Soldiers are heroes when they are sent to war. Momentarily, at least, they are heroes as they step off a plane onto a tarmac upon return, into a small sea of flags, into the waving. If they return dead, they are heroes, too, borne to final resting places in flag-draped coffins. The living, on the other hand, receive an 8.5 x 11 envelope with “Transition Assistance Program, Demobilization Toolkit” printed in black letters. Inside, a letter from the Office of the Under Secretary of Defense says, in part, “Thank you for your dedicated service. Your contributions to our nation’s security and the cause of freedom will never be forgotten.” In Saturday’s radio address, just before Memorial Day, President George W. Bush echoed the same sentiment, the pledge to remember. “Those [veterans] who have paid those costs have given us every moment we live in freedom, and every living American is in their debt,” he said. “We can never repay what they gave for this country.”
In fact, it appears that we don’t intend to.
Recently, White House budget officials reported that the Department of Veterans Affairs (VA) is scheduled to receive an almost billion-dollar budget cut by 2006, if projections stay on target. For veterans, out-of-pocket health care expenses like drug co-pays and new medical enrollment fees—of which the VA will cover less—are on the rise.
The Veterans Affairs Montana Health Care System (VAMHCS) will experience the predictable trickle-down effects. But in addition to the collective nationwide belt-tightening, VAMHCS, headquartered at Fort Harrison near Helena, has its own challenges. The Vietnam Veterans of America (VVA), a veterans service organization of 374 Montana members, initiated an investigation of Fort Harrison with a report, “Caring for Our Wounded,” which it issued in August 2001. In part, the report was a plea for an increase in mental health funding and staffing at Fort Harrison. Shortly thereafter, the VA Office of Medical Inspection (OMI) conducted three on-site reviews of the Helena hospital. In January 2003, the Fort Harrison chief of staff sued the OMI.
The OMI investigation report, “Review of Quality of Care,” called for changes the VVA knew needed to be made. VVA expected a certain level of OMI oversight and follow-through, but one year ago, say two VVA representatives, the process came to a grinding halt. Now, every minute that passes is another step toward a new wave of veterans returning from Iraq and Afghanistan.
The Veterans Service Organizations work largely independently of each other, but Kevin Grantier, with the Disabled American Veterans, sympathizes with the VVA’s tireless, and now urgent, call for more psychiatric care.
“I have a feeling, obviously, that the mental health issue will increase as we continue this war in Iraq,” says Grantier. “It’s turned out to be not the clean war that they thought it was going to be.”
W. Lee Smith, a Gulf veteran who saw combat, and member of the VVA, agrees.
Smith says that in the past six month he has seen his Post Traumatic Stress Disorder group disbanded and reinstated by Fort Harrison’s psychiatric department. “This place needs to get on the ball. It’s the calm before the storm. And the psychiatric department really needs to.”
Just west of Helena, tucked a mile or so north of U.S. Highway 12, past a cow pasture and a brick-pillared gate announcing the entrance, lies Fort Harrison, the heart of the Veterans Affairs Montana Health Care System. Cottonwoods line the 138-acre campus, named first after U.S. President Benjamin Harrison and adjusted in 1906 to honor President William Henry Harrison. A well-manicured lawn blankets the grounds, whose government employees oversee the delivery of care to the 26,000 Montana veterans who annually seek help.
The hospital is one of four in its area network, designated Veterans Integrated Service Network (VISN) 19, which runs along the Rockies. All told, Fort Harrison serves as the hub of health care and benefits services for close to 109,000 Montana veterans, of whom a reported 9.7 percent seek mental health services. Last year, medical expenditures for Montana veterans totaled $83 million.
Inside the administration building, Secretary for Veterans Affairs Anthony Principi smiles from a larger-than-life-sized photograph. A faded Korean flag hangs in the hospital lobby. Some staff wear patriotic pins secured to lapels. On Thursdays, veterans sell freshly popped popcorn at 50 cents a bag.
The warm veneer is not a disguise, but neither does it hint at the trouble within. There is no sign that mental health care at Fort Harrison receives substantially fewer funds on average than its VISN counterparts. There is no sign of the long waits for counseling appointments with the psychiatric department, no sign that some veterans, unable to wait, choose to commit suicide on the campus, soiling the manicured grounds.
The Vietnam Veterans of America, Chapter 626, keep office on the first floor of Fort Harrison’s administration building. For five years, two VVA representatives have worked the chain of command to remedy what they see as the hospital’s lack of adequate psychiatric services. They have also hoped to rid Fort Harrison of Chief of Staff Faust Alvarez, who is responsible for allocating funds among health care departments, and, they believe, shorting mental health care.
“We were trying like hell to get him fired,” says Mike Hampson, founding member of the Montana chapter of the VVA. “I have no bones about that. He needs to go.”
Alvarez’s superiors, apparently, disagree. A spokesperson for the VISN says the chief of staff received his most recent performance bonus, $3,650, in December 2003, on top of $195,184 in annual salary.
In any event, Hampson saw his group’s efforts hit a wall last year. They had reached the top of the chain of command—the VA Office of Medical Inspection in Washington, D.C. The VVA received the OMI’s report, which notes, among other things, that “In years past, mental health at the Medical Center may have received disproportionate overall staffing reductions as inpatient programs were closed without a commensurate shift of resources to outpatient mental health.” Though the recommendations resonated with VVA, the smallest veterans service organization in Montana, the report seemed to result in little change. And VVA, having reached the top of the VA food chain, had no place else to turn.
Mike Secrease, a Hulk-Hogan look-alike and representative for the VVA, sits behind a platoon of patriotic teddy bears in a paper-strewn office that accommodates just two desks. He started working with the VVA five years ago.
“There were a lot of complaints with veterans I started working with,” says Secrease. Life-threatening conditions misdiagnosed, lack of follow-up psychiatric care, and frustrated veterans alienated from the hospital. Secrease sought contact with Fort Harrison’s physicians, but says “we more or less had no access to the individual doctors. They didn’t want to talk to me even though I had power of attorney to represent the veterans with the VA.”
Secrease decided to share veterans’ concerns during his monthly meetings with the director and the chief of staff. He was soon rebuffed, he says.
“After the fourth or fifth month,” he says, “Dr. Alvarez lost his temper.”
“This is all hearsay,” Secrease says he was told, and “I’m not going to have anything else to do with it unless you can prove it with names and cases.”
Thus began a long process of soliciting veterans’ stories, culling the ones that best represented the list of woes the VVA wanted addressed. In 2000, the VVA began collecting examples of gaps in treatment. Finding veterans who weren’t afraid of retribution was difficult, says Secrease.
“Most veterans that come in here, their whole health issue, as well as income issue, is handled by the VA,” he says. “So this is their whole life, controlled by the VA, and if [the VA] decide[s] to cut them off, they’re lost.”
By August 2001, the VVA had compiled the “names and cases” Alvarez had requested into a report, “Caring for Our Wounded,” that documents problems and gathers the case histories that support them. It documents treatment delays: “From January 1, 2000 through October 2000, a veteran actually had his Fort Harrison appointment canceled six consecutive times, only to discover in December that he was the victim of kidney cancer.” Another man reported for emergency care after severe chest pains; Fort Harrison doctors told him he would need to wait two months for treatment. The veteran opted for a second opinion and the private physician diagnosed “an immediate life-threatening condition. Seventy-two hours later, the veteran underwent emergency heart surgery.” The VA, says the report, denied payment for the treatment.
A letter from veteran Fred Harbeck, dated March 10, 2001, traces an arduous and lengthy attempt to obtain cancer treatment. After a decreased dosage in medication resulted in a seizure, writes Harbeck, “[I] had to go to emergency room…that cost me $300, which we really don’t have.”
Gulf War veteran W. Lee Smith is also a member of the VVA. The “Caring for Our Wounded” report, he says, is hardly complete.
“In the process,” he says, “several of the vets died before they could testify.” One such man had throat cancer that was misdiagnosed, says Smith.
“They kept telling him it was just a sore throat, go home and gargle,” Secrease confirms. “Six months later he was dead.”
Then, the report discusses gaps in psychiatric care: “Perhaps no aspect of care is more controversial than the inadequate psychiatric services rendered at Fort Harrison.”
The report continues: “Frightened, suicidal veterans who seek help are scheduled for appointments several weeks or months hence. Although not widely reported in the media, this has resulted in suicides occurring within the Fort Harrison complex itself.”
In the “Caring” report, one witness recounts such a suicide. “In the fall of 1997, I had the most unpleasant experience of parking in the east parking lot and following a man who appeared to be distraught into the hospital entrance of the building…He appeared to be very agitated. I proceeded into the hospital area and came back down approximately 15–20 minutes later. It was late afternoon, early evening. As I exited to return to my vehicle, I observed a man’s body laying to the east of the pavement in the dirt. It was near my vehicle so I approached, but was stopped by a police officer. I got close enough to observe it was the man I had observed earlier when I went into the hospital. He had shot himself and was dead.”
“[Montana] rank[s] 10th in the nation for suicides,” says Hampson of veteran suicides.
Another incident recounts a suicidal veteran who was turned away. “In one instance,” reads the report, “after escorting a suicidal veteran to Fort Harrison for emergency treatment, police officers were turned away and forced to summon a local care provider. The veteran, escorted by the officers, subsequently received emergency treatment at Helena’s St. Peter’s Hospital (at additional taxpayer expense).”
A letter from veteran Chapman Burgess recounts three letters he sent requesting advancement of a psychiatric appointment. “I complained that the medicine I had been given…made me feel suicidal, and I asked to see them sooner than my appointed time, which was 10 to 14 days away, an appointment that had been set for several months. The only response I received was a letter showing me that that appointment had now been cancelled and moved six months into the future.”
The report’s forward says, “this presentation only ‘scratches the surface’ of an immense problem,” which the writer then describes as “emotionally overwhelming.”
The VVA delivered the report to Alvarez.
“He said that all the claims were unfounded,” says Secrease.
So the VVA submitted the report to the VA’s Inspector General (IG) office in Washington, D.C., hoping for an investigation. “The IG never bothered to show,” says Secrease. A spokesperson for the IG confirms having received the report in August 2001, and referring the matter back to the hospital for an internal investigation in October 2001. (IG receives between 15,000 and 18,000 complaints each year. They have the staff to investigate on average 1,200 complaints each year. When additional inspections are warranted, the IG orders the hospital to conduct self-investigations.)
Secrease believes the “Caring” report finally landed in Secretary Anthony Principi’s lap later that fall. Roughly one month later, the Office of Medical Inspection (OMI), another oversight branch of the VA, sent a review team to Fort Harrison.
The OMI visits, conducted in December 2001 and January and March of 2002, yielded multiple recommendations for reform. Congressman Denny Rehberg’s office provided the Quality of Care report, dated May 2003, to the Independent.
The Quality of Care report recommends changes in the mental health care arena at Fort Harrison. OMI’s second visit to the facility, in fact, was initiated to further investigate the state of mental health care specifically. In response to the VVA’s allegation of “Inadequate Psychiatric Services,” the report reads, “The OMI concluded that, based on these cases and other information, there is reason for concern about the overall availability and quality of mental health services…The Medical Center is making efforts to improve access to mental health care. However…at the time of its site visits mental health services were fragmented due to inadequate and ineffective leadership, inadequate numbers of staff and inadequate funding.”
Throughout the state, VAMHCS has 14 full-time staff dedicated to mental health care, including psychiatrists, nurses and clerks, according to Fort Harrison Public Information Officer Lee Logan. Of those 14, Logan says she “thinks” eight are employed at Fort Harrison.
Financial figures support the OMI’s narrative conclusions. The average percentage of funds allocated to mental health at Fort Harrison is low compared with the VISN 19 average.
“The FY 2000 VISN 19 dollars directed to mental health as a percentage of all costs were 14.2 percent, slightly higher than the 13.2 percent spent nationally. In [VA Montana], 6.5 percent of all costs went to mental health.”
Two years later, VISN 19’s average spending on mental health care remained at a steady 14.2 percent, according to an annual mental health status report issued by the Northeast Program Evaluation Center in 2003. But at Fort Harrison, the percentage allocated to mental health had dropped to 5.2 percent, according to the same report.
Any health care worker will acknowledge the fact that funds are stretched across the board. But the report does not excuse Fort Harrison. “Although budgetary challenges are common throughout the VHA, the staffing dedicated to mental health at the Medical Center is inadequate.” The report recommends that “VAMHCS in concert with VISN” develop a plan for staffing and for the provision of mental health services; closer oversight of mental health services; and an interdisciplinary team or teams for the diagnosis and treatment of complex mental health patients.”
Lawrence Biro is the network director for VA Rocky Mountain Network #19, to which Fort Harrison reports. Biro is the only VA official who would grant an interview regarding the OMI investigation and mental health care services at the hospital.
“We just had the final, final review three years into this,” Biro says. “My boss asked me to look personally at everything in that OMI report so we could close it out. My personal position is that it’s closed out.”
Fort Harrison administrators have addressed or refuted the recommendations in the report, he says. The hospital has conducted a needs assessment, developed a plan, and as for continued oversight, says Biro, “I’m here.”
In his new position as VISN 19 director, Biro has visited Fort Harrison seven times in the past seven months, and that, he says, is more than his predecessor had visited in seven years.
Biro, however, cannot say whether and at what levels staffing and funding for mental health care have increased, as per OMI recommendations. But his commitment to veterans, he says, is that they receive care second to none, “including mental health care.”
“Bring to me those individuals that aren’t satisfied,” says Biro.
In fact, the VVA continues to express dissatisfaction with the lack of results at Fort Harrison or follow-up by the OMI team. And they believe that staff who testified to the OMI team have slowly been pressured out of Fort Harrison.
“Once they came out with this report and [OMI Investigator] Dr. Spencer was no longer involved with this process, as oversight, three quarters of the employees who testified to the OMI team are no longer working at Fort Harrison,” says Secrease. “Many of them are no longer working for the VA at all.”
“All the good guys burn out,” says an individual who wants to be identified only as a contractor with the VA. A former medical provider at Fort Harrison agrees. “Good people have gone down hard trying to make things better,” he says. He himself was clinically depressed for two years after leaving Fort Harrison, he says.
Another former Fort Harrison medical provider, also speaking on condition of anonymity, recalls a time when she called Alvarez into her office and reprimanded him for unclear care protocols that left one of her patients lost in the system. From that point forward, she says, Alvarez never again communicated with her.
“I was able to function quite well without having to communicate with him,” she says. “Probably better. But I was definitely on ‘the list.’”
She describes how she, like other staff, felt edged out. It isn’t anything you can prove, she says.
“It seemed to me other people were kind of turning away from me. Not my immediate supervisor, but other department heads. This is just my perception. This is just what I imagine…nobody came up to me and said, ‘Dr. Alvarez told me not to talk to you.’ But that’s how it seemed to me.”
Some former Fort Harrison employees and VVA representatives point to the chief of staff as the administrator responsible for the lower-than-average funding for mental health care.
The contractor believes the COS holds in contempt veterans who have mental health needs.
“Dr. Alvarez does not believe in psychiatry,” says Secrease. “He’ll spend money on a new machine before he’ll worry about a [full-time employee] in psych.”
Social worker Gary Weglarz is the only former Fort Harrison employee willing to have his name printed.
“In my opinion, Dr. Alvarez does not have a commitment to mental health, to substance abuse,” he says. “I feel like he had to be dragged kicking and screaming by the OMI team to provide an adequate homeless program.”
Hampson and others report that nine veteran suicides have occurred in Montana in the past two years, and they believe those suicides are a direct result of unmanaged chronic pain and lack of care in the mental health care unit.
“There’s a man that killed himself not too long ago,” says Hampson. “He had back and leg problems and I believe he had diabetes.” The medication wasn’t stopping the man’s pain, says Hampson. The veteran, says Hampson, called Helena’s St. Peter’s Hospital and asked an ambulance to pick him up in the back yard before his wife returned from a shopping trip. He killed himself, says Hampson.
“He was trying to tell them here at the psych department that he was in a bad way,” he says.
Another man had driven from Kalispell to keep his counseling appointment, says the contractor, but was turned away. “He went out in the parking lot and blew his brains [out],” says the contractor.
In the office of the VVA, staffers discuss the suicides like folks at a high school reunion reminisce about football scores. There was the parking lot incident. And remember the time when a man drowned himself in Spring Meadow Lake? The time when one rammed his car into the Fort Harrison gate? This one elicits laughter from the group—they can relate to the presumed commentary on the hospital.
Other veterans, desperate for mental health care, simply fall through cracks in the system and disappear, says Secrease.
Secrease recalls intercepting a veteran storming out of the hospital. The veteran, says Secrease, had been asked to write a letter of apology for asking to see a different psychiatrist. The veteran, says Secrease, was also out of medication. “He probably would have committed suicide at that point because his meds were done,” says Secrease. Secrease says he himself “hit the roof.” He spoke with a patient advocate, he says, who had the prescription renewed after talking with COS Alvarez. But the COS also mandated that the veteran work with a psychiatrist he didn’t want to see (the VVA later says they learned she was not board certified), says Secrease.
“I haven’t seen that guy here since then,” he says.
According to a conclusion in the OMI report: “At the time of the OMI site visit, mental health services were fragmented due to inadequate and ineffective leadership, inadequate numbers of staff, and inadequate funding. The OMI recognizes that the re-alignment of mental health services at the VAMHCS was in a state of transition. Nevertheless, the transition was not being managed well. Both patients and practitioners were confused, responsibilities were ill defined, payment mechanisms were unclear, and mental health leadership was lacking.”
Members of other veteran service organizations, like the DAV, also experience repercussions from the turmoil in the psychiatric department.
“I do know that there has been a history of turnover in the psychiatry department,” the DAV’s Kevin Grantier says. “It seems for some reason, unbeknownst to us, they can’t seem to keep a full staff of psychiatrists for very long terms.”
On Jan. 23, 2003, Alvarez filed suit against the U.S. Department of Veterans Affairs, Office of Medical Inspection. The suit, which is scheduled for trial in Helena on October 12, alleges that a March 2002 OMI investigation of Fort Harrison’s leadership was initiated without reasonable cause, and was based on Alvarez’s race and national origin, which is Cuban.
OMI did not provide official comment on its investigations or Alvarez’s suit. A spokesman for Secretary Principi’s office cannot comment due to the pending litigation.
Neither Chief of Staff Faust Alvarez nor Director Joe Underkofler would grant interviews, according to Public Information Officer Lee Logan. Logan would neither confirm nor deny that administrators’ refusals to answer even pre-reviewed questions were due to pending lawsuits.
Hampson believes that the lawsuit might be the source of the sudden halt to the OMI investigation process, a supposition he has been unable to confirm. “The OMI’s investigation,” reads the Quality of Care report, “will not be closed until all actions in response to the final report recommendations have been completed to the satisfaction of the OMI.” VVA had hoped to make headway with mental health care, including purging the hospital of the COS. Now, it is at a standstill.
The final chapter is not yet written. Secrease and Hampson and others wait with some apprehension for the young men and women who will return from Iraq, Afghanistan and other combat zones. They believe that many will need counseling or some form of mental health care, but they have exhausted their efforts trying to improve what Fort Harrison will have to offer.
So hospital staff continue to care for veterans with the resources they do have.
“We’re very, very efficient on so little money, but at a huge cost to our patients who are very loyal to us,” says a longstanding Fort Harrison employee. “We’re looked at as part of a family. And they love us for the most part. And they’re willing to take a lot.”
On the campus, just past the row of cottonwoods, up a little knoll, lies a veterans cemetery, and it, like the surrounding grounds, is well groomed.
“They are more interested in burying us than taking care of us,” says the VVA’s Hampson. “Real nice cemetery, but what does that do for the living?”