The Anthropology of Veteran Healthcare

ZOE H. WOOL – In the unique social world of a military hospital, many veterans are “alone in common.”

Could you describe what would appear most striking for an outside observer walking through the halls at Walter Reed Hospital — what was your first impression when you arrived there?

What strikes most people is how young the soldiers are who are being treated; It is quite jarring to see young men missing limbs [Walter Reed specializes in prosthetics]. Additionally, the fact that these people seem to be simply going about their daily business is quite striking. People are spending time at appointments, but they also spend time going grocery shopping, going to the mall, and fixing their cars: trying to have an ordinary life.

People who spent time in a Veterans’ Administration or military hospital around 2003 would have seen a much older population: many people are not used to the new injuries and the dramatic “age drop” at these hospitals since the War in Iraq started almost a decade ago.

In your paper, Minuscule War, you ask whether “earth shattering force can be productive of social worlds.” Yet you also write about the idea of “being alone in common.” Could you describe the unique community that emerges from this seeming duality?

One of the most surprising things about Walter Reed — but which is in some ways is an intensification of the sociality soldiers have in regular military life — is that people are thrown together from often very different kinds of backgrounds, and share incredibly intense experiences. These people share very profound connections with each other, but often these connections are not built up in the same way that they might be in civilian life. A soldier may have a deep connection with another soldier. He may know intimate details about his buddy, he may seem him everyday, but he may not know the other soldier’s name. This type of relationship is characteristic of time in combat and the way people bond during basic training: it is a recurring motif in military life, but it is especially intense at a place like Walter Reed, because of the intensity of the experience of being a patient there. One of the interesting things about the way rehabilitation happens at Walter Reed and other military hospitals is that it is very much focused on the individual. The soldier’s primary relationship is often with his physical therapist. These soldiers often perform activities — learning how to run or walk, for example, around a track — in the presence of other soldiers, yet they are not engaged in collaborative activity with each other.

Because the appointments with doctors only take part of the day, much of the soldier’s time is spent killing time. The most palpable feeling at Walter Reed was boredom, not anger, frustration, or pain. People spend a great deal of time waiting for the next day or appointment; they spend a great deal of time alone, yet they spend this time knowing others are alone as well. This knowledge allows them to find things in common, yet it does not create a community.

For the soldiers with whom you worked at Walter Reed, does the grand nationalistic narrative of the so-called “War on Terror” factor into their experience?

This narrative is brought up many times, but not by the soldiers themselves. Walter Reed is not the home of the US Army Medical Command, but it was the largest army medical facility in the country, the only one with wards dedicated solely to wounded warriors, and it is considered the flagship of military medicine, research, and wartime care. It is worth clarifying here that the current-day Walter Reed is different than the one I am discussing here; today’s “Walter Reed Military Medical Center” is an expansion of what used to be Bethesda Naval Hospital. Yet, until recently,  it was strategically located at the Northern tip of Washington, D.C.; it is the place where presidents and noted politicians can receive care as well. For all of these reasons, the center is an iconic place that is easy for political activists from all sides to visit. Often, local news media will cover stories about local soldiers who are going through rehabilitation, and national media will cover broad topics from the hospital as well. Corporate campaigns can be launched from Walter Reed: Walmart launched a fundraising campaign called “Deck the Walls” whereby it distributes Walmart gift cards to military families. It launched its 2007 campaign at Walter Reed.

These groups come into the facility carrying with them the “grand national narrative” you mentioned about patriotism and national sacrifice. Soldiers are incredibly gracious and intelligent, and they appreciate the recognition that they are receiving. Yet these invocations of national sacrifice can make soldiers feel very uncomfortable because they do not match their own reasons for having joined the military, nor do they match their own experiences while deployed, that is, the violence committed and sustained while serving.

The overwhelming majority of injuries at Walter Reed were from improvised explosive devices, which usually means that the soldier was in a vehicle that exploded. This type of trauma is very different from the story of “storming the hill,” throwing one’s self on a grenade, or being engaged in an intense firefight. All of these events happen, but by far the most common way by which soldiers become injured is by driving in a vehicle. Soldiers find themselves drawn into these stories, but they do not identify with them.

Your most recent work has been to study the “traumatic flashback.” Could you describe what you mean when you describe “traumatic flashback as an encompassing genre of experience rather than a narrowly defined medicalized symptom”? 

There are not many people who have studied flashbacks from any kind of experiential perspective. They are often discussed as devices used in literature and film, but there is very little clinical research on what a flashback is — whether it can be pinpointed as a discrete biological or cognitive phenomenon — or how it might be related to dissociative states. Flashbacks are — and have always been — part of the definition of Post-Traumatic Stress Disorder (PTSD) in the Diagnostic and Statistical Manual (DSM), which is used widely as an authority on mental disorders. Yet the flashback has a shifting relationship to other symptoms of PTSD. In some versions of the DSM it has been an example of intrusive thoughts or memory, and other times it has been described as a discrete category. Sometimes it is in the same breath as “exaggerated startle response,” sometimes it is described as a nightmare. It is so-far unclear what doctors mean when they describe traumatic flashbacks, yet at the same time it is they are always associated with war trauma in the 20th century. Some people have argued that the flashback has only become associated with war trauma in the intervening years since Vietnam, but that is an empirical question on which the evidence is still inconclusive.

No matter the label, the traumatic flashback remains highly relevant and related to war, in public culture, for example. There was an episode of Grey’s Anatomy wherein one of the characters, who had been deployed to Iraq, has a flashback in the hospital; the audience knows exactly what is being described to it during this scene. More recently, the documentary “Hell and Back Again” tells the story of a marine’s return from Afghanistan, and his experience reintegrating into civilian life. The film is, in many ways, structured by the concept of the flashback, by the resonances that exist between the past and contemporary experience.

What scholars get in the flashback is not a specific, discrete biological or physiological experience, but rather a way of describing the inextricability of a painful past and the present that is marked by it. When I discuss an “encompassing genre of experience” I thinking about the flashback not as a real or false symptom. I want to think about it as a way of speaking about and describing this whole class of experience marked by intense past violence in the present. [Author’s note: The temporality of flashback is uncongenial to grammar.]

Can war, as it is illustrated in the news, media, and movies, affect the way in which soldiers view their own experiences?

There are many different schools of thought regarding PTSD and similar trauma. PTSD only became a diagnosable disorder in the DSM in 1980, which was the third edition of the manual. This change largely happened through the social and activist efforts of VA clinicians and Vietnam veteran activists who then recruited people working with victims of sexual violence.

[Interesting discussions of this topic can be found in Allan Young’s book, The Harmony of Illusions (Princeton University Press, 1997) and in Erin Finley’s book on the experiences of contemporary veterans, Fields of Combat (Cornell University Press, 2011)]

It is interesting to look at the way in which soldiers are confronted by a diagnosis of PTSD. The Army in particular — along with the other branches — has been training soldiers to be aware of what PTSD is, and to make soldiers responsible for screening themselves and fellow service members for signs of mental and behavioral health issues. Some soldiers have their first encounter with the idea of PTSD after they have been diagnosed, although the Army is trying to build resiliency by informing people of what they may encounter. Soldiers who may have symptoms of anxiety or depression — things that are often confused with PTSD — often are faced with media stereotypes of what a “PTSD Soldier” is by other people’s reaction to them. The ideas the public has of what PTSD is — especially as it relates to violence — confront soldiers in the way civilians interact with service members, what questions they ask or do not ask. What does not happen very often is that a soldier sees a description of PTSD in the media and concludes that, because of his nightmares or some other symptom the media mentions, he should get diagnosed.

How has your experience as an anthropologist studying the soldiers and military treatment systems differed from that of a political scientist or a historian? What is unique about the anthropological perspective? 

 The Institute for Health at Rutgers University where I work is quite interdisciplinary, incorporating historians, sociologists, political scientists, psychologists, and anthropologists. That environment has allowed me to realize that, as an ethnographer, I go into a place structured along rigid categories of rank, status, or diagnoses — a place like a military hospital — and work outside this rigidity. I can focus instead on the experiences of the people to whom I am speaking. The book on which I am working now, about the work I conducted at Walter Reed, focuses on the idea of “the ordinary.” As I spent time with these people, seeing them interact with journalists, volunteers, and doctors, the message they would constantly reiterate to me, because of the mode in which I was working and thinking, is that they were having ordinary lives. All of these categories into which people were trying to fit them, with which they had to engage, did not reflect their experience. As an anthropologist, I have the luxury of being able to talk about “ordinariness” in the context that seems bereft of it, and to see how these other kinds of categories impact soldiers’ ability to lead an ordinary life. Yet it is crucial to put this work into the historical, political, or psychological context.

***

ZOE H. WOOL is a Postdoctoral Fellow in the Institute for Health, Health Care Policy and Aging Research at Rutgers University. She has conducted ethnographic fieldwork with injured U.S. soldiers and their families rehabilitating at Walter Reed Army Medical Center. Her work on this and other issues related to the U.S. military since 9/11 can be found in peer reviewed journals of Anthropology and Sociology.

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