Team Effort

Illustration by Kagan McLeod

In a parking lot in Washington, DC, in the chill of late February 2008, Red Sox chairman Tom Werner caught up to Larry Ronan, the team internist, as he waited to board the bus. “Larry, I want you to think about what we can do,” Werner said.

Behind them stood Walter Reed Army Medical Center, where severely wounded soldiers are first treated upon their return to the States. The Red Sox had just left; the half-hour photo op had turned into a three-hour visit with patients. The visit had lasted so long the team ended up delaying its departing flight back to Fort Myers, where the players were to resume spring training. They were reluctant to step away from the enormity of the sacrifices they had encountered at Walter Reed: the 22-year-old missing both legs who told Dustin Pedroia that Pedroia was his hero because he’d saved a no-hitter for Clay Buchholz; the mother who asked Jason Varitek to sign her son’s glove, the son whose post-traumatic stress disorder kept him trapped in his room for fear of crowds.

Werner had spent the afternoon talking with doctors, learning about traumatic brain injury, a signature condition of the current conflicts: Body armor and swift medical attention may save the lives of soldiers thrown from a bomb blast, but the blast itself is absorbed by the brain, shaking it into a deep concussion and leaving the soldier with everything from depression to long-term memory loss to, perhaps, PTSD. Werner heard, too, about how these patients’ PTSD differs from that of previous wars: With no front line, no zone of safety, no cues allowing soldiers to differentiate friend from enemy, PTSD has found the perfect incubator in Iraq and Afghanistan. Werner listened as doctors explained that 40 percent or more of returning veterans suffer from the nightmares, anxiety, and depression of the disorder.

This was why Werner approached Ronan as the team straggled out of the hospital. And this was why, while in Japan a few weeks later for a first-of-its-kind season opener against the Oakland A’s, Werner asked Ronan what had come of their conversation: “Where is the proposal?” he said. That’s when Ronan knew to make this a priority.

The U.S. department of Veterans Affairs has offered widespread healthcare for veterans through its hospitals since 1921 – and has limited almost all care to those hospitals. Today, the VA’s healthcare system treats 5.6 million veterans of all ages nationwide. Massachusetts is part of the VA New England Healthcare System: an integrated organization of 11 medical centers and 39 outpatient clinics in six states. VA Boston alone sees 62,000 patients a year at its West Roxbury and Jamaica Plain medical centers.

And a lot of these vets aren’t happy. “All vets hate the VA. I’m sorry; they do,” says Peggy Matthews, an independent veterans’ advocate who helps guide vets through the morass of post-deployment life. Of the 500 vets she’s helped in the past 10 years, “not one,” she says, thinks highly of the VA. What her vets

complain about is a capital-B bureaucracy of endless paperwork and automated messages. Appointments are hard to get, especially for younger vets, and they’re brief, she says.

Many of Matthews’s vets expect more of hospitals associated with Harvard, Boston University, and Tufts. And in fact Massachusetts’ VA facilities are, in many respects, first-rate. Their care outperforms that of other VA hospitals nationally, internal studies show; and VA Boston beats 96 percent of all hospitals that serve poor and aging patients, according to HealthInsight, a nonprofit group that analyzes Medicare and Medicaid statistics. VA Boston’s psychiatrists are nationally recognized. In 2007, for instance, Dr. Jonathan Shay won a MacArthur Fellowship, the so-called genius grant, for his work tracing PTSD to ancient cultures.

Yet stellar care means nothing if you can’t get access to it. Although the VA says it sees almost all its patients within 14 days of a call for an appointment, vets complain about excessive wait times: One in four veterans waits at least 30 days to see a doctor in the system, the most recent Office of Inspector General report showed. One highly regarded mental health professional working at the VA Medical Center in Bedford says the waitlist for therapy sessions is about five months. And a psychiatrist in Greater Boston says he recently left the VA in part because his hourlong sessions kept getting squeezed down to shorter increments, and because he was told to meet “productivity guidelines” in terms of number of patients seen. “Basically…[the expectation is] for the psychiatrist’s door to open and close every 15 minutes,” he says.

The system is swamped because more Iraq and Afghanistan vets are seeking out treatment than federal policymakers projected, veterans groups say. Forty-six percent of returning troops have enrolled in VA care nationwide, already exceeding policymakers’ estimates. New England’s VA hospitals are treating 22,000, and that’s only four percent of the region’s overall patient load.

The costs have outstripped the VA’s resources. The agency had to request $1 billion in emergency funding to cover unexpected needs in 2005, and another $2 billion the next year. By 2008, Congress was asking for $3 billion more in emergency funding to cope with rising demand. The VA’s struggles to meet needs led veterans to file a class-action lawsuit. The plaintiffs didn’t want money; they wanted the VA to acknowledge its shortcomings. The federal judge who heard the case decided the problems were so large they required legislation, not adjudication.

Under President Obama, the VA’s budget has grown by 27 percent – and it has asked Congress for $125 billion for next year – but the increase doesn’t make up for past lags. “We’re still behind the curve on staffing,” says the mental health professional in Bedford.

Access is what the Red Sox’s Werner wanted to offer – otherwise, what a waste for suffering vets to go untreated in a city with some of the finest healthcare in the world.

One night two years ago, Gary Smith awoke to the sound of his back door

slamming. He got out of bed and went to a window that overlooked his expansive yard in Amesbury and the woods beyond. At first he noticed nothing. Then, squinting, he saw the red embers of a cigarette bobbing within the darkness. A moment more and he saw the outline of a man. A young man. His son, Evan.

But what was he doing out there? Since his return from Iraq several weeks earlier, Evan, 22, had been sleeping poorly, but his behavior hadn’t alarmed Gary, until now. By the glow of the moon he could see Evan crouching in the woods – in full combat gear, holding a BB gun.

“What are you doing?” Gary asked when Evan returned to the house.

“Walking,” Evan said.

Gary told Evan to go back to bed. He tried to do the same. He hoped that whatever tonight was, it would pass.

It didn’t. Night after night, Evan put on his sand-colored fatigues, laced up his boots, strapped on his 90-pound rucksack, grabbed his BB gun or his Army knife, lit a cigarette, and stepped out into the North Shore quiet. Bang went the back door. Evan’s parents heard it every night now. Sometimes Evan would be out there for hours. When he returned, exhausted, he slept with knives near his bed and under his mattress.

Gary was a retired masonry superintendent who had never served in the military, but he knew some of the details of Evan’s tour in Iraq – the nighttime patrols for IEDs and the insurgents who planted them – and he knew about PTSD. He called the VA hospital in Jamaica Plain, which deals with PTSD cases on an outpatient basis. When he took Evan there for an appointment, the doctors referred him to the VA Medical Center in Bedford.

Days later, father and son waited at the registration desk in Bedford for Evan to be admitted for inpatient PTSD treatment. They must have looked like tourists gaping at the unfamiliar, because soon enough another father approached. The man told Gary about his son’s tour of duty, about the OxyContin painkiller the VA prescribed when his son returned from Iraq, and about the addiction his son now battled. As Evan was led away for an evaluation, this other father grabbed Gary by the arm and said his son still wasn’t receiving the help he needed. “If you think this is going to be the only time you’ll be here, prepare yourself,” he said. “Because it’s the fourth time I’m here. The fourth time my son has been admitted.”

Evan stayed in Bedford for three months. On weekends Gary drove the hour from Amesbury to take him out to eat. Evan always seemed to get angry when they returned to the hospital. “They don’t do shit for me,” he told his dad. He said the VA was warehousing him: keeping him in a semiconscious state and on a trifecta of drugs so he wouldn’t harm himself or trouble the staff. The Vietnam

vets – the lifers of the hospital – dominated the group sessions Evan attended. He couldn’t relate. He wanted more one-on-one care, but said he only got more drugs. (The VA won’t talk about individual patients.)

Gary didn’t know what to believe. Massachusetts’ VA hospitals were supposed to be esteemed. Then again, Evan wouldn’t lie about something like this, would he? It was frustrating. It was more frustrating to learn, months later, that during Evan’s three months in Bedford the service organizations that operate within VA hospitals and are charged with putting in disability claims failed to do so for Evan. This paperwork was critical – without it, he couldn’t receive long-term VA care.

The hospital released Evan in January 2009, and for the next year he had weekly therapy sessions – but again, among Vietnam vets with whom he felt he had little in common.

He wanted to go back to school, and this past January he got the chance. The VA referred him to the Northeast Veteran Training and Rehabilitation Center in Gardner. There, Mount Wachusett Community College offers classes, free of charge, to rehabbing veterans. But Evan wasn’t ready. He couldn’t concentrate. Within two months, he got kicked out for not doing his classwork. He moved back home.

He was anxious, depressed. The night missions started up again. Intellectually, Evan knew his behavior was bizarre, but emotionally he needed to quell his apprehension until he could be sure that Amesbury at night was not Iraq at night. His parents tried to get him back into Bedford, but were told no beds were available. When the memories of Iraq became too acute – the bombs he disarmed, the insurgents and civilians killed in one particularly intense sweep, the fellow soldiers who died in IED blasts – Evan blurred them by binging on pills. He talked of suicide. The VA saw him when his parents called again, but the appointments were short and infrequent.

This past May, the VA admitted Evan into a substance-abuse program in Bedford. It would not treat Evan’s PTSD – the real cause, Evan believed, of his drug use. Yet it was a start. Evan wanted to go back to school, become an EMT, and he knew a program like this could lead him to better days. On his third night there, he took something to help him sleep – a VA doctor had prescribed it at an earlier visit – and woke up the next day to a drug test, which he failed. Administrators kicked him out of the program.

“Fuck you,” Evan told the security guards as they removed him from the building.

A few days later, and after an unsuccessful bid for admittance to another program, Evan told his parents he was done with the VA.

Stories like Evan Smith’s were not foreign to Tom Werner as he dug deeper into veterans’ care in 2008. “This is a massive problem,” he says. “Boston is a center for excellent doctors…and I thought maybe there was enough wisdom where we could come together to address this.”

Werner’s idea was this: Let Massachusetts General Hospital help treat returning vets. Mass General seemed especially equipped to help PTSD patients: Since 1994 U.S. News & World Report had ranked its psychiatry department number one in the country.

Werner and a small team of MGH physicians, psychologists, and rehab specialists came up with a three-year pilot program funded through $6 million from the Red Sox Foundation and MGH. With that sort of backing, the program could attempt to treat any veteran who walked through the door. Nothing of such scope had been tried before, anywhere, and Werner and the others weren’t sure the VA would go along with it.

The VA, especially under President Bush, had been hostile to the idea of outside care. Hyannis’s Jeff Brodeur, a national director of the Korean War Veterans Association, had seen that firsthand. He had to use his clout to get his son, Vincent Mannion-Brodeur, an active-duty soldier in Iraq, treated at Boston’s Spaulding Rehabilitation Hospital for traumatic brain injury. Brodeur believed Spaulding offered a quality of care exceeding that of the VA’s Polytrauma Rehabilitation Center in Tampa, where the government had assigned his son for treatment. A year after Mannion-Brodeur became the first active-duty soldier in Massachusetts to be treated by a private facility, the Department of Defense granted Spaulding a $3 million contract for TBI research.

The VA’s contempt for the private sector had been thawing, but Werner knew political support would be more valuable than financial support. One of his first stops, in 2008, was the office of Senator Ted Kennedy, who liked the idea of Mass General partnering with the VA. Werner then met with General Peter Chiarelli, the Army’s vice chief of staff, who was also intrigued. Last, he saw General Eric Shinseki, the Vietnam vet who heads the U.S. Department of Veterans Affairs, and assured him that MGH didn’t seek to compete with the VA for patients, that the hospital wanted only to augment the VA’s care.

The Mass General program debuted last September at Fenway Park. Called the Home Base Program, it treats Iraq and Afghanistan veterans, as well as their families – people who also must learn to cope with the vets’ conditions, physical or mental, and who, as a result, may develop medical problems of their own. (The VA doesn’t provide care for veterans’ families.) If veterans can’t pay for the care, Home Base provides it free of charge. Some vets already like it so much, they’ve joined the cause.

Andrew Delrossi was a marine stationed in Al Anbar province in western Iraq. A broad-backed, gregarious 20-year-old from Everett, DelRossi was there to help guard the Al Asad base where dignitaries often met, patrol the surrounding desert towns, and train the Iraqi army. IED explosions were common. Firefights broke out. Once, two thieves on motorcycles stole metal from a rifle range. That metal is often used as IED shrapnel. DelRossi and other Marines chased the thieves in a Humvee, DelRossi in the turret with a machine

gun. The Humvee was traveling roughly 60 miles per hour when it fell into a bomb crater. The impact sent DelRossi into the cab of the vehicle. A bit dazed, the Marines resumed the chase, forcing the thieves to crash. DelRossi detained both suspects.

The next day, he told a military doctor that his neck hurt, but he didn’t stop to have it examined; he didn’t want to leave his unit. By the time he returned to the States, in the spring of 2009, he could barely turn his head. He also had back and knee pain, and could climb stairs only by holding a handrail.

He went to the VA’s outpatient clinic on Causeway Street in the North End. He told the doctor about all his conditions; it disappointed him to receive only an X-ray for his neck – nothing for his back or knee. The staff asked him to wait for the diagnosis; this visit, he was told, would be used as evidence for his disability claim, which the VA would need to approve before DelRossi could get treatment.

He waited nine months. His back hurt so much he slept on the floor. When he walked, he shuffled like his grandfather. When the disability approval did come this past January – along with a diagnosis of cervical spondylosis, an abnormal wear on the cartilage of the neck – it carried the lowest possible disability coverage the VA offered. DelRossi would receive a monthly check of $123 – an entitlement that didn’t account for his other injuries, or what he believed to be PTSD. (He was anxious when awake, and had nightmares. He thought he would rest better if he owned a gun. “I can’t wait till I get my goddamn gun. I’m going to sleep with it every night.”)

The low monthly check led DelRossi to find care through Home Base. He wanted to see if his other ailments could be confirmed so he could claim new injuries and hopefully land a higher disability rating. First, the Home Base doctors diagnosed him with PTSD and scheduled him to meet with a Home Base psychiatrist. Then they tended to his neck, knee, and back pain. That’s when doctors discovered DelRossi didn’t suffer from cervical spondylosis, but rather from slipped disks. The pain he felt could have been more easily managed all along. DelRossi now receives steroid injections to lessen his swelling and suffering.

The VA experience left him so angry, he accepted a leadership role in Operation Enduring Freedom/Operation Iraqi Freedom Veterans of Massachusetts, an advocacy group that directs social services to the 20,000 Iraq and Afghanistan veterans who live in Massachusetts. “I didn’t want other veterans to go through what I’ve been through,” he says. If a vet calls his State House office about a VA problem, it doesn’t take DelRossi long to ask, “Have you heard about Home Base?”

By the end of May, the program had treated 124 other veterans. This month it is scheduled to open a standalone clinic on Merrimac Street near the West End.

Seven physicians, three psychologists, four outreach coordinators, and one social worker, all working for MGH or its parent company, Partners HealthCare, will treat patients by appointment. Tom Werner’s hope is that other cities will use Home Base as a template for creating their own programs to help veterans. “Caring for vets is something we all have to do,” he says.

Already, he and other Home Base founders anticipate the need to raise more money before the pilot program ends in 2012. The demand is there. So is the need.

Ask Evan Smith, who, after enrolling in Home Base this past spring, is finally getting the one-on-one counseling he said he needed all along. His father says, “I’m relieved.”