Pain (4 page)

For critics, the VA was the institutional “ground zero” for a political struggle, as elected officials in the 1940s and 1950s sought to create rules, guidelines, and laws for the determination of disability and the definition of relief, particularly with regard to vague, subjective ailments like chronic pain. Interest groups like the Veterans of Foreign Wars (VFW) and the American Legion regarded pain as a legitimate problem—and relief as a right earned by those who sacrificed. By contrast, the AMA perceived pain and disability through the lens of professional self-interest and political ideology—raising broad questions of welfare, creeping socialism, and the tension between private and public health care. At the same time, however, medical professionals worried that the growing number of synthetic pain drugs—from Demerol to Percodan—might feed another kind of dependence in the course of treating pain. Both public relief and private sector care brought their worries. The path to true relief was not simple and straight. Into this mix of anguish and ideology hobbled more and more people with a wider range of infirmities, and with them came the
suspicion from conservatives that much of this new world of pain could be feigned. Little wonder that some saw these persons in pain as a fiscal and administrative problem, others perceived them as legislative and ideological challenges, and yet others saw them as consumer possibilities.

The disabled vet was a particular worry in a society anxious about a return to normalcy. Sometimes, the veteran's problems were physically obvious, and the case for compensation easy to support: the loss of limbs, eyes, and body parts or general disfigurement. But equally often, the damage was hidden: the intense throbbing of internal tissue damage, the effects of concussions and deep scars, and (perhaps most challenging) the psychological damage done by years amid bombardment, killing, and death. Already in 1943 it was clear that “some disabilities resulting from military service leave a man with more or less permanent or recurrent pain or internal discomfort.” The end of conflict inspired concern on a grander scale. In the immediate wake of World War II, disability was everywhere. But how exactly should “internal discomfort” be measured? Whether the infirm veteran needed benefits because he
couldn't
work or because he
wouldn't
work drew much attention.
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The GI's disability was a perplexing issue, creating the framework for social calculations on disability that would move beyond military compensation to civilian life.

Experts from vocational counseling, sociology, and politics voiced deep concern about the damaged soldier's postwar adjustment. “The anticipated civilian world he once knew is found to be different from what he remembered … He has been living in a different world. Little wonder that he feels somewhat bewildered, and that feelings of insecurity and anxiety may develop.” Government programs answered some needs (offering expansive subsidized education, housing, and other benefits in the GI Bill), putting “a roof over the head of the home-hungry veterans” and alleviating many of their concerns. But the psychological challenges of readjustment were not so easily fixed and became a crucial backdrop to how experts theorized disability and pain. As the editors of
The Disabled Veteran
wrote, the veteran's “sense of inadequacy may be augmented by a reawakening fear that disablement will permanently disqualify him for the competitive existence of a civilian.”
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These lingering problems of war—the lasting ailments, suffering, and disability—could not be put aside easily.

Though the health problems of veterans would have been politically perilous under any circumstances, three demographic pressures made it
particularly so in the years immediately following World War II. First, there was the sheer scale of the infirmity of World War II fighters: in 1950, some 215,000 veterans were rated as 50 percent or more disabled, while thousands of others had lesser ailments. Second, the aging of World War I veterans now in their forties and fifties added another 50,000 people whom the VA judged disabled. Third, the start of a bloody campaign in Korea in 1952 exacerbated the problem. The VA was a system inundated with broken bodies. Over these years, a Democratic Congress and President Truman liberalized access—systematically expanding the types of ailments deemed service related and expanding the category of disability. But for Truman, there was a deeper problem: the line between veterans' and citizens' benefits was eroding, not because soldiers became citizens again, but because universal military service meant that any citizen had to be ready to take arms. Before many years, nearly all the population may be veterans or the dependents of veterans, the president acknowledged the year before he left office, and “this means a profound change in the social and economic import of Government programs which affect veterans. It requires a clear recognition that many of the needs of our veterans and their dependents can be met best through the general programs serving the whole population.”
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A better solution than adding further to veteran's health care entitlements would be expanding health insurance for the population at large.

Moves to expand disability programs riled the medical profession, of course—ever fearful of Democrats' plan to establish “socialized medicine” that would compete or do away with private practice. The AMA (a powerful mouthpiece for general practitioners) had been engaged in battle on this front since the end of the war. What Truman characterized as a “Fair Deal” for compulsory health insurance for all, the doctors' lobby labeled “socialized medicine.” For the AMA, the creation of benefits for disabled veterans could only be understood as part of a larger ideological attack on free enterprise and private medicine. But the medical grumbling was not only focused on veterans and socialized medicine. AMA doctors were also skeptical about disability in general and what they often saw as a society too quick to coddle any and every man and woman professing pain. Walking the halls at the AMA's annual meeting in 1949, journalist Ray Cromley got an earful of opinions from doctors. They had “nothing but praise for such modern drugs as penicillin and
streptomycin,” but they were sure that (powerful drugs notwithstanding) “a lot of people just don't want to get well.” Such people used vague complaints of “nerves” to hide their laziness. The AMA doctors bemoaned that “modern over-protective attitudes” were eroding a social ethic of self-support, self-care, and independence. Disability, for Dr. Miland Knapp of Minneapolis (a leading authority in rehabilitative medicine), was a byproduct of these troubling times. After an injury, he theorized, “many patients develop an attitude of inertia. They believe the surgeon or the insurance company must make them as good as ever. They are inclined to do little or nothing for themselves and expect others to do everything for them … Such patients,” Knapp speculated, “are likely to develop disabilities out of proportion to their injuries.”
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They needed not compensation or medicine but a good psychologist.

These anxieties, tinged with fears of manhood in decline, had long predated the veterans' battles. In launching a steady social critique, these physicians pointed to a powerful irony about the soldier's readjustment to citizen status: that military service had made these men obedient, hardy, and strong (enhanced their endurance to pain) but civilian society afterward had coddled and weakened them, infantilizing and mothering them and feeding a dangerous dependence. At the 1949 meeting, Dr. Albert Sullivan of New Orleans told Cromley about one case in point—“an ex-Marine who spent two years in the South Pacific without diarrhea. Then he returned to his small home town. He resented being treated as a boy by his parents and came down with chronic diarrhea. His ailment was overcome when he re-enlisted in the Marines.”
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Such strange, apocryphal stories of how masculine strength and valor abroad became sickness at home illustrated the concerns of physicians who focused on coddling and indulgence in the family, in government, and across society.

Such complaints about “disabilities out of proportion to injuries” and the dangers of coddling were part of the postwar era's recurring McCarthy-infused political debates about creeping communism, socialism, and the fate of freedom and democracy. Under pressure to defend the VA system in the Truman administration, one of its advocates insisted that such institutions were not in fact feeding dependence. Rather, they were America's best chance against totalitarianism: “those who consider the quest for social security incompatible with a free society may well be unwittingly giving aid and comfort to authoritarian regimes,” said Truman's
commissioner for Social Security Arthur Altmeyer. Far from being socialist, he argued, the VA system and the principle of social security were the nation's best bulwarks against socialism. Terming the welfare state “the great political invention of the twentieth century,” Altmeyer boldly defended social security as “the instrument of politics that the Communists fear above all else.”
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Much of this debate about the New Deal's legacy in the postwar years swirled around the question of when a disability was truly service related and when (if related to military service) it was truly disabling. Public Law 748, passed by Congress on June 24, 1948, had already begun liberalizing relief on these questions—creating a statutory list of chronic and tropical diseases that were presumed to be service connected. A long list of ailments with more tenuous connections to military service (including anemia, arteriosclerosis, arthritis, and various bone conditions like osteomalacia, as well as diabetes, cardiovascular and kidney disease, ulcers, and various tumors) had been added to the list of compensable disorders. The AMA had fought against them all. Even the director of the VA testified of his fear that some benefits for chronic conditions would adversely affect veterans' hard-won disability benefits for more obviously service-related conditions. As the 1952 VA annual report noted, there had been “six public laws enacted by the Eighty-Second Congress … [in 1951] which liberalized compensation or pension benefits … or increased the monthly rates of compensation.” These measures expanded access to veterans of earlier conflicts, opening the gates for some non-service-connected disabilities and recognizing new conditions such as multiple sclerosis (with its muscular, speech, visual, and cognitive degeneration) as legitimate when developed within two years of service.
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With such liberalized access, the numbers of covered veterans climbed steadily.

For many observers, the term “liberalization” best described what was happening, as too many injuries were increasingly presumed to be service related. As one report later commented, disability relief was a unique entitlement for those who had earned their injuries in actual conflicts: “peacetime veterans did not receive the same liberal benefits.” Other laws in 1950, 1951, and 1953 extended these presumptions of service-connected disabilities to additional disorders such as tuberculosis (if discovered within three years after service) and psychosis (if developed within two years of discharge). Driven then by the wars, politics, and shifts in
such classifications, from 1945 to 1960 the numbers of veterans receiving disability payments and pensions climbed from just over half a million in 1945 to three million in 1960. Expenditures also rose. By 1962, $2.5 billion was being spent on veterans' disability, with “the largest program, both in terms of the rolls and benefit cost, [being] the disability compensation.” Instead of dying out or declining, the number of damaged veterans was on the rise. So it was that the veteran's disability (and pain as one feature of his complaint) expanded as a flashpoint in the nation's political discourse.
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FIGURE 1.1.
The number of veterans receiving disability payments or pensions skyrocketed from just over a half million in 1945 to three million in 1960.

Image from
Annual Report, Administrator of Veterans Affairs 1960
(Washington, D.C.: Government Printing Office, 1961), 54.

With Dwight Eisenhower's victory over Adlai Stevenson in 1952, the AMA cheered that the stealthy erosive expansion of the VA would cease. The doctors declared that they had “temporarily won the battle against government control,” but they knew that other conflicts would come. AMA leaders would have taken particular comfort in Eisenhower's grim,
ascetic (and old-fashioned) acceptance of discomfort. Speaking in 1954, for example, the sixty-four-year-old president noted that “since the beginning of time men have deluded themselves—or been deluded by other men—with fantasies of life free from labor or pain or sacrifice, of limitless reward that requires no risk, or pleasure untainted by suffering.” In the former general's view, the war experience had shattered these beliefs. “From such dreams, the awakening has always been rude and the penalty a nightmare of disillusionment.”
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Ike's view on sacrifice suggested that here was a man who, knowing war, would not allow mere sympathy to drive government expansion.