Straining to keep a promise

Jeffrey Lennon returned from Iraq to his hometown of Plymouth a broken man. Soon enough, he would also be a very angry man.

A sergeant in the US Army Reserve, Lennon was racked by nightmare visions of fellow soldiers and Iraqi civilians killed during his tour of duty. Almost anything could trigger the memories, particularly smells of garbage and gasoline that steer his mind back to the roads of Iraq.

He abandoned his dream of being a police officer. He took refuge in alcohol. He contemplated suicide.

And he waited, and waited, for the Department of Veterans Affairs to help him make his way back.

Diagnosed with severe post-traumatic stress disorder in March 2004, it may take months, he said, to get an appointment for mental health counseling at the VA Medical Center in Brockton because of staffing shortages. It took more than a year before he began receiving his $348 monthly check for partial disability.

"The people at the VA want to help, but the system is broken. They are just so overwhelmed," Lennon, 30, said.

Veterans Affairs is a vast agency that makes a vast promise, one literally etched in bronze at the entrance to its headquarters in Washington -- "To Care for Him Who Shall Have Borne the Battle and for His Widow, and His Orphan."

But the VA is straining, and, many Iraq and Afghanistan war veterans say, often failing to live up to those words.

Much as military planners failed to adequately account for the enormous cost -- in lives, money, and time -- of securing Iraq after toppling Saddam Hussein, the VA failed to plan and sufficiently staff for the wave of casualties, and the kinds of injuries that have flowed from the combat zone.

A Globe review of hundreds of pages of VA memoranda and planning documents, and interviews with present and former agency officials, legislative analysts, and veterans, shows that the VA planned for a short and relatively bloodless war in Iraq, and then was slow to react when the war dragged on and casualties and other claims mounted from 14,000 in 2003 to a projected total of 206,000 this year.

The backlog of disability claims is up to more than 400,000 by the VA's count and climbing. Wait times to process claims are running nearly seven months, on average -- quicker in some places and much longer in others, as Lennon and other veterans have found. In cases where the extent of disability is disputed and an appeal is filed, resolution can take more than two years.

The rising number and complex nature of medical needs among Iraq and Afghanistan veterans are severely testing the VA's sprawling healthcare system. More than a third of all veterans of the Iraq war who seek care at the VA do so for mental health issues. The agency's spending on mental healthcare has increased but not commensurate to need, some VA officials say. The spending per patient has dropped, from $557 in 2000 to $438 last year, according VA data.

Paul Sullivan, who worked at the VA as a senior researcher for five years, is one person who saw the crisis coming and says his persistent warnings to superiors about the need to prepare went unheeded.

"Not only is there proof that they knew of increased demand [for services at the VA] and did nothing. They knew and were actively trying to conceal it," said Sullivan, who left the agency in frustration, taking with him a trove of unclassified documents that he provided to the Globe.

Stephen Meskin, who from 2000 to 2006 was chief actuary for the VA in charge of projecting the agency's client caseload and claims, said the failure to plan was rooted in an overly optimistic outlook on the war -- a bullish view widely held in the Bush administration in the early going.

"There was no apparent risk analysis being done about the impact of a war on the system even while we were at war," Meskin said, in an interview. "There were just assumptions that it would be a slam dunk and not strain the system."

Meskin, who retired in early 2006, said the VA's budget projections were rooted in the assumption that the caseload would ease as the population of World War II veterans aged and died. But the numbers grew, driven by many factors, including WWII veterans living longer, and veterans of Vietnam and Korea finding themselves without private healthcare and relying more heavily on the VA system. And then there are the newly wounded and injured returning from Iraq and Afghanistan.

"We saw the tip of the iceberg in 2005, and it was clear it was going to be hard to steer clear of that," Meskin said. "The VA's mission, and the veterans who rely on its care, are going to face significant problems as a result."

Steve Robinson, director of veterans affairs at Veterans for America, the advocacy group where Sullivan also has worked, has seen those problems up close, talking to hundreds of veterans with stories similar to Lennon's.

"Delays in claims and delays in treatment lead to lives falling apart. He [Lennon] is a classic example of what's going on out there. Soldiers who are wounded just like Lennon are not getting the treatment they need and they deserve," Robinson said.

For Lennon, the memories of war are not fading. Particularly searing is the image of a child strapped with explosives who detonated in front of his convoy.

The mental anguish was enough that he volunteered to surrender his badge as a Plymouth County deputy sheriff, a job that was a stepping stone toward becoming a police officer. Unemployed, and drinking heavily, his life has spun out of control.

"There's this wait zone," he said, describing the delays in treatment and benefits at the VA, "and that is where you fall apart."

Inside the imposing VA headquarters, the view is decidedly different. Yes, the agency is a "big ship" that can be slow to turn, as Dr. Alfonso Batres , the chief of Readjustment Counseling put it. But the VA provides and will continue to provide superior care for the nation's 24 million veterans, 1.2 million of whom live in New England, agency officials say.

The secretary of veterans affairs, R. James "Jim" Nicholson , is especially emphatic on that point.

"We are delivering a damn good product to a satisfied group of customers," Nicholson said in an interview last month.

A Vietnam War veteran, real estate developer, and former head of the Republican National Committee, Nicholson was appointed by President Bush to head the VA in 2005. He describes himself as the chief executive of what is, with 235,000 employees handling a million healthcare visits a week, the largest healthcare system in the country.

And he said he is confident that his proposed budget for next year of $86 billion -- up 8 percent from this year -- will adequately fund services for the growing number of veterans seeking them.

"I feel wonderful about the way we are treating the nation's veterans and that is exactly what they deserve," he said. "This is the largest healthcare system in America and arguably the best. . . . We used to say growing up in Iowa that it ain't a boast if it's true. And it is."

Nicholson's upbeat assessment has much to support it. There is no question the VA has many areas of excellence, delivering top-shelf medical treatment to amputees from roadside bombs and soldiers with brain trauma from the blasts. World War II and Korea veterans speak highly of a system that has been reconfigured in the last 10 years to address the needs of the aging demographic of veterans of those wars.

The VA is also praised by many -- from Business Week to Harvard Business School -- as an efficiently run healthcare organization, conscious both of quality and cost. But it is also an agency that has earned some caustic critics, particularly among Democrats in Congress who have launched investigations into what Representative Mike Michaud, Democrat of Maine, has called "a state of denial" within the VA.

"We are tired of hearing this administration say things are fine. Things aren't fine if you talk to veterans," said Michaud, who has served on the House Veterans Affairs Committee for the last five years.

For every soldier killed in this war, there are 16 wounded, a ratio that exceeds any conflict in the history of the US military.

In World War II, for example, two soldiers were wounded, on average for every one killed. (The US military prefers to calculate only those wounded in direct combat, which would make the ratio in Iraq 1 dead to 8 wounded, and still place it as the highest killed-to-wounded ratio in American history.)

That extraordinary wave of wounded, many of them with brain injuries or mental health troubles, will translate into enormous costs. Indeed, the long-term cost of caring for the 1.5 million veterans of the wars in Iraq and Afghanistan and their families is projected to exceed $700 billion if the current troop "surge" continues and an estimated $400 billion if a gradual withdrawal takes place, according to figures released recently by a Harvard University economist.

Linda Bilmes , a faculty member at Harvard University's John F. Kennedy School of Government and a former Commerce Department official in the Clinton administration, has spent the last year researching the long-term costs of providing veterans medical care and disability benefits.

"The number of veterans who are returning home with injuries or disabilities is large and growing. We have not paid careful enough attention, or devoted sufficient resources, to planning for how to take care of these men and women who have served the nation," she wrote in a 20-page research paper published in January.

Sullivan and Meskin, among others, say there were other largely unheeded warning signs about the potential for surging costs caused by the return of the so-called GWOTs, veterans of what the Pentagon calls the "Global War on Terror."

Sullivan joined the VA in 2000 as a research manager. He says he wrote memos calling for a better system of "casualty tracking" to allow the VA to more accurately respond to battlefield trends. The need for better data was evident as early as 2002, when he briefed senior VA officials, as casualties flowed back from the war in Afghanistan.

With the launch of the Iraq war in March 2003, the casualty rates were low but they climbed rapidly when the insurgency took shape. The question was how long that would continue, and at what pace.

Inside the VA, there was no clear picture of what lay ahead, according to Meskin and others involved in the process of predicting future needs. That was due in part to inadequate research and the reluctance of the Department of Defense to share data. But it was also due, they say, to a more basic failure to plan and to respond at the VA.

As early as February 2004, reports by a VA Special Committee on post-traumatic stress disorder reporting to the under secretary for health were calling for better screening of veterans during post deployment medical examinations to catch a rising tide of mental illness reported by returning veterans. The war in Iraq has placed extraordinary psychic stress on troops facing random and near-constant threats from ambushes and "IEDs," improvised explosive devices.

The committee also highlighted the need for more cooperation between the Department of Defense and the VA in identifying those returning veterans who need help and who may delay seeking help, given the stigma that can result within the military culture from seeking help for PTSD or combat stress.

In 2004, Sullivan led an effort to create a more seamless way to track veterans through their transition from active military duty to the VA system. The so-called Seamless Transition Taskforce also sought to project costs and kinds of needed care. Sullivan said his report, published in January 2005, was watered down in the editing, but that its core message was clear.

"This was bureaucratese for, 'Hey, we've got a train wreck coming!' " he said.

By summer 2005 the warnings were growing louder. One all-out alarm was sounded in a July 25, 2005, memo to the VA's under secretary for health from the Committee on Care of Veterans with Serious Mental Illness.

The committee, comprised of a panel of specialists in PTSD and VA mental health providers, presented a plan to increase funding for mental health programs.

But the plan was not implemented, according to members of the committee and consultants who worked for it. The funding for mental health has not kept up with the onslaught of veterans reporting psychological problems.

The VA spokesman, Phil Budahn , said that Sullivan's research at the VA was solid, but that his interpretation of data and much of the criticism he and others are voicing is "alarmist."

Nicholson himself conceded that in 2005 there was a VA budgeting "glitch" that resulted in some faulty projections and funding shortages. But he said the problem has since been corrected.

VA budgets now, he said, are "uncanny" in their accuracy, and the services provided are exemplary.

To underscore Nicholson's point, the VA public information office arranged for the Globe a tour of the VA Medical Center in Washington where the smoothness of the operation could be witnessed first-hand.

There in the cavernous waiting room, Sergeant Brandon Hecke sat with his wife, Jennifer, waiting for an appointment. The couple were not permitted to speak to the Globe while at the center, but in a later interview, Jennifer said her husband was wounded in a July 19, 2006, IED attack in Balad, Iraq. He was rushed to Walter Reed and diagnosed with traumatic brain injury, PTSD, a severe back injury, blinding in his right eye, and had shrapnel that had lodged itself in his brain. He is 100 percent disabled, she said.

She said care at Walter Reed has been stellar, but that the process of transitioning from the military hospital to the VA benefits system has been extremely chaotic and confusing.

She said she is an office manager at a tax accounting firm in their native Indiana and has the skills to navigate bureaucracy but still finds the paperwork unbearable. She said the strain on the system and the shortage of staffing could be felt at every turn. Her husband's Purple Heart was lost in the mail, she said, and now, eight months later, he has still not been officially pinned with the medal.

"There are definitely problems and the veterans deserve better, particularly the ones who don't have families to help them figure out all the bureaucracy," she said.

Nicholson, in the Globe interview, described as "anecdotal" exceptions the difficulties faced by such servicemen as Hecke, Lennon, and Marine Private Jonathan Schulze, who committed suicide in January after he was put on a waiting list for treatment at a Minnesota VA center. The Schulze case has caused a national outcry.

"When you are treating so many people there is always going to be a linen towel left somewhere," Nicholson said.

For veterans who find themselves falling through the cracks, the veterans centers are often the place where soldiers such as Lennon finally begin to get the help they need. The Vet Centers, a network of more than 209 storefront community outreach and counseling facilities across the country, were established in 1979 to cater to the needs of Vietnam veterans. The centers have generally received high praise from veterans, though they are, in many cases, straining under the burden of the returning troops from Iraq and Afghanistan.

At the Vets Center in Brockton the number of clients seeking services has risen 25 percent in the last three years. But so far just one staff member, who is shared by three different regional centers, has been added to cope with the crunch.

The VA's Dr. Batres's said the Vet Centers have added 100 outreach counselors nationwide to respond to a steady rise in clients among not only Iraq and Afghanistan veterans but also among Vietnam veterans. A significant number of Vietnam veterans, he said, are reporting that their PTSD, long dormant, has been re-triggered by the scenes of war in Iraq. There are national plans to build 23 new Vet Centers, one of them in Hyannis, but they are not projected to come on line until next year.

Until then the system faces troubles of the sort Dr. Frances Murphy, the under secretary for health policy coordination at the VA, outlined in the medical journal Psychiatric News last year. Murphy wrote that mental health and substance abuse care are not accessible at some VA facilities. When the services are available, Dr. Murphy asserted that, "waiting lists render that care virtually inaccessible."

Jeff Lennon knows all about that.

The lack of consistent and easily accessible care, Lennon believes, has made it difficult for him to heal. Last week, he was again trying his best to navigate the VA. He was wandering from one floor to another in the Brockton VA Medical Center, trying to renew his prescription for depression and anxiety medicine and running into problems and paper work.

The receptionist could not find his prescription history for anti anxiety drugs in the computer tracking system so he was told to go to a basement unit where it might be located. He tried to get an appointment with a psychiatrist and was told the earliest date was six weeks out.

"They didn't plan the whole damned war," he said. "So why the hell would we think they'd plan for those of us coming home with these problems?"