Cynthia Geppert, MD, MA, MPH, MSBE, DPS

Trust is built step by step, commitment by commitment, on every level.

Robert C. Solomon¹

The US Department of Veterans Affairs (VA) was created in response to criticism of its predecessors. Since its establishment in 1930, the VA has never been short of critics who denounced its corruption, called for its dismantling in favor of privatization, and derided its incompetence.² Despite multiple scandals that have handed more ammunition to those who object to its continued existence, the VA has not only survived, but thrived. This editorial is written in the form of a debate between exemplar opponents and defenders of the VA on whether it is currently fulfilling its commitment to veterans.

In May 2024, the Veterans Signals survey found that 80.4% of respondents reported trust in the VA, the highest level ever recorded.³ At its 2016 launch, the survey found that only 55% of veterans expressed trust in the VA. The survey was conducted 2 years after the scandal over access to care for veterans in Phoenix. Scores would surely have been even lower than 55% during that period when the critique of the VA—even from those who believe in its mission—was most trenchant.⁴ Administered quarterly, the survey samples > 38,000 of the 9 million enrolled veterans. Veterans surveyed were using services from all 3 branches of the VA: Veterans Health Administration, Veterans Benefits Administration, and National Cemetery Administration. Participants are asked whether they trust the VA to fulfill the country’s commitment to veterans and specifically how they rate the VA in 3 specific criteria: effectiveness, emotional resonance, and overall ease. In the latest survey, 80.5% of veterans rated the VA positively for effectiveness, 78.4% for emotional resonance, and 75.9% for overall ease. Even more impressive is the 91.8% of participants who reported they trust the VA for outpatient health care, capping a 7-year upward trend.³

The paradigmatic VA antagonist will rightly point out the well-known methodological limitations of this type of survey, including self-selection, sampling bias, and especially low response rates. However, VA researchers will counter that the 18% response rate for the latest Veterans Signals survey is higher than the industry average.⁵

VA critics might say that it would not matter if the response rate were 4 times higher; what matters is not what veterans say on a survey but what decisions they make about their care. The VA defender would be constrained to concede that even the most statistically sophisticated survey remains an indirect measure of veteran trust. They could, though, marshal far stronger evidence. Two direct demonstrations published in the literature suggest that veterans do as they say and are acting on their trust in the agency. First, the VA delivered more services, health care, and benefits to veterans during the 2023 fiscal year than ever before. Importantly for Federal Practitioner readers, the 16 million documented health care visits were 3 million more than previous records.⁶ Second, and in some ways even more encouraging for the future of the VA as a health care system, is that due in large part to the passage of the PACT Act, there has been a surge in VA enrollment by veterans. The VA recently announced that in the last year, > 400,000 veterans signed up for its health care and services. Enrollments are 30% more than the previous year and represented the highest figure in the past 5 years, a remarkable 50% increase over 2020 pandemic levels.⁷

VA critics could legitimately rebut this data by asking, “So more veterans are signing up for VA, and you are delivering more care, but what about the quality of that care? Has it improved?” The VA proponent’s rejoinder from multiple converging empirical studies would be a resounding yes. We have space to cite only a few examples of that rigorous recent research. What stands out ethically about these studies is that the VA has a broad program of research into the quality of the care it delivers and then transparently publishes those findings. The VA quality improvement research mission is truly unique and provides a shared open set of data for both critics and defenders to objectively examine VA successes and failures.

Among the most persuasive analysis was a systematic review of 37 studies contrasting VA with non-VA care from 2015 to 2023. The authors examined clinical quality, safety, patient access, experience, cost-efficiency, and equity of outcome. “VA care is consistently as good as or better than non-VA care in terms of clinical quality and safety,” the systematic review authors stated while qualifying that “Access, cost/efficiency, and patient experience between the 2 systems are not well studied.”⁸

A second systematic review looked specifically at similar key areas of quality, safety, access, patient experience, and comparative cost-efficiency for surgical treatment delivered in the VA and the community from 2015 to 2021. Only 18 studies met the inclusion criteria, but as the authors argued:

Based on limited data, these findings suggest that expanding eligibility for veterans to get care in the community may not provide benefits in terms of increasing access to surgical procedures, will not result in better quality, and may result in worse quality of care, but may reduce inpatient length of stay and perhaps cost less.⁹

At this juncture, the faultfinder may become frustrated and resort to a new tactic, challenging the very assumption that is the subject of the debate and demanding proof that there is any connection between veterans’ trust in the VA and their health and well-being. “Fair enough,” the VA side would reply, “here is some research that bolsters that connection.” Kopacz and colleagues examined the relationship between trust and healing at 6 sites and included 427 veterans and active-duty service members with combat posttraumatic stress disorder (PTSD) symptoms. The researchers found that trust and lack thereof are related to several significant mental, social, and physical health outcomes. The authors indicate the need for more research to better understand the importance and impact of trust and healing, but they show it is significant.¹⁰ Finally, veterans recognize the crucial link between trust in the unique expertise of VA practitioners in the treatment of PTSD. In a 2019 study, a majority expressed a preference to receive their PTSD treatment at the VA compared to a smaller group choosing care in the community.¹¹

You be the judge of who won the debate, but knowing the dedication of my fellow federal practitioners, many of you will endorse my sentiment that we all need to stop talking and get back to doing our best to enhance veteran trust and healing; doing our essential part to keep fulfilling our commitment.

Trust is built step by step, commitment by commitment, on every level.

Robert C. Solomon¹

The US Department of Veterans Affairs (VA) was created in response to criticism of its predecessors. Since its establishment in 1930, the VA has never been short of critics who denounced its corruption, called for its dismantling in favor of privatization, and derided its incompetence.² Despite multiple scandals that have handed more ammunition to those who object to its continued existence, the VA has not only survived, but thrived. This editorial is written in the form of a debate between exemplar opponents and defenders of the VA on whether it is currently fulfilling its commitment to veterans.

In May 2024, the Veterans Signals survey found that 80.4% of respondents reported trust in the VA, the highest level ever recorded.³ At its 2016 launch, the survey found that only 55% of veterans expressed trust in the VA. The survey was conducted 2 years after the scandal over access to care for veterans in Phoenix. Scores would surely have been even lower than 55% during that period when the critique of the VA—even from those who believe in its mission—was most trenchant.⁴ Administered quarterly, the survey samples > 38,000 of the 9 million enrolled veterans. Veterans surveyed were using services from all 3 branches of the VA: Veterans Health Administration, Veterans Benefits Administration, and National Cemetery Administration. Participants are asked whether they trust the VA to fulfill the country’s commitment to veterans and specifically how they rate the VA in 3 specific criteria: effectiveness, emotional resonance, and overall ease. In the latest survey, 80.5% of veterans rated the VA positively for effectiveness, 78.4% for emotional resonance, and 75.9% for overall ease. Even more impressive is the 91.8% of participants who reported they trust the VA for outpatient health care, capping a 7-year upward trend.³

The paradigmatic VA antagonist will rightly point out the well-known methodological limitations of this type of survey, including self-selection, sampling bias, and especially low response rates. However, VA researchers will counter that the 18% response rate for the latest Veterans Signals survey is higher than the industry average.⁵

VA critics might say that it would not matter if the response rate were 4 times higher; what matters is not what veterans say on a survey but what decisions they make about their care. The VA defender would be constrained to concede that even the most statistically sophisticated survey remains an indirect measure of veteran trust. They could, though, marshal far stronger evidence. Two direct demonstrations published in the literature suggest that veterans do as they say and are acting on their trust in the agency. First, the VA delivered more services, health care, and benefits to veterans during the 2023 fiscal year than ever before. Importantly for Federal Practitioner readers, the 16 million documented health care visits were 3 million more than previous records.⁶ Second, and in some ways even more encouraging for the future of the VA as a health care system, is that due in large part to the passage of the PACT Act, there has been a surge in VA enrollment by veterans. The VA recently announced that in the last year, > 400,000 veterans signed up for its health care and services. Enrollments are 30% more than the previous year and represented the highest figure in the past 5 years, a remarkable 50% increase over 2020 pandemic levels.⁷

VA critics could legitimately rebut this data by asking, “So more veterans are signing up for VA, and you are delivering more care, but what about the quality of that care? Has it improved?” The VA proponent’s rejoinder from multiple converging empirical studies would be a resounding yes. We have space to cite only a few examples of that rigorous recent research. What stands out ethically about these studies is that the VA has a broad program of research into the quality of the care it delivers and then transparently publishes those findings. The VA quality improvement research mission is truly unique and provides a shared open set of data for both critics and defenders to objectively examine VA successes and failures.

Among the most persuasive analysis was a systematic review of 37 studies contrasting VA with non-VA care from 2015 to 2023. The authors examined clinical quality, safety, patient access, experience, cost-efficiency, and equity of outcome. “VA care is consistently as good as or better than non-VA care in terms of clinical quality and safety,” the systematic review authors stated while qualifying that “Access, cost/efficiency, and patient experience between the 2 systems are not well studied.”⁸

A second systematic review looked specifically at similar key areas of quality, safety, access, patient experience, and comparative cost-efficiency for surgical treatment delivered in the VA and the community from 2015 to 2021. Only 18 studies met the inclusion criteria, but as the authors argued:

Based on limited data, these findings suggest that expanding eligibility for veterans to get care in the community may not provide benefits in terms of increasing access to surgical procedures, will not result in better quality, and may result in worse quality of care, but may reduce inpatient length of stay and perhaps cost less.⁹

At this juncture, the faultfinder may become frustrated and resort to a new tactic, challenging the very assumption that is the subject of the debate and demanding proof that there is any connection between veterans’ trust in the VA and their health and well-being. “Fair enough,” the VA side would reply, “here is some research that bolsters that connection.” Kopacz and colleagues examined the relationship between trust and healing at 6 sites and included 427 veterans and active-duty service members with combat posttraumatic stress disorder (PTSD) symptoms. The researchers found that trust and lack thereof are related to several significant mental, social, and physical health outcomes. The authors indicate the need for more research to better understand the importance and impact of trust and healing, but they show it is significant.¹⁰ Finally, veterans recognize the crucial link between trust in the unique expertise of VA practitioners in the treatment of PTSD. In a 2019 study, a majority expressed a preference to receive their PTSD treatment at the VA compared to a smaller group choosing care in the community.¹¹

You be the judge of who won the debate, but knowing the dedication of my fellow federal practitioners, many of you will endorse my sentiment that we all need to stop talking and get back to doing our best to enhance veteran trust and healing; doing our essential part to keep fulfilling our commitment.

Trust is built step by step, commitment by commitment, on every level.

Robert C. Solomon¹

The US Department of Veterans Affairs (VA) was created in response to criticism of its predecessors. Since its establishment in 1930, the VA has never been short of critics who denounced its corruption, called for its dismantling in favor of privatization, and derided its incompetence.² Despite multiple scandals that have handed more ammunition to those who object to its continued existence, the VA has not only survived, but thrived. This editorial is written in the form of a debate between exemplar opponents and defenders of the VA on whether it is currently fulfilling its commitment to veterans.

In May 2024, the Veterans Signals survey found that 80.4% of respondents reported trust in the VA, the highest level ever recorded.³ At its 2016 launch, the survey found that only 55% of veterans expressed trust in the VA. The survey was conducted 2 years after the scandal over access to care for veterans in Phoenix. Scores would surely have been even lower than 55% during that period when the critique of the VA—even from those who believe in its mission—was most trenchant.⁴ Administered quarterly, the survey samples > 38,000 of the 9 million enrolled veterans. Veterans surveyed were using services from all 3 branches of the VA: Veterans Health Administration, Veterans Benefits Administration, and National Cemetery Administration. Participants are asked whether they trust the VA to fulfill the country’s commitment to veterans and specifically how they rate the VA in 3 specific criteria: effectiveness, emotional resonance, and overall ease. In the latest survey, 80.5% of veterans rated the VA positively for effectiveness, 78.4% for emotional resonance, and 75.9% for overall ease. Even more impressive is the 91.8% of participants who reported they trust the VA for outpatient health care, capping a 7-year upward trend.³

The paradigmatic VA antagonist will rightly point out the well-known methodological limitations of this type of survey, including self-selection, sampling bias, and especially low response rates. However, VA researchers will counter that the 18% response rate for the latest Veterans Signals survey is higher than the industry average.⁵

VA critics might say that it would not matter if the response rate were 4 times higher; what matters is not what veterans say on a survey but what decisions they make about their care. The VA defender would be constrained to concede that even the most statistically sophisticated survey remains an indirect measure of veteran trust. They could, though, marshal far stronger evidence. Two direct demonstrations published in the literature suggest that veterans do as they say and are acting on their trust in the agency. First, the VA delivered more services, health care, and benefits to veterans during the 2023 fiscal year than ever before. Importantly for Federal Practitioner readers, the 16 million documented health care visits were 3 million more than previous records.⁶ Second, and in some ways even more encouraging for the future of the VA as a health care system, is that due in large part to the passage of the PACT Act, there has been a surge in VA enrollment by veterans. The VA recently announced that in the last year, > 400,000 veterans signed up for its health care and services. Enrollments are 30% more than the previous year and represented the highest figure in the past 5 years, a remarkable 50% increase over 2020 pandemic levels.⁷

VA critics could legitimately rebut this data by asking, “So more veterans are signing up for VA, and you are delivering more care, but what about the quality of that care? Has it improved?” The VA proponent’s rejoinder from multiple converging empirical studies would be a resounding yes. We have space to cite only a few examples of that rigorous recent research. What stands out ethically about these studies is that the VA has a broad program of research into the quality of the care it delivers and then transparently publishes those findings. The VA quality improvement research mission is truly unique and provides a shared open set of data for both critics and defenders to objectively examine VA successes and failures.

Among the most persuasive analysis was a systematic review of 37 studies contrasting VA with non-VA care from 2015 to 2023. The authors examined clinical quality, safety, patient access, experience, cost-efficiency, and equity of outcome. “VA care is consistently as good as or better than non-VA care in terms of clinical quality and safety,” the systematic review authors stated while qualifying that “Access, cost/efficiency, and patient experience between the 2 systems are not well studied.”⁸

A second systematic review looked specifically at similar key areas of quality, safety, access, patient experience, and comparative cost-efficiency for surgical treatment delivered in the VA and the community from 2015 to 2021. Only 18 studies met the inclusion criteria, but as the authors argued:

Based on limited data, these findings suggest that expanding eligibility for veterans to get care in the community may not provide benefits in terms of increasing access to surgical procedures, will not result in better quality, and may result in worse quality of care, but may reduce inpatient length of stay and perhaps cost less.⁹

At this juncture, the faultfinder may become frustrated and resort to a new tactic, challenging the very assumption that is the subject of the debate and demanding proof that there is any connection between veterans’ trust in the VA and their health and well-being. “Fair enough,” the VA side would reply, “here is some research that bolsters that connection.” Kopacz and colleagues examined the relationship between trust and healing at 6 sites and included 427 veterans and active-duty service members with combat posttraumatic stress disorder (PTSD) symptoms. The researchers found that trust and lack thereof are related to several significant mental, social, and physical health outcomes. The authors indicate the need for more research to better understand the importance and impact of trust and healing, but they show it is significant.¹⁰ Finally, veterans recognize the crucial link between trust in the unique expertise of VA practitioners in the treatment of PTSD. In a 2019 study, a majority expressed a preference to receive their PTSD treatment at the VA compared to a smaller group choosing care in the community.¹¹

You be the judge of who won the debate, but knowing the dedication of my fellow federal practitioners, many of you will endorse my sentiment that we all need to stop talking and get back to doing our best to enhance veteran trust and healing; doing our essential part to keep fulfilling our commitment.

Let the generations know that women in uniform also guaranteed their freedom.

Mary Walker, MD

Hoping to make a career in nursing, my mother, a newly graduated registered nurse, enlisted in the US Army Nurse Corps shortly after the United States entered World War II. When she married my father, a US Army doctor, in 1942, she was summarily discharged (the Army Nurse Corp changed its policy and permitted married nurses to serve later that year), while my father went on to decades of distinguished service in military medicine.¹ My mother always regretted being unable to advance through the ranks of the US Army as other woman nurses did in her training class.

March is Women’s History Month. My personal narrative of discrimination against women in military medicine is a footnote in a long volume of inequitable treatment. This column will examine a few of the most famous—or rather from a justice perspective, infamous—chapters in that story to illustrate how for centuries women heroically fought for the right to serve.

A theme of the early epochs of the American military is that women were forced to come to the difficult realization that the only way to serve was to conceal their identity. In 1776, Margaret Cochran Corbin felt called as her husband did to defend the new nation. She dressed as a man and joined him at the ramparts, helping load his cannon until he was killed, and took over firing at the enemy. Even after being shot, she remained in the ranks, entering the Invalid Regiment at West Point, New York, dedicated to caring for other injured soldiers. As recognition of her exemplary service and battlefield injury Corbin became the first US woman to receive a military pension. The Veterans Affairs New York Harbor Healthcare System Manhattan campus is named in her honor.²

The hypocrisy of the military’s gender politics was nowhere more evident than in the case of Mary Walker, MD, and the Congressional Medal of Honor. Walker graduated from Syracuse Medical College in 1855. At the beginning of the Civil War, Walker’s request to enlist as a surgeon was refused on the grounds of her gender. She declined to be a nurse, and instead volunteered for the Army where she cared for the wounded in various hospitals. Her medical degree was accepted in 1863, enabling her to become a paid surgical officer in the War Department, including 4 months as a prisoner of war.

An early and avid feminist, Walker wore men’s clothing and when she was arrested on the charge of impersonating a male, declared the government had given her permission to dress as a man to facilitate her surgical work. Walker separated from the military in 1865 and President Andrew Johnson awarded her the Congressional Medal of Honor that year. After Walker’s death in 1917, the Medal of Honor was rescinded on the grounds that she had never actually been commissioned and the medal could not be awarded to a civilian. It took 60 years of lobbying before President Jimmy Carter restored her award in 1977.³ That millions of women have served in the military since the Civil War, and Walker remains the only woman among the 3517 service members to have won the nation’s highest military honor, underscores the ongoing injustice.⁴

February commemorated Black History Month and a second theme that emerges from the study of the history of women in military medicine is intersectionality: How race, gender, sexual orientation, and other identities overlap and interact to generate distinctive forms of discrimination. Ethicists have applied the concept of intersectionality to health care and there are a plethora of examples in military medicine.⁵ Despite a dire need for nurses in the first and second world wars, and a track record of their exemplary service in prior conflicts, the government repeatedly set up arbitrary obstacles barring highly-qualified Black nurses from enlisting.⁶ Technically allowed to join the Army Nurse Corps in 1941, Black nurses confronted bureaucratic barriers that restricted them to only caring for Black servicemen and prisoners of war, and racial quotas that resulted in 500 Black nurses vs 59,000 White nurses that served during World War II. Black nurses and their supporters in government and society persisted, and once in uniform, broke through barriers to achieve administrative and clinical excellence.⁷

My mother’s experience mirrors that of thousands of women whose dreams for a career in military medicine were shattered or who enlisted only to find their aspirations for advancement in the service thwarted. Medical historians remind us that due to bias, much of the book of women healer’s accomplishments remains unwritten, itself a testimony to the pervasive and enduring marginalization of women in Western society. Yet, as this brief glimpse of women in military medicine shows, there is sufficient evidence for us to appreciate their impressive contributions.⁸

Reflecting on this sketch of women’s struggle for acceptance in military medicine in March 2024, we may presume that the fight for equity has been continuously trending upward.⁸ President Joseph R. Biden appointed, and even more surprisingly, the US Congress confirmed Rachel Levine, MD, as US Department of Health and Human Services Assistant Under Secretary for Health in 2021, making Levine the highest ranking openly transgender health official in the history of the US government.⁹ Levine also has the distinction of being the first 4-star admiral in the Commissioned Corps of the US Public Health Service and the only transgender person to achieve this rank in any branch of the US uniformed services.¹⁰

However, research suggests that the history of women in the military is far more like an undulating curve. A 2019 study of academic military surgery found evidence of gender disparity even greater than that of the civilian sector.¹¹ True and lasting equity in federal health care practice will require all of us to follow the inspiring examples of so many women known and unknown who fought the military establishment within for the right to heal those wounded fighting the enemy without.

Let the generations know that women in uniform also guaranteed their freedom.

Mary Walker, MD

Hoping to make a career in nursing, my mother, a newly graduated registered nurse, enlisted in the US Army Nurse Corps shortly after the United States entered World War II. When she married my father, a US Army doctor, in 1942, she was summarily discharged (the Army Nurse Corp changed its policy and permitted married nurses to serve later that year), while my father went on to decades of distinguished service in military medicine.¹ My mother always regretted being unable to advance through the ranks of the US Army as other woman nurses did in her training class.

March is Women’s History Month. My personal narrative of discrimination against women in military medicine is a footnote in a long volume of inequitable treatment. This column will examine a few of the most famous—or rather from a justice perspective, infamous—chapters in that story to illustrate how for centuries women heroically fought for the right to serve.

A theme of the early epochs of the American military is that women were forced to come to the difficult realization that the only way to serve was to conceal their identity. In 1776, Margaret Cochran Corbin felt called as her husband did to defend the new nation. She dressed as a man and joined him at the ramparts, helping load his cannon until he was killed, and took over firing at the enemy. Even after being shot, she remained in the ranks, entering the Invalid Regiment at West Point, New York, dedicated to caring for other injured soldiers. As recognition of her exemplary service and battlefield injury Corbin became the first US woman to receive a military pension. The Veterans Affairs New York Harbor Healthcare System Manhattan campus is named in her honor.²

The hypocrisy of the military’s gender politics was nowhere more evident than in the case of Mary Walker, MD, and the Congressional Medal of Honor. Walker graduated from Syracuse Medical College in 1855. At the beginning of the Civil War, Walker’s request to enlist as a surgeon was refused on the grounds of her gender. She declined to be a nurse, and instead volunteered for the Army where she cared for the wounded in various hospitals. Her medical degree was accepted in 1863, enabling her to become a paid surgical officer in the War Department, including 4 months as a prisoner of war.

An early and avid feminist, Walker wore men’s clothing and when she was arrested on the charge of impersonating a male, declared the government had given her permission to dress as a man to facilitate her surgical work. Walker separated from the military in 1865 and President Andrew Johnson awarded her the Congressional Medal of Honor that year. After Walker’s death in 1917, the Medal of Honor was rescinded on the grounds that she had never actually been commissioned and the medal could not be awarded to a civilian. It took 60 years of lobbying before President Jimmy Carter restored her award in 1977.³ That millions of women have served in the military since the Civil War, and Walker remains the only woman among the 3517 service members to have won the nation’s highest military honor, underscores the ongoing injustice.⁴

February commemorated Black History Month and a second theme that emerges from the study of the history of women in military medicine is intersectionality: How race, gender, sexual orientation, and other identities overlap and interact to generate distinctive forms of discrimination. Ethicists have applied the concept of intersectionality to health care and there are a plethora of examples in military medicine.⁵ Despite a dire need for nurses in the first and second world wars, and a track record of their exemplary service in prior conflicts, the government repeatedly set up arbitrary obstacles barring highly-qualified Black nurses from enlisting.⁶ Technically allowed to join the Army Nurse Corps in 1941, Black nurses confronted bureaucratic barriers that restricted them to only caring for Black servicemen and prisoners of war, and racial quotas that resulted in 500 Black nurses vs 59,000 White nurses that served during World War II. Black nurses and their supporters in government and society persisted, and once in uniform, broke through barriers to achieve administrative and clinical excellence.⁷

My mother’s experience mirrors that of thousands of women whose dreams for a career in military medicine were shattered or who enlisted only to find their aspirations for advancement in the service thwarted. Medical historians remind us that due to bias, much of the book of women healer’s accomplishments remains unwritten, itself a testimony to the pervasive and enduring marginalization of women in Western society. Yet, as this brief glimpse of women in military medicine shows, there is sufficient evidence for us to appreciate their impressive contributions.⁸

Reflecting on this sketch of women’s struggle for acceptance in military medicine in March 2024, we may presume that the fight for equity has been continuously trending upward.⁸ President Joseph R. Biden appointed, and even more surprisingly, the US Congress confirmed Rachel Levine, MD, as US Department of Health and Human Services Assistant Under Secretary for Health in 2021, making Levine the highest ranking openly transgender health official in the history of the US government.⁹ Levine also has the distinction of being the first 4-star admiral in the Commissioned Corps of the US Public Health Service and the only transgender person to achieve this rank in any branch of the US uniformed services.¹⁰

However, research suggests that the history of women in the military is far more like an undulating curve. A 2019 study of academic military surgery found evidence of gender disparity even greater than that of the civilian sector.¹¹ True and lasting equity in federal health care practice will require all of us to follow the inspiring examples of so many women known and unknown who fought the military establishment within for the right to heal those wounded fighting the enemy without.

Let the generations know that women in uniform also guaranteed their freedom.

Mary Walker, MD

Hoping to make a career in nursing, my mother, a newly graduated registered nurse, enlisted in the US Army Nurse Corps shortly after the United States entered World War II. When she married my father, a US Army doctor, in 1942, she was summarily discharged (the Army Nurse Corp changed its policy and permitted married nurses to serve later that year), while my father went on to decades of distinguished service in military medicine.¹ My mother always regretted being unable to advance through the ranks of the US Army as other woman nurses did in her training class.

March is Women’s History Month. My personal narrative of discrimination against women in military medicine is a footnote in a long volume of inequitable treatment. This column will examine a few of the most famous—or rather from a justice perspective, infamous—chapters in that story to illustrate how for centuries women heroically fought for the right to serve.

A theme of the early epochs of the American military is that women were forced to come to the difficult realization that the only way to serve was to conceal their identity. In 1776, Margaret Cochran Corbin felt called as her husband did to defend the new nation. She dressed as a man and joined him at the ramparts, helping load his cannon until he was killed, and took over firing at the enemy. Even after being shot, she remained in the ranks, entering the Invalid Regiment at West Point, New York, dedicated to caring for other injured soldiers. As recognition of her exemplary service and battlefield injury Corbin became the first US woman to receive a military pension. The Veterans Affairs New York Harbor Healthcare System Manhattan campus is named in her honor.²

The hypocrisy of the military’s gender politics was nowhere more evident than in the case of Mary Walker, MD, and the Congressional Medal of Honor. Walker graduated from Syracuse Medical College in 1855. At the beginning of the Civil War, Walker’s request to enlist as a surgeon was refused on the grounds of her gender. She declined to be a nurse, and instead volunteered for the Army where she cared for the wounded in various hospitals. Her medical degree was accepted in 1863, enabling her to become a paid surgical officer in the War Department, including 4 months as a prisoner of war.

An early and avid feminist, Walker wore men’s clothing and when she was arrested on the charge of impersonating a male, declared the government had given her permission to dress as a man to facilitate her surgical work. Walker separated from the military in 1865 and President Andrew Johnson awarded her the Congressional Medal of Honor that year. After Walker’s death in 1917, the Medal of Honor was rescinded on the grounds that she had never actually been commissioned and the medal could not be awarded to a civilian. It took 60 years of lobbying before President Jimmy Carter restored her award in 1977.³ That millions of women have served in the military since the Civil War, and Walker remains the only woman among the 3517 service members to have won the nation’s highest military honor, underscores the ongoing injustice.⁴

February commemorated Black History Month and a second theme that emerges from the study of the history of women in military medicine is intersectionality: How race, gender, sexual orientation, and other identities overlap and interact to generate distinctive forms of discrimination. Ethicists have applied the concept of intersectionality to health care and there are a plethora of examples in military medicine.⁵ Despite a dire need for nurses in the first and second world wars, and a track record of their exemplary service in prior conflicts, the government repeatedly set up arbitrary obstacles barring highly-qualified Black nurses from enlisting.⁶ Technically allowed to join the Army Nurse Corps in 1941, Black nurses confronted bureaucratic barriers that restricted them to only caring for Black servicemen and prisoners of war, and racial quotas that resulted in 500 Black nurses vs 59,000 White nurses that served during World War II. Black nurses and their supporters in government and society persisted, and once in uniform, broke through barriers to achieve administrative and clinical excellence.⁷

My mother’s experience mirrors that of thousands of women whose dreams for a career in military medicine were shattered or who enlisted only to find their aspirations for advancement in the service thwarted. Medical historians remind us that due to bias, much of the book of women healer’s accomplishments remains unwritten, itself a testimony to the pervasive and enduring marginalization of women in Western society. Yet, as this brief glimpse of women in military medicine shows, there is sufficient evidence for us to appreciate their impressive contributions.⁸

Reflecting on this sketch of women’s struggle for acceptance in military medicine in March 2024, we may presume that the fight for equity has been continuously trending upward.⁸ President Joseph R. Biden appointed, and even more surprisingly, the US Congress confirmed Rachel Levine, MD, as US Department of Health and Human Services Assistant Under Secretary for Health in 2021, making Levine the highest ranking openly transgender health official in the history of the US government.⁹ Levine also has the distinction of being the first 4-star admiral in the Commissioned Corps of the US Public Health Service and the only transgender person to achieve this rank in any branch of the US uniformed services.¹⁰

However, research suggests that the history of women in the military is far more like an undulating curve. A 2019 study of academic military surgery found evidence of gender disparity even greater than that of the civilian sector.¹¹ True and lasting equity in federal health care practice will require all of us to follow the inspiring examples of so many women known and unknown who fought the military establishment within for the right to heal those wounded fighting the enemy without.

The willingness with which our young people are likely to serve in any war, no matter how justified, shall be directly proportional to how they perceive how the veterans of earlier wars were treated and appreciated by their nation.

George Washington? ¹

This editorial is the second of the 2-part series on the recruitment crisis currently confronting the Army, Navy, and Air Force. Part 1 focused on rationales for the lack of interest or motivation among those potentially eligible to join the military. This column looks at individuals eager to serve who do not meet eligibility requirements. A 2022 article examining the 2020 Qualified Military Available Study found that without a waiver 77% of Americans in the prime recruiting age group 17 to 24 years would be ineligible for the military due to weight, substance use, or mental and physical health conditions. Most young adults met several ineligibility criteria.²

Obesity and substance use are the most common disqualifiers, mirroring the culture at large. Scores of other physical and mental health conditions render an applicant ineligible for military service or require a waiver. The justification of all eligibility criteria is to: (1) ensure that service members can safely and effectively deploy; and (2) reduce the attrition rate. Both are essential to the mission readiness of the military. In 2022, the military gave 1 in 6 of those seeking enlistment an accession waiver.³ About 4% of waivers issued were for mental health conditions, such as autism and attention-deficit hyperactivity disorder (ADHD). The response to the recruiting crisis resulted in the largest number of waivers granted in a decade. Military Times noted that exact numbers are hard to obtain, interfering with the transparency of public policy as well as high-quality research on waivers’ impact on recruits and the service.³

The War Horse reported that the current waiver process is riddled with procedural injustice and inequity in implementation.⁴ Each service sets its eligibility requirements: the rationale being that the respective branches have distinct roles necessitating distinguishing qualifications. What is far more difficult to defend is that wide variation exists in the application of the criteria. Similar cases are judged differently, depending on nonmaterial factors, such as geographic location and unwritten policies of recruiting offices. Waiver approval rates for mental health conditions range from 35% for the Army to 71% for the Marines. The prospective recruit, not the military service, bears the burden of demonstrating that their condition does not impair their fitness for duty; hence, thousands have been disqualified based on their diagnosis.⁴ This comes at a time when the US Department of Veterans Affairs (VA) and the US Department of Defense (DoD) have been battling a suicide epidemic for years. Current qualifying standards send a strong stigmatizing message to those who want to enlist and those already in the ranks at a time the DoD and VA are launching campaigns to persuade active-duty members and veterans to seek mental health treatment.⁵

The recruiting crisis brought into stark relief more fundamental questions about the clinical and ethical aspects of eligibility criteria that either disqualify outright or require a waiver process for many young Americans with mental health conditions who want to serve their country. One of the most clinically perplexing standards is that applicants with ADHD are disqualified if they have taken medications in the past 12 to 24 months, depending on the service.⁶ Despite this policy, the Army acknowledges that stimulant medications may improve the function of individuals with ADHD and reduce the rates of substance use and behavior disturbances, the real concerns for recruiters and commanders.⁷

Requirements like these place otherwise high-functioning individuals whose professional goal is to serve in the military in a double bind. The military’s studies show that recruits’ persistent nondisclosure of their diagnoses results in poorer performance and higher attrition rates of those who have enlisted, even when treated.⁸ If potential recruits disclose their psychiatric history, they may well be disqualified and/or denied a waiver. This is even more true for service members already in the military who may believe they have one of the conditions but fear that being diagnosed will negatively impact their career. Not disclosing their condition prevents service members from obtaining the clinical care and support they need to succeed and also limits the ability of commanders to make decisions about deployment that ensure maximal unit performance and the safety of the service member.⁹ However, ADHD is one of 38 diagnoses that the DoD is considering for possible removal or modification of the waiver for some subset of applicants.¹⁰

The final irony is that medicine and warfare have changed dramatically and rapidly since the initial determination that diagnoses like ADHD and autism disqualify individuals from serving. A Rand Corporation study found that individuals who are neurodivergent—the name collectively assigned to individuals with diagnoses like autism and ADHD—may have unique abilities that enable them to outperform neurotypical persons in areas like pattern recognition, attention to detail, repetitive tasks, and memory, among others. These highly technical skills are essential to intelligence analysis and cybersecurity domains that are increasingly crucial to both national defense and victory on the battlefield.¹¹ Even congressional representatives who just a few years ago criticized waivers for mental health conditions as “lowering the standards” are now pushing for more moderate policies, especially for those who have received and responded to treatment for their mental health disorders.¹²

The epigraph has been widely and persistently misattributed to the country’s first commander in chief, George Washington, because it captures a salient sentiment directly bearing on the question of who is fit for duty.¹ History has shown that discrimination in enlistment only weakens the fighting force, whereas diversity, including neurodiversity, in the military as in society is a source of strength. Equitable inclusion of those who have the discipline, desire, and dedication to serve their country may be the most positive response to the recruitment crisis.

The willingness with which our young people are likely to serve in any war, no matter how justified, shall be directly proportional to how they perceive how the veterans of earlier wars were treated and appreciated by their nation.

George Washington? ¹

This editorial is the second of the 2-part series on the recruitment crisis currently confronting the Army, Navy, and Air Force. Part 1 focused on rationales for the lack of interest or motivation among those potentially eligible to join the military. This column looks at individuals eager to serve who do not meet eligibility requirements. A 2022 article examining the 2020 Qualified Military Available Study found that without a waiver 77% of Americans in the prime recruiting age group 17 to 24 years would be ineligible for the military due to weight, substance use, or mental and physical health conditions. Most young adults met several ineligibility criteria.²

Obesity and substance use are the most common disqualifiers, mirroring the culture at large. Scores of other physical and mental health conditions render an applicant ineligible for military service or require a waiver. The justification of all eligibility criteria is to: (1) ensure that service members can safely and effectively deploy; and (2) reduce the attrition rate. Both are essential to the mission readiness of the military. In 2022, the military gave 1 in 6 of those seeking enlistment an accession waiver.³ About 4% of waivers issued were for mental health conditions, such as autism and attention-deficit hyperactivity disorder (ADHD). The response to the recruiting crisis resulted in the largest number of waivers granted in a decade. Military Times noted that exact numbers are hard to obtain, interfering with the transparency of public policy as well as high-quality research on waivers’ impact on recruits and the service.³

The War Horse reported that the current waiver process is riddled with procedural injustice and inequity in implementation.⁴ Each service sets its eligibility requirements: the rationale being that the respective branches have distinct roles necessitating distinguishing qualifications. What is far more difficult to defend is that wide variation exists in the application of the criteria. Similar cases are judged differently, depending on nonmaterial factors, such as geographic location and unwritten policies of recruiting offices. Waiver approval rates for mental health conditions range from 35% for the Army to 71% for the Marines. The prospective recruit, not the military service, bears the burden of demonstrating that their condition does not impair their fitness for duty; hence, thousands have been disqualified based on their diagnosis.⁴ This comes at a time when the US Department of Veterans Affairs (VA) and the US Department of Defense (DoD) have been battling a suicide epidemic for years. Current qualifying standards send a strong stigmatizing message to those who want to enlist and those already in the ranks at a time the DoD and VA are launching campaigns to persuade active-duty members and veterans to seek mental health treatment.⁵

The recruiting crisis brought into stark relief more fundamental questions about the clinical and ethical aspects of eligibility criteria that either disqualify outright or require a waiver process for many young Americans with mental health conditions who want to serve their country. One of the most clinically perplexing standards is that applicants with ADHD are disqualified if they have taken medications in the past 12 to 24 months, depending on the service.⁶ Despite this policy, the Army acknowledges that stimulant medications may improve the function of individuals with ADHD and reduce the rates of substance use and behavior disturbances, the real concerns for recruiters and commanders.⁷

Requirements like these place otherwise high-functioning individuals whose professional goal is to serve in the military in a double bind. The military’s studies show that recruits’ persistent nondisclosure of their diagnoses results in poorer performance and higher attrition rates of those who have enlisted, even when treated.⁸ If potential recruits disclose their psychiatric history, they may well be disqualified and/or denied a waiver. This is even more true for service members already in the military who may believe they have one of the conditions but fear that being diagnosed will negatively impact their career. Not disclosing their condition prevents service members from obtaining the clinical care and support they need to succeed and also limits the ability of commanders to make decisions about deployment that ensure maximal unit performance and the safety of the service member.⁹ However, ADHD is one of 38 diagnoses that the DoD is considering for possible removal or modification of the waiver for some subset of applicants.¹⁰

The final irony is that medicine and warfare have changed dramatically and rapidly since the initial determination that diagnoses like ADHD and autism disqualify individuals from serving. A Rand Corporation study found that individuals who are neurodivergent—the name collectively assigned to individuals with diagnoses like autism and ADHD—may have unique abilities that enable them to outperform neurotypical persons in areas like pattern recognition, attention to detail, repetitive tasks, and memory, among others. These highly technical skills are essential to intelligence analysis and cybersecurity domains that are increasingly crucial to both national defense and victory on the battlefield.¹¹ Even congressional representatives who just a few years ago criticized waivers for mental health conditions as “lowering the standards” are now pushing for more moderate policies, especially for those who have received and responded to treatment for their mental health disorders.¹²

The epigraph has been widely and persistently misattributed to the country’s first commander in chief, George Washington, because it captures a salient sentiment directly bearing on the question of who is fit for duty.¹ History has shown that discrimination in enlistment only weakens the fighting force, whereas diversity, including neurodiversity, in the military as in society is a source of strength. Equitable inclusion of those who have the discipline, desire, and dedication to serve their country may be the most positive response to the recruitment crisis.

The willingness with which our young people are likely to serve in any war, no matter how justified, shall be directly proportional to how they perceive how the veterans of earlier wars were treated and appreciated by their nation.

George Washington? ¹

This editorial is the second of the 2-part series on the recruitment crisis currently confronting the Army, Navy, and Air Force. Part 1 focused on rationales for the lack of interest or motivation among those potentially eligible to join the military. This column looks at individuals eager to serve who do not meet eligibility requirements. A 2022 article examining the 2020 Qualified Military Available Study found that without a waiver 77% of Americans in the prime recruiting age group 17 to 24 years would be ineligible for the military due to weight, substance use, or mental and physical health conditions. Most young adults met several ineligibility criteria.²

Obesity and substance use are the most common disqualifiers, mirroring the culture at large. Scores of other physical and mental health conditions render an applicant ineligible for military service or require a waiver. The justification of all eligibility criteria is to: (1) ensure that service members can safely and effectively deploy; and (2) reduce the attrition rate. Both are essential to the mission readiness of the military. In 2022, the military gave 1 in 6 of those seeking enlistment an accession waiver.³ About 4% of waivers issued were for mental health conditions, such as autism and attention-deficit hyperactivity disorder (ADHD). The response to the recruiting crisis resulted in the largest number of waivers granted in a decade. Military Times noted that exact numbers are hard to obtain, interfering with the transparency of public policy as well as high-quality research on waivers’ impact on recruits and the service.³

The War Horse reported that the current waiver process is riddled with procedural injustice and inequity in implementation.⁴ Each service sets its eligibility requirements: the rationale being that the respective branches have distinct roles necessitating distinguishing qualifications. What is far more difficult to defend is that wide variation exists in the application of the criteria. Similar cases are judged differently, depending on nonmaterial factors, such as geographic location and unwritten policies of recruiting offices. Waiver approval rates for mental health conditions range from 35% for the Army to 71% for the Marines. The prospective recruit, not the military service, bears the burden of demonstrating that their condition does not impair their fitness for duty; hence, thousands have been disqualified based on their diagnosis.⁴ This comes at a time when the US Department of Veterans Affairs (VA) and the US Department of Defense (DoD) have been battling a suicide epidemic for years. Current qualifying standards send a strong stigmatizing message to those who want to enlist and those already in the ranks at a time the DoD and VA are launching campaigns to persuade active-duty members and veterans to seek mental health treatment.⁵

The recruiting crisis brought into stark relief more fundamental questions about the clinical and ethical aspects of eligibility criteria that either disqualify outright or require a waiver process for many young Americans with mental health conditions who want to serve their country. One of the most clinically perplexing standards is that applicants with ADHD are disqualified if they have taken medications in the past 12 to 24 months, depending on the service.⁶ Despite this policy, the Army acknowledges that stimulant medications may improve the function of individuals with ADHD and reduce the rates of substance use and behavior disturbances, the real concerns for recruiters and commanders.⁷

Requirements like these place otherwise high-functioning individuals whose professional goal is to serve in the military in a double bind. The military’s studies show that recruits’ persistent nondisclosure of their diagnoses results in poorer performance and higher attrition rates of those who have enlisted, even when treated.⁸ If potential recruits disclose their psychiatric history, they may well be disqualified and/or denied a waiver. This is even more true for service members already in the military who may believe they have one of the conditions but fear that being diagnosed will negatively impact their career. Not disclosing their condition prevents service members from obtaining the clinical care and support they need to succeed and also limits the ability of commanders to make decisions about deployment that ensure maximal unit performance and the safety of the service member.⁹ However, ADHD is one of 38 diagnoses that the DoD is considering for possible removal or modification of the waiver for some subset of applicants.¹⁰

The final irony is that medicine and warfare have changed dramatically and rapidly since the initial determination that diagnoses like ADHD and autism disqualify individuals from serving. A Rand Corporation study found that individuals who are neurodivergent—the name collectively assigned to individuals with diagnoses like autism and ADHD—may have unique abilities that enable them to outperform neurotypical persons in areas like pattern recognition, attention to detail, repetitive tasks, and memory, among others. These highly technical skills are essential to intelligence analysis and cybersecurity domains that are increasingly crucial to both national defense and victory on the battlefield.¹¹ Even congressional representatives who just a few years ago criticized waivers for mental health conditions as “lowering the standards” are now pushing for more moderate policies, especially for those who have received and responded to treatment for their mental health disorders.¹²

The epigraph has been widely and persistently misattributed to the country’s first commander in chief, George Washington, because it captures a salient sentiment directly bearing on the question of who is fit for duty.¹ History has shown that discrimination in enlistment only weakens the fighting force, whereas diversity, including neurodiversity, in the military as in society is a source of strength. Equitable inclusion of those who have the discipline, desire, and dedication to serve their country may be the most positive response to the recruitment crisis.

Word to the Nation: Guard zealously your right to serve in the Armed Forces, for without them, there will be no other rights to guard.

  John F. Kennedy ¹

The title of this Veterans Day editorial is a paraphrase of the legendary folk artist Pete Seeger’s protest song popularized during the Vietnam War. On January 27, 1973, in the wake of the widespread antiwar movement, Secretary of Defense Melvin Laird announced an end to the dreaded draft.²

For nearly 50 years, the all-volunteer military was celebrated as an outstanding achievement that professionalized the armed services and arguably made the US military among the most highly trained and effective fighting forces in the world. That was until an ongoing recruitment crisis threatened to write a different and far more disturbing conclusion to what the government had heralded as a “success story.”³

The recruiting crisis is a complicated problem with many facets that have received increasing attention from journalists, the media, experts, think tanks, and the government. Given this complexity, this will be a 2-part editorial: This column examines the scope of the crisis and the putative causes of the problem with recruiting Americans to serve in uniform. The next column will examine the potential impact of the shortage of service members on federal health care practice.

The Recruiting Crisis

Over the past several years, nearly every branch of the armed forces has struggled with recruitment, especially the Army. In April of this year, the US Department of Defense (DoD) reported that the Army, Navy, and Air Force would all fail to meet recruitment goals; only the Marines and Space Forces were expected to reach their targets.⁴ At the end of its fiscal year (October 1), the Army acknowledged that its 55,000 recruits were 10,000 fewer soldiers than it had aimed to enlist.⁵ But this was still more people joining the ranks than in 2022 when the Army was 15,000 recruits below the mark.⁶

Challenging Trends

There are many putative causes and proposed solutions for the recruitment crisis. Among the most serious is a marked drop in the American public’s confidence in the military. A June 2023 Gallup poll found that only 60% of citizens expressed “a great deal” or “quite a lot” of confidence in the military. This was the nadir of a 5-year decline that this year reached the lowest point since 1997/1998.⁷ For many Americans in and out of uniform, the ignoble end to the long war in Afghanistan leaving behind friends and allies contrary to the military ethos is cited as a significant contributor to both the loss of confidence in the military and the recruiting crisis.⁸

These cultural developments reinforce each other. Now, many veterans do not want their relatives and friends to follow them into the armed services. A 2021 survey by the Military Family Advisory Network found that slightly more than 60% of veterans and active-duty service members would recommend a military career to a potential recruit. This was down from 75% in 2019.⁹ Veterans cite a variety of reasons for discouraging their fellow citizens from serving, including low pay compared with civilian employment, especially in a labor-hungry job market; and the military failure to fulfill health care promises, housing, and other social services, especially for the growing number experiencing mental health disorders related to their service.¹⁰

Two facts about recruitment heighten the negative impact of some veterans’ change of attitude toward joining the services. First, since the end of the draft, military life in the US has become a family tradition. Published in 2011, a Pew Research Center study found that even then, a decreasing number of Americans had a family connection to the military. More respondents aged ≥ 50 years had a parent, child, spouse, or sibling who had served compared with those aged 30 to 49 years and those aged 18 to 29 (77%, 57%, and 33%, respectively).¹¹ Second, since the end of the draft, far fewer Americans have had military experience. Only 1% of the nation is currently in military service, and the veteran population is steadily declining. In 1980, 18% of adult Americans were veterans; 20 years later, that number is only 7%.¹² This makes it less likely that a high school or college student will have a personal or even a passing relationship with a teacher, coach, or other mentoring adult who is or has been a military member. This demographic discrepancy has generated what sociologists call the military-civilian gap.¹⁰ That division has been manipulated in the increasingly vehement culture wars and generational struggles that are splitting the country.¹²

This relatively recent sociological trend is reflected in a growing lack of interest among many young Americans in armed forces service. A DoD survey of participants aged 16 to 24 years regarding their intention to serve in the military found that 89% were probably not going to pursue a career in uniform. More than 65% of respondents indicated that the possibility of physical injury, death, or psychological trauma was the primary deterrent for considering enlisting.¹³ The latter barrier is directly related to our work as practitioners caring for service members and veterans, and through our compassion and competence, we may help bridge the widening divide between the military and civilian spheres. These numbers speak to the unwilling; there is also a significant group of Americans who want to serve yet are unable to due to their history, diagnoses, or condition.¹⁴ Their motivation to be military members in the face of the recruitment challenges highlighted here present federal practitioners with ethical questions that will be the subject of the next column.

Armed Forces and Veterans Day

This column’s epigraph is from President John F. Kennedy, a decorated World War II Navy combat veteran who decreed Armed Forces Day an official holiday a decade before conscription ended.¹ The commemoration was to thank and honor all individuals currently serving in the military for their patriotism and sacrifice. President Kennedy’s Word to the Nation could not be timelier on Veterans Day 2023. The data reviewed here raise profound questions as to where tomorrow’s service members and the veterans of the future will come from, and how we will persuade them that though there are real risks to military service, the rewards are both tangible and transcendent.

Word to the Nation: Guard zealously your right to serve in the Armed Forces, for without them, there will be no other rights to guard.

  John F. Kennedy ¹

The title of this Veterans Day editorial is a paraphrase of the legendary folk artist Pete Seeger’s protest song popularized during the Vietnam War. On January 27, 1973, in the wake of the widespread antiwar movement, Secretary of Defense Melvin Laird announced an end to the dreaded draft.²

For nearly 50 years, the all-volunteer military was celebrated as an outstanding achievement that professionalized the armed services and arguably made the US military among the most highly trained and effective fighting forces in the world. That was until an ongoing recruitment crisis threatened to write a different and far more disturbing conclusion to what the government had heralded as a “success story.”³

The recruiting crisis is a complicated problem with many facets that have received increasing attention from journalists, the media, experts, think tanks, and the government. Given this complexity, this will be a 2-part editorial: This column examines the scope of the crisis and the putative causes of the problem with recruiting Americans to serve in uniform. The next column will examine the potential impact of the shortage of service members on federal health care practice.

The Recruiting Crisis

Over the past several years, nearly every branch of the armed forces has struggled with recruitment, especially the Army. In April of this year, the US Department of Defense (DoD) reported that the Army, Navy, and Air Force would all fail to meet recruitment goals; only the Marines and Space Forces were expected to reach their targets.⁴ At the end of its fiscal year (October 1), the Army acknowledged that its 55,000 recruits were 10,000 fewer soldiers than it had aimed to enlist.⁵ But this was still more people joining the ranks than in 2022 when the Army was 15,000 recruits below the mark.⁶

Challenging Trends

There are many putative causes and proposed solutions for the recruitment crisis. Among the most serious is a marked drop in the American public’s confidence in the military. A June 2023 Gallup poll found that only 60% of citizens expressed “a great deal” or “quite a lot” of confidence in the military. This was the nadir of a 5-year decline that this year reached the lowest point since 1997/1998.⁷ For many Americans in and out of uniform, the ignoble end to the long war in Afghanistan leaving behind friends and allies contrary to the military ethos is cited as a significant contributor to both the loss of confidence in the military and the recruiting crisis.⁸

These cultural developments reinforce each other. Now, many veterans do not want their relatives and friends to follow them into the armed services. A 2021 survey by the Military Family Advisory Network found that slightly more than 60% of veterans and active-duty service members would recommend a military career to a potential recruit. This was down from 75% in 2019.⁹ Veterans cite a variety of reasons for discouraging their fellow citizens from serving, including low pay compared with civilian employment, especially in a labor-hungry job market; and the military failure to fulfill health care promises, housing, and other social services, especially for the growing number experiencing mental health disorders related to their service.¹⁰

Two facts about recruitment heighten the negative impact of some veterans’ change of attitude toward joining the services. First, since the end of the draft, military life in the US has become a family tradition. Published in 2011, a Pew Research Center study found that even then, a decreasing number of Americans had a family connection to the military. More respondents aged ≥ 50 years had a parent, child, spouse, or sibling who had served compared with those aged 30 to 49 years and those aged 18 to 29 (77%, 57%, and 33%, respectively).¹¹ Second, since the end of the draft, far fewer Americans have had military experience. Only 1% of the nation is currently in military service, and the veteran population is steadily declining. In 1980, 18% of adult Americans were veterans; 20 years later, that number is only 7%.¹² This makes it less likely that a high school or college student will have a personal or even a passing relationship with a teacher, coach, or other mentoring adult who is or has been a military member. This demographic discrepancy has generated what sociologists call the military-civilian gap.¹⁰ That division has been manipulated in the increasingly vehement culture wars and generational struggles that are splitting the country.¹²

This relatively recent sociological trend is reflected in a growing lack of interest among many young Americans in armed forces service. A DoD survey of participants aged 16 to 24 years regarding their intention to serve in the military found that 89% were probably not going to pursue a career in uniform. More than 65% of respondents indicated that the possibility of physical injury, death, or psychological trauma was the primary deterrent for considering enlisting.¹³ The latter barrier is directly related to our work as practitioners caring for service members and veterans, and through our compassion and competence, we may help bridge the widening divide between the military and civilian spheres. These numbers speak to the unwilling; there is also a significant group of Americans who want to serve yet are unable to due to their history, diagnoses, or condition.¹⁴ Their motivation to be military members in the face of the recruitment challenges highlighted here present federal practitioners with ethical questions that will be the subject of the next column.

Armed Forces and Veterans Day

This column’s epigraph is from President John F. Kennedy, a decorated World War II Navy combat veteran who decreed Armed Forces Day an official holiday a decade before conscription ended.¹ The commemoration was to thank and honor all individuals currently serving in the military for their patriotism and sacrifice. President Kennedy’s Word to the Nation could not be timelier on Veterans Day 2023. The data reviewed here raise profound questions as to where tomorrow’s service members and the veterans of the future will come from, and how we will persuade them that though there are real risks to military service, the rewards are both tangible and transcendent.

Word to the Nation: Guard zealously your right to serve in the Armed Forces, for without them, there will be no other rights to guard.

  John F. Kennedy ¹

The title of this Veterans Day editorial is a paraphrase of the legendary folk artist Pete Seeger’s protest song popularized during the Vietnam War. On January 27, 1973, in the wake of the widespread antiwar movement, Secretary of Defense Melvin Laird announced an end to the dreaded draft.²

For nearly 50 years, the all-volunteer military was celebrated as an outstanding achievement that professionalized the armed services and arguably made the US military among the most highly trained and effective fighting forces in the world. That was until an ongoing recruitment crisis threatened to write a different and far more disturbing conclusion to what the government had heralded as a “success story.”³

The recruiting crisis is a complicated problem with many facets that have received increasing attention from journalists, the media, experts, think tanks, and the government. Given this complexity, this will be a 2-part editorial: This column examines the scope of the crisis and the putative causes of the problem with recruiting Americans to serve in uniform. The next column will examine the potential impact of the shortage of service members on federal health care practice.

The Recruiting Crisis

Over the past several years, nearly every branch of the armed forces has struggled with recruitment, especially the Army. In April of this year, the US Department of Defense (DoD) reported that the Army, Navy, and Air Force would all fail to meet recruitment goals; only the Marines and Space Forces were expected to reach their targets.⁴ At the end of its fiscal year (October 1), the Army acknowledged that its 55,000 recruits were 10,000 fewer soldiers than it had aimed to enlist.⁵ But this was still more people joining the ranks than in 2022 when the Army was 15,000 recruits below the mark.⁶

Challenging Trends

There are many putative causes and proposed solutions for the recruitment crisis. Among the most serious is a marked drop in the American public’s confidence in the military. A June 2023 Gallup poll found that only 60% of citizens expressed “a great deal” or “quite a lot” of confidence in the military. This was the nadir of a 5-year decline that this year reached the lowest point since 1997/1998.⁷ For many Americans in and out of uniform, the ignoble end to the long war in Afghanistan leaving behind friends and allies contrary to the military ethos is cited as a significant contributor to both the loss of confidence in the military and the recruiting crisis.⁸

These cultural developments reinforce each other. Now, many veterans do not want their relatives and friends to follow them into the armed services. A 2021 survey by the Military Family Advisory Network found that slightly more than 60% of veterans and active-duty service members would recommend a military career to a potential recruit. This was down from 75% in 2019.⁹ Veterans cite a variety of reasons for discouraging their fellow citizens from serving, including low pay compared with civilian employment, especially in a labor-hungry job market; and the military failure to fulfill health care promises, housing, and other social services, especially for the growing number experiencing mental health disorders related to their service.¹⁰

Two facts about recruitment heighten the negative impact of some veterans’ change of attitude toward joining the services. First, since the end of the draft, military life in the US has become a family tradition. Published in 2011, a Pew Research Center study found that even then, a decreasing number of Americans had a family connection to the military. More respondents aged ≥ 50 years had a parent, child, spouse, or sibling who had served compared with those aged 30 to 49 years and those aged 18 to 29 (77%, 57%, and 33%, respectively).¹¹ Second, since the end of the draft, far fewer Americans have had military experience. Only 1% of the nation is currently in military service, and the veteran population is steadily declining. In 1980, 18% of adult Americans were veterans; 20 years later, that number is only 7%.¹² This makes it less likely that a high school or college student will have a personal or even a passing relationship with a teacher, coach, or other mentoring adult who is or has been a military member. This demographic discrepancy has generated what sociologists call the military-civilian gap.¹⁰ That division has been manipulated in the increasingly vehement culture wars and generational struggles that are splitting the country.¹²

This relatively recent sociological trend is reflected in a growing lack of interest among many young Americans in armed forces service. A DoD survey of participants aged 16 to 24 years regarding their intention to serve in the military found that 89% were probably not going to pursue a career in uniform. More than 65% of respondents indicated that the possibility of physical injury, death, or psychological trauma was the primary deterrent for considering enlisting.¹³ The latter barrier is directly related to our work as practitioners caring for service members and veterans, and through our compassion and competence, we may help bridge the widening divide between the military and civilian spheres. These numbers speak to the unwilling; there is also a significant group of Americans who want to serve yet are unable to due to their history, diagnoses, or condition.¹⁴ Their motivation to be military members in the face of the recruitment challenges highlighted here present federal practitioners with ethical questions that will be the subject of the next column.

Armed Forces and Veterans Day

This column’s epigraph is from President John F. Kennedy, a decorated World War II Navy combat veteran who decreed Armed Forces Day an official holiday a decade before conscription ended.¹ The commemoration was to thank and honor all individuals currently serving in the military for their patriotism and sacrifice. President Kennedy’s Word to the Nation could not be timelier on Veterans Day 2023. The data reviewed here raise profound questions as to where tomorrow’s service members and the veterans of the future will come from, and how we will persuade them that though there are real risks to military service, the rewards are both tangible and transcendent.

The psychological and moral comfort of a presence at once humble and understanding—this is the greatest benefit that the dog has bestowed upon man. Percy Bysshe Shelley

Ever since their domestication about 20,000 years ago, dogs have been cherished for their indomitable and generous spirit, ability to assist humans in myriad ways, and unconditional love. August heralds National Dog Month, and September honors the loyal companionship and dedicated work of service dogs so valuable to service members and veterans.

The nature of their special training to perform specific tasks for the safety and well-being of veterans distinguishes service dogs from pets or emotional support animals. Most of us recognize the happiness and meaning animals bring to our lives. What we may not appreciate is the impressive contribution service dogs make to the health and rehabilitation of those who have served their country. Veteran patients with neurologic conditions such as seizures know the difference a service dog trained to warn them of an emerging seizure makes for their freedom of movement and peace of mind. Veterans with diabetes have described times when their service dogs sought help before they realized their blood sugar was dangerously low.

Patients, friends, and neighbors who have been paired with service dogs describe ways their new companion helped them transition from a life in which even surviving was a struggle to one of holistic thriving. A Vietnam veteran neighbor with a significant tremor due to Parkinson disease benefitted from the ability of his dog to fetch and bring, retrieve, and carry. His dog has learned to hold essential items still, which would otherwise be too shaky in human hands, enabling the veteran to open his closet door and dress independently each morning. One veteran classmate avoided all forms of public transportation due to memories of a traumatic mobile-based mass evacuation she assisted with during her military service. She dreaded her long, inconvenient daily drive back and forth to work. She was then partnered with a large dog breed that was trained to stand a short distance from her to protect her sense of space and open air. The dog would stretch out his body to claim more space for her among crowds. This veteran started to ride the bus to campus each morning and appreciated the interaction with other riders as well as the saved travel time, mileage, gasoline expense, and parking stress.

A veteran brought his sweet retriever to the neighborhood weekly “Paws-itive Reading” program for children in the local public library. When MW’s daughter was busy reading to his furry friend, the veteran shared that for at least 5 years after his combat tours, he rarely left his window-shuttered home. His dog’s steady comfort re-established his ability to participate in his community. He now generously shares his dog’s patient affection with children learning to read.

MW recently witnessed the profound and protective presence of a service dog in comforting a veteran during a posttraumatic stress disorder (PTSD)–related crisis. The service dog offered a lean and reassuring paw pressure on the veteran’s shoulder if he was reexperiencing trauma. The dog’s steady breathing and familiar warmth helped to reorient their human companion to the safety of his present physical surroundings. Bearing witness to the dog’s trained interaction with the veteran left MW speechless. The trust between them was therapeutic in a way that transcended her ability to articulate what she experienced. This compelled MW to investigate whether this was a rare relationship or whether there was existing data on the impact of trained service dogs and PTSD.

Service dog placement with veterans with PTSD has been shown to have a positive influence on both physiological (arousal-related functioning and cortisol awakening response) and psychosocial well-being, including decreased isolation and increased physical activity.^1,2 Veterans with PTSD paired with service dogs showed significantly fewer PTSD-related symptoms, better sleep quality, and improved well-being, compared with those with just a pet.³ A recent meta-analysis revealed that veteran partnerships with a service dog had a clinically meaningful, significant, and large effect on PTSD severity scores (P < .001).² The mechanism for impact is thought to be not only the dog’s working role but also the transcendent loyalty of the canine-veteran bond.

Many accredited dog training programs describe a certain reciprocity to the dog-human relationship. Some use rescue puppies to give the dogs a new life and purpose. Dogs who have undergone challenges often need patience, time, safe relationships, and trustworthy new experiences to maximize their potential. Reciprocally, trained service dogs have the potential to foster access to these same emotional, relational, existential, and physical safety needs for veterans exposed to trauma.

Recent legislation has made progress in recognizing the role of service dogs for veterans and improving access. The Puppies Assisting Wounded Servicemembers (PAWS) for Veterans Therapy Act (38 USC §1705, 1714) was passed in 2021. The PAWS Act implemented a policy and 5-year pilot program to connect trained canines to eligible veterans diagnosed with PTSD as an element of an integrative health program, regardless of whether the veteran has a mobility impairment. The PAWS Act gives federal funding to accredited dog training organizations to help pair eligible veterans with service dogs by covering veteran travel expenses for the training, training program participation, and relevant veterinary expenses. The bipartisan Service Dogs Assisting Veterans Act (SAVES) Act was introduced this summer to award grants to nonprofit organizations Assistance Dog International has accredited to help these groups provide service dogs to veterans.

The US Department of Veterans Affairs (VA) has made strides in welcoming service dogs. Trained service dogs of all breeds under the control of a human companion are now allowed in VA facilities other than in areas where safety and infection control standards would be compromised (ie, sterile equipment rooms).⁴ A prescribing clinician can now evaluate eligible veterans to determine their ability, resources, and goals for having a service dog.⁵ An assessment of the veteran’s ability to care for a dog and education on expectations for the partnership is critical to success and animal welfare. Those veterans approved for a service dog are then referred to accredited agencies. The VA Veterinary Health Insurance Benefit includes aspects of coverage for the veteran to attend service dog training, veterinary wellness (preventive care, immunizations, dental cleanings, certain prescriptions, etc), and care for the dog’s illnesses when treatment enables the dog to perform duties in service to the veteran.⁶

The productive purpose and friendship of a service dog become a formidable force in a veteran’s life. Veterans spent an average of 82% of their time with service dogs (assessed via Bluetooth proximity between collar and smartphone).⁷ Human partners of veterans with service dogs may experience improved quality of life and relationship functioning with the inclusion of a service dog in the family unit.⁸ Veterans depict increased community engagement, social connectedness, and personal confidence as a result of the canine companionship.^9,10 Veterans with service dogs often speak of the ways the dog’s presence transformed their lives and many speak of the dog literally saving their lives.¹¹ Meta-analyses showed improved mental health treatment engagement, medication adherence, and decreased suicidality.^2,12

A story was recently shared with us about the compassion and competence of VA staff in a perioperative unit. A veteran was scheduled for a life-altering surgery and yet was anxious about entering the room for his scheduled pre-anesthesia check-in, knowing his service dog could not accompany him through the entire procedure. The staff recognized that the veteran was increasingly nervous and even started to question whether he would stay for the scheduled procedure they deemed would benefit his health. The perioperative team then proactively worked together to safely walk the veteran through the preparation processes in a sterile setting while keeping the dog within sight of the veteran. They then ensured that the veteran’s service dog was by his side early in the recovery room so that the veteran woke to wags and licks. In these months of canine recognition, we honor the ways the VA has fostered companionship and courage in veterans’ lives through the inclusion of service dogs in so many aspects of their care and life.

The psychological and moral comfort of a presence at once humble and understanding—this is the greatest benefit that the dog has bestowed upon man. Percy Bysshe Shelley

Ever since their domestication about 20,000 years ago, dogs have been cherished for their indomitable and generous spirit, ability to assist humans in myriad ways, and unconditional love. August heralds National Dog Month, and September honors the loyal companionship and dedicated work of service dogs so valuable to service members and veterans.

The nature of their special training to perform specific tasks for the safety and well-being of veterans distinguishes service dogs from pets or emotional support animals. Most of us recognize the happiness and meaning animals bring to our lives. What we may not appreciate is the impressive contribution service dogs make to the health and rehabilitation of those who have served their country. Veteran patients with neurologic conditions such as seizures know the difference a service dog trained to warn them of an emerging seizure makes for their freedom of movement and peace of mind. Veterans with diabetes have described times when their service dogs sought help before they realized their blood sugar was dangerously low.

Patients, friends, and neighbors who have been paired with service dogs describe ways their new companion helped them transition from a life in which even surviving was a struggle to one of holistic thriving. A Vietnam veteran neighbor with a significant tremor due to Parkinson disease benefitted from the ability of his dog to fetch and bring, retrieve, and carry. His dog has learned to hold essential items still, which would otherwise be too shaky in human hands, enabling the veteran to open his closet door and dress independently each morning. One veteran classmate avoided all forms of public transportation due to memories of a traumatic mobile-based mass evacuation she assisted with during her military service. She dreaded her long, inconvenient daily drive back and forth to work. She was then partnered with a large dog breed that was trained to stand a short distance from her to protect her sense of space and open air. The dog would stretch out his body to claim more space for her among crowds. This veteran started to ride the bus to campus each morning and appreciated the interaction with other riders as well as the saved travel time, mileage, gasoline expense, and parking stress.

A veteran brought his sweet retriever to the neighborhood weekly “Paws-itive Reading” program for children in the local public library. When MW’s daughter was busy reading to his furry friend, the veteran shared that for at least 5 years after his combat tours, he rarely left his window-shuttered home. His dog’s steady comfort re-established his ability to participate in his community. He now generously shares his dog’s patient affection with children learning to read.

MW recently witnessed the profound and protective presence of a service dog in comforting a veteran during a posttraumatic stress disorder (PTSD)–related crisis. The service dog offered a lean and reassuring paw pressure on the veteran’s shoulder if he was reexperiencing trauma. The dog’s steady breathing and familiar warmth helped to reorient their human companion to the safety of his present physical surroundings. Bearing witness to the dog’s trained interaction with the veteran left MW speechless. The trust between them was therapeutic in a way that transcended her ability to articulate what she experienced. This compelled MW to investigate whether this was a rare relationship or whether there was existing data on the impact of trained service dogs and PTSD.

Service dog placement with veterans with PTSD has been shown to have a positive influence on both physiological (arousal-related functioning and cortisol awakening response) and psychosocial well-being, including decreased isolation and increased physical activity.^1,2 Veterans with PTSD paired with service dogs showed significantly fewer PTSD-related symptoms, better sleep quality, and improved well-being, compared with those with just a pet.³ A recent meta-analysis revealed that veteran partnerships with a service dog had a clinically meaningful, significant, and large effect on PTSD severity scores (P < .001).² The mechanism for impact is thought to be not only the dog’s working role but also the transcendent loyalty of the canine-veteran bond.

Many accredited dog training programs describe a certain reciprocity to the dog-human relationship. Some use rescue puppies to give the dogs a new life and purpose. Dogs who have undergone challenges often need patience, time, safe relationships, and trustworthy new experiences to maximize their potential. Reciprocally, trained service dogs have the potential to foster access to these same emotional, relational, existential, and physical safety needs for veterans exposed to trauma.

Recent legislation has made progress in recognizing the role of service dogs for veterans and improving access. The Puppies Assisting Wounded Servicemembers (PAWS) for Veterans Therapy Act (38 USC §1705, 1714) was passed in 2021. The PAWS Act implemented a policy and 5-year pilot program to connect trained canines to eligible veterans diagnosed with PTSD as an element of an integrative health program, regardless of whether the veteran has a mobility impairment. The PAWS Act gives federal funding to accredited dog training organizations to help pair eligible veterans with service dogs by covering veteran travel expenses for the training, training program participation, and relevant veterinary expenses. The bipartisan Service Dogs Assisting Veterans Act (SAVES) Act was introduced this summer to award grants to nonprofit organizations Assistance Dog International has accredited to help these groups provide service dogs to veterans.

The US Department of Veterans Affairs (VA) has made strides in welcoming service dogs. Trained service dogs of all breeds under the control of a human companion are now allowed in VA facilities other than in areas where safety and infection control standards would be compromised (ie, sterile equipment rooms).⁴ A prescribing clinician can now evaluate eligible veterans to determine their ability, resources, and goals for having a service dog.⁵ An assessment of the veteran’s ability to care for a dog and education on expectations for the partnership is critical to success and animal welfare. Those veterans approved for a service dog are then referred to accredited agencies. The VA Veterinary Health Insurance Benefit includes aspects of coverage for the veteran to attend service dog training, veterinary wellness (preventive care, immunizations, dental cleanings, certain prescriptions, etc), and care for the dog’s illnesses when treatment enables the dog to perform duties in service to the veteran.⁶

The productive purpose and friendship of a service dog become a formidable force in a veteran’s life. Veterans spent an average of 82% of their time with service dogs (assessed via Bluetooth proximity between collar and smartphone).⁷ Human partners of veterans with service dogs may experience improved quality of life and relationship functioning with the inclusion of a service dog in the family unit.⁸ Veterans depict increased community engagement, social connectedness, and personal confidence as a result of the canine companionship.^9,10 Veterans with service dogs often speak of the ways the dog’s presence transformed their lives and many speak of the dog literally saving their lives.¹¹ Meta-analyses showed improved mental health treatment engagement, medication adherence, and decreased suicidality.^2,12

A story was recently shared with us about the compassion and competence of VA staff in a perioperative unit. A veteran was scheduled for a life-altering surgery and yet was anxious about entering the room for his scheduled pre-anesthesia check-in, knowing his service dog could not accompany him through the entire procedure. The staff recognized that the veteran was increasingly nervous and even started to question whether he would stay for the scheduled procedure they deemed would benefit his health. The perioperative team then proactively worked together to safely walk the veteran through the preparation processes in a sterile setting while keeping the dog within sight of the veteran. They then ensured that the veteran’s service dog was by his side early in the recovery room so that the veteran woke to wags and licks. In these months of canine recognition, we honor the ways the VA has fostered companionship and courage in veterans’ lives through the inclusion of service dogs in so many aspects of their care and life.

The psychological and moral comfort of a presence at once humble and understanding—this is the greatest benefit that the dog has bestowed upon man. Percy Bysshe Shelley

Ever since their domestication about 20,000 years ago, dogs have been cherished for their indomitable and generous spirit, ability to assist humans in myriad ways, and unconditional love. August heralds National Dog Month, and September honors the loyal companionship and dedicated work of service dogs so valuable to service members and veterans.

The nature of their special training to perform specific tasks for the safety and well-being of veterans distinguishes service dogs from pets or emotional support animals. Most of us recognize the happiness and meaning animals bring to our lives. What we may not appreciate is the impressive contribution service dogs make to the health and rehabilitation of those who have served their country. Veteran patients with neurologic conditions such as seizures know the difference a service dog trained to warn them of an emerging seizure makes for their freedom of movement and peace of mind. Veterans with diabetes have described times when their service dogs sought help before they realized their blood sugar was dangerously low.

Patients, friends, and neighbors who have been paired with service dogs describe ways their new companion helped them transition from a life in which even surviving was a struggle to one of holistic thriving. A Vietnam veteran neighbor with a significant tremor due to Parkinson disease benefitted from the ability of his dog to fetch and bring, retrieve, and carry. His dog has learned to hold essential items still, which would otherwise be too shaky in human hands, enabling the veteran to open his closet door and dress independently each morning. One veteran classmate avoided all forms of public transportation due to memories of a traumatic mobile-based mass evacuation she assisted with during her military service. She dreaded her long, inconvenient daily drive back and forth to work. She was then partnered with a large dog breed that was trained to stand a short distance from her to protect her sense of space and open air. The dog would stretch out his body to claim more space for her among crowds. This veteran started to ride the bus to campus each morning and appreciated the interaction with other riders as well as the saved travel time, mileage, gasoline expense, and parking stress.

A veteran brought his sweet retriever to the neighborhood weekly “Paws-itive Reading” program for children in the local public library. When MW’s daughter was busy reading to his furry friend, the veteran shared that for at least 5 years after his combat tours, he rarely left his window-shuttered home. His dog’s steady comfort re-established his ability to participate in his community. He now generously shares his dog’s patient affection with children learning to read.

MW recently witnessed the profound and protective presence of a service dog in comforting a veteran during a posttraumatic stress disorder (PTSD)–related crisis. The service dog offered a lean and reassuring paw pressure on the veteran’s shoulder if he was reexperiencing trauma. The dog’s steady breathing and familiar warmth helped to reorient their human companion to the safety of his present physical surroundings. Bearing witness to the dog’s trained interaction with the veteran left MW speechless. The trust between them was therapeutic in a way that transcended her ability to articulate what she experienced. This compelled MW to investigate whether this was a rare relationship or whether there was existing data on the impact of trained service dogs and PTSD.

Service dog placement with veterans with PTSD has been shown to have a positive influence on both physiological (arousal-related functioning and cortisol awakening response) and psychosocial well-being, including decreased isolation and increased physical activity.^1,2 Veterans with PTSD paired with service dogs showed significantly fewer PTSD-related symptoms, better sleep quality, and improved well-being, compared with those with just a pet.³ A recent meta-analysis revealed that veteran partnerships with a service dog had a clinically meaningful, significant, and large effect on PTSD severity scores (P < .001).² The mechanism for impact is thought to be not only the dog’s working role but also the transcendent loyalty of the canine-veteran bond.

Many accredited dog training programs describe a certain reciprocity to the dog-human relationship. Some use rescue puppies to give the dogs a new life and purpose. Dogs who have undergone challenges often need patience, time, safe relationships, and trustworthy new experiences to maximize their potential. Reciprocally, trained service dogs have the potential to foster access to these same emotional, relational, existential, and physical safety needs for veterans exposed to trauma.

Recent legislation has made progress in recognizing the role of service dogs for veterans and improving access. The Puppies Assisting Wounded Servicemembers (PAWS) for Veterans Therapy Act (38 USC §1705, 1714) was passed in 2021. The PAWS Act implemented a policy and 5-year pilot program to connect trained canines to eligible veterans diagnosed with PTSD as an element of an integrative health program, regardless of whether the veteran has a mobility impairment. The PAWS Act gives federal funding to accredited dog training organizations to help pair eligible veterans with service dogs by covering veteran travel expenses for the training, training program participation, and relevant veterinary expenses. The bipartisan Service Dogs Assisting Veterans Act (SAVES) Act was introduced this summer to award grants to nonprofit organizations Assistance Dog International has accredited to help these groups provide service dogs to veterans.

The US Department of Veterans Affairs (VA) has made strides in welcoming service dogs. Trained service dogs of all breeds under the control of a human companion are now allowed in VA facilities other than in areas where safety and infection control standards would be compromised (ie, sterile equipment rooms).⁴ A prescribing clinician can now evaluate eligible veterans to determine their ability, resources, and goals for having a service dog.⁵ An assessment of the veteran’s ability to care for a dog and education on expectations for the partnership is critical to success and animal welfare. Those veterans approved for a service dog are then referred to accredited agencies. The VA Veterinary Health Insurance Benefit includes aspects of coverage for the veteran to attend service dog training, veterinary wellness (preventive care, immunizations, dental cleanings, certain prescriptions, etc), and care for the dog’s illnesses when treatment enables the dog to perform duties in service to the veteran.⁶

The productive purpose and friendship of a service dog become a formidable force in a veteran’s life. Veterans spent an average of 82% of their time with service dogs (assessed via Bluetooth proximity between collar and smartphone).⁷ Human partners of veterans with service dogs may experience improved quality of life and relationship functioning with the inclusion of a service dog in the family unit.⁸ Veterans depict increased community engagement, social connectedness, and personal confidence as a result of the canine companionship.^9,10 Veterans with service dogs often speak of the ways the dog’s presence transformed their lives and many speak of the dog literally saving their lives.¹¹ Meta-analyses showed improved mental health treatment engagement, medication adherence, and decreased suicidality.^2,12

A story was recently shared with us about the compassion and competence of VA staff in a perioperative unit. A veteran was scheduled for a life-altering surgery and yet was anxious about entering the room for his scheduled pre-anesthesia check-in, knowing his service dog could not accompany him through the entire procedure. The staff recognized that the veteran was increasingly nervous and even started to question whether he would stay for the scheduled procedure they deemed would benefit his health. The perioperative team then proactively worked together to safely walk the veteran through the preparation processes in a sterile setting while keeping the dog within sight of the veteran. They then ensured that the veteran’s service dog was by his side early in the recovery room so that the veteran woke to wags and licks. In these months of canine recognition, we honor the ways the VA has fostered companionship and courage in veterans’ lives through the inclusion of service dogs in so many aspects of their care and life.