates parked at her front door, and a couple of soldiers in shiny shoes and class A dress uniforms there to notify her that he had been killed. Every time. “Why would you think that?” Jessica wondered aloud to me. “Why would you do that to yourself?”

Army spouses like Jessica and her friend say that “they also serve” and invoke their status as “the silent ranks”: there is a state of war that happens in the sudden sense that your easygoing, imperturbable husband is silently crawling out of his skin as he stands next to you, or that violent death may reach you through the thing you value most and find you out of nowhere on the way home from the grocery store.

They and others told me stories of the terror that can come from the sound of a phone ringing or a knock at the door when a loved one is deployed, the discipline it takes to avoid watching or reading news about the war, the force of will required to ignore gossip and reign in rumor. Jessica kept herself on an even keel by assiduously not giving in to anxious fantasies, not thinking the worst, or indeed trying not to think about the whole thing at all — no simple feat. “I’d rather not go there,” she said. But there is nevertheless an inescapable “there” to go to: the brute fact of loved ones being sent into harm’s way over and over again, of the pain of their absence, of the changed and uncertain condition in which they return home.

‘To Know If You’re Crazy’

The Army has a massive medical system meant to treat the physical injuries that such circumstances produce as well as their mental impacts. Anywhere from 15 to 50 percent of U.S. service members who served in Iraq and Afghanistan are estimated to suffer from post-traumatic stress disorder (PTSD), and even more from related conditions like depression and anxiety. But what exactly becomes of veterans with these conditions is another question, especially given the tremendous overburdening of the Army medical system and the pressure it is under to keep soldiers healthy, able-bodied, and ready to deploy. The Army’s own medical command estimated that a soldier with PTSD could cost the military $1.5 million over the course of a lifetime. There are numerous examples over the last 10 years of individual and concerted efforts by military and Veterans Health Administration personnel to minimize or deny PTSD diagnoses or to rediagnose soldiers with other, non-service-connected afflictions for which the military will not bear as much financial responsibility.

At worst, medicalizing the routine work of war provides yet another way for civilians to fear and pity soldiers without actually understanding them any better.The medical system that cares for ill and injured soldiers also places them under careful scrutiny, trying to distinguish if their pains and complaints are real and if they are worthy of care and compensation. So soldiers themselves often have an ambivalent relationship to a PTSD diagnosis — not least because they know how readily the Army can bend it to suit its purposes, but also because the diagnosis may not accord terribly well with how soldiers think about their war experiences.

Since 2004, all soldiers have been screened for PTSD and other mental illnesses when they return from deployment with questions about whether they participated in combat, were shot at, saw friends get injured, felt afraid that they might be hurt or killed, experienced intrusive memories or dreams, and so on. But soldiers know that answering affirmatively to any of these questions can, at the very least, keep them tied up with doctors and counselors when all they want to do is go on leave and see their families. Even worse, it could stick with them in their medical records, rendering them (officially or unofficially — it happens both ways) unsuitable for their jobs, ineligible for a security clearance, or unfit for promotion.

Aside from these structural disincentives, there is a more basic contradiction at work in these screening questions. The point of the questions, an infantry NCO I’ll call Ernie, who had led countless combat patrols in eastern Iraq, told me, is “to know if you’re crazy,” but the things they are asking after — seeing dead bodies, feeling afraid — were from his perspective simply normal parts of going to war. It is only on contact with the civilian world that the experience of soldiering is made to seem crazy. Ernie told me stories of firefights, near-miss IED strikes, and the gruesome aftermaths of car and suicide bombers — all the things that civilians know are part of war, and may even be comfortable consuming as entertainment, but which we are rarely comfortable hearing about in real life.

Doing and seeing these things and leading his fellow soldiers through them was all part of Ernie’s job, though. “Everything you go through, you go through with the same people you see day in and day out,” Ernie said. “So when you’re talking about it, it’s perfectly normal because you were doing the same shit I was doing, so you’re talking about it like it’s nothing.” In this catch-22, Ernie seems to be saying, it is not war but the experience of diagnosis that makes you “crazy,” both fitting you with the label and upending your own sense of what’s normal.

This process — by which a normal, routine experience comes to be understood as a sign of medical or psychiatric pathology — is what anthropologists refer to as medicalization. Medicalization can be a boon to people afflicted with a previously unnamed or unrecognized condition, giving them access to care and legitimating their suffering. This has unquestionably been the case with PTSD, which names a very real set of symptoms that often go unrecognized and provides at least some hope of care and treatment.

But medicalization can simultaneously have stigmatizing or pathologizing effects of its own, especially when it comes to mental illness diagnoses: Subjectively normal feelings become signs of illness, dysfunction, madness. Reducing soldiers’ experiences to nothing more than individual psychological phenomena in this way makes it all the easier to ignore how our ways of waging war make their suffering inevitable, not exceptional. At worst, medicalizing the routine work of war provides yet another way for civilians to fear and pity soldiers without actually understanding them any better.

Empathizing With a Ticking Bomb

And so we are left with the “war makes you crazy” story that is being offered as an explanation for this week’s shooting. In the understandable search for answers, questions about Lopez’s mental illness were among the first to be asked. The Army was quick to provide answers and the media quick to pass them on. But to what end? The New Yorks Times’s online headlines for the story on Thursday, for instance, announced that Lopez suffered from depression and was being treated by a psychiatrist. We also learned that he was “being assessed” for PTSD and had been prescribed medication, though the only drug named was the sleep aid Ambien. It was also revealed that Lopez had served in Iraq.

Seeing mental illness as a potential source of violence magnifies the stigma already attached to it.The implication was clear that deployment, military status, and above all mental illness and psychopharmaceuticals could somehow explain his murderous actions. Of course it is tempting to turn to mental illness now, as has also been the case with other incidences of both military violence (like Robert Bales’ massacre of Afghan civilians) and domestic mass shooting in the U.S. (Newtown, Appleton, Aurora) over the past several years. Diagnosing Lopez and other mass shooters seems to provide a comfortingly rational scientific explanation for a terrifyingly irrational act. But while particular details of some mass shootings may seem to justify such assumptions, on the whole the connections between mental illness and mass violence are slim to nonexistent.

This is the case with conditions more typically (though wrongly) associated with violence in popular imagination, like schizophrenia, but just as much with the depression, anxiety, and PTSD mentioned in connection with Lopez. People with severe mental illnesses are in fact far more likely to be the victims of violent crime, and those with severe depression potentially a far greater risk to themselves than to those around them. Psychiatrist Jeffrey Swanson has pointed out that mass shootings are incredibly rare events, and that focusing on their links to mental illness entails creating “common evidence” out of “uncommon things.” In the case of Fort Hood, we might also add that the very “common things” that are the source of regular suffering there disappear from view: the impact of long wars, long deployments, and insufficient resources only enter public perception at these moments of uncommon violence.

Even worse than this misunderstanding, however, is the fact that perpetually referring to mental illness as a potential source of violence magnifies the stigma already attached to it. In a military setting like Fort Hood, where many soldiers and those close to them already struggle to find care, sympathy, and assistance for their mental suffering — perhaps even more so in the wake of recent events — the damaging impact of such stigma is only made worse. The notion of stressed-out veterans as over-medicated “ticking bombs” primed to “go postal” — exactly as Lopez is alleged to have done — is often deployed with good intentions to emphasize the real and urgent need for better military health care, as will doubtless happen now, too.

But this rhetoric itself only serves to reproduce the stereotype of what my friend Stan, an Iraq War vet and veterans advocate, refers to as the “crazy vet” stereotype, according to which those touched by war are damaged, vulnerable victims — and also prone to deadly violence. Even as the stereotype pathologizes all soldiers, it focuses attention on a very narrow range of extreme behaviors, actually making it harder to see the broad and far-subtler range of burdens that war inevitably lays on those whose job it is to produce it.

Regardless of one’s perspective on this war, or war in general, the “crazy vet” can both confirm our worst fears about war and justify our outrage about it without prompting us to face these more everyday violences. This haze of pity, anxiety, and fear that swirls around many images of service members is fueled by popular culture, from Vietnam War films to breathless news reports like the ones we are reading this week. But a “ticking bomb” can never be the object of our empathy our understanding — it only tells us to run the other way.

The Stories We Tell About War

One of the things I found in my research is that the stories we tell about war tend to confirm what we think we already know. They often do this at the expense of the people who actually make war, letting us pretend that the violence of war is an exception rather than its essence. Allowing spectacular mass violence like this week’s shooting to be the thing that prompts public concern about the constant stresses faced by soldiers, vets, their families — and anyone who lives with ongoing war — does exactly this.

If we want people afflicted with mental illnesses to be well cared for, we need to talk about their suffering in ways that do not marginalize or pathologize it. And if we truly care about soldiers, veterans, and those close to them, we need to put aside the stereotypes that pop culture, military publicity, media saturation, and “common sense” offer us.

We need to listen to the “normal” experiences of making war — not least so that we may better hear the stories of those in pain in the wake of this most recent violence.

Kenneth T. MacLeish is an assistant professor at Vanderbilt University’s Center for Medicine, Health and Society. He is the author of Making War at Fort Hood: Life and Uncertainty in a Military Community (Princeton University Press, 2013), from which this essay is adapted.

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