Veterans for Common Sense

April 9, 2007 – Jon Town has spent the last few years fighting two battles, one against his body, the other against the US Army. Both began in October 2004 in Ramadi, Iraq. He was standing in the doorway of his battalion’s headquarters when a 107-millimeter rocket struck two feet above his head. The impact punched a piano-sized hole in the concrete facade, sparked a huge fireball and tossed the 25-year-old Army specialist to the floor, where he lay blacked out among the rubble.

“The next thing I remember is waking up on the ground.” Men from his unit had gathered around his body and were screaming his name. “They started shaking me. But I was numb all over,” he says. “And it’s weird because… because for a few minutes you feel like you’re not really there. I could see them, but I couldn’t hear them. I couldn’t hear anything. I started shaking because I thought I was dead.”

Eventually the rocket shrapnel was removed from Town’s neck and his ears stopped leaking blood. But his hearing never really recovered, and in many ways, neither has his life. A soldier honored twelve times during his seven years in uniform, Town has spent the last three struggling with deafness, memory failure and depression. By September 2006 he and the Army agreed he was no longer combat-ready.

But instead of sending Town to a medical board and discharging him because of his injuries, doctors at Fort Carson, Colorado, did something strange: They claimed Town’s wounds were actually caused by a “personality disorder.” Town was then booted from the Army and told that under a personality disorder discharge, he would never receive disability or medical benefits.

Town is not alone. A six-month investigation has uncovered multiple cases in which soldiers wounded in Iraq are suspiciously diagnosed as having a personality disorder, then prevented from collecting benefits. The conditions of their discharge have infuriated many in the military community, including the injured soldiers and their families, veterans’ rights groups, even military officials required to process these dismissals.

They say the military is purposely misdiagnosing soldiers like Town and that it’s doing so for one reason: to cheat them out of a lifetime of disability and medical benefits, thereby saving billions in expenses.

The Fine Print

In the Army’s separations manual it’s called Regulation 635-200, Chapter 5-13: “Separation Because of Personality Disorder.” It’s an alluring choice for a cash-strapped military because enacting it is quick and cheap. The Department of Veterans Affairs doesn’t have to provide medical care to soldiers dismissed with personality disorder. That’s because under Chapter 5-13, personality disorder is a pre-existing condition. The VA is only required to treat wounds sustained during service.

Soldiers discharged under 5-13 can’t collect disability pay either. To receive those benefits, a soldier must be evaluated by a medical board, which must confirm that he is wounded and that his wounds stem from combat. The process takes several months, in contrast with a 5-13 discharge, which can be wrapped up in a few days.

If a soldier dismissed under 5-13 hasn’t served out his contract, he has to give back a slice of his re-enlistment bonus as well. That amount is often larger than the soldier’s final paycheck. As a result, on the day of their discharge, many injured vets learn that they owe the Army several thousand dollars.

One military official says doctors at his base are doing more than withholding this information from wounded soldiers; they’re actually telling them the opposite: that if they go along with a 5-13, they’ll get to keep their bonus and receive disability and medical benefits. The official, who demanded anonymity, handles discharge papers at a prominent Army facility. He says the soldiers he works with know they don’t have a personality disorder. “But the doctors are telling them, this will get you out quicker, and the VA will take care of you. To stay out of Iraq, a soldier will take that in a heartbeat. What they don’t realize is, those things are lies. The soldiers, they don’t read the fine print,” he says. “They don’t know to ask for a med board. They’re taking the word of the doctors. Then they sit down with me and find out what a 5-13 really means–they’re shocked.”

Russell Terry, founder of the Iraq War Veterans Organization (IWVO), says he’s watched this scenario play itself out many times. For more than a year, his veterans’ rights group has been receiving calls from distraught soldiers discharged under Chapter 5-13. Most, he says, say their military doctors pushed the personality disorder diagnosis, strained to prove that their problems existed before their service in Iraq and refused to acknowledge evidence of posttraumatic stress disorder (PTSD), traumatic brain injury and physical traumas, which would allow them to collect disability and medical benefits.

“These soldiers are coming home from Iraq with all kinds of problems,” Terry says. “They go to the VA for treatment, and they’re turned away. They’re told, ‘No, you have a pre-existing condition, something from childhood.'” That leap in logic boils Terry’s blood. “Everybody receives a psychological screening when they join the military. What I want to know is, if all these soldiers really did have a severe pre-existing condition, how did they get into the military in the first place?”

Terry says that trying to reverse a 5-13 discharge is a frustrating process. A soldier has to claw through a thicket of paperwork, appeals panels and backstage political dealing, and even with the guidance of an experienced advocate, few are successful. “The 5-13,” he says, “it’s like a scarlet letter you can’t get taken off.”

In the last six years the Army has diagnosed and discharged more than 5,600 soldiers because of personality disorder, according to the Defense Department. And the numbers keep rising: 805 cases in 2001, 980 cases in 2003, 1,086 from January to November 2006. “It’s getting worse and worse every day,” says the official who handles discharge papers. “At my office the numbers started out normal. Now it’s up to three or four soldiers each day. It’s like, suddenly everybody has a personality disorder.”

The reason is simple, he says. “They’re saving a buck. And they’re saving the VA money too. It’s all about money.”

Exactly how much money is difficult to calculate. Defense Department records show that across the entire armed forces, more than 22,500 soldiers have been dismissed due to personality disorder in the last six years. How much those soldiers would have collected in disability pay would have been determined by a medical board, which evaluates just how disabled a veteran is. A completely disabled soldier receives about $44,000 a year. In a recent study on the cost of veterans’ benefits for the Iraq and Afghanistan wars, Harvard professor Linda Bilmes estimates an average disability payout of $8,890 per year and a future life expectancy of forty years for soldiers returning from service.

Using those figures, by discharging soldiers under Chapter 5-13, the military could be saving upwards of $8 billion in disability pay. Add to that savings the cost of medical care over the soldiers’ lifetimes. Bilmes estimates that each year the VA spends an average of $5,000 in medical care per veteran. Applying those numbers, by discharging 22,500 soldiers because of personality disorder, the military saves $4.5 billion in medical care over their lifetimes.

Town says Fort Carson psychologist Mark Wexler assured him that he would receive disability benefits, VA medical care and that he’d get to keep his bonus–good news he discussed with Christian Fields and Brandon Murray, two soldiers in his unit at Fort Carson. “We talked about it many times,” Murray says. “Jon said the doctor there promised him benefits, and he was happy about it. Who wouldn’t be?” Town shared that excitement with his wife, Kristy, shortly after his appointment with Wexler. “He said that Wexler had explained to him that he’d get to keep his benefits,” Kristy says, “that the doctor had looked into it, and it was all coming with the chapter he was getting.”

In fact, Town would not get disability pay or receive long-term VA medical care. And he would have to give back the bulk of his $15,000 bonus. Returning that money meant Town would leave Fort Carson less than empty-handed: He now owed the Army more than $3,000. “We had this on our heads the whole way, driving home to Ohio,” says Town. Wexler made him promises, he says, about what would happen if he went along with the diagnosis. “The final day, we find out, none of it was true. It was a total shock. I felt like I’d been betrayed by the Army.”

Wexler denies discussing benefits with Town. In a statement, the psychologist writes, “I have never discussed benefits with my patients as that is not my area of expertise. The only thing I said to Spc. Town was that the Chapter 5-13 is an honorable discharge…. I assure you, after over 15 years in my position, both as active duty and now civilian, I don’t presume to know all the details about benefits and therefore do not discuss them with my patients.”

Wexler’s boss, Col. Steven Knorr, chief of the Department of Behavioral Health at Evans Army Hospital, declined to speak about Town’s case. When asked if doctors at Fort Carson were assuring patients set for a 5-13 discharge that they’ll receive disability benefits and keep their bonuses, Knorr said, “I don’t believe they’re doing that.”

Not the Man He Used to Be

Interviews with soldiers diagnosed with personality disorder suggest that the military is using the psychological condition as a catch-all diagnosis, encompassing symptoms as diverse as deafness, headaches and schizophrenic delusions. That flies in the face of the Army’s own regulations.

According to those regulations, to be classified a personality disorder, a soldier’s symptoms had to exist before he joined the military. And they have to match the “personality disorder” described in the Diagnostic and Statistical Manual of Mental Disorders, the national standard for psychiatric diagnosis. Town’s case provides a clear window into how these personality disorder diagnoses are being used because even a cursory examination of his case casts grave doubt as to whether he fits either criterion.

Town’s wife, for one, laughs in disbelief at the idea that her husband was suffering from hearing loss before he headed to Iraq. But since returning, she says, he can’t watch TV unless the volume is full-blast, can’t use the phone unless its volume is set to high. Medical papers from Fort Carson list Town as having no health problems before serving in Iraq; after, a Fort Carson audiologist documents “functional (non-organic) hearing loss.” Town says his right ear, his “good” ear, has lost 50 percent of its hearing; his left is still essentially useless.

He is more disturbed by how his memory has eroded. Since the rocket blast, he has struggled to retain new information. “Like, I’ll be driving places, and then I totally forget where I’m going,” he says. “Numbers, names, dates–unless I knew them before, I pretty much don’t remember.” When Town returned to his desk job at Fort Carson, he found himself straining to recall the Army’s regulations. “People were like, ‘What are you, dumb?’ And I’m like, ‘No, I’m probably smarter than you. I just can’t remember stuff,'” he says, his melancholy suddenly replaced by anger. “They don’t understand–I got hit by a rocket.”

Those bursts of rage mark the biggest change, says Kristy Town. She says the man she married four years ago was “a real goofball. He’d do funny voices and faces–a great Jim Carrey imitation. When the kids would get a boo-boo, he’d fall on the ground and pretend he got a boo-boo too.” Now, she says, “his emotions are all over the place. He’ll get so angry at things, and it’s not toward anybody. It’s toward himself. He blames himself for everything.” He has a hard time sleeping and doesn’t spend as much time as he used to with the kids. “They get rowdy when they play, and he just has to be alone. It’s almost like his nerves can’t handle it.”

Kristy begins to cry, pauses, before forcing herself to continue. She’s been watching him when he’s alone, she says. “He kind of… zones out, almost like he’s in a daze.”

In May 2006 Town tried to electrocute himself, dropping his wife’s hair dryer into the bathtub. The dryer short-circuited before it could electrify the water. Fort Carson officials put Town in an off-post hospital that specializes in suicidal depression. Town had been promoted to corporal after returning from Iraq; he was stripped of that rank and reduced back to specialist. “When he came back, I tried to be the same,” Kristy says. “He just can’t. He’s definitely not the man he used to be.”

Town says his dreams have changed too. They keep taking him back to Ramadi, to the death of a good friend who’d been too near an explosion, taken too much shrapnel to the face. In his dreams Town returns there night after night to soak up the blood.

He stops his description for a rare moment of levity. “Sleep didn’t use to be like that,” he says. “I used to sleep just fine.”

How the Army determined then that Town’s behavioral problems existed before his military service is unclear. Wexler, the Fort Carson psychologist who made the diagnosis, didn’t interview any of Town’s family or friends. It’s unclear whether he even questioned Town’s fellow soldiers in 2-17 Field Artillery, men like Fields, Murray and Michael Forbus, who could have testified to his stability and award-winning performance before the October 2004 rocket attack. As Forbus puts it, before the attack Town was “one of the best in our unit”; after, “the son of a gun was deaf in one ear. He seemed lost and disoriented. It just took the life out of him.”

Town finds his diagnosis especially strange because the Diagnostic Manual appears to preclude cases like his. It says that a pattern of erratic behavior cannot be labeled a “personality disorder” if it’s from a head injury. The specialist asserts that his hearing loss, headaches and anger all began with the rocket attack that knocked him unconscious.

Wexler did not reply to repeated requests seeking comment on Town’s diagnosis. But Col. Knorr of Fort Carson’s Evans hospital says he’s confident his doctors are properly diagnosing personality disorder. The colonel says there is a simple explanation as to why in so many cases the lifelong condition of personality disorder isn’t apparent until after serving in Iraq. Traumatic experiences, Knorr says, can trigger a condition that has lain dormant for years. “They may have done fine in high school and before, but it comes out during the stress of service.”

“I’ve never heard of that occurring,” says Keith Armstrong, a clinical professor with the Department of Psychiatry at the University of California, San Francisco. Armstrong has been counseling traumatized veterans for more than twenty years at the San Francisco VA; most recently he is the co-author of Courage After Fire: Coping Strategies for Troops Returning From Iraq and Afghanistan and Their Families. “Personality disorder is a diagnosis I’m very cautious about,” he says. “My question would be, has PTSD been ruled out? It seems to me that if it walks like a duck, looks like a duck, let’s see if it’s a duck before other factors are implicated.”

Knorr admits that in most cases, before making a diagnosis, his doctors only interview the soldier. But he adds that interviewing family members, untrained to recognize signs of personality disorder, would be of limited value. “The soldier’s perception and their parents’ perception is that they were fine. But maybe they didn’t or weren’t able to see that wasn’t the case.”

Armstrong takes a very different approach. He says family is a “crucial part” of the diagnosis and treatment of soldiers returning from war. The professor sees parents and wives as so important, he encourages his soldiers to invite their families into the counseling sessions. “They bring in particular information that can be helpful,” he says. “By not taking advantage of their knowledge and support, I think we’re doing soldiers a disservice.”

Knorr would not discuss the specifics of Town’s case. He did note, however, that his department treats thousands of soldiers each year and says within that population, there are bound to be a small fraction of misdiagnosed cases and dissatisfied soldiers. He adds that the soldiers he’s seen diagnosed and discharged with personality disorder are “usually quite pleased.”

The Army holds soldiers’ medical records and contact information strictly confidential. But The Nation was able to locate a half-dozen soldiers from bases across the country who were diagnosed with personality disorder. All of them rejected that diagnosis. Most said military doctors tried to force the diagnosis upon them and turned a blind eye to symptoms of PTSD and physical injury.

One such veteran, Richard Dykstra, went to the hospital at Fort Stewart, Georgia, complaining of flashbacks, anger and stomach pains. The doctor there diagnosed personality disorder. Dykstra thinks the symptoms actually stem from PTSD and a bilateral hernia he suffered in Iraq. “When I told her my symptoms, she said, ‘Oh, it looks like you’ve been reading up on PTSD.’ Then she basically said I was making it all up,” he says.

In her report on Dykstra, Col. Ana Parodi, head of Behavioral Health at Fort Stewart’s Winn Army Hospital, writes that the soldier gives a clear description of PTSD symptoms but lays them out with such detail, it’s “as if he had memorized the criteria.” She concludes that Dykstra has personality disorder, not PTSD, though her report also notes that Dykstra has had “no previous psychiatric history” and that she confirmed the validity of his symptoms with the soldier’s wife.

Parodi is currently on leave and could not be reached for comment. Speaking for Fort Stewart, Public Affairs Officer Lieut. Col. Randy Martin says that the Army’s diagnosis procedures “have been developed over time, and they are accepted as being fair.” Martin said he could not address Dykstra’s case specifically because his files have been moved to a storage facility in St. Louis.

William Wooldridge had a similar fight with the Army. The specialist was hauling missiles and tank ammunition outside Baghdad when, he says, a man standing at the side of the road grabbed hold of a young girl and pushed her in front of his truck. “The little girl,” Wooldridge says, his voice suddenly quiet, “she looked like one of my daughters.”

When he returned to Fort Polk, Louisiana, Wooldridge told his doctor that he was now hearing voices and seeing visions, hallucinations of a mangled girl who would ask him why he had killed her. His doctor told him he had personality disorder. “When I heard that, I flew off the handle because I said, ‘Hey, that ain’t me. Before I went over there, I was a happy-go-lucky kind of guy.'” Wooldridge says his psychologist, Capt. Patrick Brady of Baynes-Jones Army Community Hospital, saw him for thirty minutes before making his diagnosis. Soon after, Wooldridge was discharged from Fort Polk under Chapter 5-13.

He began to fight that discharge immediately, without success. Then in March 2005, eighteen months after Wooldridge’s dismissal, his psychiatrist at the Memphis VA filed papers rejecting Brady’s diagnosis and asserting that Wooldridge suffered from PTSD so severe, it made him “totally disabled.” Weeks later the Army Discharge Review Board voided Wooldridge’s 5-13 dismissal, but the eighteen months he’d spent lingering without benefits had already taken its toll.

“They put me out on the street to rot, and if I had left things like they were, there would have been no way I could have survived. I would have had to take myself out or had someone do it for me,” he says. The way they use personality disorder to diagnose and discharge, he says, “it’s like a mental rape. That’s the only way I can describe it.”

Captain Brady has since left Fort Polk and is now on staff at Fort Wainwright, Alaska; recently he deployed to Iraq and was unavailable for comment. In a statement, Maj. Byron Strother, chief of the Department of Behavioral Health at Baynes-Jones hospital, writes that allegations that soldiers at Fort Polk are being misdiagnosed “are not true.” Strother says diagnoses at his hospital are made “only after careful consideration of all relevant clinical observation, direct examination [and] appropriate testing.”

If there are dissatisfied soldiers, says Knorr, the Fort Carson official, “I’ll bet not a single one of them has been diagnosed with conditions that are clear-cut and makes them medically unfit, like schizophrenia.”

Linda Mosier disputes that. When her son Chris left for Iraq in 2004, he was a “normal kid,” she says, who’d call her long-­distance and joke about the strange food and expensive taxis overseas. When he returned home for Christmas 2005, “he wouldn’t sit down for a meal with us. He just kept walking around. I took him to the department store for slacks, and he was inside rushing around saying, ‘Let’s go, let’s go, let’s go.’ He wouldn’t sleep, and the one time he did, he woke up screaming.”

Mosier told his mother of a breaking point in Iraq: a roadside bomb that blew up the truck in front of his. “He said his buddies were screaming. They were on fire,” she says, her voice trailing off. “He was there at the end to pick up the hands and arms.” After that Mosier started having delusions. Dr. Wexler of Fort Carson diagnosed personality disorder. Soon after, Mosier was discharged under Chapter 5-13.

Mosier returned home, still plagued by visions. In October he put a note on the front door of their Des Moines, Iowa, home saying the Iraqis were after him and he had to protect the family, then shot himself.

Mosier’s mother is furious that doctors at Fort Carson treated her son for such a brief period of time and that Wexler, citing confidentiality, refused to tell her anything about that treatment or give her family any direction on how to help Chris upon his return home. She does not believe her son had a personality disorder. “They take a normal kid, he comes back messed up, then nobody was there for him when he came back,” Linda says. “They discharged him so they didn’t have to treat him.”

Wexler did not reply to a written request seeking comment on Mosier’s case.

Thrown to the Wolves

Today Jon Town is home, in small-town Findlay, Ohio, with no job, no prospects and plenty of time to reflect on how he got there. Diagnosing him with personality disorder may have saved the Army thousands of dollars, he says, but what did Wexler have to gain?

Quite a lot, says Steve Robinson, director of veterans affairs at Veterans for America, a Washington, DC-based soldiers’ rights group. Since the Iraq War began, he says, doctors have been facing an overflow of wounded soldiers and a shortage of rooms, supplies and time to treat them. By calling PTSD a personality disorder, they usher one soldier out quickly, freeing up space for the three or four who are waiting.

Terry, the veterans’ advocate from IWVO, notes that unlike doctors in the private sector, Army doctors who give questionable diagnoses face no danger of malpractice suits due to Feres v. U.S., a 1950 Supreme Court ruling that bars soldiers from suing for negligence. To maintain that protection, Terry says, most doctors will diagnose personality disorder when prodded to do so by military officials.

That’s precisely how the system works, says one military official familiar with the discharge process. The official, who requested anonymity, is a lawyer with Trial Defense Services (TDS), a unit of the Army that guides soldiers through their 5-13 discharge. “Commanders want to get these guys out the door and get it done fast. Even if the next soldier isn’t as good, at least he’s good to go. He’s deployable. So they’re telling the docs what diagnosis to give to get what discharge.”

The lawyer says he knows this is happening because commanders have told him that they’re doing it. “Some have come to me and talked about doing this. They’re saying, ‘Give me a specific diagnosis. It’ll support a certain chapter.'”

Colonel Martin of Fort Stewart said the prospect of commanders pressuring doctors to diagnose personality disorder is “highly unlikely.” “Doctors are making these determinations themselves,” Martin says. In a statement, Col. William Statz, commander at Fort Polk’s Baynes-Jones hospital, says, “Any allegations that clinical decisions are influenced by either political considerations or command pressures, at any level, are untrue.”

But a second TDS lawyer, who also demanded anonymity, says he’s watched the same process play out at his base. “What I’ve noticed is right before a unit deploys, we see a spike in 5-13s, as if the commanders are trying to clean house, get rid of the soldiers they don’t really need,” he says. “The chain of command just wants to eliminate them and get a new body in there fast to plug up the holes.” If anyone shows even moderate signs of psychological distress, he says, “they’re kicking them to the curb instead of treating them.”

Both lawyers say that once a commander steps in and pushes for a 5-13, the diagnosis and discharge are carved in stone fairly fast. After that happens, one lawyer says he points soldiers toward the Army Board for Correction of Military Records, where a 5-13 label could be overturned, and failing that, advises them to seek redress from their representative in Congress. Town did that, contacting Republican Representative Michael Oxley of Ohio, with little success. Oxley, who has since retired, did not return calls seeking comment.

Few cases are challenged successfully or overturned later, say the TDS lawyers. The system, says one, is essentially broken. “Right now, the Army is eating its own. What I want to see is these soldiers getting the right diagnosis, so they can get the right help, not be thrown to the wolves right away. That is what they’re doing.”

Still, Town tries to remain undaunted. He got his story to Robinson of Veterans for America, who brought papers on his case to an October meeting with several top Washington officials, including Deputy Surgeon General Gale Pollock, Assistant Surgeon General Bernard DeKoning and Republican Senator Kit Bond of Missouri. There Robinson laid out the larger 5-13 problem and submitted a briefing specifically on Town.

“We got a very positive response,” Robinson says. “After we presented, they were almost appalled, like we are every day. They said, ‘We didn’t know this was happening.'” Robinson says the deputy surgeon general promised to look into Town’s case and the others presented to her. Senator Bond, whose son has served in Iraq, floated the idea of a Congressional hearing if the 5-13 issue isn’t resolved. The senator did not return calls seeking comment.

In the meantime, Town is doing his best to keep his head in check. He says his nightmares have been waning in recent weeks, but most of his problems persist. He’s thinking of going to a veterans support group in Toledo, forty-five miles north of Findlay. There will be guys there who have been through this, he says, vets who understand.

Town hesitates, his voice suddenly much softer. “I have my good days and my bad days,” he says. “It all depends on whether I wake up in Findlay or Iraq.”

Michael Johnson can’t go one day without sweating profusely, experiencing night terrors and venting his anger. It has been almost a year since the 40-year-old finished his tour of duty in Afghanistan, where he was left with many scars from endless days in the trenches.

But the scars are not from bullet wounds or as a result of combat. Johnson’s scars are ingrained in his memory from witnessing bloody and dismembered casualties of war.

“I was in combat all the time even though I never fired a gun,” Johnson said. “I experienced things people should never see. I don’t think people should live like this.”

Johnson, like many veterans who have returned from the war in the last four years, is suffering from Post-Traumatic Stress Disorder and other war- related medical problems.

U.S. Sen. Dick Durbin, D-Illinois, met with veterans Tuesday who served in the Middle East at the North Chicago Veterans Affairs Medical Center who are dealing with PTSD, and said treatment for the potentially debilitating disorder is long overdue.

“Without treatment, veterans with this issue are at high risk for alcohol and drug abuse, relationship problems and worse,” Durbin said.

Durbin estimates the prevalence of PTSD sufferers returning from Iraq and Afghanistan range from 15 to 30 percent. The wide range in estimates shows the difficulty in diagnosing PTSD and the complicated road ahead for the more than 200,000 to 300,000 veterans who seek VA treatment, he said.

A study released last month by the Department of Veterans Affairs reported that one-third of veterans coming back from the war who seek care at VA hospitals have some form of mental health issue.

Durbin said in the coming weeks he intends to continue visiting VA medical centers throughout the state in hopes of introducing legislation to improve the way the country responds to the many veterans who sustained injury during combat.

“Injured troops come home to find, in too many cases, substandard outpatient care and a big fight on their hands to justify the need for ongoing care,” he said.

Last week, the Senate passed a supplemental appropriations bill that contained $1.8 billion for the Department of Veterans Affairs, and the Veterans Health Administration was to receive $454 million for medical services, including $300 million for mental health enhancements to treat veterans.

David Reisberg, a former Army Ranger, said he supports the government stepping in and doing something to aid troops who suffer from PTSD.

“After we come back from our tour of duty, we don’t know where to go for help or who to ask for help,” Reisberg said.

Reisberg said when he finally did seek help from the VA, his medical records were lost and he was not able to receive treatment — an issue that Durbin is tired of hearing.

North Chicago VA social worker Nancy Gallagher, who consults with returning veterans, said thousands of veterans have been lost in the system and have experienced difficulty getting treatment. However, Gallagher said she has gotten word from government officials that those issue will be addressed.

“I mean it is unfortunate that something like that happens to our veterans,” she said. “That’s why it is important we work with the soldiers soon after they return home.”

But Cary resident Amanda Schumacher said every veterans does not seek help due to fear and the uncertainty of public perception.

“We are taught to be tough and be strong the whole time we are in the Army,” Schumacher said. “Once you get out of that environment it is tough to express your feelings. Not many people understand what it is like to be in war.”

The 22-year-old Army truck driver said she indulged herself in work and school after returning home from Iraq to not have to deal with her own issues.

“My family noticed I was totally different after I came home. I was depressed and angry, but I did not always know why.”

Dr. Tariq Hassan, chief of staff and the North Chicago VA, said it is important once a veteran returns home they immediately talk about their problems to a loved one or a counselor.

Hassan said many of the 300 patients, both inpatients and outpatients at the hospital, are assessed by doctors and then placed in group treatment where they are able to express their feelings to without ridicule.

Johnson said after being placed in a five-week program, he has seen a tremendous improvement in his condition.

“I probably will never be normal, but without this program I would probably be living in a car somewhere,” he said. “It saved my life.”

Hundreds of Thousands of Disability Claims Pending at VA; Current Wars Likely to Strain System Further

In his last years, World War II veteran Seymour D. Lewis would stand at the door of his home in Savannah, Ga., waiting for a letter that never arrived.

The family of the former Army private, who lost the hearing in his right ear to a grenade explosion in basic training in 1944, spent years wrestling with the federal bureaucracy for his disability benefits, at one point waiting more than a year just to be told to fill out more forms.

In 2001, the Department of Veterans Affairs started sending Lewis a monthly check for $200, an amount he appealed as too little and too late for the lasting physical sacrifice he made for his country, his family said. The appeal was still pending when Lewis died last year at age 80.

“Every time I would call, they would send me a new form to fill out, with exactly the same information that they already had,” said his son Frank A. Lewis, 61, a Navy veteran. “They run you around. They keep you dangling. . . . My father was elderly. He would wait at the front door for the mailman, waiting for something from the VA. When he would get a letter, he would anxiously open it, and when it said nothing, the depression he would go into was unreal. I have a feeling they were just waiting for my father to drop dead so they wouldn’t have to pay any money. It’s been one big nightmare.”

Hundreds of thousands of veterans, many approaching the winter of their lives, await VA disability claim decisions that will provide or deny a key source of income. The monthly payments, which range from $115 to $2,471 for individuals, are available to veterans of any age whose disability is “a result of disease or injury incurred or aggravated during active military service,” according to the Veterans Benefits Administration.

Nearly 400,000 disability claims were pending as of February, including 135,741 that exceeded VA’s 160-day goal for processing them. The department takes six months, on average, to process a claim, and the waiting time for appeals averages nearly two years.

This already strained system may grow more overburdened in years ahead as many of the troops deployed to Iraq and Afghanistan return from those wars, experts say. VA gives veterans from the current conflicts top priority in claims processing.

“The projected number of claims from the wars in Iraq and Afghanistan will rapidly turn the disability claims problem into a crisis,” said Linda J. Bilmes, a Harvard University professor of public policy who has studied the claims process and met with VA Secretary Jim Nicholson last month to discuss ways to improve it. Bilmes, who noted that those officially wounded in combat would be a small percentage of new veterans applying for compensation, estimated the long-term cost of providing them disability benefits at $70 billion to $150 billion.

Presidents, members of Congress and VA leaders have long promised to eliminate the backlog, but still the veterans wait. Some depict a cultural problem at VA — an attitude of indifference or hostility among claims workers, a lack of appreciation for veterans’ service reflected in snubbed phone calls, slow answers and repetitive paperwork. Some even believe the delays are deliberate, a way to keep costs down by deterring new claims or postponing awards until older veterans die.

“Once we can no longer be utilized as a soldier, we are of no use to them,” said Michael Foley, 52, a former Navy intelligence specialist who served in Vietnam and Cyprus during the 1970s. “There is an impression of indifference when you are dealing with the VA benefits people. They are going to get a paycheck no matter what.”

Foley has trouble sleeping and endures nightmares from things he saw in the service. The Thomasville, N.C., resident said he is in therapy for post-traumatic stress disorder, but VA denied the disability benefits claim that he filed more than 2 1/2 years ago. He has appealed. Foley also wants VA compensation for a heart procedure in 2004 that he says left him in the hospital for 137 days with complications that included a paralyzed right leg.

“A lot of people think all veterans want a handout. That’s not it,” said Foley, who is unemployed and lives on less than $1,100 a month, including a $240 VA pension. “When I was in the Navy, they asked me to do things. At the time, it was exciting. My grandfather warned me that this was going to come back and bite me . . . one day. And it has. I lost my job, my house and everything else.”

Ronald R. Aument, VA deputy undersecretary for benefits, acknowledged that the department needs to do better, but he rejected the idea that the delays and denials are motivated by money concerns.

“It’s not as though we’re working on commission here,” Aument said. “There is very much a shared passion in this organization in trying to do right by veterans. . . . As far as whether or not we treat people rudely, I would certainly hope that’s just an exception as opposed to the rule.”

The department fields 7 million phone calls about disability claims each year, he said. Forty-eight percent of the workers who handle claims are veterans. In part, the process is slow so that veterans have time to submit documents and other evidence bolstering their cases, Aument said.

The VA load is getting heavier. Disability-related claims rose to 806,000 in 2006 — a 39 percent increase from the claims filed in 2000. The workforce handling them grew by 36 percent over the same period, to 7,858 employees. VA officials expect 800,000 new claims this year.

Veterans’ disabilities are also growing more complex, with increasing claims for PTSD, diabetes (often tied to herbicide exposure in Vietnam) and multiple ailments. As the veteran population grows older, those who suffer from chronic, progressive conditions — heart, joint and hearing problems, for example — file repeat claims, which account for more than half of all claims, VA says.

Earl Armstrong, 87, a former Army technician from Ravenna, Ohio, is a repeat filer.

Armstrong drove an armored vehicle and won a Purple Heart and a Bronze Star while serving under Gen. George Patton in France and Germany in 1944. He suffers from PTSD and persistent ringing in his ears, the latter from the machine gun that was mounted a few feet from his head, he said. The problems have worsened, and for three years Armstrong and his wife have tried to persuade VA to raise his disability rating from 50 percent to 100 percent, which would more than triple the couple’s $781 monthly compensation to $2,610.

“I am sick of the VA and the way they’ve been treating us,” Armstrong said. “I can’t understand it. There’s too many [claims], I guess, and they don’t have enough people to handle them.”

VA handed out $34.5 billion in disability payments to more than 3.5 million veterans and their survivors last year. Aument said VA has increased its claims workforce by more than 580 people in the past year and plans to hire more than 400 additional staff by June. “The cornerstone of our long-term strategy is to develop more processing capacity,” he said.

It is too early to predict whether there will be a “huge surge” of claims from Iraq and Afghanistan veterans, Aument said, and claims for severe disabilities such as lost limbs are those VA can process fastest. Still, some older veterans say their younger counterparts are in for a rude awakening when they apply.

Army veteran Raymond L. Goings, 61, served as a military policeman in Vietnam from 1969 to 1971, an experience that left the Las Vegas resident with PTSD, he said. He praised his VA psychiatrists, but not the regional office that denied the disability claim he has pursued for three years.

“Basically they said I was never being shot at, that the things I told them I saw, I didn’t see,” said Goings, who has appealed. “They wanted dates and times, even though I tried to explain to them that there are a lot of things about combat that I can’t remember.”

Jerrel Cook of Joplin, Mo., another Army veteran, breathes with the help of an oxygen tank and suffers from asthma, chronic bronchitis, hearing loss, hypertension and thyroid problems. Cook, 62, blames biological and chemical testing in Alaska while he was stationed there in the mid-1960s. VA has denied his five-year-old disability claim.

“They are playing a waiting game,” he said. “It’s easier to stall out until the veteran dies rather than to pay his claim. . . . This is ongoing practice with the VA, and it’s certainly something that needs to be corrected.”

DUNBAR, Pennsylvania — Blinded and disabled on the 54th day of the war in Iraq, Sam Ross returned home to a rousing parade that outdid anything this small, depressed Appalachian town had ever seen. “Sam’s parade put Dunbar on the map,” his grandfather said.

That was then.

Now Mr. Ross, 24, faces charges of attempted homicide, assault and arson in the burning of a family trailer in February. Nobody in the trailer was hurt, but Mr. Ross fought the assistant fire chief who reported to the scene, and later threatened a state trooper with his prosthetic leg, which was taken away from him, according to the police.

The police locked up Mr. Ross in the Fayette County prison. In his cell, he tried to hang himself with a sheet. After he was cut down, Mr. Ross was committed to a state psychiatric hospital, where, he said in a recent interview there, he is finally getting — and accepting — the help he needs, having spiraled downward in the years since the welcoming fanfare faded.

“I came home a hero, and now I’m a bum,” Mr. Ross, whose full name is Salvatore Ross Jr., said.

The story of Sam Ross has the makings of a ballad, with its heart-rending arc from hardscrabble childhood to decorated war hero to hardscrabble adulthood. His effort to create a future for himself by enlisting in the Army exploded in the desert during a munitions disposal operation in Baghdad. He was 20.

He was also on his own. Mr. Ross, who is estranged from his mother and whose father is serving a life sentence for murdering his stepmother, does not have the family support that many other severely wounded veterans depend on. Various relatives have stepped in at various times, but Mr. Ross, embittered by a difficult childhood and by what the war cost him, has had a push-pull relationship with those who sought to assist him.

Several people have taken a keen interest in Mr. Ross, among them Representative John P. Murtha, the once-hawkish Democrat from Pennsylvania. When Mr. Murtha publicly turned against the war in Iraq in 2005, he cited the shattered life of Mr. Ross, one of his first constituents to be seriously wounded, as a pivotal influence.

Mr. Murtha’s office assisted Mr. Ross in negotiating the military health care bureaucracy. Homes for Our Troops, a nonprofit group based in Massachusetts, built him a beautiful log cabin. Military doctors carefully tended Mr. Ross’s physical wounds: the loss of his eyesight, of his left leg below the knee and of his hearing in one ear, among other problems.

But that help was not enough to save Mr. Ross from the loneliness and despair that engulfed him. Overwhelmed by severe symptoms of post-traumatic stress disorder, including routine nightmares of floating over Iraq that ended with a blinding boom, he “self-medicated” with alcohol and illegal drugs. He finally hit rock bottom when he landed in the state psychiatric hospital, where he is, sadly, thrilled to be.

“Seventeen times of trying to commit suicide, I think it’s time to give up,” Mr. Ross said, speaking in the forensic unit of the Mayview State Hospital in Bridgeville. “Lots of them were screaming out cries for help, and nobody paid attention. But finally somebody has.”

Finding a Way Out

Fayette County in southwestern Pennsylvania, once a prosperous coal mining center, is now one of the poorest counties in the state. The bucolic but ramshackle town of Dunbar sits off State Route 119 near the intersection marked by the Butchko Brothers junkyard.

Past the railroad tracks and not far up Hardy Hill Road, the blackened remains of Mr. Ross’s hillside trailer are testament to his disintegration. The Support our Troops ribbon is charred, the No Trespassing sign unfazed.

Mr. Ross lived in that trailer, where his father shot his stepmother, at several points in his life, including alone after he returned from Iraq. Its most recent tenant, his younger brother, Thomas, was in jail when the fire occurred.

Many in Mr. Ross’s large, quarreling family are on one side of the law or the other, prison guards or prisoners, police officers or probationers. Their internal feuds are so commonplace that family reunions have to be carefully plotted with an eye to who has a protective order out against whom, Mr. Ross’s 25-year-old cousin, Joseph Lee Ross, joked.

Sam Ross’s childhood was not easy. “Sam’s had a rough life from the time he was born,” his grandfather, Joseph Frank Ross, said. His parents fought, sometimes with guns, until they separated and his mother moved out of state. Mr. Ross bore some of the brunt of the turmoil.

“When that kid was little, the way he got beat around, it was awful,” his uncle, Joseph Frank Ross Jr., a prison guard, said.

When he was just shy of 12, Mr. Ross moved in with his father’s father, who for a time was married to his mother’s mother. The grandfather-grandson relationship was and continues to be tumultuous.

“I idolized my grandpaps, but he’s an alcoholic and he mentally abuses people,” Mr. Ross said.

His grandfather, 72, a former coal miner who sells used cars, said, “I’m not an alcoholic. I can quit. I just love the taste of it.”

The grandfather, who still keeps an A-plus English test by Mr. Ross on his refrigerator, said his grandson did well in school, even though he cared most about his wrestling team, baseball, hunting and fishing. Mr. Ross graduated in June 2001.

“Sammy wanted me to pay his way to college, but I’m not financially fixed to do that,” his grandfather said.

Feeling that Fayette County was a dead end, Mr. Ross said he had wanted to find a way out after he graduated. One night in late 2001, he said, he saw “one of those ‘Be all you can be’ ads” on television. The next day, he went to the mall and enlisted, getting a $3,000 bonus for signing up to be a combat engineer.

From his first days of basic training, Mr. Ross embraced the military as his salvation. “It was like, ‘Wow, man, I was born for the Army,’ ” he said. “I was an adrenaline junkie. I was super, super fit. I craved discipline. I wanted adventure. I was patriotic. I loved the bonding. And there was nothing that I was feared of. I mean, man, I was made for war.”

In early 2003, Private Ross, who earned his jump wings as a parachutist, shipped off to Kuwait with the 82nd Airborne Division, which pushed into Iraq with the invasion in March. The early days of the war were heady for many soldiers like Private Ross, who reveled in the appreciation of Iraqis. He was assigned to an engineer squad given the task of rounding up munitions.

On May 18, Private Ross and his squad set out to de-mine an area in south Baghdad. Moving quickly, as they did on such operations, he collected about 15 UXO’s, or unexploded ordnances, in a pit. Somehow, something — he never learned what — caused them to detonate.

“The initial blast hit me and I went numb and everything went totally silent,” he said. “Then I hear people start hollering, ‘Ross! Ross! Ross!’ It started getting louder, louder, louder. My whole body was mangled. I was spitting up blood. I faded in and out. I was bawling my eyes out, saying, ‘Please don’t let me go; don’t let me go.’ ”

A Casualty of War

When his relatives first saw Mr. Ross at Walter Reed Army Hospital in Washington, he was in a coma. “That boy was dead,” his grandfather said. “We was looking at a corpse lying in that bed.”

As he lay unconscious, the Army discharged him — one year, four months and 18 days after he enlisted, by his calculation. After 31 days, Mr. Ross came off the respirator. Groggily but insistently, he pointed to his eyes and then to his leg. An aunt gingerly told him he was blind and an amputee. He cried for days, he said.

It was during Mr. Ross’s stay at Walter Reed that Representative Murtha, a former Marine colonel, first met his young constituent and presented him with a Purple Heart.

From the start of the war, Mr. Murtha said in an interview, he made regular, painful excursions to visit wounded soldiers. Gradually, those visits, combined with his disillusionment about the Bush administration’s management of the war, led him to call in late 2005 for the troops to be brought home in six months.

“Sam Ross had an impact on me,” Mr. Murtha said. “Eventually, I just felt that we had gotten to a point where we were talking so much about winning the war itself — and it couldn’t be won militarily — that we were forgetting about the results of the war on individuals like Sam.”

Over the next three years, Mr. Ross underwent more than 20 surgical procedures, including: “Five on my right eye, one on my left eye, two or three when they cut my left leg off, three or four on my right leg, a couple on my throat, skin grafts, chest tubes and, you know, one where they gutted me from belly button to groin” to remove metal fragments from his intestines.

But, although he was prescribed psychiatric medication, he never received in-patient treatment for the post-traumatic stress disorder that was diagnosed at Walter Reed. And, in retrospect he, like his relatives, said he believes he should have been put in an intensive program soon after his urgent physical injuries were addressed.

“They should have given him treatment before they let him come back into civilization,” his grandfather said.

A Hero’s Welcome

The parade, on a sunny day in late summer 2003, was spectacular. Hundreds of flag-waving locals lined the streets. Mr. Ross had just turned 21. Wearing his green uniform and burgundy beret, he rode in a Jeep, accompanied by other veterans and the Connellsville Area Senior High School Marching Band. The festivities included bagpipers, Civil War re-enactors and a dunking pool.

“It wasn’t the medals on former Army Pfc. Sam Ross’s uniform that reflected his courage yesterday,” The Pittsburgh Post-Gazette wrote. “It was the Dunbar native’s poise as he greeted well-wishers and insisted on sharing attention with other soldiers that proved the grit he’ll need to recover from extensive injuries he suffered in Iraq.”

For a little while, “it was joy joy, happiness happiness,” Mr. Ross said. He felt the glimmerings of a new kind of potential within himself, and saw no reason why he could not go on to college, even law school. Then the black moods, the panic attacks, the irritability set in. He was dogged by chronic pain; fragments of metal littered his body.

Mr. Ross said he was “stuck in denial” about his disabilities. The day he tried to resume a favorite pastime, fishing, hit him hard. Off-balance on the water, it came as a revelation that, without eyesight, he did not know where to cast his rod. He threw his equipment in the water and sold his boat.

“I just gave up,” he said. “I give up on everything.”

About a year after he was injured, Mr. Ross enrolled in an in-patient program for blind veterans in Chicago. He learned the Braille alphabet, but his fingers were too numb from embedded shrapnel to read, he said. He figured that he did not have much else to learn since he had been functioning blind for a year. He left the program early.

Similarly, Mr. Ross repeatedly declined outpatient psychiatric treatment at the veterans hospital in Pittsburgh, according to the Department of Veterans Affairs. He said he felt that people at the hospital had disrespected him.

After living with relatives, Mr. Ross withdrew from the world into the trailer on the hill in 2004. That year, he got into a dispute with his grandfather over old vehicles on the property, resolving it by setting them on fire. His run-ins with local law enforcement, which did not occur before he went to Iraq, the Fayette County sheriff said, had begun.

But his image locally had not yet been tarnished. In early 2005, Mr. Murtha held a second Purple Heart ceremony for Mr. Ross at a Fayette County hospital “to try to show him how much affection we had for him and his sacrifice,” Mr. Murtha said.

A local newspaper article about Mr. Ross’s desire to build himself a house came to the attention of Homes for Our Troops.

“He’s a great kid; he really is,” said Kirt Rebello, the group’s director of projects and veterans affairs. “Early on, even before he was injured, the kid had this humongous deck stacked against him in life. That’s one of the reasons we wanted to help him.”

Mr. Ross, who had received a $100,000 government payment for his catastrophic injury, bought land adjacent to his grandfather’s. Mr. Rebello asked Mr. Ross whether he might prefer to move to somewhere with more services and opportunities. But Mr. Ross said that Dunbar’s winding roads were implanted in his psyche, “that he could see the place in his mind,” Mr. Rebello said.

A Life Falls Apart

In May 2005, Mr. Ross broke up with a girlfriend and grew increasingly depressed. He felt oppressively idle, he said. One day, he tacked a suicide note to the door of his trailer and hitched a ride to a trail head, disappearing into the woods. A daylong manhunt ensued.

Mr. Ross fell asleep in the woods that night, waking up with the sun on his face, which he took to be a sign that God wanted him to live. When he was found, he was taken to a psychiatric ward and released after a few weeks.

The construction of his house proved a distraction from his misery. Mr. Ross enjoyed the camaraderie of the volunteers who fashioned him a cabin from white pine logs. But when the house, which he named Second Heaven, was finished in early 2006, “they all left, I moved in and I was all alone,” he said. “That’s when the drugs really started.”

At first, Mr. Ross said, he used drugs — pills, heroin, crack and methadone — “basically to mellow myself out and to have people around.” Local ne’er-do-wells enjoyed themselves on Mr. Ross’s tab for quite some time, his relatives said.

“These kids were loading him into a car, taking him to strip clubs, letting him foot the bills,” his uncle, Joseph Ross Jr., said. “They were dopies and druggies.”

Mr. Ross’s girlfriend, Barbara Hall, moved in with him. But relationships with many of his relatives had deteriorated.

“If that boy would have come home and accepted what happened to him, that boy never would have wanted for anything in Dunbar,” his grandfather said. “If he had accepted that he’s wounded and he’s blinded, you know? He’s not the only one that happened to. There’s hundreds of boys like him.”

Some sympathy began to erode in the town, too. “There’s pro and con on him,” a local official said. “Some people don’t even believe he’s totally blind.”

After overdosing first on heroin and then on methadone last fall, Mr. Ross said, he quit consuming illegal drugs, replacing them with drinking until he blacked out.

Mr. Ross relied on his brother, Thomas, when he suffered panic attacks. When Thomas was jailed earlier this year, Mr. Ross reached out to older members of his family. In early February, his uncle, Joseph Ross Jr., persuaded him to be driven several hours to the veterans’ hospital in Coatesville to apply for its in-patient program for post-traumatic stress disorder.

“Due to the severity of his case, they accepted him on the spot and gave him a bed date for right after Valentine’s Day,” his uncle said. “Then he wigged out five days before he was supposed to go there.”

It started when his brother’s girlfriend, Monica Kuhns, overheard a phone call in which he was arranging to buy antidepressants. She thought it was a transaction to buy cocaine, he said, and he feared that she would tell his sister and brother.

After downing several beers, Mr. Ross, in a deranged rage, went to his old trailer, where Ms. Kuhns was living with her young son, he said.

“He started pounding on the door,” said Ms. Hall, who accompanied him. “He went in and threatened to burn the place down. Me and Monica didn’t actually think he was going to do it. But then he pulled out the lighter.”

Having convinced himself that the trailer — a source of so much family misery — needed to be destroyed, Mr. Ross set a pile of clothing on fire. The women and the child fled. When a volunteer firefighter showed up, Mr. Ross attacked and choked him, according to a police complaint.

A judge set bail at $250,000. In the Fayette County prison, Mr. Ross got “totally out of hand,” the sheriff, Gary Brownfield, said. Mr. Ross’s lawyer, James Geibig, said the situation was a chaotic mess.

“It was just a nightmare,” Mr. Geibig said. “First the underlying charges — attempted homicide, come on — were blown out of proportion. Then bail is set sky high, straight cash. They put him in a little cell, in isolation, and barely let him shower. Things went from bad to worse until they found him hanging.”

Now Mr. Geibig’s goal is to get Mr. Ross sentenced into the post-traumatic stress disorder program he was supposed to attend.

“He does not need to be in jail,” Mr. Geibig said. “He has suffered enough. I’m not a bleeding heart, but his is a pretty gut-wrenching tale. And at the end, right before this incident, he sought out help. It didn’t arrive in time. But it’s not too late, I hope, for Sam Ross to have some kind of future.”

BECKLEY, West Virginia — Senator Jay Rockefeller has asked Veterans Affairs Secretary Jim Nicholson to investigate complaints of chronic staffing shortages and low morale at the Beckley VA Medical Center.

Rockefeller, D-W.Va., said he has received numerous complaints about the hospital. He said the hospital’s administration has ignored the problems.

“I have complained about it for a long time,” said Rockefeller, “but the secretary was given false information about Beckley, by Beckley, about the shortages, and therefore they were satisfied there wasn’t a problem, so nothing happened.”

There currently are nine physician vacancies and ten other provider vacancies, hospital officials said.

Many nurses and doctors in the VA health care system will not fill open positions at the Beckley hospital because it has a negative reputation, said Rockefeller, chairman of the Senate Veterans Affairs Committee.

“I can’t put it any more bluntly than that. I’m sure it will be denied by them, but it’s the truth,” he said.

Jerry Husson, director of the Beckley hospital, defended the quality of care provided by the hospital. He said staffing shortages are not a problem.

“Did the physicians have a hard time for a while? Certainly. When they were down they were pulling some extra duties,” he said. “At one time people just opted to go. Every one of them that left said to me that they were either going for personal reasons or they were leaving for family reasons.”

Dr. Andrew Thymius, who worked at the hospital until May 2005, said the facility could not meet the demand for services. He said patients had to wait months for appointments.

“It’s cruel to make them wait that long. They run on HMO mentality. So if you see the patient face to face, it tends to be not what they want. They want more indirect patient care than direct,” Thymius said.

The federal government mandated an onsite training program, “Civility and Respect in the Workplace,” at the hospital after a national VA employee survey last year indicated low morale at the facility.

LOS ANGELES, April 2 — Five deaths in recent months at the nation’s largest Veterans Affairs medical complex are troubling and could be a further sign of a system badly in need of closer oversight, two members of Congress said here Monday.

The deaths occurred in residential rehabilitation or emergency housing programs at the West Los Angeles Healthcare Center from November to February.

“What is going on here?” Representative Jane Harman, a Democrat whose district includes neighborhoods adjacent to the complex, said at a House Veterans’ Affairs Committee meeting on veterans’ health care in the Los Angeles area.

The committee chairman, Representative Bob Filner, a Democrat from San Diego, noted that the five deaths here, mostly involving veterans with a history of substance abuse or mental health problems, coincided with anecdotal reports of suicides among other deaths at additional V.A. hospitals across the country.

Mr. Filner said the Veterans Affairs Department had not been sufficiently forthcoming about such episodes.

“There are errors all the time,” he said, “and we have to get that down to zero. But what I object to is a V.A. that seems to want to cover it up.”

The hospital’s director, Charles Dorman, told the panel that the deaths were “unfortunate” but were an occasionally inevitable outcome of treating people troubled by substance abuse or mental problems.

“We take a big chance, a big risk, taking care of a difficult population,” Mr. Dorman said after testifying. “And I’m proud of the work we do.”

Three of the five deaths occurred at a rehabilitation clinic called the Domiciliary, which treats veterans with physical, mental or substance abuse problems in a setting much like that of a dormitory.

One of the men, Justin Bailey, 27, an Iraq war veteran who was suffering from a groin injury and post-traumatic stress disorder, overdosed on the prescription painkiller methadone and died on Jan. 27, officials said.

Members of Mr. Bailey’s family said that they had warned officials that he might have abused prescription medication in the past. But V.A. officials said that this had not been clear to the staff and that he had been allowed to take the medicine without supervision, in keeping with common practice at the facility.

Five days later, Mark Torres, 55, who was undergoing treatment for abuse of heroin, died at the Domiciliary, apparently of an overdose of that drug. A third man died there that day, but officials said his death appeared to stem from medical complications, not substance abuse.

The deaths of Mr. Bailey and Mr. Torres prompted changes in security and procedures at the Domiciliary, including additional clinical workers and searches for contraband drugs, Dr. Dean C. Norman, the hospital’s chief of staff, said in a recent interview. The V.A.’s medical inspector is investigating the deaths, as is a panel of doctors commissioned by the department.

The two other deaths occurred in November and February at the Haven, an emergency shelter for homeless veterans on the grounds that is run by the Salvation Army. They involved veterans in their 50s with a history of medical complications and substance abuse, V.A. officials said, though the coroner has not yet ruled on the cause of death in these cases.

A newborn baby was one of at least 14 children and adults killed when a suicide bomber detonated a lorry laden with explosives close to a primary school in the northern Iraqi city of Kirkuk yesterday.

The latest massacre of Iraqi children came as 21 Shia market workers were ambushed, bound and shot dead north of the capital. The victims came from the Baghdad market visited the previous day by John McCain, the US presidential candidate, who said that an American security plan in the capital was starting to show signs of progress.

The Kirkuk bloodshed erupted when a bomber driving a truck full of explosives hidden by sacks of flour targeted an Iraqi police station that US soldiers were visiting. The full force of the blast hit a nearby primary school.

Buthayna Mahmud, 10, was horrified to see the bodies of her classmates strewn on the ground in flames. “Everyone I saw was wearing the blue school uniform drenched with blood. Some of their dresses were torn. I only saw fire. I heard teachers and students shouting,” she said. “When we rushed out of the school, we saw pupils on the ground, some of them burning.”

“We were at the last lesson and we heard the explosion. I saw two of my classmates sitting near the window. They fell on the floor, drenched in blood,” said Naz Omar, a girl in the fifth form. “They could not speak. I was terrified. I said, ‘God is Great. I need my mother. I need my father’.”

Terrified children fled the carnage in the ethnically mixed city of Kurds, Turkomans and Arabs, many of whom were settled there by Saddam Hussein in an attempt to “Arabicise” Kirkuk and “ethnically cleanse” it of Kurds. Local observers said that the death toll among the school children would have been worse if most of the pupils had not been inside when the bomber struck.

Terrorists in Iraq have frequently killed large groups of children, either while aiming at nearby American or Iraqi security forces or as an end in itself. US forces said last month that two children had been used by terrorists to sneak a car bomb through a checkpoint and it had been detonated while they were still inside.

As well as the killings of the children and the Shia market vendors, four people were blown up by another suicide bomber at a police checkpoint in Baghdad, while a roadside bomb killed four civilians in a Shia town just north of Baghdad. Yet another roadside bomb killed an Iraqi soldier and wounded seven others near the Iranian border. The US announced the deaths of six of its soldiers at the weekend.

More than 600 Iraqis have been killed in the past week despite a US-Iraqi security plan to quell violence in the capital. Most of the killings have been the result of truck bombs outside Baghdad.

Mr. McCain said that the situation was showing signs of improvement and blamed waning support in the United States for the war on the media, which were portraying an overly negative image of the crisis.

Kirkuk is seen as a potentially explosive fault line between various ethnic and religious groups because it sits on a vast reserve of crude oil and is claimed by the Kurds as part of their autonomous northern region. Their claims have elicited fears from Sunni Arabs that the Kurds and the Shia, who control the oil-rich south, are trying to cut the once-powerful Sunni minority out of the country’s mineral wealth.

It took 15 months and a phone call to U.S. Rep. Harry Mitchell before Iraq war veteran Ruben Gallego could get treatment for his injured knee. Gallego left the Marines in September 2005 and didn’t seek help right away. Once he did, delays and roadblocks he encountered with the Veterans Health Administration left him feeling frustrated and abandoned by the country he risked his life to serve.

“I was willing to give the ultimate sacrifice to my country,” he said. “All we ask of the government in return is some adequate response, some assistance.”

Though not as shocking as crippled soldiers left to fend for themselves in cockroach-infested outpatient housing at Walter Reed Army Medical Center, problems within the VA health care system – including long waits, backlogged claims and computer snafus – have drawn scrutiny in the wake of the Walter Reed scandal.

That’s despite the fact that it’s run by a separate civilian agency, the U.S. Department of Veterans Affairs, whose leaders have won raves for turning crumbling urban hospitals into national models.

The government-run, single payer health care system cares for some 5.8 million veterans, including 2,000 Phoenix-area soldiers who served in Iraq and Afghanistan. Roughly 64,000 local veterans were treated last year at the Carl T. Hayden VA Medical Center or one of its four area clinics, including the Southeast Health Care Clinic in Mesa.

The VA has earned accolades in recent years for patient care and satisfaction, lower prescription drug prices and its electronic medical records system.

But, symbolic of its bureaucratic challenges, VA computers still can’t get medical data from the Defense Department on newly discharged soldiers.

Staffing shortages and bales of paperwork have health care workers putting in nights and weekends to keep up. The Phoenix hospital, for example, is down five psychiatrists. It has opened a Saturday clinic, which has seen up to 150 patients, to keep up with the needs of new veterans.

And the kinds of injuries suffered in the Middle East conflicts have put tremendous strains on mental health and neurology programs. A new support group for posttraumatic stress disorder was launched last month at the Mesa clinic.

“Anytime that demand exceeds supply, it’s a problem,” said Dr. Keith Piatt, associate chief of staff for ambulatory care at the Phoenix VA Medical Center. “There have been some that have fallen through the cracks. We want the patients to call. We want to fix the problems.”

At the same time, the Veterans Benefits Administration, which deems veterans eligible for health care, has 400,000 men and women – including nearly 7,400 Arizonans of which 703 served in Iraq or Afghanistan – caught in a claims processing backlog. It takes an average of nearly six months for an Arizona veteran’s claim to be processed.

Mitchell, D-Ariz., and other congressional Democrats have vowed to take care of the country’s veterans. In the wake of news reports last month about conditions at Walter Reed, they have toured VA and military hospitals, passed legislation to beef-up funding and staffing, and called for quicker turnarounds for disability claims.

“Too many soldiers are finding an endless stream of red tape as they try and secure the benefits they have earned in the VA system,” Mitchell, a former Tempe mayor and civics teacher, said in a floor speech last month.

Mitchell held a hearing as chairman of an oversight subcommittee of the Veterans’ Affairs Committee, taking testimony from Arizona veterans about their difficulty getting care from military and VA hospitals.

Like testimony during the congressional hearings, complaints in the Phoenix VA hospital system deal mostly with out-patient access to care, rather than quality of care. Veterans are frustrated about long waits to see specialists, delays in scheduling and phone calls that go unanswered.

“Our biggest concerns are in our outpatient,” said Sue Colvin, the VA’s patient advocate coordinator. “Our veterans were having problems with just not being able to get ahold of anybody.”

Colvin said a new phone system for appointment scheduling has corrected most of that problem, but concerns remain, particularly among older veterans, that they’re not getting treatment in a timely manner.

Mesa veteran John Pancrazio was repulsed by the VA after he returned to his native Iowa from three tours in Vietnam.

“I went to the VA hospital and didn’t go back for 30 years,” he said. “They were uncaring and rotten and I wanted nothing to do with them.”

Still, he spent the past 15 years helping veterans become eligible for VA benefits as a service officer for the Vietnam Veterans of America. In 2000, he gave the health care system another chance, found “they had completely reversed it” and filed his own disability claim.

Pancrazio said Vietnam vets are instrumental in helping returning combat soldiers get the care they need.

“We were basically abandoned by the other veterans organizations when we returned,” Pancrazio said. “Our founding principle is: Never again will one generation abandon another.

But claims get lost and workers get behind, he said. Veterans shouldn’t try to complete the paperwork alone, he said. Service organizations and the Phoenix office of the Veterans Benefits Administration have counselors who can help.

“A lot of times, people will file a claim on their own and it’ll be denied and they can’t figure out why,” he said. “They’ll just give up.”

Ruben Gallego refused to give up. He first noticed the pain in his left knee during his stint as a Marine infantryman in Iraq in 2005. Each step caused a jabbing sensation in his leg.

He saw other U.S. service men and women suffer far worse combat injuries nearly every day, however, and he wanted to remain with his unit. So Gallego continued to strap on his armor and equipment and go on patrol.

“Sometimes it hurt, sometimes it didn’t,” said Gallego, a 27-year-old corporal. “So I could always push off the pain a little while longer.”

Over time, the knee became deformed, as if a tennis ball had been lodged under his skin.

When his tour ended, he took a few months to clear his head and then called the VA to get treatment for his knee, which prevents him from jogging or walking long distances. Iraq and Afghanistan combat veterans are entitled to two years of free health care upon release from active duty.

The first VA doctor referred Gallego to a specialist, who referred him to another specialist for a second opinion. After two months without hearing from any of the physicians and still without even a diagnosis, Gallego said, he started calling the first specialist.

“He hadn’t even read the report or even talked to the other doctor,” he said. “This happens all the time with the VA, it seems. It’s like I just keep falling through the cracks.

In frustration, he called Mitchell and soon afterward, he said, he was contacted by the VA. The physicians had agreed on a treatment plan.

“There are veterans out there that are in a lot worse shape than I am,” he said. “I just hope that they’re getting much better treatment than I am.”

Social worker Pat Tuli has met many of those veterans through her work as the point of contact at the Phoenix VA hospital for Iraq and Afghanistan veterans.

She helps them fill out forms, coordinates their care and generally holds their hands. She’s created three new support groups and reaches out to community organizations and state and local agencies for extra help.

“They have a lot of issues just based on where they were and what they were exposed to over there,” she said. “As we find problems, we start putting things into place to help solve them.”

Tuli and other VA staff have adjusted schedules and taken on extra duties to accommodate the influx of new patients. But Tuli remains a one-woman show, pedaling as fast as she can.

“We’re working at full capacity and we’re working overtime and we’re working late,” she said. “We’re getting to the point where it’s difficult to manage.”