Pain (8 page)

How much discomfort or distress should the nation ask a citizen, called to serve, to bear in service of country? In the end, the commission's ambivalence on the question captured society's quandary. One on hand, the Bradley report appeared to take a hard line on this question—insisting that “the performance of citizenship duties cannot be expected to be painless or free from sacrifice … Our national survival requires that all citizens do their part and make whatever contribution they are required to make.” Therefore, not all veteran pains and bodily sacrifices should result in financial compensation. On the other hand, the report also acknowledged the need for a supportive system for the truly disabled man. As it noted, the expectation of sacrifice “does not mean that military service must be rendered without compensation or that maintenance should not be provided to those who are invalided … as a result of military service.” With extraordinary sacrifice came the rightful expectation of long-term support. But then, pivoting once again, the report commented, “It is fallacious to … claim that just because the uniform was worn for awhile [
sic
] the Government owes the former wearer a living. Much of the pain and suffering of military service … cannot be compensated.”
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Here was an articulate ambivalence befitting the time. The report covered all sides of the question, illustrating why the pitched battles being waged by doctors and veterans would not be settled quietly or easily.

By asking doctors to itemize and “rate” particular ailments for their levels of disability, the commission learned that their ideologically sharp views softened when it came to the specifics. Everyone agreed that at one end of the spectrum were major disfigurement, immobility, and loss of multiple limbs. In such cases it was easy to declare the vet disabled without criticism or continuing judgment. But what about cases where those disabilities were less graphic, where recovery was possible even if very
difficult, or where clear evidence of anatomical damage was lacking? Scars, for example, came in many forms—from the minor kind to major disfigurement. Not all scars warranted compensation. But for some doctors, the pain associated with the scar needed to be taken into account in the calculus of disability. As one wrote, “The compensation of wound scars at 10 percent cannot be related to impairment of earning capacity and indicates that an allowance for pain and suffering has been included.” One VA rehabilitation specialist observed, “Scars about the face, severe neuralgias, and upper extremity amputees should be entitled to extra compensation.” As questions of pain became more specific in relation to the body, then, the report produced much evidence supporting the VA, the veterans' groups, and liberal New Deal politicians committed to expanding disability benefits by considering “loss of physical integrity, shortening of life, social inconvenience, disfigurement, pain, suffering, anguish, and possibly others.”
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At the more abstract level, however, many doctors insisted that compensating pain as a disability pointed to an underlying disease: “excessive liberalism.” Some survey respondents even dismissed the very concept of disability as a liberal concoction. As the commission report noted, “Some critics of pension legislation … viewed this legislation as a move to ‘the left,' i.e., a device to weaken the moral fiber of the American people, etc.” One respondent, Oscar P. Hampton, saw only the deceitful hand of liberalism at work: “The yardsticks by which total disability is awarded seem rather liberal since the percentage awards throughout the schedule are excessively liberal. I do not believe there is medical validity for the liberalizing provisions.” For Hugh Morgan, the problem was that liberalism threatened to bankrupt the system altogether: “in order to conserve this for deserving veterans it is all the more important to exclude the now [i.e., newly] eligible who could bankrupt and destroy the undertaking.” Going even further in castigating dependency, Hedwig Kuhn dismissed the idea of disability outright: “I doubt if there are very many people in the world who are truly disabled,” he barked. Technology and medical innovation, he thought, was lightening the burden of afflicted people: “Even a polio victim in an iron lung is not truly disabled if he has imagination. He can even support himself by writing music, writing books, talking into dictaphones and what not.” The belief that effective treatments were at hand informed such skepticism. If a “crippled”
man had prostheses and an “imagination” in Hedwig Kuhn's view, why would he ever need benefits?
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As to the question of what ailments could be considered service connected, the doctors' views were at once politically attuned and clinically informed. Yet their theories of disease and disability were shifting—particularly as once recalcitrant conditions seemed, in the context of postwar medical innovation, to be more treatable. Tuberculosis is a case in point of what some physicians saw as disabilities yielding to cures. As Dr. John Minor argued, “Modern developments have had a marked effect on the problem of disability, the best example of which is furnished by tuberculosis with the shortening of hospital and institutional or home care time, early return to activity, etc.” The miracle drug penicillin and other antibiotics were laying siege to TB-related disability. But Walter Bauer knew that there were new, chronic diseases gaining prominence in the wake of TB's decline: ailments like arthritis, multiple sclerosis, and cardiovascular disease. The question before the commission was whether these maladies, new and old, were service related. “It is not possible to be definite in many of these instances … when the illness manifests itself after separation from service,” wrote Bauer. The evidence could not speak for itself, so like many of his colleagues he relied on his views about the soldier. “Since all questionable problems of this type are settled by giving the veterans the benefit of the doubt, it is the latter policy which really underlies the presumption—not a group of medical facts.” In judging the soldier's pain, then, doctors confronted several political assessments: first, whether a “grateful and efficient country” should give the veteran the benefit of the doubt; second, how to connect the new, late-manifesting chronic diseases, ailments with uncertain etiology, directly to the war; and, third, the social impact of converting disability ratings into monetary benefits.
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In the end, the Bradley report captured the ambivalence of the moment—even as the politics of disability was taking a dramatically liberal turn in a Congress consumed by health-care intrigue. The commission called for caution in further expanding veterans' benefits. Eisenhower (himself ill, recovering from the heart attack, and running for re-election in the summer of 1956) was not inclined to take any major steps on questions of civilian or veteran disability. But, heading into the elections, he found himself boxed in by an energized and Democratically controlled Congress pushing to expand disability benefits. Two formidable demographic
pressures kept health politics before the Congress: ailing veterans and the growing number of older Americans lacking the resources to purchase health care in a booming market. As historian Philip Fungiello has noted, the crafty Senate majority leader saw the political opening. Johnson understood that disability among the elderly was a wedge issue for Democrats heading into the elections and pushed hard for a bill establishing a new Social Security disability entitlement. Johnson's maneuver forced Republicans into choosing between compassion for all disabled citizens (not only veterans) on one hand or allegiance to the AMA on the other. Eisenhower opposed the legislation, hoping to bottle it up in committee and to keep it from the floor of the Senate. Johnson, however, skillfully maneuvered a successful committee and Senate vote, and the bill's narrow passage forced the president to sign or veto a sweeping new law establishing benefits for disabled Americans. Political expediency prevailed. Ever ambivalent and caught between true conservatives and ardent liberals, Eisenhower signed the law, much to the AMA's dismay, even as he agreed with them that its effects could be dire. He promised steady monitoring of the program, he pledged efficient and effective management of the disability plan, and he said that future policies must place greater emphasis on helping “rehabilitate the disabled so that they return to useful employment.” Signing the law, Eisenhower fell back on the language of security, hoping that the legislation would “advance the economic security of the American people.”
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Security
, Eisenhower hoped, was a potent political watchword (social security, national security, economic security) that all Americans could rally around—whether they were New Deal liberals or right-wingers.

There is no question that the law ushered in a new era in disability relief and altered the landscape of the nation's pain politics—for citizens, for veterans, for the VA, for physicians, and for the practice of disability administration that would grow in its wake. The law also pushed doctors, reluctantly and often angrily, into new roles as “raters” of disability and adjudicators of pain. It was a role for which by their own testimony many were unsuited, both because theories of disability and illness were in such flux and because of their sharp professional animosity to the law. There was no consensus on the criteria for disability and little agreement on relief. Yet, who else but physicians would rate disability? From here on, adjudication about the nature, severity, and effects of impairment
would unfold with all parties—patients, doctors, bureaucrats, and often judges in the courts—cognizant of the economic and political stakes. But even after the law was passed, skeptics did not cease warning about the dangers of subjective evidence in disability determination; the problem would never go away. Nor would their complaints subside about the cost of this new social commitment, whether through the VA or through Social Security. At the VA, the burden expanded; by 1958, disability compensation cost $1.4 billion for two million veterans. “Requests for reconsideration [of rejections] jumped from 13,500 in 1955, to 44,610 in 1956, to 64,678 in 1957, to 92,664 in 1958.”
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By 1960, the new disability provision was also stressing the system with sharp increases in requests for benefits, increased numbers of rejections, and an expanding bureaucracy to manage requests, rejections, and appeals.

The pain complaint became, then, a complex cultural symbol in the 1950s. In the wake of the new disability benefit, an angry critique of people claiming to be disabled (and those claiming pain as their disability) sharpened. It proved impossible for AMA leaders not to see the soldier as part of an elaborate charade, but the hostility to disability claimants went deeper. For many physicians, a web of postwar developments—the booming drug market, the rise of government disability benefits, the actions of disability lawyers, and the commodification of pain relief (that is, its translation into monetary benefits)—made them profoundly uneasy about the pain topic. Out of their critique would emerge a distinctive and stigmatized pain persona—a stock figure standing in for government corruption and personal deceit, and focusing their tirade.

Writing for the AMA in the wake of the disability law's passage, Louis Orr launched a blistering counterattack against the president. Having fought fiercely against Truman's national health-care plans, the doctors' lobby had not expected this from a Republican administration. Betrayed by Eisenhower, Orr exclaimed, “We look about us and realize that right here in our own back yard, without any prodding from planners and socializers, we have allowed politicians to create a Trojan horse of ominous dimensions.” As the AMA chair of the Committee on Medical Service, he
saw Ike's concession as conjoined with the expansion of veterans' health, which led “to Socialized Medicine and Socialism by way of the Veterans Administration.” Orr's essay was later published simply as “The Trojan Horse.” As he saw matters, the VA's slow expansion was a sneak attack on free enterprise itself. Accusations of socialist infiltration, of course, had been the stock in trade of Senator Joseph McCarthy's “witch trials.” But in 1956, with McCarthy only recently disgraced, the AMA took up the flag, insisting in its own inflammatory fashion that these silent threats to democracy were real. Truman's 1949 proposal for national compulsory health insurance had failed, but now these many “so-called fringe measures” (as Orr put it) intruded the federal government into medical education, insurance, and medical care.
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To Orr, wars and the subsequent elevation of the needy GI in postwar American civilian life were a subterfuge for the slow creep of social dependency. In the previous two decades, wars had produced a fourfold increase in the number of veterans; at home, their numbers constituted a profound threat. Orr found society's increasing commitment to nonservice-related injuries particularly outrageous. Of the half a million veterans the VA treated in 1951, “85 percent of them had non-service-connected disabilities”; the numbers were increasing. The future looked bleak, for “if we have any more ‘small' wars like Korea … then our veteran population will again increase rapidly, and the entire problem will be compounded many times over.”
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For decades, the AMA and the VFW (a powerful veterans' lobby) had been at odds over the question of who was disabled. Since World War I, the AMA had consistently battled to block expansion of the VA's care for veterans with non-service-connected disabilities. By law, the VA was permitted to care for such cases only when beds were available. In the aftermath of World War II, however, the power of the veterans' lobby grew, as did their support for the VA system. Once small, the VFW had seen a “meteoric upsurge” in membership after the war, with two million new members; and it now rivaled its big-brother organization, the American Legion (although, as one observer noted, the VFW was “neither as influential as the Legion nor as affluential”). After the Second World War, it is revealing that the littlest brother making up the “Big Three” veterans' lobby was the DAV, “which has sprung up after World War I, and now numbered some 130,000—its numbers doubling since Pearl Harbor.”
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