Him Who Shall Have Borne the Battle: The Complex Costs of War

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By Julie E. Fischer – “Support
the troops” has become a mantra for US policymakers, political
shorthand freighted with different connotations for those who seek an
imminent military exit from Iraq and those who favor open-ended
commitment of US forces. In this charged environment, media coverage
describing the grim welcome — from dilapidated housing to demoralizing
bureaucracy — awaiting some soldiers making the transition from combat
to convalescence at Walter Reed Army Medical Center sent shockwaves
through US public discourse. The revelations triggered Congressional
hearings, internal investigations, high-level resignations, a military
review panel and a blue-ribbon commission, and widening scrutiny on the
Departments of Defense and Veterans Affairs.


investigations will doubtless add detail to early sketches: some
defense and VA programs offer high-quality care, including cutting-edge
prosthetics and unique rehabilitation for complex traumas. Others
suffer from suboptimal funding and staffing and more facilities have
fallen into neglect than those already marked for closure (such as
Walter Reed). In the week marking the fourth anniversary of the war in
Iraq, VA identified more than 1,000 deficiencies of varying seriousness
in its 1,400 hospitals and clinics, GAO alleged serious neglect in a
home for military retirees, and staff of the highly praised National
Naval Medical Center warned that overwork and “compassion fatigue”
could yet take a toll on services.


The reports rippling
outward from Walter Reed may be shameful, but they should not be
shocking. In 2003, reporter Mark Benjamin described shoddy living
conditions for reservists and National Guard troops trapped in “medical
limbo” prior to mobilization. A 1999 staff report initiated by
then-Senate Committee on Veterans’ Affairs Ranking Member John D.
Rockefeller IV warned that budget cuts and a changing health care model
might compromise VA’s ability to serve combat-wounded veterans —
specifically those with spinal cord injuries, amputations, blindness,
and post-traumatic stress disorder. GAO reports on the rocky transition
from active duty to civilian life would fill a shelf.


did recovering soldiers still end up sleeping in moldering rooms while
celebrities and political leaders visited other wounded troops in
gleaming halls only steps away? Blame an ignoble history of budget woes
and interagency conflicts, exacerbated by the current Administration’s
deliberate underestimates of the costs of waging war.


the U.S. military shifted to an all-volunteer force in 1973, economists
correctly predicted that active duty forces would become increasingly
educated (high-school graduation rates among enlisted personnel exceed
those of age-matched cohorts), professionalized (evidenced by high
re-enlistment rates), and representative of the U.S. population
(although the South is slightly over-represented, the military’s racial
make-up matches the general population more closely than ever).
Economists inaccurately assumed that, as the military’s payroll budget
rose to attract qualified personnel, competitive wages would supplant
programs such as the GI Bill. After a few hiccups in the late 1970’s,
the military met marketplace demands with a comprehensive package of
healthcare, education, and retirement benefits. Over time, salaries for
active duty personnel declined compared to civilian wages, but an
increasingly generous benefits package compensated, and the military
could recruit fastidiously.


Thus, diverse military and VA
benefits programs, including health services, complement military
recruitment and retention strategies. These programs compete for
appropriated dollars against other force readiness priorities; recent
increases in military budgets have been accompanied paradoxically by an
erosion of health funding. The current Administration’s annual VA
budgets have relied upon curious assumptions: in 2006, the White House
grudgingly admitted that VA’s budget planning process had ignored the
war, leading to a $1.3 billion shortfall for health care. An emergency
supplemental appropriation closed the gap, but spurred Republican
leadership to remove the House VA Committee chairman for advocating
veterans’ funding too passionately. Although the president’s fiscal
year 2008 budget proposes increasing VA’s healthcare budget by about 6%
to $34.2 billion, it also assumes that VA healthcare costs will freeze
or shrink beginning in 2009, despite an anticipated influx of more than
250,000 veterans of Iraq and Afghanistan in 2008. Ignoring an ongoing
war that makes more veterans eligible for VA services daily again appears more than disingenuous.


Reed illustrates not only funding dilemmas (how many scarce dollars to
spend on a facility designated for the scrap heap), but the onerous
process of determining fitness for duty. A serious illness or injury
should trigger an evaluation to determine whether a servicemember meets
medical standards. If not, a physical evaluation board rates the degree
of disability on a scale of 0-100%, determining whether the member will
return to the home unit, assume alternate or limited duties, or
separate or retire from service. Ratings also determine the level of
any benefits to compensate for lost earning potential. The evaluation
can be delayed or repeated if the disability is deemed “unstable.” The
Army’s need to retain every soldier capable of serving in order to
maintain troop levels, combined with an overburdened evaluation system
scaled for peacetime separation levels, cultivates a holding pattern
for all but the most profoundly disabled. A high disability rating can
translate into higher costs to the military, providing an incentive to
“lowball” estimates for soldiers uncertain of their rights or willing
to compromise to end a Kafkaesque paperwork process. Because VA depends
heavily on military disability ratings when making decisions on
pensions and healthcare access, soldiers may trade lifetime support for
a quicker return to civilian life.


Media reports
understandably focus on egregious facility defects, but the laundry
list of leaks and stains cannot compare to stultifying interagency
cooperation problems that delay care. The increased scrutiny has
already prompted the military to examine the need to bolster “wounded
warrior” regiments and provide better information to families of
injured servicemembers. In contrast, years of laws, threats, and
cajoling have failed to stir the Pentagon’s interest in facilitating a
seamless transition between military and VA services. Despite its
stature as the second-largest Federal agency, VA has little leverage to
force its still-larger counterpart to adopt common electronic medical
records, exchange clinical information easily, or allow its case
managers to explain veterans’ services and benefits to injured troops
before separation is incontrovertible.


As some decision
makers have argued, demands on military and VA services continue to
evolve. Improvised explosive devices favored by insurgents in Iraq and
Afghanistan increase traumatic brain injuries and amputations. Advances
in body armor, trauma care, and medical technologies mean that more
desperately injured servicemembers survive than ever before and need
intensive clinical management, some for months and some for the rest of
their lives. The invisible symptoms of post-traumatic stress disorder,
estimated to occur in up to 10% of troops returning from Iraq, can be
difficult to diagnose and too easy to self-medicate with alcohol or
drugs if no other relief is offered.


However, the
absolute numbers of casualties (about 23,400 injured to date, according
to, although accurate figures are elusive) should not
have overwhelmed military and VA capacities if realistic assessments
had been used to fund and staff these programs. When Congress enacted
VA eligibility reform in the wake of the first Gulf War, streamlining
the system for determining who had access to what type of facility, all
combat veterans earned the right to access VA healthcare for two years
post-discharge regardless of whether they sustained a service-connected
injury. A decade’s worth of data should make predicting the number of
active duty forces, veterans, and their families seeking healthcare
through either the military or VA a relatively straightforward
actuarial exercise.


The comprehensive costs of
redeployment — from support services for re-integration into civilian
life to the full range of needed medical care — should be placed into
the context of strategic planning for this and future missions. If
moral obligations are not compelling enough, policymakers must consider
whether military and VA health infrastructures can be divorced from
their context as a downstream part of the U.S. war-fighting capability,
contributing to recruitment and personnel readiness, in determining
levels of funding. Legislation requiring already overtaxed staffs to
complete “report cards” will not replace honest public discussion about
national willingness to support the troops in more than sentiment
alone. So far, the American public has shown little taste for
nickel-and-diming those who placed themselves in harm’s way to buttress
theories about fighting a war on the cheap.


In the
best-case scenario, the high-level commissions charged with looking to
and beyond Walter Reed can cut through the political miasma surrounding
the war and focus purely on meeting promises made to those deployed to
Afghanistan and Iraq, and those who will don uniforms for the missions
future leaders deem necessary. President Lincoln’s words of the second
inaugural, a portion of which are inscribed on the walls of VA
headquarters, summarize the challenge best: “Let us strive on to finish
the work we are in, to bind up the nation’s wounds, to care for him who
shall have borne the battle and for his widow and his orphan, to do all
which may achieve and cherish a just and lasting peace among ourselves
and with all nations.”


Dr. Julie E. Fischer leads the Stimson Center’s Global Health Security
program which explores the growing demands on the world’s public health
infrastructure, from policies intended to contain transnational disease
threats to a new role for international health interventions in defense
and diplomacy.


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