The following manuscript was submitted to the February 2017 Social Medicine Themed Writing Contest.
As a child of immigrant parents, I had limited exposure to the American military. Ironically, my sole memory of the American military exists outside of America — in Japan. I spent part of my childhood in Tokyo and fondly recall the excitement that came from visiting the American Naval Base in Yokosuka to buy “American groceries,” specifically Eggo waffles. Those Eggo waffles connected me back to my birthplace, the United States of America. My family moved back to the United States when I was ten years old.
Years later, I am an internal medicine resident with a continuity clinic based at a Veterans Affairs Hospital. I cared for veterans in medical school and knew them to be appreciative, outgoing, and most of all, resilient. As a resident, I initially saw their medical care as no different from other patients. After all, my calling was to care for the ill, regardless of background. My second month of residency challenged this assumption as I embarked on an intensive experience in the care of veterans: Deployment Health. I worked in two clinics, one for new veterans returning from combat deployments to Iraq or Afghanistan and one for veterans exposed to environmental hazards such as agent orange. This experience twisted my initial perspective of the military like a washrag, wrung out all of my notions of the military, laying it out dry to be used again for cleaning the stains of war. In their cleaning, I developed an empathy for veterans in relation to my own career as a physician, realizing the parallels of our callings and reinforcing the importance of veteran health.
War is bad for health. This became increasingly clear to me with each encounter. It’s seemingly obvious: broken bones, post-traumatic stress disorder, hearing loss, but this direct relationship between war and health also became seriously complex. Yes, war is bad for health, but were the health consequences of war a necessary evil? I struggled immensely to reconcile these two ideas. I was confused about agency: Who do I blame? Does working at the VA mean that I support the institution of war? Certainly not. I fight the social and medical consequences of war, both modern and historical, every day in the clinic. I engage in many smoking cessation conversations only to learn that a carton of cigarettes was a standard part of a soldier’s lunch, causing many soldiers to become addicted to tobacco at an early age, making it harder for them to quit now. I feel powerless when I hear stories of how veterans were told spraying agent orange was safe for them, knowing what we do now about its health effects. In these and other ways, soldiers and VA doctors alike have a strained moral relationship with the institution of the military, and sometimes, that is challenging in the practice of health care. I found resolve in sage advice from Johnathan Shay in Achilles in Vietnam: “There is no contradiction between hating war and honoring the soldier.” In caring for the veteran, we are honoring the soldier, and therein lies the foundation of my care of veteran patients.
Perhaps the most important facet of honoring the soldier is acknowledging the mental health consequences of war. Post-traumatic stress disorder, including military sexual trauma, is all too common. Veterans are hesitant to share their stories and often encounter civilians who are unwilling to listen to their narratives of brutality. Shay writes of a veteran who experienced exactly this, “I had just come back [from Vietnam], and my first wife’s parents gave a dinner for me and my parents and her brothers and their wives. And after dinner we were all sitting in the living room and her father said, ‘So tell us what it was like.’ And I started to tell them, and I told them. And do you know within five minutes the room was empty. They was all gone, except my wife. After that I didn’t tell anybody I had been in Vietnam.” In my practice, unless I bring it up in relation to their health, veterans rarely share the gruesome details of war. In an attempt to communalize grief, work at the VA must encourage storytelling, no matter the story.
Though often portrayed as such, war is rarely glamorous, and VA health care professionals must encourage the communalization of trauma through narrative medicine. Vulnerable stories evoke the bare truths of the consequences of war. Many patients have told me how their relationships failed because of PTSD, unable to sleep next to their partners for fear of accidental harm when triggered by a small noise. Another patient unintentionally fractured a childhood friend’s jaw when she covered his eyes from behind to say a surprise “hello.” Too many of them have poor sleep and walk the perimeter of their house at night, minds trained to be on guard. I learned to never underestimate the importance of being a listener to veterans’ stories as they make the difficult leap between military and civilian life. Paul Kalanathi in When Breath Becomes Air captured it perfectly: “…the physician’s duty is not to stave off death or return patients to their old lives, but to take into our arms a patient and family whose lives have disintegrated and work until they can stand back up and face, and make sense of, their own existence.” I may never understand what veterans experienced that caused their lives to disintegrate, but I hold all stories I hear sacred, a thread that weaves the fabric of a patient’s complex medical narrative.
Spending time with veterans, I began to see that their narratives parallel my own as a developing physician, thus cultivating a new level of empathy. A heroism similar to that which exists in the military also exists in medicine. We sacrifice our time, our relationships, and our sleep. We enter an intensely hierarchical structure and fail to question the rigid organization and culture of discipline. Our experiences with life and death are eerily similar. In our training, we often become numb to dead bodies, while grappling with the consequences of death beyond loss. Who had this person been? How will their death change the dynamics in their family, their community? Will anyone remember them? If not, how do we conceptualize the meaning of legacy? In the battles we fight, how we define victory and defeat is constantly challenged. The risks of hurting civilians or detrimental side effects of a surgery may or may not outweigh the benefits of a particular war strategy or operation. Physicians and veterans are physicians and veterans at all times; our work does not end at 5 p.m. and we are always there to help when help is needed. The calling of medicine is not dissimilar from the calling of the military: we all go into it with bright eyes, perhaps become cynical, all the while maintaining a sense of purpose, having faith that our fight is not futile.
Reflecting on the reasons we do anything — for ourselves, for our families, for our society — I began to reconcile the tense relationship between war and health. Soldiers and physicians alike fight on the front lines, ready to accept whatever challenge may come, including the challenging relationship between health and war. As I constantly change my approach to patient care, one thing remains true: my sole military connection with Eggo waffles has grown into an experience with empathy, empathy for the men and women who fight on the front lines. My care for veterans is strengthened by their stories and our parallel callings, and I am so grateful for the opportunity to honor the soldier. I write this during the holiday season, a season I learned many veterans dislike because they are alone. My thoughts for veterans at this time of year reflect the message of the “Longest Night” service the VA held for winter solstice: let us light a candle and watch the hurt of the past melt away as we light up with hope and healing.
Image credit: Veterans Day by Southern Arkansas University licensed under CC BY 2.0.
Fellow Physician Contributing Writer
Stanford University School of Medicine
Megha Shankar is a health services research fellow at the Palo Alto VA and CHP/PCOR at Stanford University. She completed her undergraduate degree in anthropology and biology at the University of Chicago, medical school at the University of Illinois at Chicago College of Medicine, and internal medicine residency at the University of Washington.