STEVE INSKEEP, HOST:
The United States ended a 20-year war in Afghanistan over the summer. Its duty to the veterans of that war will not end for decades. So this week, we question President Biden's choice as secretary of Veterans Affairs. Denis McDonough met us in an office that overlooks the White House. His agency's job is to work with up to 19 million living American veterans of many wars.
DENIS MCDONOUGH: I have one job here, right? It's to take care of the vets, full stop.
INSKEEP: And after 20 years of war, the agency is under pressure to deliver, even though it is the largest health network in the United States. It offers health care, disability benefits and burials. Its services also include counseling and mental health, which some veterans needed as the U.S. withdrew from Afghanistan.
MCDONOUGH: In some instances, an intensification of distress because of the images. And that's veterans across eras, Vietnam-era veterans younger veterans, post-9/11 veterans.
INSKEEP: You're saying even people who did not serve in Afghanistan.
MCDONOUGH: Correct. We've heard that some of the imagery and some of the stories from Afghanistan impacted them. So they sought an intensification of services from us.
INSKEEP: Are you able to get mental health care in a timely manner to everybody who needs it?
MCDONOUGH: In general, the answer to that question, Steve, is yes, but there's inevitably going to be pockets where vets have to wait too long.
INSKEEP: McDonough says he heard about one such veteran on NPR. This week, our colleague Quil Lawrence described a military couple.
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QUIL LAWRENCE, BYLINE: Her husband has struggled on and off for nearly 10 years since he was wounded in a deadly attack in southern Afghanistan. He's got survivor's guilt. At least once, he's come close to suicide. But last month when he reached out to the VA for an initial psychiatric evaluation the soonest appointment was in March next year.
UNIDENTIFIED PERSON: And so it's it's kind of amazing to me that, you know, now looking at a system that's supposed to be so helpful is backlogged six months for an initial intake for somebody who has documented suicidal issues.
INSKEEP: And they reached out to the VA for help and were offered an appointment in March for something that is obviously urgent.
MCDONOUGH: Yeah. So I listened closely to the reporting. It is urgent. And I - you know, we feel like that overall cross-system average is if we have an urgent referral, we're meeting those urgent referrals in under two days.
INSKEEP: You said there are pockets where it's not working. You mean regions of the country where...
MCDONOUGH: I mean that inevitably, I fear that there's places where there's a wait time that's longer. I mean, that's the law of averages, A. But B, I just worry - in fact, this is my principal worry in this job - to make sure that vets get care on a timely basis. I won't rest in this job until that happens across the board, which is why I was so distressed to hear Quil's story and why we're working hard to try to make sure that we can get in touch with that vet.
INSKEEP: I want people to know, if they don't, that this agency is wrestling with people who've reported respiratory ailments that they believe are connected to burn pits in Iraq and Afghanistan. I feel like this is an issue that some people will know painfully well and other people not know at all. Would you define the problem as you see it?
MCDONOUGH: Yeah. Since 1991, we've been having military personnel in and out of a region that stretch stretches really, let's say, from Somalia up to Uzbekistan and all the countries in between.
INSKEEP: Iraq, Afghanistan.
MCDONOUGH: The - for two. We've had vets come home with ailments that they believe - and this - their doctors have told them are a result of toxic exposures that they were subjected to during that 30-year period.
INSKEEP: It's just burning trash on military bases.
MCDONOUGH: One example is burning trash, other pollution or just sand. I think it's a failing of the United States government that it took until now that anybody in that 30-year window has gotten any payment or benefits for the maladies that they've suffered in the meantime.
INSKEEP: This is not a small matter. A quarter of a million veterans have reported some exposure to airborne hazards overseas. Last summer, for the first time, the VA began presuming that some veterans' illnesses, like asthma, may be linked to the air they breathed overseas. That makes it easier to receive disability benefits and care. But the agency has yet to document a scientific link to far more serious conditions.
MCDONOUGH: We're now adding science from the Department of Defense, from the Department of Labor, from NIH, from HHS, from organizations like the firefighters so that we can, with urgency, see if we can't establish connection to these other conditions.
INSKEEP: I know you are hearing from activists who are saying, why are you not acting on what they know, what they've experienced.
MCDONOUGH: Yes.
INSKEEP: Military Times reported the story of a woman. She was a veteran. She was trying to stay healthy in Fallujah, Iraq. So she went running daily around a burn pit and had a doctor who was aware that this might be an issue and said, you should get tested early for breast cancer. And she had stage 4 breast cancer at the age of 38, which is remarkably young.
MCDONOUGH: And it's heartbreaking.
INSKEEP: You must have heard many stories like this.
MCDONOUGH: You know, I think we all have, Steve. We all have friends who have served in Iraq and Afghanistan. Almost to a person they tell me it was three months, six months before they felt like they could actually breathe normally again when they'd work out for example and they'd run. And so I've - what I found when I got here is the existing way of making those decisions was too narrow and sufficiently urgent and sufficiently publicly responsive. I've tried to answer those three charges - are we getting science from additional places? Are we recognizing that there may be a wider array of conditions associated with service? And are we doing this on an urgent basis consistent with a 38-year-old woman in stage 4 breast cancer, who is not afforded the luxury of time for us to consider these things?
INSKEEP: And if she came to you right now, you would have to tell her, no, that is not a qualifying...
MCDONOUGH: If she came to us and if she applied, if she filed a claim, we would adjudicate that claim. It would not be presumptively considered to be connected. I'm hoping we can get to the point where it is presumptively considered connected because that's the fastest way to get this done. It would be individually assessed.
INSKEEP: President Biden said a couple of years ago that he suspected that his son Beau Biden, who died of cancer, may have had an illness that was connected to his military service. Has he spoken to you about this?
MCDONOUGH: I've obviously spoken to him many times about Beau and about his obviously deep love for and longing for - the fact that he misses him so much. I've not talked at length with him about the specific connection, although when I most recently saw him, he - you know, he had mentioned this. And I hear that he has mentioned it to others. But let me make this point. He is constantly pushing us, constantly pushing us to get to decisions on this.
INSKEEP: Rosie Torres, who's an activist on this...
MCDONOUGH: Yes.
INSKEEP: ...Has said what you've done so far is breadcrumbs.
MCDONOUGH: Yeah, I know. And I'm not asking anybody to commend it. I have not met Rosie, but I've read extensively about her. And I admire her fortitude, and I appreciate the public accountability that she brings to us on this. And I hope one day to have - to convince her that we are doing the right thing and that we have done the right thing. I'm not suggesting that we have yet.
INSKEEP: Mr. Secretary, thanks so much.
MCDONOUGH: Thank you, Steve.
INSKEEP: And let's bring in another voice here. NPR's Quil Lawrence has covered veterans for years, and he was in the room when we spoke with Denis McDonough yesterday. Quil, good morning.
LAWRENCE: Hi.
INSKEEP: Why has it taken so long for the VA to determine how burn pits are affecting veterans?
LAWRENCE: Yeah, I mean, the VA over the years has progressed from denying them and disbelieving them and kind of gaslighting them, vets will tell you, to now, in recent years, inviting vets to sign up for this Burn Pit Registry. And a quarter million have reported that they think they have an illness linked to those burn pits. What the advocates still want to know is why they won't recognize, why the VA won't link deadly conditions like lung disease to these burn pits. They say there's enough evidence to do that. McDonough - you know, he's been in the job for nine months now. And he says that's a question that he's also asking, presumably, of his own department - why they haven't made those connections.
INSKEEP: Yeah. As we were talking, you got an impression of a guy who was a little baffled himself and wanted to know the answers. We got to talk about a lot of different things in this conversation, which went for quite some time. And one of them was the federal vaccine mandate. The VA has hundreds of thousands of employees who are supposed to get vaccinated - 400,000 employees. A lot of them have yet to document that. And so we asked McDonough about that. Let's listen.
MCDONOUGH: Right now what we're doing, Steve, is we're - we've started a disciplinary process. And step one of the disciplinary process is counseling. So we have - 70% of our employees have shown their record. I did it yesterday myself. I cop to the fact that that's a little late. I was supposed to have done it 10 days ago, but I did it yesterday myself. I uploaded...
INSKEEP: Did someone come and discipline you? Did you have to go through the counseling?
MCDONOUGH: I was trying to avoid the counseling.
INSKEEP: I see.
MCDONOUGH: So I uploaded it. I hope others are making the same decision.
INSKEEP: There's a lot at stake here, Quil - 400,000 people. Thirty percent have yet to verify their vaccination status. That's a hundred thousand federal employees. What happens to them?
LAWRENCE: Yeah. I mean, they're still tallying up these results to find out what the vaccination rate is across the VA workforce. He also mentioned that there's been a much higher number of people asking for religious exemptions than had asked to be exempt from, say, the flu vaccine mandate at the VA. And the VA is nationwide. And attitudes to the vaccine might mirror the nation's attitude. And whether they'll have to fire people and then face even worse shortages of providers is another question.
INSKEEP: Yeah. Now, how does McDonough's situation compare with that of other VA secretaries you've covered over the years?
LAWRENCE: He's confronting some of the same problems that his predecessors have struggled with. This week, he was in LA, which is sort of the epicenter of homeless veterans in this country. And he's vowed to house some veterans he found sleeping right outside the VA's West LA campus. If he's able to keep that promise and house hundreds of others he said he would get done by the end of the year, that'll be a good indication of whether he's going to be the one to fix many of these VA problems that have lasted so long.
INSKEEP: Quil, thanks for your insights on this occasion and many others. Good talking with you.
LAWRENCE: Thank you, Steve.
INSKEEP: That's NPR's Quil Lawrence.
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