Eva Barth

Honors 392 A
December 14, 2016

The Treatment of Post-9/11 Amputee Veterans

Throughout the history of war, battle has always produced injured soldiers. These injuries

affect both the physical and mental capabilities of veterans, causing a person to return from war

in a different state than the one they left in. Perhaps the most serious, and definitely the most

apparent type of injury is an amputation. A veteran with an amputated limb is a constant

reminder of the true cost of war. These veterans cannot escape nor hide from their disability.

There are social stigmas surrounding amputation that have plagued amputee veterans for years,

beginning in the aftermath of the American Civil War. However, due to the increase in blast

injuries and advancements in medical response teams during the OIF and OEF wars, we have

seen a recent increase in surviving veterans with amputations (Ott, 2005). Today there are

several laws and policies in place to support these young amputee veterans. Specifically, Public

Law 102-405 known as The Veterans Medical Programs Amendment of 1992 has laid

groundwork that is fundamental is continuing to provide all veterans with amputations with top-

notch care and access to prosthetics.

During the last few decades the disability rights movement has come to define disability

in two models: the medical model and the social model. In the medical model disability is

viewed as an ailment that can be treated or cured and it is often regarded as an individuals issue.

Contrastingly, the social model displays disability as a construct of society, something the

individual is faced with due to their surrounding environment. The social model also
distinguishes between an impairment (the physical manifestation) and disability (the resulting

disadvantages due to society) (Barnes & Mercer, 2003). It is clear that the social model offers a

more just and realistic view of disability. Although it is a physical ailment, an amputation can

affect all aspects of a veterans life. Additionally, an amputation should by no means

automatically disqualify someone from participating in certain activities. I will be examining

whether the Veterans Medical Programs Amendment truly helped integrate veterans with

amputations back into society or if it just perpetuates the medicalization of disability.

The Veterans Medical Programs Amendment has several important effects on veterans

with amputations. First and foremost, it names veterans with amputations as a special disability

group thus qualifying them for separate funding and programs (102nd Congress, 1991-1992).

However, the label of a special disability also comes with a heavy cloud of stigma. An

amputation is a very visible disability and often time amputees are pitied or treated awkwardly

by both strangers and loved ones. These issues are applicable to all amputees, but veteran

amputees are faced with additional veteran-specific obstacles as well. Soldiers who have

experienced combat-related amputations in OIF or OEF are often relatively young and

accustomed to an active lifestyle (Sigford, 2010). An amputation often leads to a medical

discharge from the military which can strip the soldier of his or her identity. The concurrent

timing of an individual losing their sense of purpose as well as physically losing a limb can result

in feelings of de-masculinization and self-internalization. Historically, the Department of

Veterans Affairs has done little to address these social and emotional issues surrounding

amputation. The focus has always been on improving physical functionality. However, beginning

with the Veterans Medical Programs Amendment of 1992 the VA has made changes to their care
accumulating with a claimed paradigm shift for VA amputation care that changes the care to

be completely person-centered (Sigford, 2010).

The first step towards the shift of the method of amputation care was the creation of the

VA Advisory Committee on Prosthetics and Special-Disabilities Programs. Public Law 102-405

states that this committee must operate as if required to by law. The committee serves as an

overseeing board which reports on the status of VA amputation care to the senate as well as to

the House Veterans Affairs Committee. This oversight has resulted in increased accountability

and follow through by VA amputation centers nationwide. The Advisory Committee also attains

funding for amputation related programs within the VA and coordinates programs to test and

develop prosthetic devices (102nd Congress, 1991-1992). With proper funding and

organization the VA has become a world leader in providing amputation care and access to

advanced prosthetics.

The VA was able to finally achieve their paradigm shift in care with the creation of the

Department of Veterans Affairs Amputation System of Care (ASoC) implemented in 2008. The

stated vision of ASoC is To be a world leader in providing lifelong amputation care and the

VA claims to be The premiere system for amputation care (Rehabilitation and Prosthetics,

2010). These are lofty claims for an organization to make. What is it that makes the Amputation

System of Care so good and are they actually as effective as they claim to be? A major challenge

is to provide the same level of high quality care to all veteran amputees nationwide. Currently

there are seven regional amputee centers and eighteen network sites throughout the country. The

number of network sites is an increase from the thirteen that existed in 2008 (Webster, 2014).

However, there is still not enough coverage to ensure that veterans who reside in rural areas can

access care in a timely and affordable manner. Lack of care may result in a veteran living a
dependent and isolated lifestyle. ASoC must also provide effective lifelong care to veterans. As

earlier discussed, many amputees from the Afghanistan and Iraq conflicts are young with long

active lives ahead of them. However, these conflicts have occurred too recently to effectively

judge whether or not the VA is able to adequately provide long term care.

The Amputation System of Care provides resources to all veterans with amputations,

whether or not they are combat-related. A large fraction of veteran amputees are older veterans

with diabetes-caused lower limb amputation. These veterans often have different care

requirements than a young veteran with a trauma-induced amputation. Studies have shown that

in general older veterans are less concerned with regaining full functionality and mobility

following an amputation. (Karmaker, 2009). It can therefore be inferred that a young veteran is

more disabled by their amputation than an older veteran is. The VA has to have systems in place

to keep both these groups of veterans happy. The Karmaker 2009 study Prosthesis and

wheelchair use in veterans with lower-limb amputation examined the outcome of different

approaches that the VA can take. It reported that many older amputees opt to use a wheelchair as

they find prosthetic devices uncomfortable, but many young veterans opt for prosthetics as they

find wheelchairs to be limiting. However the overall consensus was that prosthesis users reported

lower pain scores and higher satisfaction with functionality than the wheelchair user group. This

finding supports that the research and money that the ASoC puts into prosthetics is worth it. A

prosthetic device can serve as a very effective method to treat a disability to allow for

reintegration back into daily life.

The Veterans Medical Programs Amendment has in no doubt helped veterans receive

top-notch amputation care, however most of this care only addresses the medical side of

disability. It is understandable that the medical community largely adheres to the medical model
which aims to treat or cure a disability, as this is what most healthcare professionals are trained

to do (Johnson, 2016). The VA is no exception. For example, the Amputation System of Care

largely relies on a medical team to tell the veteran what to do and how to improve their

condition. It also puts a lot of pressure on the injured veteran to constantly work hard and believe

that one day they can be fully cured. These actions support the notion that disability is the issue

of an individual and not of society. There is the additional issue of the concept of a prosthesis.

Prosthetic devices are largely designed to hide a disability. They alter the individual in order to

make them conform to the accepted appearance. However with advancements in technology,

prosthetics are becoming much more functional than simply aesthetic.

On the other hand, the Amputation System of Care has made some moves to address the

social side of disability as well. One of the sub-goals of ASoC is To optimize each individual's

activity and participation in recognized social roles through an interdisciplinary care approach.

(Rehabilitation and Prosthetics, 2010). The VA is aware that a disability like amputation does

much more than just affect ones physicality. It is important to recognize that an amputation can

alter all levels of societal participation and interaction. The interdisciplinary care team that the

VA utilizes is comprised of rehabilitation physicians, physical therapists, occupational therapists,

vocational counselors and psychologists. These professionals work as a unit to provide holistic

care to the amputee. The ASoC also offers education and support groups to the family and

friends of the amputee. This is extremely important, as a strong support system can make the

recovery process much smoother.

In 2014 the Webster study Department of Veterans Affairs Amputation System of Care: 5

years of accomplishments and outcomes was published. It conducted a comprehensive patient

satisfaction questionnaire and on average veterans reported overall very high satisfaction with
the amputation care they received (Webster, 2014). This suggests that the VA has indeed been

successful at implementing an effective amputation care system. However, from a disability

perspective I believe that the VA can go even further. The ASoC strives to be the world leader in

amputation care, and they likely are in terms of research and medical care. But a true world

leader should be an advocate for amputees in all areas of life. I envision this occurring by the VA

spearheading movements that fight to make all public areas accessible to people with disabilities

like amputations. Additionally I believe it would be beneficial for the VA to expand their

amputation educational groups so that an increased percentage of veterans family and friends

can access this information. Perhaps most importantly, the VA and ASoC can play a monumental

role in the portrayal of amputation in society. The VA can stop showing veteran amputees as

broken war heroes and instead launch a campaign that portrays them as citizens living their daily

lives.

As long as wars continue to be fought, soldiers will continue to become amputated from

battle. Although the best course of action would be to prevent these disabilities before they occur

it is unlikely that we will ever live in a completely war-free and safe world. Instead, the

government and society have to adapt to welcome these veterans back to daily life as smoothly

as possible. The Veterans Medical Programs Amendment of 1992 was undoubtedly a key piece

of legislation in assisting amputee veterans. The oversight and funding provided by the Advisory

Committee on Prosthetics and Special-Disabilities Programs provided the structure necessary to

conduct a successful care network. The Amputation System of Care employs innovative and

comprehensive techniques to ensure that care is truly person-centered. Without a doubt, these

changes have allowed veterans to live a more independent and fulfilling life, however we as a

society must continue to address the stigmas surrounding amputation.

 References

Barnes, Colin. "Disability: A Choice of Models." Disability. Ed. Geof Mercer. Cambridge:
Polity, 2003. 1-18. Print.
Johnson, E. (2016, April). Disability, Medicine, and Ethics. AMA Journal of Ethics, 18(4), 355-
358. doi:10.1001/journalofethics.2016.18.04.fred1-1604
Karmarkar, A. M., Collins, D. M., Wichman, T., Franklin, A., Fitzgerald, S. G., Dicianno, B. E.,
Cooper, R. A. (2009). Prosthesis and wheelchair use in veterans with lower-limb
amputation. The Journal of Rehabilitation Research and Development, 46(5), 567-576.
doi:10.1682/jrrd.2008.08.0102

Ott, K. (2005). Carnage Remembered: Prosthetics in the United States Military Since the
1860s, in Bernard Finn and Barton Hacker, eds., Materializing the Military. London:
Science Museum, 2005: 47-64.
Rehabilitation and Prosthetic Services. (2010, June 10). Retrieved November 07, 2016, from
http://www.prosthetics.va.gov/PROSTHETICS/asoc/index.asp

S.2344 - 102nd Congress (1991-1992): Veterans' Medical Programs Amendments of 1992.

(n.d.). Retrieved November 07, 2016, from https://www.congress.gov/bill/102nd-
congress/senate-bill/2344

Sigford, B. J. (2010). Paradigm shift for VA amputation care. The Journal of Rehabilitation
Research and Development, 47(4), Xv-Xix. doi:10.1682/jrrd.2009.02.0020

Webster, J. B., Poorman, C. E., Cifu, D. X., Webster, J. B., Poorman, C. E., & Cifu, D. X.
(2014). Department of Veterans Affairs Amputation System of Care: 5 years of
accomplishments and outcomes. Journal of Rehabilitation Research and Development,
51(4), Vii-Xvi. doi:10.1682/jrrd.2014.01.0025