The Culture and Politics of Health Care Work

Understanding PTSD among Veterans of Iraq and Afghanistan

Erin P. Finley

• Publisher: ILR Press
• Year: 2011
• ISBN:
  9780801461187
• Topic: Psychology
• Subtopic: Post-Traumatic Stress Disorder (PTSD)
• Index: Psychology

For many of the 1.6 million U.S. service members who have served in Iraq and Afghanistan since 2001, the trip home is only the beginning of a longer journey. Many undergo an awkward period of readjustment to civilian life after long deployments. Some veterans may find themselves drinking too much, unable to sleep or waking from unspeakable dreams, lashing out at friends and loved ones. Over time, some will struggle so profoundly that they eventually are diagnosed with post-traumatic stress Disorder (PTSD).

Both heartbreaking and hopeful, Fields of Combat tells the story of how American veterans and their families navigate the return home. Following a group of veterans and their their personal stories of war, trauma, and recovery, Erin P. Finley illustrates the devastating impact PTSD can have on veterans and their families. Finley sensitively explores issues of substance abuse, failed relationships, domestic violence, and even suicide and also challenges popular ideas of PTSD as incurable and permanently debilitating.

Drawing on rich, often searing ethnographic material, Finley examines the cultural, political, and historical influences that shape individual experiences of PTSD and how its sufferers are perceived by the military, medical personnel, and society at large. Despite widespread media coverage and public controversy over the military's response to wounded and traumatized service members, debate continues over how best to provide treatment and compensation for service-related disabilities. Meanwhile, new and highly effective treatments are revolutionizing how the Department of Veterans Affairs (VA) provides trauma care, redefining the way PTSD itself is understood in the process. Carefully and compassionately untangling each of these conflicts, Fields of Combat reveals the very real implications they have for veterans living with PTSD and offers recommendations to improve how we care for this vulnerable but resilient population.

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FOURTH OF JULY

A Tradition of Service in San Antonio

July 4, 2007, dawned rainy in San Antonio, but the day had turned sunny and sweltering by the time I found a seat at an empty picnic table down at the local Veterans of Foreign Wars (VFW) post. An older woman in a red shirt came and joined me at the same table, sheltering under the shade of its umbrella. She introduced herself as Melissa, and we chatted for a while, laughing about the fact that we had both gotten lost on the way to the VFW.

We were both there for the same reason. As part of its Fourth of July celebration, the VFW was dedicating a new memorial to fifty-three local men and women who had been killed in the Global War on Terror, then more than five years in the making. I had at that point spent six months working with veterans of Iraq and Afghanistan out of the local Department of Veterans Affairs (VA) hospital, and it was with these men and women in mind that I ended up at the VFW that day. As it turned out, the events that afternoon hinted at something of what I had come to San Antonio seeking to understand: how war and its aftermath become part of daily life for veterans and their families, and how generations of American warriors have embarked upon military service only to find themselves faced with unexpected consequences.

In the age of the all-volunteer force, individual Americans must make the choice to join the military, and generally they do so with some at least abstract awareness that this may mean going off to war. The reasons they give for making this choice say a lot about both the worlds they are coming from and where they hope, upon enlisting, that the military will take them. More than that, their reasons reveal how the tradition of military service has remained firmly embedded in some sectors of American society, even as the 1970s shift away from compulsory military service (the draft) has resulted in a growing cultural separation between those who join the military and those who, for the most part, do not. Although all the veterans in the PDS study were living in the San Antonio area in 2007–8, only about half were born and raised in Texas. Of these, there was a roughly fifty-fifty split between those who grew up in San Antonio and those who were raised elsewhere in the state.1 A few of the non–San Antonio Texans were from cities like Dallas, Houston, or El Paso, but mostly they came from rural towns, each about a dozen miles from nowhere. Mirroring Texas’s demographic split, Latino veterans were more likely to have come from primarily Mexican-American South Texas, while white veterans were more likely to have come from the northern or eastern parts of the state.

Those who were born elsewhere came from across the United States and Puerto Rico, from Michigan, California, Oklahoma, Missouri, Louisiana, South Dakota, and so on. They came both from cities—San Juan, New Orleans, Detroit—and small towns—Ruidoso, Claremore, Rock Springs. Almost all came to San Antonio as a result of their military service, although the routes differed. Many found their way to South Texas for the first time as part of their military training at Lackland Air Force Base or Fort Sam Houston, returning later because they liked the area or thought they could find work here.2 San Antonio Military Medical Center—which combines the hospital and clinic resources of Wilford Hall Medical Center, located on base at Lackland, and Brooke Army Medical Center, located on Fort Sam Houston—provides tertiary health care for all service personnel in the central United States, and some veterans initially came for treatment of service-related injuries or other health problems. (BAMC, in particular, is renowned for its state-of-the-art care of service members with burns or amputations.) Many of these veterans, particularly those seriously wounded while on combat duty, chose to make San Antonio their home during the long period of recuperation and rehabilitation. Others found themselves in San Antonio after following friends from the service who knew the area, hearing it was a cheap place to live or wanting to be close to their buddies.

San Antonio is often jokingly described as the “northernmost city in Mexico” because its population is majority Mexican American—the 2000 U.S. census reported that Latinos make up 58 percent of the city’s population, alongside 32 percent non-Hispanic whites and 7 percent African Americans3—but it is better characterized as a place of vivid cultural fluidity. The city of 1.3 million people4 incorporates influences from the conservative American South and Midwest and, closer to hand, the liberal capital of Austin to the east, the historically German Hill Country to the north, ranching and oil country to the west, and the Rio Grande Valley to the south.

Those who have grown up in San Antonio describe a city in transition. Beto, a former marine with giant shoulders and a wide gentle face, grew up on the west side, a predominantly Latino neighborhood adjacent to downtown, known for high rates of poverty and crime. Describing what it has been like to return home after ten years in the service, he says, “It’s changed a lot since I’ve been away. The neighborhood, the city used to be more dangerous. It was more gangs, more things to be worried about. A lot more drugs, more violence out there. Since I came back, it’s there, but I see more police, neighborhoods looking better, people trying to help out. The neighborhood I grew up in, I could point to each house and tell you what drugs they were selling. It’s not like that anymore.”5

Many of those who grew up in the urban world Beto describes chose the military as a way to escape poverty and, at times, to move past early forays into crime and violence. Tony, another marine, tells the story of growing up “rough” on the south side, exposed to “a lot of drinking and a lot of violence.” He says, “It’s a recipe for failure, you know? And I was falling into it.” At twenty-one he was arrested for a DUI and was put on probation for six months. As soon as his six months was up, he signed up for the marines. “I was going in the wrong direction before I joined the marines, and that gave me more reason to get out of there.”

Other veterans also described seeking out military service as an escape, and not only from violent urban environments. Jerry grew up in rural South Texas, helping out his ranch-hand father from the time he was eight years old. He worked in the family’s grocery store, the center of commerce for their small town, and contributed to the family income by doing odd jobs on the side. By the time he was sixteen, he was working four jobs. He joined up in September of the year he finished high school. “I wanted to get out of that town,” he says. “I wanted to do something. I always wanted to be an army guy, a soldier.” It was a dream that sounded good to him, an opportunity that seemed a lot bigger than the town where he grew up, although he admits now that as a kid, “You watch movies, and [military service looks] totally different from what it actually is.”

There is a strong sense of either/or in these stories, for military service was one of very few options for many of these men. I was surprised at how frequently people around the area reiterated this point, even those who had chosen other paths. One day I ended up talking to a salesman at Macy’s after he commented that he couldn’t place my accent. I said it came from ‘moving around,’ and he asked if I was in the military.

‘No,’ I said, ‘but that’s a good guess around here.’

He said that he was from San Antonio and that his whole family was military—‘My Dad, uncles, cousins, everybody.’ He said that he was the only one who didn’t want to go that route, that he ‘went to college instead.’

‘A good alternative,’ I said.

‘Yeah,’ he laughed, ‘and safer.’

I heard the same thing from a local psychologist, a tall Latina who grew up down in the valley. She described the area as being hugely military precisely because it is so poor. She said that the recruiters go to all the ‘sorriest’ high schools, and that for a lot of those who sign up, the military is their ‘only way out.’ She snorted and added that she hadn’t even known college was an option until she was a junior in high school.

In contrast to those who chose between military service and college, another group of veterans entered the service as a way of accessing education. Todd, a young white man from outside Dallas, volunteered right out of high school. He said he knew that his fireman father could not afford to send him to college, and he figured that between the GI Bill and the Hazlewood Act (which extends college benefits to veterans who are Texas residents), he would be able to get an education if he enlisted. Some of the veterans who had joined when they were older described a similar decision-making process, choosing a term and branch of service that would provide them with desired schooling or career training. I met one man in his late twenties who joined the marine reserves to get his degree in nursing and then signed up for the navy reserves as a way to finance a shift into dentistry.

For young men and women from poor or underprivileged backgrounds, then, joining up may represent a choice from among limited options. There is no longer a draft in the United States, but even in an all-volunteer force some volunteers are more voluntary than others. The disproportionate recruitment of service members from among low- and middle-income communities6 and the reliance placed upon the less privileged to be willing to sacrifice their lives toward the advancement of national interests provide a classic example of what Johan Galtung called structural violence, that subtle process by which social inequalities take dramatic shape in the form of differential health and well-being.7

The risks and sacrifices of military service are significant enough, in fact, that to focus solely on the material benefits of enlisting would be to vastly oversimplify a decision that means giving up considerable freedom in order to commit, if necessary, to putting life and limb in jeopardy on a foreign battlefield. The navy reservist made this clear as we sat and talked about the fact that a lot of people join up to get their education paid for. He told me that he had another year before graduating, then one more year of advanced training, and then would owe the U.S. Navy four years of service. I asked if he would be eligible for combat deployment (as opposed to a noncombat deployment to somewhere like Guam or Korea), and he said yes. He listened mildly as I started doing calculations aloud that if he had two more years in school, maybe he wouldn’t have to deploy. Maybe the United States would be out of Iraq by then. He laughed at me a little, nicely enough, and said, ‘Well, I didn’t join the navy to avoid deployment.’

Point taken.

Toward the end of the time I know him, Beto lays out a more tangled knot of reasons for joining up, giving greater substance to his decision than in earlier-quoted comments about just wanting to get out of the barrio. I ask him again, “How did you end up in the military?”

And this time he answers, “A recruiter came to the high school, and someone said, ‘You go talk to him, you can get out of class.’”

He grins at this and goes on. “I was like, well, why not? They keep hassling me at the house, I might as well get out of class. And being in the Marine Corps, being in the navy interested me a lot. That’s what I wanted to do—go to other places, learn. I figured if I can’t go to college, I might as well educate myself. [The recruiter] was real talkative. . . . I liked what he was saying, his appearance. It got me thinking: if I can do the hardest branch of service, then I can do anything. Money for college, too, so I figured—I’m working, making a paycheck, learning a trade, and paying benefits. It didn’t seem like there was anything bad to it.” He grins again. “Until you go.”

Beto’s answer underscores two of the already noted reasons for enlisting: a way out of a rough neighborhood (or small town) and a series of options for education and a career that were better than anything else around. But he also hints at some glimmer of a future self that he saw reflected in the recruiter’s manner and self-presentation (“I liked his appearance”). There is a sense in his words of a promise to himself, the belief that “if I can do the hardest branch of service, then I can do anything.” Many veterans chuckle as they admit to an early fascination with how soldiers or marines are portrayed in the movies or to being awed by a particular uniform, but there is something seriously captivating in these images that grab them, some vision of a future that might be theirs.

We also shouldn’t forget the sheer high-adrenaline fun that many young men in particular associate with joining the military.8 Brian, a middle-aged army reservist, talks about how he had wanted to go into the military even as a little kid, irresistibly caught up in the masculine adventure of it. “They have cool uniforms, and you get to shoot things. Just very manly stuff!” He tells stories about his younger son, who at eight was already ready to sign up, falling asleep each night with the TV in his room turned to the Military Channel. “We go out and play paintball, and he’ll go out there and play paintball and he’s getting shot at and he thinks it’s the coolest thing in the world. We go down to the farm and go shooting and he’s got all the regular weapons. The.22 rifle that’s his. Just one of those kids. Destined!”

Like Beto, veterans more often than not acknowledge some confluence of all these reasons in describing their decision to join up; they admit to having been drawn by both the honor and excitement of military service and its more practical aspects, the economic and educational benefits.9 Brian was exuberant about the fun of military things for himself and his younger son (who was still ten years too young to actually enlist). But when he described his own decision to enlist—and later on in the time I knew him, his older son’s—he spoke of the impossibility of raising a family on a minimum wage salary and about the military as an opportunity for career building and vocational training.

And finally, for those with family or other social ties to the military, the decision to join the service was often described in relation to those ties. Carlos’s father was a marine in Vietnam before becoming an engineer. Carlos reported that his father was proud of his three sons when all of them decided to enlist; he was even more proud when he learned that Carlos had decided on the air force over the marines, as there was less chance of his “getting killed.” A woman in her forties whom I met on a plane out of San Antonio—I couldn’t understand why she was peering over my shoulder at an article on combat PTSD until she introduced herself as a psychiatric nurse for the air force—recited a long string of carefully considered reasons for enlisting in her late thirties: there was still time for her to serve out a full twenty years; the air force would pay for her master’s degree; the benefits were good. Even so, it wasn’t until she began talking about her husband, who had completed his career in the army, and her father, who was also a veteran, that she began to speak with any warmth. She said that she was the only one of her father’s children who had gone into the military, and that it ‘meant a lot’ to him to see her do it. Speaking proudly of her husband’s service, she said, ‘He’s the face I see in front of me and the boot in my rear,’ both her inspiration and her support on this chosen path.

Family history may itself be a source of pride. Brian pointed out with some satisfaction that “there’s been an O’Neil from my direct ancestry in every war that’s been fought since the beginning of America.” Derek, an African American soldier whose left leg was amputated after he was wounded by an improvised explosive device (IED) in Iraq, had no regrets about his service, despite his loss. He, too, felt his time in the military placed him in line with his ancestors, since “all of the males in my family as far back as you can count have served in some capacity.” His words point to how profoundly military service may be embedded in social histories, reflecting both an identity as part of a family tradition and...

Table of contents

• Acknowledgments
• INTRODUCTION
• 1. FOURTH OF JULY
• 2. WAR STORIES
• 3. HOME AGAIN
• 4. OF MEN AND MESSAGES
• 5. CLINICAL HISTORIES
• 6. UNDER PRESSURE
• 7. EMBATTLED
• 8. NAVIGATION
• CONCLUSION
• Notes
• References