Healing at the VA
We don't want to know too much about Veterans Administration hospitals. They're full of broken people who don't look altogether great in Gap ads.
Like prisons and nursing homes, VA facilities are stealth institutions to be observed ever so briefly in the emotional distance beyond a car window. We recall horror stories, real and imagined, of rat-infested rooms and forgotten souls.
"The only way to get rid of that legacy is to perform your way out of it," says Michael Lawson, chief executive officer of the VA Boston Healthcare System.
Which is what they're doing, despite shortages of money and personnel. The Boston VA passed its accreditation review last fall with flying colors. But with huge facilities in Jamaica Plain, West Roxbury, and Brockton, along with six satellite clinics, it's got its hands full. The outfit deserves a shot in the arm for doing the work, however imperfectly, that no one else will touch.
The West Roxbury facility is nationally known as a center of excellence for spinal cord injuries and cardiothoracic surgery. Jamaica Plain is home to a branch of the National Center for Post-Traumatic Stress Disorder that includes cutting-edge investigation of the effects of PTSD on women. (There's a powerful poster there with a photo of a soldier's dog tags and the words, "Not all women wore love beads in the Sixties.") Brockton does great work in mental health.
The Boston VA conducts research in everything from macular degeneration to diabetes and substance abuse. It runs a methadone clinic and is recognized in the Boston medical community as a leader in patient safety. It is a major player in geriatric medicine. The average age of its medical and surgical patients, after all, is over 60 and its psychological patients, over 50.
Most important, the Boston VA is the training ground for about 250 residents from Boston's top teaching hospitals, primarily Boston University Medical Center and Brigham and Women's Hospital. This pool of young players is superb. The problem is they don't stay. VAs traditionally have been known for tyros on the way up and older doctors on the way out.
The latest challenge is Iraq. New England troops, overwhelmingly reservists, are returning from there onto the VA caseload. Thus far, about 250 have been treated. Most have passed through the system for problems like headaches, rashes, eating disorders, and diarrhea. Reservists are usually older than regular Army infantry troops and susceptible to more problems. And, says Chief of Medicine Deborah Cotton, "This is a reservist war."
But then there's the 19-year-old kid in the spinal cord unit who was dealt a lousy hand. Among others. "I walked down the hall one day and saw a kid young enough to be my son on a gurney," recalls Cotton. "He was in his early 20s and he was scared to death. I said to myself, `This is it. This is the beginning.' The men in their 70s and 80s were once those kids."
Full-blown PTSD has not surfaced yet, but wait. Specialists know there's an incubation period lasting weeks, months, or even years before its onset. "We're starting to see readjustment problems as opposed to PTSD," says Terence Keane, who directs the PTSD program here. "We're seeing marital problems, work problems, the beginnings of traumatic reaction. But the ultimate outcome remains in question."
The VA is always up against it. The members of the Greatest Generation are ancients now, many lifelong heavy smokers, in need of expensive care. But the Boston budget has suffered because VA dollars follow the veteran, as they should, and veterans have deserted the Northeast in droves for warm climes in Texas and Arizona, directing the money with them.
The salaries arms race against teaching hospitals is a losing proposition. Then there are cutbacks. The system lost about 1,000 people at all levels when the Brockton, Jamaica Plain, and West Roxbury facilities underwent a brutal three-year consolidation that began in 1999.
The VA contracts out to teaching hospitals for subspecialists but comes up short on a laundry list of them like ophthalmologists and orthopedic surgeons, neurologists and podiatrists, dermatologists and dentists. Most patients need major dental work. The 170-bed West Roxbury in-patient hospital has one full-time neurosurgeon.
Shortages mean big waits. Cotton says that can mean six to nine months for a routine colonoscopy. And there's no space left in West Roxbury. She received an e-mail from a section chief looking for an office for a new hire who wrote that he'd found a great linen closet that could be converted. Cotton lost a prospective chief of infectious diseases because her labs are not at the top level of protective containment. "We're really strapped," she says. "There's no question about it."
That said, she maintains that overall care is very strong. "Absolutely astronomical," says Air Force vet Charles Schena of Plymouth about the neurologists who help him with his multiple sclerosis. Now, says Cotton, comes a different challenge:
"We hear the Vietnam vets say about Iraq, `I hope what happened to us doesn't happen to these kids' -- where they were blamed for the politics of Vietnam."
Sam Allis's e-mail address is: allis@globe.com 
