In March 2004, after being hired by UMBC, I attended a meeting at Walter Reed Army Medical Center with a colleague from my new department and several military and civilian clinicians. There we discussed the specific and the vague challenges that faced the increasing number of US military service-members who were coming into the hospital after having sustained a ‘traumatic amputation’ as a result of the ongoing conflicts in Iraq and Afghanistan. Aside from discussing the main goals of the rehabilitation program – to return patients to as close an approximation to their pre-injury level of functioning as possible – the military clinicians noted a significant gap in their knowledge. Since there had been nearly no follow up of Vietnam War era servicemembers with limb-loss, and little attention paid to the ‘psychosocial’ needs of these past patients, there was little understanding of what the emotional or identity issues facing the current patients might be. One of the main challenges that a prosthetist at Walter Reed spoke about was the twinned problem of understanding how patients in the program incorporate or otherwise integrate their prosthetic limbs into their bodies, and how they also go on from the rehabilitation program to make lives for themselves.
I was invited to apply for funding through a new research mechanism that had been established by a Congressional appropriation. This program, called the Military Amputee Research Program, was designed to support a wide range of projects from basic science and discovery to evaluating outcomes of patients as they move through the rehabilitation program. By December I had submitted a proposal in which I applied to explore what happens to a person’s sense of themselves and their identity both personally and also in terms of all the factors that make up their lives (family, gender, job, etc) after having experienced the loss of a limb. There had been a considerable amount of research into these and similar questions. This was particularly the case in the UK and Ireland. Also, among anthropologists Geyla Frank’s work with Diane DeVries covered much of this too as did Steve Kurzman’s significant work in addition to the work done by Lenore Manderson and Narelle Warren. Vivian Sobchak’s essays combined the biographical with the phenomenological in at least two sensitive discussions of her life as a person with limb-loss. Two areas that were not much taken up by the literature, either in the US or internationally was the way in which traumatic circumstances impacted these questions, and also, my focus on military members.
A protocol was submitted to Walter Reed in December 2004 and sixteen months later all the various bureaucratic hurdles had been cleared allowing me to start recruiting interlocutors and collecting observations. There have been a handful of publications already that look at different aspects of the experience of service-member patients in the US Armed Forces Amputee Patient Care Program and I will discuss them briefly in a moment. First I want to describe what it is like to do research as an “embedded investigator” in a military treatment facility. I had gone into my Walter Reed research fairly anxious about the extent to which I would be allowed to work without a lot of scrutiny. On the one hand I was overjoyed about how wearing my hospital ID, which identified me as a contractor to the post and by extension to the Army, was enough to grant me the freedom to move about the installation and to recruit whomever I wished among the patients and the clinicians in the Amputee Patient Care Program. On the other hand, I became aware of the way in which the military imposed a form of governance on my work. Not so much in terms of what kinds of questions I asked patients or clinicians or what kinds of conversations I had more generally. But, the knowledge that my manuscripts would be seen by the Department of Clinical Investigation (which grants research authorization) and by the Operational Security desk led me to reflect on whether any claims I made were modest out of natural caution or because of these institutional constraints.
At the same time these constraints could also be unintentionally funny. When I submitted the manuscript that became the article “Rehabilitating Time,” which was recently published by Medical Anthropology, I had noted that the service-members I interviewed had been injured by improvised explosive devices. This led to several phone calls with an Army Captain assigned to operational security at Walter Reed who told me I could not use the phrase “improvised explosive device” because it could provide tactical information to the insurgents. I pointed out that the term was in wide usage in official Department of Defense materials and that there was unit within Department of Defense called JIEDDO – the Joint Improvised Explosive Device Defeat Organization. All of this was to no avail – the Captain recognized that the term was widely used, but nonetheless insisted my using it in the context of service-members recovering from injuries could provide tactical information. This began a process of negotiating what might be an acceptable term. Roadside bomb was rejected for the same reasons despite the wide usage it has within Department of Defense publications and press releases. Eventually we settled on “explosive device” and since that conversation that is the way that I have referred to this particular mechanism of injury.
I was “embedded” at Walter Reed for about eighteen months – from July 2006 to the end of January in 2008. I observed and interviewed patients in a wide variety of settings including the physical therapy and occupational therapy clinics, the prosthetic clinic where patients are fitted for prosthetic limbs, as well as the weekly “amputee clinic” where patients waited to see physicians from the physical rehabilitation and orthopedic services to have their residual limbs examined and to address any medical issues such as pain, infections, prescriptions for new prosthetics. I also spent time with patients in the dining facility, at restaurants off post in the Washington, DC and Maryland communities, in the residential facilities on post (the Mologne and Fisher Houses) as well as in my own home. Lastly, I was part of the Walter Reed delegation to the 2007 “Miracle on a Mountainside” winter adaptive sports clinics near Aspen, Colorado. The Disabled American Veterans and the Department of Veterans Affairs host this annual event that attracts several hundred veterans with disabilities for almost a week of winter sports.
My write up, which is an ongoing project in itself, has organized itself around one of the more prominent themes associated with the rehabilitation program – and that is the role of sports as a means and a measure of a good outcome for these patients. Sports provide an over-arching ideology and set of metaphors for soldiering (using the term inclusively rather than simply to refer to members of the Army), war fighting and is also an important theme in the rehabilitation program. For instance patients are, at times, referred to as tactical athletes because of the kinds of physical conditioning they undertake as part of their job. Additionally, the sports model is used as a rehabilitative model. This approach combines physical rehabilitation program goals to maximize physical functioning with a so-called wellness model of a healthy life that relies on the integration of sports and physical activity into one’s daily activities.
At Walter Reed this sports model has become a structure through which patients receive therapy as well as a way to measure their commitment and their progress. An Army physical therapist described an ideal patient as “someone who was a high school athlete and is used to listening to his coach.” A veteran associated with the rehabilitation program who lost his leg during the Vietnam War and serves as both an advisor and as a peer visitor to patients described the benefits of sports in this way: “If you can do a backflip you realize that you can do pretty much anything.” Patients in the program often embrace these ideas. These kinds of goals can serve to make the challenges of recovery from these grievous injuries more manageable. For instance one junior officer who lost his arm below the elbow and his leg below the knee told me that simply getting into a gym environment meant so much to him in the early days of his recovery.
Over the many months that patients remained in the rehabilitation program it became clear that the focus on physical functioning did not respond to the whole range of their concerns or interests. Many patients began to set their aspirations at an angle to the program’s goals and to develop their own more idiosyncratic ideas about what constituted a good outcome. This has been the main focus of my work and has been where much of my writing has occurred. Recent publications include “Getting Past the Accident,” published in Medical Anthropology Quarterly, and “Rehabilitating Time,” both of which have discussed this in various ways. I have also focused more narrowly on explanations about divergent outcomes in a commentary published in Disability and Rehabilitation.
I pursue this perspective by taking what amounts to a case ethnography approach to highlight the contrasts between the rehabilitative care program (embodied in many of the clinicians) and the more idiosyncratic goals produced by patients themselves. The key interlocutors that I engage in these articles with were selected based upon their openness to having lengthy and minimally structured conversations about their experiences in the military and their hopes and goals for their recovery. One feature that they all shared in common was being highly rated by their physical and occupational therapists on the various periodic evaluations that they were subjected to.
In general, across these three articles, the patients that I interviewed saw their goals as congruent with the over-arching program theme of returning to a pre-injury level of functioning. The key difference was that clinicians placed their emphasis on physical functioning and while the patients that I worked with also felt that goal was a priority there were other goals that did not fit so easily within that category. These goals tended to circulate around questions and issues of identity, meaning of injury, and the future. Patients face several disruptions as a result of their limb-loss and world making is an important aspect of their more personal notions of what constitutes recovery. This, more personal, focus on recovery could fit well with the overall program goals, but often put patients at a remove, or at cross purposes, with their therapists and physicians and was a source of tension which could have potentially negative implications in terms of how patients were evaluated.
Seth Messinger is an associate professor of anthropology in the Department of Sociology and Anthropology at the University of Maryland, Baltimore County. His current research looks at social reintegration of US military service-members in the aftermath of traumatic injury sustained in Afghanistan or Iraq.