Q&A WITH JESSICA L. ADLER, Burdens of War: Creating the United States Veterans Health System

Q: Why did you decide to write Burdens of War?

I was a health reporter for a small daily newspaper in Paterson, New Jersey in the early 2000s, writing about issues ranging from the rollout of Medicare Part D and the financial woes of small inner city hospitals to how patients and their families coped with chronic and acute illnesses. During conversations with caregivers, providers, representatives of advocacy organizations, and others, I found myself wondering how certain programs and services came to be, and why some were so idiosyncratic. Around the same time, the wars in Iraq and Afghanistan were ramping up, and there was discussion and debate about how returning service members were being treated. In that larger context, I was drawn to explore the history of the army health system. My initial research focused on the origins of Walter Reed Army Medical Center, which, of course, has always played a highly visible role in providing care for military personnel, including in the first decade of the twenty-first century. As I perused the hospital’s early annual reports at the National Archives in Washington, D.C., I came across information about the World War I era and recognized that this was a crucial turning point, not just in the history of military health care, but also in the history of veterans’ care. The reports showed that by the 1920s, care for some patients in the hospital was being funded by an agency called the Veterans’ Bureau. Walter Reed, it turned out, was just one site – one part of a much larger story about how discharged military personnel became recipients of publicly sponsored health services. Although there were some books and articles that touched on the history of veterans’ health care, it seemed there was room for further exploration of its connection to larger themes: how war impacts society and vice versa, how policies are developed and implemented, how citizens fight for recognition and entitlements from their government, how state-sponsored programs are created and perceived, and how the conditions of those programs change over time to reflect larger realities.

Q: What were some of the most surprising things you learned while writing and researching your book?

It was really interesting the see how preparation for war shaped postwar policies and experiences. When it came to health and medical services for veterans, conservative lawmakers in the 1920s were obliged to follow through on expansive promises made by Progressive-minded reformers and legislators during mobilization. It was also remarkable to realize the diverse ways that multiple parties justified support for, or questioned, publicly sponsored veterans’ care, which was hardly an uncontroversial issue. Some veterans’ advocates, for example, worked to reconcile support for expanding government entitlements with their overarching beliefs in fiscal conservatism. I was also fascinated to see the unabashedly negative attitude of the organized medical profession towards veterans’ health care in the 1930s, and how it was combatted or reinforced by veterans, elected officials, bureaucrats, and the American public. Observing how congressional debates about legislation pertaining to veterans’ health care unfolded between 1917 and 1935 was interesting, too. Even as legislators acknowledged problems and shortfalls in the system as it stood, they also expressed dissatisfaction with proposed bills that offered inadequate, vague, or impractical solutions. But they voted “yay” anyway, because they were eager to support veterans for humanitarian and political reasons. Thus, the Veterans Administration bureaucracy was, in many cases, constrained by sloppy legislation that was difficult to implement. (This is one example of a challenge that remains to this day.) Finally, policy history scholars have noted that big government programs often come about “incrementally” – meaning they are built over time. The veterans’ health system is a case in point. There was no one moment when it was created. Instead, its institutions and bureaucratic infrastructure grew gradually, with the passage of various pieces of legislation and federal policies in the interwar years. By 1941, on the eve of World War II, more than 58,000 former service members were being treated in veterans’ hospitals.

Q: Did you encounter any other eye opening statistics while writing Burdens of War?

• In 1917, there were zero so-called veterans’ hospitals in the United States. Some Soldiers’ Home campuses dating back to the nineteenth century featured hospitals, but they were widely viewed as antiquated. By 1924, three years after it was established, the Veterans’ Bureau had taken control of a variety of previously existing public institutions and some newly built facilities, and officially owned and operated 44 hospitals. About ten years later, in 1933, the number of veterans’ hospitals in the United States stood at 71. By 1941, veterans had special access to 91 facilities in 45 states and the District of Columbia. 
• The number of diagnoses for “neuropsychiatric” conditions consistently increased in the 1930s from about 13,500 to 34,000, as did the number of diagnoses for “general” conditions, which climbed from about 8,000 to 19,000.
• Women and black men, who used veterans’ hospitals in increasing numbers in the interwar years, faced extra barriers when attempting to access care. Between June 1923 and June 1941, the number of women veterans remaining in hospitals at the expense of the government climbed from 220 to 404. In the same period, the number of black men receiving hospital care quadrupled, from approximately 1,300 to 5,540.

Q: Does your book uncover or debunk any long-standing myths?

The post-Civil War and World War II eras are both viewed as transitional moments in the history of veterans’ benefits and the larger welfare state. This book shows that the modern veterans’ benefits system is, in fact, rooted in the interwar years, when the Veterans’ Bureau and Veterans’ Administration were founded. Most broadly, the book serves as a case study of how a unique, massive, and lasting system of government sponsored health care was created in the United States.

Jessica L. Adler is an assistant professor in the Departments of History and Health Policy & Management at Florida International University. Her book, Burdens of War: Creating the United States Veterans Health System, is available now.