Commentary

Exogenously, hypochlorous acid (HOCl) is a powerful oxidizing agent formed from chlorine dissolved in water. Within the body, it is part of the immune response, created by activated leukocytes, which form HOCl from hydrogen peroxide and chloride. HOCl has been used as a disinfectant in wound care due to its antimicrobial properties via inhibition of DNA synthesis, protein synthesis, and decreased adenosine triphosphate production. It specifically targets bacteria by blocking bacterial cell wall synthesis and decreasing DNA replication.¹ 

During the COVID-19 pandemic, HOCl was recommended by the US Environmental Protection Agency as a disinfectant.² HOCl can be purchased from a supplier, though its major limitation is its shelf life. The main environmental factors affecting its stability are sunlight exposure, temperatures > 25 °C, and air exposure. HOCl is stable and most potent when the pH falls between 3.5 and 5.5.³ It is best stored in a cool, dark environment to maintain efficacy for 2 weeks. Rossi-Fedele et al found that when exposed to sunlight, chlorine reduction starts on day 4, whereas solutions kept in dark storage remained more stable, with this process starting after day 14.⁴ 

HOCl can also be made on-site via a machine, which ranges in price from a portable version costing < $200 to a large commercial option that can cost $7000 to $25,000. HOCl is produced by mixing noniodinated salt and water, and using electrolysis, which generally takes less than 10 minutes before it is ready for use.² Given the cost and nonreusable nature of disinfecting wipes, HOCl may be more worthwhile for economic and disposal purposes in the long term. 

Different concentrations of HOCl are readily available commercially. Because topical application of 1% HOCl may cause skin irritation, solutions with lower concentrations have been developed including Vashe (0.03% HOCl; SteadMed), PhaseOne (0.025% HOCl solution; IHT), OCuSOFT (0.02% HOCl; OCuSOFT), Bruder (0.02% HOCl; Bruder Healthcare), Acuicyn (0.01% HOCl solution in dilute saline; Sonoma Pharmaceuticals), and Avenova (0.01% HOCl solution; NovaBay Pharmaceuticals).⁵ 

Aside from its surface utility, HOCl has been researched for its beneficial effects on skin. HOCl has been shown to be helpful intraoperatively and postoperatively in improving adverse effects (AEs) after hair restoration, including erythema and pruritus, and in optimizing healing by reducing inflammation, likely due to its antimicrobial properties and ability to promote oxygenation.⁶ Bucko et al demonstrated that Microcyn scar gel (with HOCl) was a superior nonirritating, nontoxic method of not only improving scar appearance (vascularity, scar height, and pliability) but also reducing scar symptoms of pain and pruritus in comparison to 100% silicone scar gel (traditional application used to improve scarring).⁷ Zhang et al demonstrated that HOCl consistently improved symptom relief of blepharitis, including meibomian gland, eyelash, and eyelid redness, irritation, and appearance in comparison as well as were better tolerated in comparison to traditional recommendations of eyelid compresses and wash (tea tree oil, diluted baby shampoo, and topical antibiotics).⁸ In children with moderate to severe atopic dermatitis, Majewski et al compared a traditional bleach bath with a body wash containing hypochlorite (NaOCl; hypochlorous acid in alkaline aqueous solution). The body wash proved to be more convenient (showering vs 10-minute bath) and significantly improved symptoms while reducing the need for topical corticosteroids (common treatment modality for atopic dermatitis).⁹ 

The skin is the body’s primary defense against both dermatologic and respiratory infections. The face is especially vulnerable to microbes via airborne or environmental transmission, mechanical irritation, and touch. In the military environment, personal protective equipment (PPE) or uniform items may increase the risk of dermatologic conditions such as allergic or irritant dermatitis, infection, and friction blisters. 

In a literature review of 312 dermatologic articles published between 2002 and 2022, Singal and Lipner found that among deployed soldiers serving in hot and dry climates, dermatitis and eczematous conditions were the most common, whereas bacterial and fungal conditions were most common in hot and humid settings. In the nondeployed setting, dermatitis and eczematous, acne, and fungal infections were the most common skin conditions. This is reflected by the unique circumstances that service members face at home and while deployed, when they may be more vulnerable to developing new or worsening chronic skin conditions depending on the environment (access to shelter, humid vs dry environments), and decreased access or time for hygiene (shared quarters at home in barracks or on deployment). Occupation-related conditions also play a large role in military dermatologic conditions.¹⁰ 

Dever et al noted the unique risks and exposures in the environment itself (plants, arthropods) as well as uniform items (protective gear) that carry an increased risk of friction irritation and dermatitis. Occupational exposures commonly associated with irritant contact dermatitis include alcohols, oils, fuel, disinfectants, and solvents. Chemicals in military uniforms themselves (eg, formaldehyde resins, disperse dyes, and chromate-containing dyes) also have the potential to cause allergic contact dermatitis, which can be challenging to address given the emphasis on uniformity and standards.¹¹ PPE also may exacerbate rosacea and acne. 

Some pathologies are associated specifically with bacteria, such as Cutibacterium acnes, as seen in acne vulgaris. Colonization of bacteria on the face may create biofilms that are difficult to detect, may be resistant to antibiotic therapy, and are implicated in other dermatologic conditions, such as persistent wounds, atopic dermatitis, and candidiasis.¹² 

Biofilm and antibiotic resistance already pose a risk to patient care, but the unique environmental conditions and exposures of military settings can amplify this risk in the military population.¹³ Using HOCl in austere environments or the field for wound care may help reduce microbial load and the subsequent need for systemic antibiotics which carry the risk of gastrointestinal AEs and resistance.¹ 

An optimized healing rate would support operational objectives by enabling service members to remain on full duty and avoid medications, which may prevent them from special duty, such as aviation. Sakarya et al found that HOCl solution enhanced wound healing in contrast with povidone-iodine (PI), while a study by Dharap et al discussed how HOCl provided major improvement in ulcer wound size (and infection), as well as significant reduction of inflammation.¹³ 

Anagnostopoulos et al studied the efficacy of 0.01% HOCl vs other disinfectants (5% PI, 4% chlorhexidine gluconate [CHG] and 70% isopropyl alcohol [IPA]) against common skin organisms, including methicillin-susceptible Staphylococcus aureus and methicillin-susceptible Staphylococcus epidermidis. The study found that HOCl had at least equal if not greater efficacy to PI, CHG, and IPA depending on the bacterial strain, demonstrating immediate bactericidal effects.¹⁴ 

Furthermore, HOCl has been shown to be useful in suturing and wound closure by reducing microbial load when soaked gauze is placed in wound beds prior to closure, while not harming surrounding tissue.¹⁵ This would be especially advantageous for military health care when specialist follow-up would be delayed or to prevent infection risk while en route to higher care. Aside from its disinfectant strength, it’s also well tolerated. HOCl studies on human tissue demonstrate its efficacy to prevent irritation and AEs while also preventing infection and promoting wound healing. 

Gozukucuk and Cakiroglu studied the use of HOCl as a skin disinfectant before neonatal circumcision and demonstrated fewer adverse effects compared with the more commonly used PI. Neonates treated with PI prior to circumcision resulted in greater postoperative edema and increased duration of wound healing compared with infants treated with HOCl.¹⁶ Furthermore, studies have shown that PI can lead to irritant dermatitis or chemical burns if not properly dried or if it becomes pooled because of occlusion dressings.¹⁷ 

Aside from its indicated use for infection or wound care, anti-inflammatory properties of HOCl also may be beneficial for off-label use in preventing flareups of chronic conditions as well as for treating symptoms while awaiting specialist evaluation. This might be the case during US-based training exercises, in remote locations without nearby dermatologists, or during virtual care because of internet constraints. For chronic conditions such as rosacea or atopic dermatitis, which research has shown are related to mast cell activation and degranulation and cytokine release, HOCl has been shown to reduce histamine, neutrophil-generated leukotrienes, in addition to interleukin-6 and interleukin-2 to improve symptoms by reducing inflammation.¹⁸ 

Limitations of HOCl to explore would be extending its shelf life, exploring its various forms (eg, spray, topical) and storage limitations, and training of the machine and materials needed to be made in-house if not purchased. There are also no official guidelines for clinicians to recommend HOCl to patients, and research should be expanded on its use in humans, though it generally is well tolerated without AEs. HOCl has the potential to be a potent, nontoxic, inexpensive tool in med bags or at austere clinics to help maintain a sterile space for procedures, prevent infection while rendering care, and help with exacerbations or prevent flare-ups of chronic conditions such as psoriasis, acne, and atopic dermatitis while specialist care is pending. 

Exogenously, hypochlorous acid (HOCl) is a powerful oxidizing agent formed from chlorine dissolved in water. Within the body, it is part of the immune response, created by activated leukocytes, which form HOCl from hydrogen peroxide and chloride. HOCl has been used as a disinfectant in wound care due to its antimicrobial properties via inhibition of DNA synthesis, protein synthesis, and decreased adenosine triphosphate production. It specifically targets bacteria by blocking bacterial cell wall synthesis and decreasing DNA replication.¹ 

During the COVID-19 pandemic, HOCl was recommended by the US Environmental Protection Agency as a disinfectant.² HOCl can be purchased from a supplier, though its major limitation is its shelf life. The main environmental factors affecting its stability are sunlight exposure, temperatures > 25 °C, and air exposure. HOCl is stable and most potent when the pH falls between 3.5 and 5.5.³ It is best stored in a cool, dark environment to maintain efficacy for 2 weeks. Rossi-Fedele et al found that when exposed to sunlight, chlorine reduction starts on day 4, whereas solutions kept in dark storage remained more stable, with this process starting after day 14.⁴ 

HOCl can also be made on-site via a machine, which ranges in price from a portable version costing < $200 to a large commercial option that can cost $7000 to $25,000. HOCl is produced by mixing noniodinated salt and water, and using electrolysis, which generally takes less than 10 minutes before it is ready for use.² Given the cost and nonreusable nature of disinfecting wipes, HOCl may be more worthwhile for economic and disposal purposes in the long term. 

Different concentrations of HOCl are readily available commercially. Because topical application of 1% HOCl may cause skin irritation, solutions with lower concentrations have been developed including Vashe (0.03% HOCl; SteadMed), PhaseOne (0.025% HOCl solution; IHT), OCuSOFT (0.02% HOCl; OCuSOFT), Bruder (0.02% HOCl; Bruder Healthcare), Acuicyn (0.01% HOCl solution in dilute saline; Sonoma Pharmaceuticals), and Avenova (0.01% HOCl solution; NovaBay Pharmaceuticals).⁵ 

Aside from its surface utility, HOCl has been researched for its beneficial effects on skin. HOCl has been shown to be helpful intraoperatively and postoperatively in improving adverse effects (AEs) after hair restoration, including erythema and pruritus, and in optimizing healing by reducing inflammation, likely due to its antimicrobial properties and ability to promote oxygenation.⁶ Bucko et al demonstrated that Microcyn scar gel (with HOCl) was a superior nonirritating, nontoxic method of not only improving scar appearance (vascularity, scar height, and pliability) but also reducing scar symptoms of pain and pruritus in comparison to 100% silicone scar gel (traditional application used to improve scarring).⁷ Zhang et al demonstrated that HOCl consistently improved symptom relief of blepharitis, including meibomian gland, eyelash, and eyelid redness, irritation, and appearance in comparison as well as were better tolerated in comparison to traditional recommendations of eyelid compresses and wash (tea tree oil, diluted baby shampoo, and topical antibiotics).⁸ In children with moderate to severe atopic dermatitis, Majewski et al compared a traditional bleach bath with a body wash containing hypochlorite (NaOCl; hypochlorous acid in alkaline aqueous solution). The body wash proved to be more convenient (showering vs 10-minute bath) and significantly improved symptoms while reducing the need for topical corticosteroids (common treatment modality for atopic dermatitis).⁹ 

The skin is the body’s primary defense against both dermatologic and respiratory infections. The face is especially vulnerable to microbes via airborne or environmental transmission, mechanical irritation, and touch. In the military environment, personal protective equipment (PPE) or uniform items may increase the risk of dermatologic conditions such as allergic or irritant dermatitis, infection, and friction blisters. 

In a literature review of 312 dermatologic articles published between 2002 and 2022, Singal and Lipner found that among deployed soldiers serving in hot and dry climates, dermatitis and eczematous conditions were the most common, whereas bacterial and fungal conditions were most common in hot and humid settings. In the nondeployed setting, dermatitis and eczematous, acne, and fungal infections were the most common skin conditions. This is reflected by the unique circumstances that service members face at home and while deployed, when they may be more vulnerable to developing new or worsening chronic skin conditions depending on the environment (access to shelter, humid vs dry environments), and decreased access or time for hygiene (shared quarters at home in barracks or on deployment). Occupation-related conditions also play a large role in military dermatologic conditions.¹⁰ 

Dever et al noted the unique risks and exposures in the environment itself (plants, arthropods) as well as uniform items (protective gear) that carry an increased risk of friction irritation and dermatitis. Occupational exposures commonly associated with irritant contact dermatitis include alcohols, oils, fuel, disinfectants, and solvents. Chemicals in military uniforms themselves (eg, formaldehyde resins, disperse dyes, and chromate-containing dyes) also have the potential to cause allergic contact dermatitis, which can be challenging to address given the emphasis on uniformity and standards.¹¹ PPE also may exacerbate rosacea and acne. 

Some pathologies are associated specifically with bacteria, such as Cutibacterium acnes, as seen in acne vulgaris. Colonization of bacteria on the face may create biofilms that are difficult to detect, may be resistant to antibiotic therapy, and are implicated in other dermatologic conditions, such as persistent wounds, atopic dermatitis, and candidiasis.¹² 

Biofilm and antibiotic resistance already pose a risk to patient care, but the unique environmental conditions and exposures of military settings can amplify this risk in the military population.¹³ Using HOCl in austere environments or the field for wound care may help reduce microbial load and the subsequent need for systemic antibiotics which carry the risk of gastrointestinal AEs and resistance.¹ 

An optimized healing rate would support operational objectives by enabling service members to remain on full duty and avoid medications, which may prevent them from special duty, such as aviation. Sakarya et al found that HOCl solution enhanced wound healing in contrast with povidone-iodine (PI), while a study by Dharap et al discussed how HOCl provided major improvement in ulcer wound size (and infection), as well as significant reduction of inflammation.¹³ 

Anagnostopoulos et al studied the efficacy of 0.01% HOCl vs other disinfectants (5% PI, 4% chlorhexidine gluconate [CHG] and 70% isopropyl alcohol [IPA]) against common skin organisms, including methicillin-susceptible Staphylococcus aureus and methicillin-susceptible Staphylococcus epidermidis. The study found that HOCl had at least equal if not greater efficacy to PI, CHG, and IPA depending on the bacterial strain, demonstrating immediate bactericidal effects.¹⁴ 

Furthermore, HOCl has been shown to be useful in suturing and wound closure by reducing microbial load when soaked gauze is placed in wound beds prior to closure, while not harming surrounding tissue.¹⁵ This would be especially advantageous for military health care when specialist follow-up would be delayed or to prevent infection risk while en route to higher care. Aside from its disinfectant strength, it’s also well tolerated. HOCl studies on human tissue demonstrate its efficacy to prevent irritation and AEs while also preventing infection and promoting wound healing. 

Gozukucuk and Cakiroglu studied the use of HOCl as a skin disinfectant before neonatal circumcision and demonstrated fewer adverse effects compared with the more commonly used PI. Neonates treated with PI prior to circumcision resulted in greater postoperative edema and increased duration of wound healing compared with infants treated with HOCl.¹⁶ Furthermore, studies have shown that PI can lead to irritant dermatitis or chemical burns if not properly dried or if it becomes pooled because of occlusion dressings.¹⁷ 

Aside from its indicated use for infection or wound care, anti-inflammatory properties of HOCl also may be beneficial for off-label use in preventing flareups of chronic conditions as well as for treating symptoms while awaiting specialist evaluation. This might be the case during US-based training exercises, in remote locations without nearby dermatologists, or during virtual care because of internet constraints. For chronic conditions such as rosacea or atopic dermatitis, which research has shown are related to mast cell activation and degranulation and cytokine release, HOCl has been shown to reduce histamine, neutrophil-generated leukotrienes, in addition to interleukin-6 and interleukin-2 to improve symptoms by reducing inflammation.¹⁸ 

Limitations of HOCl to explore would be extending its shelf life, exploring its various forms (eg, spray, topical) and storage limitations, and training of the machine and materials needed to be made in-house if not purchased. There are also no official guidelines for clinicians to recommend HOCl to patients, and research should be expanded on its use in humans, though it generally is well tolerated without AEs. HOCl has the potential to be a potent, nontoxic, inexpensive tool in med bags or at austere clinics to help maintain a sterile space for procedures, prevent infection while rendering care, and help with exacerbations or prevent flare-ups of chronic conditions such as psoriasis, acne, and atopic dermatitis while specialist care is pending. 

Exogenously, hypochlorous acid (HOCl) is a powerful oxidizing agent formed from chlorine dissolved in water. Within the body, it is part of the immune response, created by activated leukocytes, which form HOCl from hydrogen peroxide and chloride. HOCl has been used as a disinfectant in wound care due to its antimicrobial properties via inhibition of DNA synthesis, protein synthesis, and decreased adenosine triphosphate production. It specifically targets bacteria by blocking bacterial cell wall synthesis and decreasing DNA replication.¹ 

During the COVID-19 pandemic, HOCl was recommended by the US Environmental Protection Agency as a disinfectant.² HOCl can be purchased from a supplier, though its major limitation is its shelf life. The main environmental factors affecting its stability are sunlight exposure, temperatures > 25 °C, and air exposure. HOCl is stable and most potent when the pH falls between 3.5 and 5.5.³ It is best stored in a cool, dark environment to maintain efficacy for 2 weeks. Rossi-Fedele et al found that when exposed to sunlight, chlorine reduction starts on day 4, whereas solutions kept in dark storage remained more stable, with this process starting after day 14.⁴ 

HOCl can also be made on-site via a machine, which ranges in price from a portable version costing < $200 to a large commercial option that can cost $7000 to $25,000. HOCl is produced by mixing noniodinated salt and water, and using electrolysis, which generally takes less than 10 minutes before it is ready for use.² Given the cost and nonreusable nature of disinfecting wipes, HOCl may be more worthwhile for economic and disposal purposes in the long term. 

Different concentrations of HOCl are readily available commercially. Because topical application of 1% HOCl may cause skin irritation, solutions with lower concentrations have been developed including Vashe (0.03% HOCl; SteadMed), PhaseOne (0.025% HOCl solution; IHT), OCuSOFT (0.02% HOCl; OCuSOFT), Bruder (0.02% HOCl; Bruder Healthcare), Acuicyn (0.01% HOCl solution in dilute saline; Sonoma Pharmaceuticals), and Avenova (0.01% HOCl solution; NovaBay Pharmaceuticals).⁵ 

Aside from its surface utility, HOCl has been researched for its beneficial effects on skin. HOCl has been shown to be helpful intraoperatively and postoperatively in improving adverse effects (AEs) after hair restoration, including erythema and pruritus, and in optimizing healing by reducing inflammation, likely due to its antimicrobial properties and ability to promote oxygenation.⁶ Bucko et al demonstrated that Microcyn scar gel (with HOCl) was a superior nonirritating, nontoxic method of not only improving scar appearance (vascularity, scar height, and pliability) but also reducing scar symptoms of pain and pruritus in comparison to 100% silicone scar gel (traditional application used to improve scarring).⁷ Zhang et al demonstrated that HOCl consistently improved symptom relief of blepharitis, including meibomian gland, eyelash, and eyelid redness, irritation, and appearance in comparison as well as were better tolerated in comparison to traditional recommendations of eyelid compresses and wash (tea tree oil, diluted baby shampoo, and topical antibiotics).⁸ In children with moderate to severe atopic dermatitis, Majewski et al compared a traditional bleach bath with a body wash containing hypochlorite (NaOCl; hypochlorous acid in alkaline aqueous solution). The body wash proved to be more convenient (showering vs 10-minute bath) and significantly improved symptoms while reducing the need for topical corticosteroids (common treatment modality for atopic dermatitis).⁹ 

The skin is the body’s primary defense against both dermatologic and respiratory infections. The face is especially vulnerable to microbes via airborne or environmental transmission, mechanical irritation, and touch. In the military environment, personal protective equipment (PPE) or uniform items may increase the risk of dermatologic conditions such as allergic or irritant dermatitis, infection, and friction blisters. 

In a literature review of 312 dermatologic articles published between 2002 and 2022, Singal and Lipner found that among deployed soldiers serving in hot and dry climates, dermatitis and eczematous conditions were the most common, whereas bacterial and fungal conditions were most common in hot and humid settings. In the nondeployed setting, dermatitis and eczematous, acne, and fungal infections were the most common skin conditions. This is reflected by the unique circumstances that service members face at home and while deployed, when they may be more vulnerable to developing new or worsening chronic skin conditions depending on the environment (access to shelter, humid vs dry environments), and decreased access or time for hygiene (shared quarters at home in barracks or on deployment). Occupation-related conditions also play a large role in military dermatologic conditions.¹⁰ 

Dever et al noted the unique risks and exposures in the environment itself (plants, arthropods) as well as uniform items (protective gear) that carry an increased risk of friction irritation and dermatitis. Occupational exposures commonly associated with irritant contact dermatitis include alcohols, oils, fuel, disinfectants, and solvents. Chemicals in military uniforms themselves (eg, formaldehyde resins, disperse dyes, and chromate-containing dyes) also have the potential to cause allergic contact dermatitis, which can be challenging to address given the emphasis on uniformity and standards.¹¹ PPE also may exacerbate rosacea and acne. 

Some pathologies are associated specifically with bacteria, such as Cutibacterium acnes, as seen in acne vulgaris. Colonization of bacteria on the face may create biofilms that are difficult to detect, may be resistant to antibiotic therapy, and are implicated in other dermatologic conditions, such as persistent wounds, atopic dermatitis, and candidiasis.¹² 

Biofilm and antibiotic resistance already pose a risk to patient care, but the unique environmental conditions and exposures of military settings can amplify this risk in the military population.¹³ Using HOCl in austere environments or the field for wound care may help reduce microbial load and the subsequent need for systemic antibiotics which carry the risk of gastrointestinal AEs and resistance.¹ 

An optimized healing rate would support operational objectives by enabling service members to remain on full duty and avoid medications, which may prevent them from special duty, such as aviation. Sakarya et al found that HOCl solution enhanced wound healing in contrast with povidone-iodine (PI), while a study by Dharap et al discussed how HOCl provided major improvement in ulcer wound size (and infection), as well as significant reduction of inflammation.¹³ 

Anagnostopoulos et al studied the efficacy of 0.01% HOCl vs other disinfectants (5% PI, 4% chlorhexidine gluconate [CHG] and 70% isopropyl alcohol [IPA]) against common skin organisms, including methicillin-susceptible Staphylococcus aureus and methicillin-susceptible Staphylococcus epidermidis. The study found that HOCl had at least equal if not greater efficacy to PI, CHG, and IPA depending on the bacterial strain, demonstrating immediate bactericidal effects.¹⁴ 

Furthermore, HOCl has been shown to be useful in suturing and wound closure by reducing microbial load when soaked gauze is placed in wound beds prior to closure, while not harming surrounding tissue.¹⁵ This would be especially advantageous for military health care when specialist follow-up would be delayed or to prevent infection risk while en route to higher care. Aside from its disinfectant strength, it’s also well tolerated. HOCl studies on human tissue demonstrate its efficacy to prevent irritation and AEs while also preventing infection and promoting wound healing. 

Gozukucuk and Cakiroglu studied the use of HOCl as a skin disinfectant before neonatal circumcision and demonstrated fewer adverse effects compared with the more commonly used PI. Neonates treated with PI prior to circumcision resulted in greater postoperative edema and increased duration of wound healing compared with infants treated with HOCl.¹⁶ Furthermore, studies have shown that PI can lead to irritant dermatitis or chemical burns if not properly dried or if it becomes pooled because of occlusion dressings.¹⁷ 

Aside from its indicated use for infection or wound care, anti-inflammatory properties of HOCl also may be beneficial for off-label use in preventing flareups of chronic conditions as well as for treating symptoms while awaiting specialist evaluation. This might be the case during US-based training exercises, in remote locations without nearby dermatologists, or during virtual care because of internet constraints. For chronic conditions such as rosacea or atopic dermatitis, which research has shown are related to mast cell activation and degranulation and cytokine release, HOCl has been shown to reduce histamine, neutrophil-generated leukotrienes, in addition to interleukin-6 and interleukin-2 to improve symptoms by reducing inflammation.¹⁸ 

Limitations of HOCl to explore would be extending its shelf life, exploring its various forms (eg, spray, topical) and storage limitations, and training of the machine and materials needed to be made in-house if not purchased. There are also no official guidelines for clinicians to recommend HOCl to patients, and research should be expanded on its use in humans, though it generally is well tolerated without AEs. HOCl has the potential to be a potent, nontoxic, inexpensive tool in med bags or at austere clinics to help maintain a sterile space for procedures, prevent infection while rendering care, and help with exacerbations or prevent flare-ups of chronic conditions such as psoriasis, acne, and atopic dermatitis while specialist care is pending. 

A professional is someone who can do his best work when he doesn’t feel like it. 
Alistair Cooke

When I was a young person with no idea about growing up to be something, my father used to tell me there were 4 learned professions: medicine to heal the body, law to protect the body politic, teaching to nurture the mind, and the clergy to care for the soul.¹ That adage, or some version of it, is attributed to a variety of sources, likely because it captures something essential and timeless about the learned professions. I write this as a much older person, and it has been my privilege to have worked in some capacity in all 4 of these venerable vocations.

There are many more recognized professions now than in my father’s time with new ones still emerging as the world becomes more complicated and specialized. In November 2025, however, the growth of the professions was dealt a serious blow when the US Department of Education (DOE) redefined what constitutes a profession for the purpose of federal funding of graduate degrees.² The internet is understandably abuzz with opinions across the political spectrum. What is missing from many of these discussions is an understanding of the criteria for a profession and, even more importantly, who has the authority to decide when an individual or a group has met that standard.

But first, what and why did the DOE make this change? The One Big Beautiful Bill Act charged the DOE with reducing what it claims is massive overspending on graduate education by limiting the programs that meet the definition of a “professional degree” eligible for higher funding. Of my father’s 4, medicine (including dentistry) and law made the cut with students in those professions able to borrow up to $200,000 in direct unsubsidized student loans while those in other programs would be limited to $100,000.²

As one of the oldest and most respected professions in America, nursing has received the most media attention, yet there are also other important and valued professions that are missing from the DOE list.³ The excluded professions also include: physician assistants, physical therapists, audiologists, architects, accountants, educators, and social workers. The proposed regulatory changes are not yet finalized and Congressional representatives, health care experts, and a myriad of professional associations have rightly objected the reclassification will only worsen the critical shortage of nurses, teachers, and other helping professions the country is already facing.⁴

There are thousands of federal health care professionals who worked long and hard to achieve their goals whom this Act undervalues. Moreover, the regulatory change leaves many students enrolled in education and training programs under federal practice auspices confused and overwhelmed. Perhaps they can take some hope and inspiration from the recognition that historically and philosophically, no agency or administration can unilaterally define what is a profession.

The literature on professionalism is voluminous, in large part because it has been surprisingly difficult to reach a consensus definition. A proposed definition from scholars captures most of the key aspects of a profession. While it is drawn from the medical literature, it applies to most of the caring professions the DOE disqualified. For pedagogic purposes, the definition is parsed into discrete criteria in the Table.⁵

Even this simple summary makes it obvious that a government agency alone could not possibly have the competence to determine who meets these complex technical and moral criteria. The members of the profession must assume a primary role in that determination. The complicated history of the professions shows that the locus of these decisions has resided in various combinations of educational institutions, such as nursing schools,⁶ professional societies (eg, National Association of Social Workers),⁷ and certifying boards (eg, National Commission on Certification of Physician Assistants).⁸ States, not the federal government, have long played a key part in defining professions in the US, through their authority to grant licenses to practice.⁹

In response to criticism, the DOE has stated that “the definition of a ‘professional degree’ is an internal definition used by the Department of Education to distinguish among programs that qualify for higher loan limits, not a value judgment about the importance of programs. It has no bearing on whether a program is professional in nature or not.”² Given the ancient compact between society and the professions in which the government subsidizes the training of professionals dedicated to public service, it is hard to see how these changes can be dismissed as merely semantic and not a promissory breach.¹⁰

I recognize that this abstract editorial is little comfort to beleaguered and demoralized professionals and students. Still, it offers a voice of support for each federal practitioner or trainee who fulfills the epigraph’s description of a professional day after day. The nurse who works the extra shift without complaint or resentment so that veterans receive the care they deserve, the social worker who responds on a weekend night to an active duty family without food so they do not spend another night hungry, and the physician assistant who makes it into the isolated public health clinic despite the terrible weather so there is someone ready to take care for patients in need. The proposed policy shift cannot in any meaningful sense rob them of their identity as individuals committed to a code of caring. However, without an intact social compact, it may well remove their practical ability to remain and enter the helping professions to the detriment of us all.

A professional is someone who can do his best work when he doesn’t feel like it. 
Alistair Cooke

When I was a young person with no idea about growing up to be something, my father used to tell me there were 4 learned professions: medicine to heal the body, law to protect the body politic, teaching to nurture the mind, and the clergy to care for the soul.¹ That adage, or some version of it, is attributed to a variety of sources, likely because it captures something essential and timeless about the learned professions. I write this as a much older person, and it has been my privilege to have worked in some capacity in all 4 of these venerable vocations.

There are many more recognized professions now than in my father’s time with new ones still emerging as the world becomes more complicated and specialized. In November 2025, however, the growth of the professions was dealt a serious blow when the US Department of Education (DOE) redefined what constitutes a profession for the purpose of federal funding of graduate degrees.² The internet is understandably abuzz with opinions across the political spectrum. What is missing from many of these discussions is an understanding of the criteria for a profession and, even more importantly, who has the authority to decide when an individual or a group has met that standard.

But first, what and why did the DOE make this change? The One Big Beautiful Bill Act charged the DOE with reducing what it claims is massive overspending on graduate education by limiting the programs that meet the definition of a “professional degree” eligible for higher funding. Of my father’s 4, medicine (including dentistry) and law made the cut with students in those professions able to borrow up to $200,000 in direct unsubsidized student loans while those in other programs would be limited to $100,000.²

As one of the oldest and most respected professions in America, nursing has received the most media attention, yet there are also other important and valued professions that are missing from the DOE list.³ The excluded professions also include: physician assistants, physical therapists, audiologists, architects, accountants, educators, and social workers. The proposed regulatory changes are not yet finalized and Congressional representatives, health care experts, and a myriad of professional associations have rightly objected the reclassification will only worsen the critical shortage of nurses, teachers, and other helping professions the country is already facing.⁴

There are thousands of federal health care professionals who worked long and hard to achieve their goals whom this Act undervalues. Moreover, the regulatory change leaves many students enrolled in education and training programs under federal practice auspices confused and overwhelmed. Perhaps they can take some hope and inspiration from the recognition that historically and philosophically, no agency or administration can unilaterally define what is a profession.

The literature on professionalism is voluminous, in large part because it has been surprisingly difficult to reach a consensus definition. A proposed definition from scholars captures most of the key aspects of a profession. While it is drawn from the medical literature, it applies to most of the caring professions the DOE disqualified. For pedagogic purposes, the definition is parsed into discrete criteria in the Table.⁵

Even this simple summary makes it obvious that a government agency alone could not possibly have the competence to determine who meets these complex technical and moral criteria. The members of the profession must assume a primary role in that determination. The complicated history of the professions shows that the locus of these decisions has resided in various combinations of educational institutions, such as nursing schools,⁶ professional societies (eg, National Association of Social Workers),⁷ and certifying boards (eg, National Commission on Certification of Physician Assistants).⁸ States, not the federal government, have long played a key part in defining professions in the US, through their authority to grant licenses to practice.⁹

In response to criticism, the DOE has stated that “the definition of a ‘professional degree’ is an internal definition used by the Department of Education to distinguish among programs that qualify for higher loan limits, not a value judgment about the importance of programs. It has no bearing on whether a program is professional in nature or not.”² Given the ancient compact between society and the professions in which the government subsidizes the training of professionals dedicated to public service, it is hard to see how these changes can be dismissed as merely semantic and not a promissory breach.¹⁰

I recognize that this abstract editorial is little comfort to beleaguered and demoralized professionals and students. Still, it offers a voice of support for each federal practitioner or trainee who fulfills the epigraph’s description of a professional day after day. The nurse who works the extra shift without complaint or resentment so that veterans receive the care they deserve, the social worker who responds on a weekend night to an active duty family without food so they do not spend another night hungry, and the physician assistant who makes it into the isolated public health clinic despite the terrible weather so there is someone ready to take care for patients in need. The proposed policy shift cannot in any meaningful sense rob them of their identity as individuals committed to a code of caring. However, without an intact social compact, it may well remove their practical ability to remain and enter the helping professions to the detriment of us all.

A professional is someone who can do his best work when he doesn’t feel like it. 
Alistair Cooke

When I was a young person with no idea about growing up to be something, my father used to tell me there were 4 learned professions: medicine to heal the body, law to protect the body politic, teaching to nurture the mind, and the clergy to care for the soul.¹ That adage, or some version of it, is attributed to a variety of sources, likely because it captures something essential and timeless about the learned professions. I write this as a much older person, and it has been my privilege to have worked in some capacity in all 4 of these venerable vocations.

There are many more recognized professions now than in my father’s time with new ones still emerging as the world becomes more complicated and specialized. In November 2025, however, the growth of the professions was dealt a serious blow when the US Department of Education (DOE) redefined what constitutes a profession for the purpose of federal funding of graduate degrees.² The internet is understandably abuzz with opinions across the political spectrum. What is missing from many of these discussions is an understanding of the criteria for a profession and, even more importantly, who has the authority to decide when an individual or a group has met that standard.

But first, what and why did the DOE make this change? The One Big Beautiful Bill Act charged the DOE with reducing what it claims is massive overspending on graduate education by limiting the programs that meet the definition of a “professional degree” eligible for higher funding. Of my father’s 4, medicine (including dentistry) and law made the cut with students in those professions able to borrow up to $200,000 in direct unsubsidized student loans while those in other programs would be limited to $100,000.²

As one of the oldest and most respected professions in America, nursing has received the most media attention, yet there are also other important and valued professions that are missing from the DOE list.³ The excluded professions also include: physician assistants, physical therapists, audiologists, architects, accountants, educators, and social workers. The proposed regulatory changes are not yet finalized and Congressional representatives, health care experts, and a myriad of professional associations have rightly objected the reclassification will only worsen the critical shortage of nurses, teachers, and other helping professions the country is already facing.⁴

There are thousands of federal health care professionals who worked long and hard to achieve their goals whom this Act undervalues. Moreover, the regulatory change leaves many students enrolled in education and training programs under federal practice auspices confused and overwhelmed. Perhaps they can take some hope and inspiration from the recognition that historically and philosophically, no agency or administration can unilaterally define what is a profession.

The literature on professionalism is voluminous, in large part because it has been surprisingly difficult to reach a consensus definition. A proposed definition from scholars captures most of the key aspects of a profession. While it is drawn from the medical literature, it applies to most of the caring professions the DOE disqualified. For pedagogic purposes, the definition is parsed into discrete criteria in the Table.⁵

Even this simple summary makes it obvious that a government agency alone could not possibly have the competence to determine who meets these complex technical and moral criteria. The members of the profession must assume a primary role in that determination. The complicated history of the professions shows that the locus of these decisions has resided in various combinations of educational institutions, such as nursing schools,⁶ professional societies (eg, National Association of Social Workers),⁷ and certifying boards (eg, National Commission on Certification of Physician Assistants).⁸ States, not the federal government, have long played a key part in defining professions in the US, through their authority to grant licenses to practice.⁹

In response to criticism, the DOE has stated that “the definition of a ‘professional degree’ is an internal definition used by the Department of Education to distinguish among programs that qualify for higher loan limits, not a value judgment about the importance of programs. It has no bearing on whether a program is professional in nature or not.”² Given the ancient compact between society and the professions in which the government subsidizes the training of professionals dedicated to public service, it is hard to see how these changes can be dismissed as merely semantic and not a promissory breach.¹⁰

I recognize that this abstract editorial is little comfort to beleaguered and demoralized professionals and students. Still, it offers a voice of support for each federal practitioner or trainee who fulfills the epigraph’s description of a professional day after day. The nurse who works the extra shift without complaint or resentment so that veterans receive the care they deserve, the social worker who responds on a weekend night to an active duty family without food so they do not spend another night hungry, and the physician assistant who makes it into the isolated public health clinic despite the terrible weather so there is someone ready to take care for patients in need. The proposed policy shift cannot in any meaningful sense rob them of their identity as individuals committed to a code of caring. However, without an intact social compact, it may well remove their practical ability to remain and enter the helping professions to the detriment of us all.

The Veterans Health Administration (VHA) is the largest US integrated health care system, providing health care to > 9 million veterans annually. Dementia affects > 7.2 million Americans, and an estimated 450,000 veterans live with Alzheimer disease (AD).^1,2 Compared with the general population, veterans have a higher burden of chronic medical conditions and are disproportionately affected by AD due to exposure to military-related risk factors (eg, traumatic brain injury and posttraumatic stress disorder) and the high prevalence of nonmilitary risk factors, such as cardiovascular disease. The VHA is a pioneer in dementia care, having established a Dementia System of Care to provide primary and specialty care to veterans with dementia. The VHA also is leading the way in implementing the Institute for Healthcare Improvement Age-Friendly Health Systems (AFHS) framework for providing goal-concordant care in > 100 VHA medical centers. The VHA aims to be the largest AFHS in the country.

AD profoundly affects individuals and their families. The progressive nature of the most common form of dementia diminishes the quality of life for patients as well as their care partners in an ongoing fashion, often leading to emotional, physical, and financial strain. Costs for health and long-term care for people living with AD and other dementias were projected at $360 billion in 2024, largely due to the need for nursing home care.¹ Although several oral medications are available, their capacity to effectively mitigate the negative effects of AD is limited. Cholinesterase inhibitors and memantine may offer temporary symptomatic relief, but they do not alter disease progression.³ The use of these agents is relatively low, with about one-third of patients diagnosed with AD receiving these medications.⁴

Amyloid-Targeting Therapies

Recent advancements in biologics, particularly amyloid-targeting therapies, such as lecanemab and donanemab, offer new hope for managing AD. Older adults treated with these medications show less decline on measures of cognition and function than those receiving a placebo at 18 months.^5,6 However, accessing and using these medications is challenging.

Use of amyloid-targeting therapies poses challenges. The medications are expensive, potentially placing a financial burden on patients, families, and health care systems.⁷ Determining initial eligibility for treatment requires a battery of cognitive assessments, laboratory tests, advanced radiologic studies (eg, magnetic resonance imaging [MRI] of the brain and amyloid positron emission tomography [PET] scans), and possible cerebrospinal fluid (CSF) testing. Frequent ongoing assessments are necessary to monitor safety and efficacy. These treatments carry substantial risks, particularly amyloid-related imaging abnormalities (ARIA) such as cerebral edema, microhemorrhages, and superficial siderosis. Therefore, follow-up assessments typically occur around months 2, 3, 4, and 7, depending on which medication is selected. Finally, at present, both agents must be intravenous (IV)-administered in a monitored clinical setting, which requires additional coordination, transportation, and cost.

Ongoing evaluations and in-person administration particularly affect patients and care partners with limitations regarding transportation, time off work, and navigating complex health care systems.⁸ VHA clinicians at sites that have implemented or are interested in implementing amyloid-targeting therapy programs endorse similar challenges when implementing these therapies in their US Department of Veterans Affairs (VA) medical centers (VAMCs).⁹

The VHA was one of the first health care systems to use amyloid-targeting therapies, covering the cost of lecanemab and donanemab, in addition to costs associated with concomitant evaluation and testing. However, given the safety concerns with this novel class of medications, the VHA National Formulary Committee developed criteria for use and recommended the VA Center for Medication Safety (VAMedSAFE) conduct a mandatory real-time medication use evaluation (MUE). VAMedSAFE developed the MUE to monitor the safe and appropriate use of amyloid-targeting therapy for AD. Two authors (AJO, SMH) partnered with VAMedSAFE through the VA Pittsburgh Healthcare System Technology Enhancing Cognition and Health–Geriatric Research, Education, and Clinical Center (TECH-GRECC) to provide clinical expertise, substantive feedback for the development of the MUE, and guidance for VHA sites starting amyloid targeting-therapy programs. We started a VHA Amyloid-Targeting Therapy for AD SharePoint collaborative platform and VHA AD Therapeutics Community of Practice (CoP) for shared learning (Figure). The private SharePoint platform houses an array of implementation materials for VAMCs starting programs: key documents and links; educational materials; sample guidelines; note templates; and electronic health record screenshots. The CoP allows VHAs to share best practices and discuss challenges.

Even with these advantages, we found that ensuring the safe and appropriate use of amyloid-targeting therapies did not overcome the barriers associated with their complexity. This was especially true for veterans living in rural areas. Only 4 VAMCs had administered amyloid-targeting therapies in the first year they were available. Preliminary data demonstrated that 27 (84%) of 32 veterans who initiated lecanemab in the VHA between October 2023 and September 2024 resided in urban areas.¹⁰ To address the underutilization of amyloid-targeting therapy, we propose leveraging the strengths of VHA telehealth to facilitate expansion of access to these medications for veterans with early AD. Telehealth may substantially increase access to evaluation for veterans with early dementia and, when medically appropriate, to receive amyloid-targeting therapies by reducing transportation needs and mitigating costs while ensuring appropriate monitoring through ongoing clinical assessments.

Using Telehealth

The VHA is a pioneer in telehealth, with programs dating back to 2003.¹¹ Between October 1, 2018, and September 30, 2019, the VHA served > 900,000 veterans through the provision of > 2.6 million episodes of care via telehealth.¹² The COVID-19 pandemic further cemented the role of telemedicine as an essential component of health care. Telehealth has demonstrated success in the assessment and management of individuals living with dementia. At the VHA, the GRECC-Connect Project is a partnership between 9 urban GRECC sites that seek to provide consultative geriatric and dementia care to rural veterans through telehealth.¹³ Additional evidence supports the potential to leverage telehealth to effectively communicate results of amyloid PET scans.¹⁴

This approach is not without limitations such as the digital divide, or the gap that separates technology-enabled individuals and those unprepared to adopt technology due to limited digital literacy levels or access to needed hardware, software, and connectivity. The VHA has taken steps to address these digital divide barriers by broadly providing tools—such as tablets and broadband connectivity—to veterans. Specifically, the VHA has instituted digital divide consults to determine whether telehealth could be a potential solution for appropriate veterans and to provide an iPad (if eligible) to connect with VA clinicians. Complementary to the digital divide consult, a VHA-specific telehealth preparedness assessment tool is under development and being tested by 2 authors (JF, SMH). This telehealth preparedness assessment tool is designed to aid in the seamless integration of telehealth services with the support of tailored education materials specific to gaps in digital literacy that a veteran might experience.

Building on these initiatives, there is an opportunity to expand access to amyloid-targeting therapies, regardless of distance to large VAMCs, by leveraging telehealth as an alternative method of connecting patients with specialty care. Specifically, a hybrid approach could be used to accomplish the myriad initial and follow-up tasks involved in the provision of amyloid-targeting therapies (Table). Not all VHA facilities possess the specialty expertise to prescribe these medications, and local clinicians may not have sufficient knowledge and clinical support to prescribe and monitor these therapies.

The first step is identifying local and regional subject matter experts, followed by the development and expansion of these networks. The National TeleNeurology Program is a good example of a national telehealth program that leverages technology to bring specialty services to rural areas with limited access to care. Although amyloid-targeting therapies often require more complex logistics, such as laboratory tests and imaging, these initial hurdles can be overcome through localized services and collaboration between VAMCs.

While treatment and imaging will most likely need to occur at a VAMC, most basic laboratory studies can be performed at community-based outpatient clinics (CBOCs). Some CBOCs may not be able to process more specialized laboratory tests such as apolipoprotein E genetic testing. Samples for these tests can be collected and processed at VAMCs, which usually have contracts with outside laboratories capable of performing these studies. Most, although not all, VAMCs offer advanced imaging, including MRI of the brain and amyloid PETs. VAMCs without those modalities may need to coordinate with other regional VAMCs. Additionally, a pilot program is already underway whereby VAMCs without the ability to quantify the amount of amyloid on PETs are able to leverage technology and collaborations with other VAMCs to obtain these data.

Once the initial phases of evaluation and care are completed, telemedicine can be leveraged for follow-up and ongoing management. Interdisciplinary teams can help facilitate care related to amyloid-targeting therapies, including the close monitoring of veterans for development of ARIA.¹⁵ To achieve this monitoring, specialty clinic teams prescribing amyloid-targeting therapies, which may be geographically distant, need to coordinate with local primary care clinical teams and emergency clinicians. All of these health care team members, along with neurologists and neurosurgeons, should be involved in the development and implementation of protocols in the event that patients present to their local primary or specialty care clinics or emergency department with ARIA symptoms.

If amyloid-targeting therapies are to be provided along with other emerging treatments for rural veterans, telehealth must be part of the solution. There is a pressing need to explore innovative evaluation and delivery models for these therapies, particularly as we expect additional diagnostics and therapeutics to be available in the future. With the advent of commercially available blood tests (ie, blood biomarkers) for AD, there is hope for a transition away from PETs and CSF testing given their cost, limited access, and invasiveness for diagnosis and monitoring of AD. These advances will increase the utility of telehealth to help rural veterans access amyloid-targeting therapies.

Additionally, administering the drug at home or at local clinics, supported by a dedicated health care team or home health agency, could further improve accessibility. Telehealth can be leveraged in this scenario, allowing specialty clinics and specialists to connect with patients and clinicians based out of local clinics or even home health agencies. In this scenario, specialists can provide hands-on care guidance and oversight even though they may be geographically distant from care recipients. Transitioning from IV administration to subcutaneous formulations would further enhance convenience and reduce barriers; these formulations may be available soon.¹⁶ Addressing logistical challenges to care and access through technology-based solutions will require coordinated efforts and continued VHA investment.

Conclusions

The VHA has a large population of veterans with dementia, and the costs to care for these veterans will only increase. While the current benefits of amyloid-targeting therapies are modest, now is the time to establish care processes that will support future innovations in amyloid-targeting therapies and other treatments and diagnostics. We are developing better ways to detect AD using clinical decision support tools, improving care pathways and the management of AD, and leveraging telehealth to improve access. The VA is conducting research to investigate whether a cognitive screening and laboratory evaluation that includes a telehealth preparedness assessment will be feasible and effective for improving the detection of AD and access to treatment, and we plan to publish the results.

The lessons learned can be extended to non-VHA care settings to help achieve potential benefits for other patients with early AD. Emerging therapies have the potential to improve the quality of life for both patients and care partners, adding life to years and not just years to life. Policymakers and payors must prioritize research funding to evaluate the safety and efficacy of these approaches to the delivery of health services, ensuring that emerging therapies are accessible for all individuals affected by AD.

The Veterans Health Administration (VHA) is the largest US integrated health care system, providing health care to > 9 million veterans annually. Dementia affects > 7.2 million Americans, and an estimated 450,000 veterans live with Alzheimer disease (AD).^1,2 Compared with the general population, veterans have a higher burden of chronic medical conditions and are disproportionately affected by AD due to exposure to military-related risk factors (eg, traumatic brain injury and posttraumatic stress disorder) and the high prevalence of nonmilitary risk factors, such as cardiovascular disease. The VHA is a pioneer in dementia care, having established a Dementia System of Care to provide primary and specialty care to veterans with dementia. The VHA also is leading the way in implementing the Institute for Healthcare Improvement Age-Friendly Health Systems (AFHS) framework for providing goal-concordant care in > 100 VHA medical centers. The VHA aims to be the largest AFHS in the country.

AD profoundly affects individuals and their families. The progressive nature of the most common form of dementia diminishes the quality of life for patients as well as their care partners in an ongoing fashion, often leading to emotional, physical, and financial strain. Costs for health and long-term care for people living with AD and other dementias were projected at $360 billion in 2024, largely due to the need for nursing home care.¹ Although several oral medications are available, their capacity to effectively mitigate the negative effects of AD is limited. Cholinesterase inhibitors and memantine may offer temporary symptomatic relief, but they do not alter disease progression.³ The use of these agents is relatively low, with about one-third of patients diagnosed with AD receiving these medications.⁴

Amyloid-Targeting Therapies

Recent advancements in biologics, particularly amyloid-targeting therapies, such as lecanemab and donanemab, offer new hope for managing AD. Older adults treated with these medications show less decline on measures of cognition and function than those receiving a placebo at 18 months.^5,6 However, accessing and using these medications is challenging.

Use of amyloid-targeting therapies poses challenges. The medications are expensive, potentially placing a financial burden on patients, families, and health care systems.⁷ Determining initial eligibility for treatment requires a battery of cognitive assessments, laboratory tests, advanced radiologic studies (eg, magnetic resonance imaging [MRI] of the brain and amyloid positron emission tomography [PET] scans), and possible cerebrospinal fluid (CSF) testing. Frequent ongoing assessments are necessary to monitor safety and efficacy. These treatments carry substantial risks, particularly amyloid-related imaging abnormalities (ARIA) such as cerebral edema, microhemorrhages, and superficial siderosis. Therefore, follow-up assessments typically occur around months 2, 3, 4, and 7, depending on which medication is selected. Finally, at present, both agents must be intravenous (IV)-administered in a monitored clinical setting, which requires additional coordination, transportation, and cost.

Ongoing evaluations and in-person administration particularly affect patients and care partners with limitations regarding transportation, time off work, and navigating complex health care systems.⁸ VHA clinicians at sites that have implemented or are interested in implementing amyloid-targeting therapy programs endorse similar challenges when implementing these therapies in their US Department of Veterans Affairs (VA) medical centers (VAMCs).⁹

The VHA was one of the first health care systems to use amyloid-targeting therapies, covering the cost of lecanemab and donanemab, in addition to costs associated with concomitant evaluation and testing. However, given the safety concerns with this novel class of medications, the VHA National Formulary Committee developed criteria for use and recommended the VA Center for Medication Safety (VAMedSAFE) conduct a mandatory real-time medication use evaluation (MUE). VAMedSAFE developed the MUE to monitor the safe and appropriate use of amyloid-targeting therapy for AD. Two authors (AJO, SMH) partnered with VAMedSAFE through the VA Pittsburgh Healthcare System Technology Enhancing Cognition and Health–Geriatric Research, Education, and Clinical Center (TECH-GRECC) to provide clinical expertise, substantive feedback for the development of the MUE, and guidance for VHA sites starting amyloid targeting-therapy programs. We started a VHA Amyloid-Targeting Therapy for AD SharePoint collaborative platform and VHA AD Therapeutics Community of Practice (CoP) for shared learning (Figure). The private SharePoint platform houses an array of implementation materials for VAMCs starting programs: key documents and links; educational materials; sample guidelines; note templates; and electronic health record screenshots. The CoP allows VHAs to share best practices and discuss challenges.

Even with these advantages, we found that ensuring the safe and appropriate use of amyloid-targeting therapies did not overcome the barriers associated with their complexity. This was especially true for veterans living in rural areas. Only 4 VAMCs had administered amyloid-targeting therapies in the first year they were available. Preliminary data demonstrated that 27 (84%) of 32 veterans who initiated lecanemab in the VHA between October 2023 and September 2024 resided in urban areas.¹⁰ To address the underutilization of amyloid-targeting therapy, we propose leveraging the strengths of VHA telehealth to facilitate expansion of access to these medications for veterans with early AD. Telehealth may substantially increase access to evaluation for veterans with early dementia and, when medically appropriate, to receive amyloid-targeting therapies by reducing transportation needs and mitigating costs while ensuring appropriate monitoring through ongoing clinical assessments.

Using Telehealth

The VHA is a pioneer in telehealth, with programs dating back to 2003.¹¹ Between October 1, 2018, and September 30, 2019, the VHA served > 900,000 veterans through the provision of > 2.6 million episodes of care via telehealth.¹² The COVID-19 pandemic further cemented the role of telemedicine as an essential component of health care. Telehealth has demonstrated success in the assessment and management of individuals living with dementia. At the VHA, the GRECC-Connect Project is a partnership between 9 urban GRECC sites that seek to provide consultative geriatric and dementia care to rural veterans through telehealth.¹³ Additional evidence supports the potential to leverage telehealth to effectively communicate results of amyloid PET scans.¹⁴

This approach is not without limitations such as the digital divide, or the gap that separates technology-enabled individuals and those unprepared to adopt technology due to limited digital literacy levels or access to needed hardware, software, and connectivity. The VHA has taken steps to address these digital divide barriers by broadly providing tools—such as tablets and broadband connectivity—to veterans. Specifically, the VHA has instituted digital divide consults to determine whether telehealth could be a potential solution for appropriate veterans and to provide an iPad (if eligible) to connect with VA clinicians. Complementary to the digital divide consult, a VHA-specific telehealth preparedness assessment tool is under development and being tested by 2 authors (JF, SMH). This telehealth preparedness assessment tool is designed to aid in the seamless integration of telehealth services with the support of tailored education materials specific to gaps in digital literacy that a veteran might experience.

Building on these initiatives, there is an opportunity to expand access to amyloid-targeting therapies, regardless of distance to large VAMCs, by leveraging telehealth as an alternative method of connecting patients with specialty care. Specifically, a hybrid approach could be used to accomplish the myriad initial and follow-up tasks involved in the provision of amyloid-targeting therapies (Table). Not all VHA facilities possess the specialty expertise to prescribe these medications, and local clinicians may not have sufficient knowledge and clinical support to prescribe and monitor these therapies.

The first step is identifying local and regional subject matter experts, followed by the development and expansion of these networks. The National TeleNeurology Program is a good example of a national telehealth program that leverages technology to bring specialty services to rural areas with limited access to care. Although amyloid-targeting therapies often require more complex logistics, such as laboratory tests and imaging, these initial hurdles can be overcome through localized services and collaboration between VAMCs.

While treatment and imaging will most likely need to occur at a VAMC, most basic laboratory studies can be performed at community-based outpatient clinics (CBOCs). Some CBOCs may not be able to process more specialized laboratory tests such as apolipoprotein E genetic testing. Samples for these tests can be collected and processed at VAMCs, which usually have contracts with outside laboratories capable of performing these studies. Most, although not all, VAMCs offer advanced imaging, including MRI of the brain and amyloid PETs. VAMCs without those modalities may need to coordinate with other regional VAMCs. Additionally, a pilot program is already underway whereby VAMCs without the ability to quantify the amount of amyloid on PETs are able to leverage technology and collaborations with other VAMCs to obtain these data.

Once the initial phases of evaluation and care are completed, telemedicine can be leveraged for follow-up and ongoing management. Interdisciplinary teams can help facilitate care related to amyloid-targeting therapies, including the close monitoring of veterans for development of ARIA.¹⁵ To achieve this monitoring, specialty clinic teams prescribing amyloid-targeting therapies, which may be geographically distant, need to coordinate with local primary care clinical teams and emergency clinicians. All of these health care team members, along with neurologists and neurosurgeons, should be involved in the development and implementation of protocols in the event that patients present to their local primary or specialty care clinics or emergency department with ARIA symptoms.

If amyloid-targeting therapies are to be provided along with other emerging treatments for rural veterans, telehealth must be part of the solution. There is a pressing need to explore innovative evaluation and delivery models for these therapies, particularly as we expect additional diagnostics and therapeutics to be available in the future. With the advent of commercially available blood tests (ie, blood biomarkers) for AD, there is hope for a transition away from PETs and CSF testing given their cost, limited access, and invasiveness for diagnosis and monitoring of AD. These advances will increase the utility of telehealth to help rural veterans access amyloid-targeting therapies.

Additionally, administering the drug at home or at local clinics, supported by a dedicated health care team or home health agency, could further improve accessibility. Telehealth can be leveraged in this scenario, allowing specialty clinics and specialists to connect with patients and clinicians based out of local clinics or even home health agencies. In this scenario, specialists can provide hands-on care guidance and oversight even though they may be geographically distant from care recipients. Transitioning from IV administration to subcutaneous formulations would further enhance convenience and reduce barriers; these formulations may be available soon.¹⁶ Addressing logistical challenges to care and access through technology-based solutions will require coordinated efforts and continued VHA investment.

Conclusions

The VHA has a large population of veterans with dementia, and the costs to care for these veterans will only increase. While the current benefits of amyloid-targeting therapies are modest, now is the time to establish care processes that will support future innovations in amyloid-targeting therapies and other treatments and diagnostics. We are developing better ways to detect AD using clinical decision support tools, improving care pathways and the management of AD, and leveraging telehealth to improve access. The VA is conducting research to investigate whether a cognitive screening and laboratory evaluation that includes a telehealth preparedness assessment will be feasible and effective for improving the detection of AD and access to treatment, and we plan to publish the results.

The lessons learned can be extended to non-VHA care settings to help achieve potential benefits for other patients with early AD. Emerging therapies have the potential to improve the quality of life for both patients and care partners, adding life to years and not just years to life. Policymakers and payors must prioritize research funding to evaluate the safety and efficacy of these approaches to the delivery of health services, ensuring that emerging therapies are accessible for all individuals affected by AD.

The Veterans Health Administration (VHA) is the largest US integrated health care system, providing health care to > 9 million veterans annually. Dementia affects > 7.2 million Americans, and an estimated 450,000 veterans live with Alzheimer disease (AD).^1,2 Compared with the general population, veterans have a higher burden of chronic medical conditions and are disproportionately affected by AD due to exposure to military-related risk factors (eg, traumatic brain injury and posttraumatic stress disorder) and the high prevalence of nonmilitary risk factors, such as cardiovascular disease. The VHA is a pioneer in dementia care, having established a Dementia System of Care to provide primary and specialty care to veterans with dementia. The VHA also is leading the way in implementing the Institute for Healthcare Improvement Age-Friendly Health Systems (AFHS) framework for providing goal-concordant care in > 100 VHA medical centers. The VHA aims to be the largest AFHS in the country.

AD profoundly affects individuals and their families. The progressive nature of the most common form of dementia diminishes the quality of life for patients as well as their care partners in an ongoing fashion, often leading to emotional, physical, and financial strain. Costs for health and long-term care for people living with AD and other dementias were projected at $360 billion in 2024, largely due to the need for nursing home care.¹ Although several oral medications are available, their capacity to effectively mitigate the negative effects of AD is limited. Cholinesterase inhibitors and memantine may offer temporary symptomatic relief, but they do not alter disease progression.³ The use of these agents is relatively low, with about one-third of patients diagnosed with AD receiving these medications.⁴

Amyloid-Targeting Therapies

Recent advancements in biologics, particularly amyloid-targeting therapies, such as lecanemab and donanemab, offer new hope for managing AD. Older adults treated with these medications show less decline on measures of cognition and function than those receiving a placebo at 18 months.^5,6 However, accessing and using these medications is challenging.

Use of amyloid-targeting therapies poses challenges. The medications are expensive, potentially placing a financial burden on patients, families, and health care systems.⁷ Determining initial eligibility for treatment requires a battery of cognitive assessments, laboratory tests, advanced radiologic studies (eg, magnetic resonance imaging [MRI] of the brain and amyloid positron emission tomography [PET] scans), and possible cerebrospinal fluid (CSF) testing. Frequent ongoing assessments are necessary to monitor safety and efficacy. These treatments carry substantial risks, particularly amyloid-related imaging abnormalities (ARIA) such as cerebral edema, microhemorrhages, and superficial siderosis. Therefore, follow-up assessments typically occur around months 2, 3, 4, and 7, depending on which medication is selected. Finally, at present, both agents must be intravenous (IV)-administered in a monitored clinical setting, which requires additional coordination, transportation, and cost.

Ongoing evaluations and in-person administration particularly affect patients and care partners with limitations regarding transportation, time off work, and navigating complex health care systems.⁸ VHA clinicians at sites that have implemented or are interested in implementing amyloid-targeting therapy programs endorse similar challenges when implementing these therapies in their US Department of Veterans Affairs (VA) medical centers (VAMCs).⁹

The VHA was one of the first health care systems to use amyloid-targeting therapies, covering the cost of lecanemab and donanemab, in addition to costs associated with concomitant evaluation and testing. However, given the safety concerns with this novel class of medications, the VHA National Formulary Committee developed criteria for use and recommended the VA Center for Medication Safety (VAMedSAFE) conduct a mandatory real-time medication use evaluation (MUE). VAMedSAFE developed the MUE to monitor the safe and appropriate use of amyloid-targeting therapy for AD. Two authors (AJO, SMH) partnered with VAMedSAFE through the VA Pittsburgh Healthcare System Technology Enhancing Cognition and Health–Geriatric Research, Education, and Clinical Center (TECH-GRECC) to provide clinical expertise, substantive feedback for the development of the MUE, and guidance for VHA sites starting amyloid targeting-therapy programs. We started a VHA Amyloid-Targeting Therapy for AD SharePoint collaborative platform and VHA AD Therapeutics Community of Practice (CoP) for shared learning (Figure). The private SharePoint platform houses an array of implementation materials for VAMCs starting programs: key documents and links; educational materials; sample guidelines; note templates; and electronic health record screenshots. The CoP allows VHAs to share best practices and discuss challenges.

Even with these advantages, we found that ensuring the safe and appropriate use of amyloid-targeting therapies did not overcome the barriers associated with their complexity. This was especially true for veterans living in rural areas. Only 4 VAMCs had administered amyloid-targeting therapies in the first year they were available. Preliminary data demonstrated that 27 (84%) of 32 veterans who initiated lecanemab in the VHA between October 2023 and September 2024 resided in urban areas.¹⁰ To address the underutilization of amyloid-targeting therapy, we propose leveraging the strengths of VHA telehealth to facilitate expansion of access to these medications for veterans with early AD. Telehealth may substantially increase access to evaluation for veterans with early dementia and, when medically appropriate, to receive amyloid-targeting therapies by reducing transportation needs and mitigating costs while ensuring appropriate monitoring through ongoing clinical assessments.

Using Telehealth

The VHA is a pioneer in telehealth, with programs dating back to 2003.¹¹ Between October 1, 2018, and September 30, 2019, the VHA served > 900,000 veterans through the provision of > 2.6 million episodes of care via telehealth.¹² The COVID-19 pandemic further cemented the role of telemedicine as an essential component of health care. Telehealth has demonstrated success in the assessment and management of individuals living with dementia. At the VHA, the GRECC-Connect Project is a partnership between 9 urban GRECC sites that seek to provide consultative geriatric and dementia care to rural veterans through telehealth.¹³ Additional evidence supports the potential to leverage telehealth to effectively communicate results of amyloid PET scans.¹⁴

This approach is not without limitations such as the digital divide, or the gap that separates technology-enabled individuals and those unprepared to adopt technology due to limited digital literacy levels or access to needed hardware, software, and connectivity. The VHA has taken steps to address these digital divide barriers by broadly providing tools—such as tablets and broadband connectivity—to veterans. Specifically, the VHA has instituted digital divide consults to determine whether telehealth could be a potential solution for appropriate veterans and to provide an iPad (if eligible) to connect with VA clinicians. Complementary to the digital divide consult, a VHA-specific telehealth preparedness assessment tool is under development and being tested by 2 authors (JF, SMH). This telehealth preparedness assessment tool is designed to aid in the seamless integration of telehealth services with the support of tailored education materials specific to gaps in digital literacy that a veteran might experience.

Building on these initiatives, there is an opportunity to expand access to amyloid-targeting therapies, regardless of distance to large VAMCs, by leveraging telehealth as an alternative method of connecting patients with specialty care. Specifically, a hybrid approach could be used to accomplish the myriad initial and follow-up tasks involved in the provision of amyloid-targeting therapies (Table). Not all VHA facilities possess the specialty expertise to prescribe these medications, and local clinicians may not have sufficient knowledge and clinical support to prescribe and monitor these therapies.

The first step is identifying local and regional subject matter experts, followed by the development and expansion of these networks. The National TeleNeurology Program is a good example of a national telehealth program that leverages technology to bring specialty services to rural areas with limited access to care. Although amyloid-targeting therapies often require more complex logistics, such as laboratory tests and imaging, these initial hurdles can be overcome through localized services and collaboration between VAMCs.

While treatment and imaging will most likely need to occur at a VAMC, most basic laboratory studies can be performed at community-based outpatient clinics (CBOCs). Some CBOCs may not be able to process more specialized laboratory tests such as apolipoprotein E genetic testing. Samples for these tests can be collected and processed at VAMCs, which usually have contracts with outside laboratories capable of performing these studies. Most, although not all, VAMCs offer advanced imaging, including MRI of the brain and amyloid PETs. VAMCs without those modalities may need to coordinate with other regional VAMCs. Additionally, a pilot program is already underway whereby VAMCs without the ability to quantify the amount of amyloid on PETs are able to leverage technology and collaborations with other VAMCs to obtain these data.

Once the initial phases of evaluation and care are completed, telemedicine can be leveraged for follow-up and ongoing management. Interdisciplinary teams can help facilitate care related to amyloid-targeting therapies, including the close monitoring of veterans for development of ARIA.¹⁵ To achieve this monitoring, specialty clinic teams prescribing amyloid-targeting therapies, which may be geographically distant, need to coordinate with local primary care clinical teams and emergency clinicians. All of these health care team members, along with neurologists and neurosurgeons, should be involved in the development and implementation of protocols in the event that patients present to their local primary or specialty care clinics or emergency department with ARIA symptoms.

If amyloid-targeting therapies are to be provided along with other emerging treatments for rural veterans, telehealth must be part of the solution. There is a pressing need to explore innovative evaluation and delivery models for these therapies, particularly as we expect additional diagnostics and therapeutics to be available in the future. With the advent of commercially available blood tests (ie, blood biomarkers) for AD, there is hope for a transition away from PETs and CSF testing given their cost, limited access, and invasiveness for diagnosis and monitoring of AD. These advances will increase the utility of telehealth to help rural veterans access amyloid-targeting therapies.

Additionally, administering the drug at home or at local clinics, supported by a dedicated health care team or home health agency, could further improve accessibility. Telehealth can be leveraged in this scenario, allowing specialty clinics and specialists to connect with patients and clinicians based out of local clinics or even home health agencies. In this scenario, specialists can provide hands-on care guidance and oversight even though they may be geographically distant from care recipients. Transitioning from IV administration to subcutaneous formulations would further enhance convenience and reduce barriers; these formulations may be available soon.¹⁶ Addressing logistical challenges to care and access through technology-based solutions will require coordinated efforts and continued VHA investment.

Conclusions

The VHA has a large population of veterans with dementia, and the costs to care for these veterans will only increase. While the current benefits of amyloid-targeting therapies are modest, now is the time to establish care processes that will support future innovations in amyloid-targeting therapies and other treatments and diagnostics. We are developing better ways to detect AD using clinical decision support tools, improving care pathways and the management of AD, and leveraging telehealth to improve access. The VA is conducting research to investigate whether a cognitive screening and laboratory evaluation that includes a telehealth preparedness assessment will be feasible and effective for improving the detection of AD and access to treatment, and we plan to publish the results.

The lessons learned can be extended to non-VHA care settings to help achieve potential benefits for other patients with early AD. Emerging therapies have the potential to improve the quality of life for both patients and care partners, adding life to years and not just years to life. Policymakers and payors must prioritize research funding to evaluate the safety and efficacy of these approaches to the delivery of health services, ensuring that emerging therapies are accessible for all individuals affected by AD.

He who thus considers things in their first growth and origin ... will obtain the clearest view of them. Politics, Book I, Part II by Aristotle

Many seasoned observers of federal practice have signaled that the future of US Department of Veterans Affairs (VA) health care is threatened as never before. Political forces and economic interests are siphoning Veterans Health Administration (VHA) capital and human resources into the community with an ineluctable push toward privatization.¹

This Veterans Day, the vitality, if not the very viability of veteran health care, is in serious jeopardy, so it seems fitting to review the rationale for having institutions dedicated to the specialized medical treatment of veterans. Aristotle advises us on how to undertake this intellectual exercise in the epigraph. This column will revisit the historical origins of VA medicine to better appreciate the justification of an agency committed to this unique purpose and what may be sacrificed if it is decimated. 

The provision of medical care focused on the injuries and illnesses of warriors is as old as war. The ancient Romans had among the first veterans’ hospital, named a valetudinarium. Sick and injured members of the Roman legions received state-of-the-art medical and surgical care from military doctors inside these facilities.²

In the United States, federal practice emerged almost simultaneously with the birth of a nation. Wounded troops and families of slain soldiers required rehabilitation and support from the fledgling federal government. This began a pattern of development in which each war generated novel injuries and disorders that required the VA to evolve (Table).³

Many arguments can be marshalled to demonstrate the importance of not just ensuring VA health care survives but also has the resources needed to thrive. I will highlight what I argue are the most important justifications for its existence.

The ethical argument: President Abraham Lincoln and a long line of government officials for more than 2 centuries have called the provision of high-quality health care focused on veterans a sacred trust. Failing to fulfill that promise is a violation of the deepest principles of veracity and fidelity that those who govern owe to the citizens who selflessly sacrificed time, health, and even in some cases life, for the safety and well-being of their country.⁴

The quality argument: Dozens of studies have found that compared to the community, many areas of veteran medical care are just plain better. Two surveys particularly salient in the aging veteran population illustrate this growing body of positive research. The most recent and largest survey of Medicare patients found that VHA hospitals surpassed community-based hospitals on all 10 metrics.⁵ A retrospective cohort study of mortality compared veterans transported by ambulance to VHA or community-based hospitals. The researchers found that those taken to VHA facilities had a 30-day all cause adjustment mortality 20 times lower than those taken to civilian hospitals, especially among minoritized populations who generally have higher mortality.⁶

The cultural argument: Glance at almost any form of communication from veterans or about their health care and you will apprehend common cultural themes. Even when frustrated that the system has not lived up to their expectations, and perhaps because of their sense of belonging, they voice ownership of VHA as their medical home. Surveys of veteran experiences have shown many feel more comfortable receiving care in the company of comrades in arms and from health care professionals with expertise and experience with veterans’ distinctive medical problems and the military values that inform their preferences for care.⁷

The complexity argument: Anyone who has worked even a short time in a VHA hospital or clinic knows the patients are in general more complicated than similar patients in the community. Multiple medical, geriatric, neuropsychiatric, substance use, and social comorbidities are the expectation, not the exception, as in some civilian systems. Many of the conditions common in the VHA such as traumatic brain injury, service-connected cancers, suicidal ideation, environmental exposures, and posttraumatic stress disorder would be encountered in community health care settings. The differences between VHA and community care led the RAND Corporation to caution that “Community care providers might not be equipped to handle the needs of veterans.”⁸

Let me bring this 1000-foot view of the crisis facing federal practice down to the literal level of my own home. For many years I have had a wonderful mechanic who has a mobile bike service. I was talking to him as he fixed my trike. I never knew he was a Vietnam era veteran, and he didn’t realize that I was a career VA health care professional at the very VHA hospital where he received care. He spontaneously told me that, “when I first got out, the VA was awful, but now it is wonderful and they are so good to me. I would not go anywhere else.” For the many veterans of that era who would echo his sentiments, we must not allow the VA to lose all it has gained since that painful time

Another philosopher, Søren Kierkegaard, wrote that “life must be understood backwards but lived forwards.”⁹ Our own brief back to the future journey in this editorial has, I hope, shown that VHA medical institutions and health professionals cannot be replaced with or replicated by civilian systems and clinicians. Continued attempts to do so betray the trust and risks the health and well-being of veterans. It also would deprive the country of research, innovation, and education that make unparalleled contributions to public health. Ultimately, these efforts to diminish VHA compromise the solidarity of service members with each other and with their federal practitioners. If this trend to dismantle an organization that originated with the sole purpose of caring for veterans continues, then the public expressions of respect and gratitude will sound shallower and more tentative with each passing Veterans Day.

He who thus considers things in their first growth and origin ... will obtain the clearest view of them. Politics, Book I, Part II by Aristotle

Many seasoned observers of federal practice have signaled that the future of US Department of Veterans Affairs (VA) health care is threatened as never before. Political forces and economic interests are siphoning Veterans Health Administration (VHA) capital and human resources into the community with an ineluctable push toward privatization.¹

This Veterans Day, the vitality, if not the very viability of veteran health care, is in serious jeopardy, so it seems fitting to review the rationale for having institutions dedicated to the specialized medical treatment of veterans. Aristotle advises us on how to undertake this intellectual exercise in the epigraph. This column will revisit the historical origins of VA medicine to better appreciate the justification of an agency committed to this unique purpose and what may be sacrificed if it is decimated. 

The provision of medical care focused on the injuries and illnesses of warriors is as old as war. The ancient Romans had among the first veterans’ hospital, named a valetudinarium. Sick and injured members of the Roman legions received state-of-the-art medical and surgical care from military doctors inside these facilities.²

In the United States, federal practice emerged almost simultaneously with the birth of a nation. Wounded troops and families of slain soldiers required rehabilitation and support from the fledgling federal government. This began a pattern of development in which each war generated novel injuries and disorders that required the VA to evolve (Table).³

Many arguments can be marshalled to demonstrate the importance of not just ensuring VA health care survives but also has the resources needed to thrive. I will highlight what I argue are the most important justifications for its existence.

The ethical argument: President Abraham Lincoln and a long line of government officials for more than 2 centuries have called the provision of high-quality health care focused on veterans a sacred trust. Failing to fulfill that promise is a violation of the deepest principles of veracity and fidelity that those who govern owe to the citizens who selflessly sacrificed time, health, and even in some cases life, for the safety and well-being of their country.⁴

The quality argument: Dozens of studies have found that compared to the community, many areas of veteran medical care are just plain better. Two surveys particularly salient in the aging veteran population illustrate this growing body of positive research. The most recent and largest survey of Medicare patients found that VHA hospitals surpassed community-based hospitals on all 10 metrics.⁵ A retrospective cohort study of mortality compared veterans transported by ambulance to VHA or community-based hospitals. The researchers found that those taken to VHA facilities had a 30-day all cause adjustment mortality 20 times lower than those taken to civilian hospitals, especially among minoritized populations who generally have higher mortality.⁶

The cultural argument: Glance at almost any form of communication from veterans or about their health care and you will apprehend common cultural themes. Even when frustrated that the system has not lived up to their expectations, and perhaps because of their sense of belonging, they voice ownership of VHA as their medical home. Surveys of veteran experiences have shown many feel more comfortable receiving care in the company of comrades in arms and from health care professionals with expertise and experience with veterans’ distinctive medical problems and the military values that inform their preferences for care.⁷

The complexity argument: Anyone who has worked even a short time in a VHA hospital or clinic knows the patients are in general more complicated than similar patients in the community. Multiple medical, geriatric, neuropsychiatric, substance use, and social comorbidities are the expectation, not the exception, as in some civilian systems. Many of the conditions common in the VHA such as traumatic brain injury, service-connected cancers, suicidal ideation, environmental exposures, and posttraumatic stress disorder would be encountered in community health care settings. The differences between VHA and community care led the RAND Corporation to caution that “Community care providers might not be equipped to handle the needs of veterans.”⁸

Let me bring this 1000-foot view of the crisis facing federal practice down to the literal level of my own home. For many years I have had a wonderful mechanic who has a mobile bike service. I was talking to him as he fixed my trike. I never knew he was a Vietnam era veteran, and he didn’t realize that I was a career VA health care professional at the very VHA hospital where he received care. He spontaneously told me that, “when I first got out, the VA was awful, but now it is wonderful and they are so good to me. I would not go anywhere else.” For the many veterans of that era who would echo his sentiments, we must not allow the VA to lose all it has gained since that painful time

Another philosopher, Søren Kierkegaard, wrote that “life must be understood backwards but lived forwards.”⁹ Our own brief back to the future journey in this editorial has, I hope, shown that VHA medical institutions and health professionals cannot be replaced with or replicated by civilian systems and clinicians. Continued attempts to do so betray the trust and risks the health and well-being of veterans. It also would deprive the country of research, innovation, and education that make unparalleled contributions to public health. Ultimately, these efforts to diminish VHA compromise the solidarity of service members with each other and with their federal practitioners. If this trend to dismantle an organization that originated with the sole purpose of caring for veterans continues, then the public expressions of respect and gratitude will sound shallower and more tentative with each passing Veterans Day.

He who thus considers things in their first growth and origin ... will obtain the clearest view of them. Politics, Book I, Part II by Aristotle

Many seasoned observers of federal practice have signaled that the future of US Department of Veterans Affairs (VA) health care is threatened as never before. Political forces and economic interests are siphoning Veterans Health Administration (VHA) capital and human resources into the community with an ineluctable push toward privatization.¹

This Veterans Day, the vitality, if not the very viability of veteran health care, is in serious jeopardy, so it seems fitting to review the rationale for having institutions dedicated to the specialized medical treatment of veterans. Aristotle advises us on how to undertake this intellectual exercise in the epigraph. This column will revisit the historical origins of VA medicine to better appreciate the justification of an agency committed to this unique purpose and what may be sacrificed if it is decimated. 

The provision of medical care focused on the injuries and illnesses of warriors is as old as war. The ancient Romans had among the first veterans’ hospital, named a valetudinarium. Sick and injured members of the Roman legions received state-of-the-art medical and surgical care from military doctors inside these facilities.²

In the United States, federal practice emerged almost simultaneously with the birth of a nation. Wounded troops and families of slain soldiers required rehabilitation and support from the fledgling federal government. This began a pattern of development in which each war generated novel injuries and disorders that required the VA to evolve (Table).³

Many arguments can be marshalled to demonstrate the importance of not just ensuring VA health care survives but also has the resources needed to thrive. I will highlight what I argue are the most important justifications for its existence.

The ethical argument: President Abraham Lincoln and a long line of government officials for more than 2 centuries have called the provision of high-quality health care focused on veterans a sacred trust. Failing to fulfill that promise is a violation of the deepest principles of veracity and fidelity that those who govern owe to the citizens who selflessly sacrificed time, health, and even in some cases life, for the safety and well-being of their country.⁴

The quality argument: Dozens of studies have found that compared to the community, many areas of veteran medical care are just plain better. Two surveys particularly salient in the aging veteran population illustrate this growing body of positive research. The most recent and largest survey of Medicare patients found that VHA hospitals surpassed community-based hospitals on all 10 metrics.⁵ A retrospective cohort study of mortality compared veterans transported by ambulance to VHA or community-based hospitals. The researchers found that those taken to VHA facilities had a 30-day all cause adjustment mortality 20 times lower than those taken to civilian hospitals, especially among minoritized populations who generally have higher mortality.⁶

The cultural argument: Glance at almost any form of communication from veterans or about their health care and you will apprehend common cultural themes. Even when frustrated that the system has not lived up to their expectations, and perhaps because of their sense of belonging, they voice ownership of VHA as their medical home. Surveys of veteran experiences have shown many feel more comfortable receiving care in the company of comrades in arms and from health care professionals with expertise and experience with veterans’ distinctive medical problems and the military values that inform their preferences for care.⁷

The complexity argument: Anyone who has worked even a short time in a VHA hospital or clinic knows the patients are in general more complicated than similar patients in the community. Multiple medical, geriatric, neuropsychiatric, substance use, and social comorbidities are the expectation, not the exception, as in some civilian systems. Many of the conditions common in the VHA such as traumatic brain injury, service-connected cancers, suicidal ideation, environmental exposures, and posttraumatic stress disorder would be encountered in community health care settings. The differences between VHA and community care led the RAND Corporation to caution that “Community care providers might not be equipped to handle the needs of veterans.”⁸

Let me bring this 1000-foot view of the crisis facing federal practice down to the literal level of my own home. For many years I have had a wonderful mechanic who has a mobile bike service. I was talking to him as he fixed my trike. I never knew he was a Vietnam era veteran, and he didn’t realize that I was a career VA health care professional at the very VHA hospital where he received care. He spontaneously told me that, “when I first got out, the VA was awful, but now it is wonderful and they are so good to me. I would not go anywhere else.” For the many veterans of that era who would echo his sentiments, we must not allow the VA to lose all it has gained since that painful time

Another philosopher, Søren Kierkegaard, wrote that “life must be understood backwards but lived forwards.”⁹ Our own brief back to the future journey in this editorial has, I hope, shown that VHA medical institutions and health professionals cannot be replaced with or replicated by civilian systems and clinicians. Continued attempts to do so betray the trust and risks the health and well-being of veterans. It also would deprive the country of research, innovation, and education that make unparalleled contributions to public health. Ultimately, these efforts to diminish VHA compromise the solidarity of service members with each other and with their federal practitioners. If this trend to dismantle an organization that originated with the sole purpose of caring for veterans continues, then the public expressions of respect and gratitude will sound shallower and more tentative with each passing Veterans Day.