Abstract
The title of this book, Burdens of War, is appropriately named. What are the human costs of war? When young men answer the call to war, whose responsibility is it to care for them upon return? The story begins with discussions among the federal legislature, veterans groups, military health-care leaders, and policy makers concerning how to care for veterans, in particular, those from the Spanish–American and Civil Wars, right before eve of the Great War. At this time, a Congressional act created the Bureau of War Risk (BWR)—responsible for the protection of men and women who served in the armed forces, including monetary compensation for death and disability. There were 4 million veterans of the Great War. Approximately 234,000 soldiers suffered combat wounds—bullet wounds, gas exposure, and still more from “shell shock.” Many of these conditions were treated by the Army Medical Department, though capacity was limited and further treatment of chronic conditions and extended rehabilitation greatly limited its functioning.
In 1918, the Public Health Service (PHS) was the only government hospital services accessible to veterans. At the time, the PHS had about 19 hospitals and 120 relief stations to available service members. As the need for veterans’ medical care multiplied, key policy questions arose: For what conditions was the government obliged to treat, specifically, conditions among draftees that led to their rejection? Adler cites one example of 52,600 young men who were accepted into military service but later rejected due to physical and mental health problems. In late 1919, Congress passed a law stipulating that such individuals were eligible for compensation and medical care. Among those who served, there was debate whether to treat preexisting conditions and yet not-so-recognized neurological conditions such as mental defect, mental disease and pathological mental states, organic nervous diseases, and confirmed inebriety. Many conditions were difficult to trace to the battlefield. Regarding what services to receive, should there be standard screening for referral services? What care was to be provided—hospitalization, rehabilitation, vocational training, and long-term living arrangements? Many agreed that the soldier “must not return to his home until he can make a living for himself better than he did before—until he can enjoy life” (p. 27). Concerning longevity of care, how long should care be provided to veterans? What was the government’s responsibility to veterans after discharge? At the more practical level, who should provide such services and in what facilities? How should a variety of federal agencies administer such services—including the military, PHS, and American Red Cross? To what extent should the medical profession be used in providing health care to veterans? What role should private medical schools and hospitals play?
The 1919 Congressional Bill also established a formal relationship between BWR and PHS. The bill also attempted to tackle some emerging and difficult questions about veteran health care—who was eligible for care and how veterans should be compensated for their military service, including dependents. During Woodrow Wilson’s presidency, Congress passed the “Langley Bill,” providing more funds for the BWR to improve, expand, and build hospitals. During President Harding’s administration, a bill was passed to create the Veterans Bureau, combining several government health agencies including the PHS. One year later, the Veterans Bureau managed 47 hospitals. In 1930, the Veterans Bureau was combined with the Bureau of Pensions and National Home for Disabled Volunteer Soldiers; the combined agencies was renamed the Veterans Administration (VA) and provided veterans with a broad array of medical, surgical, and rehabilitative care. A few years later, the VA operated hospitals at 70 locations in some 43 states. Around the same time, the U.S. economy had deteriorated, and resentment grew toward health services provided to veterans. Efforts were made to limit veterans’ medical services, though short-lived. World War II brought many service members who needed health care. Between 1944 and 1946, hospital admissions increased from 194,000 to more than 346,000, and the veteran population grew 5 million to 17 million. By this time, the VA as we know it was pretty much in place; the book ends in a few pages later.
Burdens of War presents a story of a significant shift from 19th-century domicile care to accessible health services for a large segment of the U.S. population. What perhaps accelerated the policies and services for veterans was the fact veterans represented a unique population. Ideologically, it is population who served in the military for national interests, often involuntarily. Practically, veterans began to increasingly represent a large number of individuals.
The book is an in-depth examination of how the modern veterans’ health-care system developed after the Great War. Adler considers ideological debates of who and how to provide for veterans, competing interests of existing heath entities (e.g., PHSs, BWR, American Red Cross, and American Medical Association) and veterans groups such as the American Legion. Adler writes a very detailed book on the historical development of the modern VA with voluminous references.
In terms of the book’s content and layout, the chapters might have had greater chronology, and within each, emerging themes that span across time periods with some sort of time line of key and pivotal events would be useful guides to the reader. Specifically, the author might have included more tables with prevalence data and information on emerging health services, in particular, across time, for example, the number of veterans, those needing health for what conditions, and so on. To conclude, this book offers some insight into the current universal health-care debate. As the old adage states, “history can serve as lessons”; that is, many of the issues and vying political and advocacy groups in the establishment of veterans health care mirror today’s debate about universal health care. These issues include eligibility, qualifying conditions, which services, goals (discharged and rehabilitative), and costs. Scholars, health-care providers, policy makers, and general audiences should be highly interested in the book.