Cynthia M.A. Geppert

Memorial Day is the most solemn of all American military commemorations. It is the day when we honor those who sacrificed their lives so that their fellow citizens could flourish in freedom. At 3 PM, a grateful nation is called to observe 2 minutes of silence in remembrance of the heroes who died in battle or of the wounds they sustained in combat. Communities across the country will carry out ceremonies, lining national cemeteries with flags, holding patriotic parades, and conducting spiritual observances.¹

Sadly, almost as long as there has been a United States, there has been a parallel practice dishonoring the uniform and deceiving veterans and the public alike known as stolen valor. Stolen valor is a persistent, yet strange, psychological behavior: individuals who never served in the US Armed Forces claim they have done heroic deeds for which they often sustained serious injuries in the line of duty and almost always won medals for their heroism.² This editorial will trace the US legal history of stolen valor cases to provide the background for next month’s editorial examining its clinical and ethical aspects.

While many cases of stolen valor do not receive media attention, the experience of Sarah Cavanaugh, a former VA social worker who claimed to be a marine veteran who served in Iraq and Afghanistan, was the subject of the Deep Cover podcast series.³ Cavanaugh had claimed that an improvised explosive device blew up her Humvee, crushing her hip. Still she somehow was able to help her fellow Marines and earned the Bronze Star among other decorations for her heroism. That was not the only lie Cavanaugh told: she also told her friends and wife that she had advanced lung cancer due to burn pit exposure. In line with the best-worst of those who have stolen valor, her mastery of manipulation enabled her to become the commander of a local Veterans of Foreign Wars post. Using stolen identities and fraudulent documents, Cavanaugh was able to purloin veteran benefits, donated leave from other VA employees and money, and stole goods and services from various charitable organizations whose mission was to help wounded veterans and those struggling to adjust to civilian life. Before law enforcement unraveled her sordid tale, she misappropriated hundreds of thousands of dollars in VA benefits and donations and exploited dozens of generous veterans and compassionate civilians.⁴

Cavanaugh’s story was so sordidly compelling that I kept saying out loud to myself (and my spouse), “This has to be illegal.” The truth about stolen valor law is far more ambivalent and frustrating than I had anticipated or wanted. The first insult to my sense of justice was that lying about military service is not in itself illegal: you can pad your military resume with unearned decorations or impress a future partner or employer with your combat exploits without much fear of legal repercussions. The legal history of attempting to make stealing valor a crime has almost as many twists and turns as the fallacious narratives of military imposters and illustrates the uniquely American experiment in balancing freedom and fairness.

The Stolen Valor Act of 2005 made it a federal misdemeanor to wear, manufacture, or sell military decorations, or medals (Cavanaugh bought her medals online) without legal authorization. It also made it a crime to falsely represent oneself as having been the recipient of a decoration, medical, or service badge that Congress or the Armed Forces authorized. There were even stiffer penalties if the medal was a Silver Star, Distinguished Service Cross, US Air Force or US Navy Cross, or Purple Heart. Punishments include fines and imprisonment. The stated legislative purpose was to prohibit fraud that devalued military awards and the dignity of those who legitimately earned them.⁵

Next comes a distinctly American reaction to the initial Congressional attempt to protect the legacy of those who served—a lawsuit. Xavier Alvarez was an official on a California district water board claimed to be a 25-year veteran of the US Marine Corps wounded in combat and received the Congressional Medal of Honor. The Federal Bureau of Investigation exposed the lie and instead of the nation’s highest honor, Alvarez was the first to be convicted under the Stolen Valor Act of 2005. Alvarez appealed the decision, ironically claiming the law violated his free speech rights. The case landed in the Supreme Court, which ruled that the Stolen Valor Act did indeed violate the Free Speech Clause of the First Amendment. The majority opinion found the Act as passed was too encompassing of all speech and needed to target only cases in which false statements resulted in actual harm.⁶

The Stolen Valor Act of 2013 amends the criminal code regarding fraudulent claims about military service to include those who don’t only lie but also profit from it, as Cavanaugh did. The revised act specifically focuses on individuals who claim to have earned military honors for the intended purpose of obtaining money, property, or any other tangible benefit.⁷

Despite the complicated nature of Stolen Valor Law, it did prevail in Cavanaugh’s case. A US District Court Judge in Rhode Island found her guilty of stolen valor in all its permutations, along with identity theft of other veterans’ military and medical records and fraud in obtaining benefits and services intended for real veterans. Cavanaugh was sentenced to 70 months in federal prison, 3 years of supervised release, ordered to pay $284,796.82 in restitution, and to restore 261 hours of donated leave to the federal government, charitable organizations, and good Samaritans she duped and swindled.⁸

The revised law under which Cavanaugh was punished lasted 10 years until another classically American ethical concern—privacy—motivated additional legislative effort. A 2023/2024 US House of Representatives proposal to amend the Stolen Valor Act would have strengthened the privacy protections afforded military records. It would have required the information to only be accessed with the permission of the individual who served or their family or through a Freedom of Information Act request. This would make the kind of journalistic and law enforcement investigations that eventually caught Cavanaugh in her lies far more laborious for false valor hunters while at the same time preventing unscrupulous inquiries into service members’ personal information. Advocates for free speech and defenders of military honor are both lobbying Congress; as of this writing the legislation has not been passed.⁹

As we close part 1 of this review of stolen valor, we return to Memorial Day. This day provides the somber recognition that without the brave men and women of integrity who died in defense of a democracy that promotes the political activity of its citizens, we would not even be able to have this debate over justice, freedom, and truth.

Memorial Day is the most solemn of all American military commemorations. It is the day when we honor those who sacrificed their lives so that their fellow citizens could flourish in freedom. At 3 PM, a grateful nation is called to observe 2 minutes of silence in remembrance of the heroes who died in battle or of the wounds they sustained in combat. Communities across the country will carry out ceremonies, lining national cemeteries with flags, holding patriotic parades, and conducting spiritual observances.¹

Sadly, almost as long as there has been a United States, there has been a parallel practice dishonoring the uniform and deceiving veterans and the public alike known as stolen valor. Stolen valor is a persistent, yet strange, psychological behavior: individuals who never served in the US Armed Forces claim they have done heroic deeds for which they often sustained serious injuries in the line of duty and almost always won medals for their heroism.² This editorial will trace the US legal history of stolen valor cases to provide the background for next month’s editorial examining its clinical and ethical aspects.

While many cases of stolen valor do not receive media attention, the experience of Sarah Cavanaugh, a former VA social worker who claimed to be a marine veteran who served in Iraq and Afghanistan, was the subject of the Deep Cover podcast series.³ Cavanaugh had claimed that an improvised explosive device blew up her Humvee, crushing her hip. Still she somehow was able to help her fellow Marines and earned the Bronze Star among other decorations for her heroism. That was not the only lie Cavanaugh told: she also told her friends and wife that she had advanced lung cancer due to burn pit exposure. In line with the best-worst of those who have stolen valor, her mastery of manipulation enabled her to become the commander of a local Veterans of Foreign Wars post. Using stolen identities and fraudulent documents, Cavanaugh was able to purloin veteran benefits, donated leave from other VA employees and money, and stole goods and services from various charitable organizations whose mission was to help wounded veterans and those struggling to adjust to civilian life. Before law enforcement unraveled her sordid tale, she misappropriated hundreds of thousands of dollars in VA benefits and donations and exploited dozens of generous veterans and compassionate civilians.⁴

Cavanaugh’s story was so sordidly compelling that I kept saying out loud to myself (and my spouse), “This has to be illegal.” The truth about stolen valor law is far more ambivalent and frustrating than I had anticipated or wanted. The first insult to my sense of justice was that lying about military service is not in itself illegal: you can pad your military resume with unearned decorations or impress a future partner or employer with your combat exploits without much fear of legal repercussions. The legal history of attempting to make stealing valor a crime has almost as many twists and turns as the fallacious narratives of military imposters and illustrates the uniquely American experiment in balancing freedom and fairness.

The Stolen Valor Act of 2005 made it a federal misdemeanor to wear, manufacture, or sell military decorations, or medals (Cavanaugh bought her medals online) without legal authorization. It also made it a crime to falsely represent oneself as having been the recipient of a decoration, medical, or service badge that Congress or the Armed Forces authorized. There were even stiffer penalties if the medal was a Silver Star, Distinguished Service Cross, US Air Force or US Navy Cross, or Purple Heart. Punishments include fines and imprisonment. The stated legislative purpose was to prohibit fraud that devalued military awards and the dignity of those who legitimately earned them.⁵

Next comes a distinctly American reaction to the initial Congressional attempt to protect the legacy of those who served—a lawsuit. Xavier Alvarez was an official on a California district water board claimed to be a 25-year veteran of the US Marine Corps wounded in combat and received the Congressional Medal of Honor. The Federal Bureau of Investigation exposed the lie and instead of the nation’s highest honor, Alvarez was the first to be convicted under the Stolen Valor Act of 2005. Alvarez appealed the decision, ironically claiming the law violated his free speech rights. The case landed in the Supreme Court, which ruled that the Stolen Valor Act did indeed violate the Free Speech Clause of the First Amendment. The majority opinion found the Act as passed was too encompassing of all speech and needed to target only cases in which false statements resulted in actual harm.⁶

The Stolen Valor Act of 2013 amends the criminal code regarding fraudulent claims about military service to include those who don’t only lie but also profit from it, as Cavanaugh did. The revised act specifically focuses on individuals who claim to have earned military honors for the intended purpose of obtaining money, property, or any other tangible benefit.⁷

Despite the complicated nature of Stolen Valor Law, it did prevail in Cavanaugh’s case. A US District Court Judge in Rhode Island found her guilty of stolen valor in all its permutations, along with identity theft of other veterans’ military and medical records and fraud in obtaining benefits and services intended for real veterans. Cavanaugh was sentenced to 70 months in federal prison, 3 years of supervised release, ordered to pay $284,796.82 in restitution, and to restore 261 hours of donated leave to the federal government, charitable organizations, and good Samaritans she duped and swindled.⁸

The revised law under which Cavanaugh was punished lasted 10 years until another classically American ethical concern—privacy—motivated additional legislative effort. A 2023/2024 US House of Representatives proposal to amend the Stolen Valor Act would have strengthened the privacy protections afforded military records. It would have required the information to only be accessed with the permission of the individual who served or their family or through a Freedom of Information Act request. This would make the kind of journalistic and law enforcement investigations that eventually caught Cavanaugh in her lies far more laborious for false valor hunters while at the same time preventing unscrupulous inquiries into service members’ personal information. Advocates for free speech and defenders of military honor are both lobbying Congress; as of this writing the legislation has not been passed.⁹

As we close part 1 of this review of stolen valor, we return to Memorial Day. This day provides the somber recognition that without the brave men and women of integrity who died in defense of a democracy that promotes the political activity of its citizens, we would not even be able to have this debate over justice, freedom, and truth.

Memorial Day is the most solemn of all American military commemorations. It is the day when we honor those who sacrificed their lives so that their fellow citizens could flourish in freedom. At 3 PM, a grateful nation is called to observe 2 minutes of silence in remembrance of the heroes who died in battle or of the wounds they sustained in combat. Communities across the country will carry out ceremonies, lining national cemeteries with flags, holding patriotic parades, and conducting spiritual observances.¹

Sadly, almost as long as there has been a United States, there has been a parallel practice dishonoring the uniform and deceiving veterans and the public alike known as stolen valor. Stolen valor is a persistent, yet strange, psychological behavior: individuals who never served in the US Armed Forces claim they have done heroic deeds for which they often sustained serious injuries in the line of duty and almost always won medals for their heroism.² This editorial will trace the US legal history of stolen valor cases to provide the background for next month’s editorial examining its clinical and ethical aspects.

While many cases of stolen valor do not receive media attention, the experience of Sarah Cavanaugh, a former VA social worker who claimed to be a marine veteran who served in Iraq and Afghanistan, was the subject of the Deep Cover podcast series.³ Cavanaugh had claimed that an improvised explosive device blew up her Humvee, crushing her hip. Still she somehow was able to help her fellow Marines and earned the Bronze Star among other decorations for her heroism. That was not the only lie Cavanaugh told: she also told her friends and wife that she had advanced lung cancer due to burn pit exposure. In line with the best-worst of those who have stolen valor, her mastery of manipulation enabled her to become the commander of a local Veterans of Foreign Wars post. Using stolen identities and fraudulent documents, Cavanaugh was able to purloin veteran benefits, donated leave from other VA employees and money, and stole goods and services from various charitable organizations whose mission was to help wounded veterans and those struggling to adjust to civilian life. Before law enforcement unraveled her sordid tale, she misappropriated hundreds of thousands of dollars in VA benefits and donations and exploited dozens of generous veterans and compassionate civilians.⁴

Cavanaugh’s story was so sordidly compelling that I kept saying out loud to myself (and my spouse), “This has to be illegal.” The truth about stolen valor law is far more ambivalent and frustrating than I had anticipated or wanted. The first insult to my sense of justice was that lying about military service is not in itself illegal: you can pad your military resume with unearned decorations or impress a future partner or employer with your combat exploits without much fear of legal repercussions. The legal history of attempting to make stealing valor a crime has almost as many twists and turns as the fallacious narratives of military imposters and illustrates the uniquely American experiment in balancing freedom and fairness.

The Stolen Valor Act of 2005 made it a federal misdemeanor to wear, manufacture, or sell military decorations, or medals (Cavanaugh bought her medals online) without legal authorization. It also made it a crime to falsely represent oneself as having been the recipient of a decoration, medical, or service badge that Congress or the Armed Forces authorized. There were even stiffer penalties if the medal was a Silver Star, Distinguished Service Cross, US Air Force or US Navy Cross, or Purple Heart. Punishments include fines and imprisonment. The stated legislative purpose was to prohibit fraud that devalued military awards and the dignity of those who legitimately earned them.⁵

Next comes a distinctly American reaction to the initial Congressional attempt to protect the legacy of those who served—a lawsuit. Xavier Alvarez was an official on a California district water board claimed to be a 25-year veteran of the US Marine Corps wounded in combat and received the Congressional Medal of Honor. The Federal Bureau of Investigation exposed the lie and instead of the nation’s highest honor, Alvarez was the first to be convicted under the Stolen Valor Act of 2005. Alvarez appealed the decision, ironically claiming the law violated his free speech rights. The case landed in the Supreme Court, which ruled that the Stolen Valor Act did indeed violate the Free Speech Clause of the First Amendment. The majority opinion found the Act as passed was too encompassing of all speech and needed to target only cases in which false statements resulted in actual harm.⁶

The Stolen Valor Act of 2013 amends the criminal code regarding fraudulent claims about military service to include those who don’t only lie but also profit from it, as Cavanaugh did. The revised act specifically focuses on individuals who claim to have earned military honors for the intended purpose of obtaining money, property, or any other tangible benefit.⁷

Despite the complicated nature of Stolen Valor Law, it did prevail in Cavanaugh’s case. A US District Court Judge in Rhode Island found her guilty of stolen valor in all its permutations, along with identity theft of other veterans’ military and medical records and fraud in obtaining benefits and services intended for real veterans. Cavanaugh was sentenced to 70 months in federal prison, 3 years of supervised release, ordered to pay $284,796.82 in restitution, and to restore 261 hours of donated leave to the federal government, charitable organizations, and good Samaritans she duped and swindled.⁸

The revised law under which Cavanaugh was punished lasted 10 years until another classically American ethical concern—privacy—motivated additional legislative effort. A 2023/2024 US House of Representatives proposal to amend the Stolen Valor Act would have strengthened the privacy protections afforded military records. It would have required the information to only be accessed with the permission of the individual who served or their family or through a Freedom of Information Act request. This would make the kind of journalistic and law enforcement investigations that eventually caught Cavanaugh in her lies far more laborious for false valor hunters while at the same time preventing unscrupulous inquiries into service members’ personal information. Advocates for free speech and defenders of military honor are both lobbying Congress; as of this writing the legislation has not been passed.⁹

As we close part 1 of this review of stolen valor, we return to Memorial Day. This day provides the somber recognition that without the brave men and women of integrity who died in defense of a democracy that promotes the political activity of its citizens, we would not even be able to have this debate over justice, freedom, and truth.

The uselessness of men above sixty years of age and the incalculable benefit it would be in commercial, in political, and in professional life, if as a matter of course, men stopped working at this age.

Sir William Osler¹

The first time I remember hearing the word retirement was when I was 5 or 6 years old. My mother told me that my father had been given new orders: either be promoted to general and move to oversee a hospital somewhere far away, or retire from the Army. He was a scholar, teacher, and physician with no interest or aptitude for military politics and health care administration. Reluctantly, he resigned himself to retirement before he had planned. I recall being angry with him, because in my solipsistic child mind he was depriving me of the opportunity to live in a big house across from the parade field, where the generals lived or having a reserved parking spot in front of the post exchange. As a psychiatrist, I suspect that the anger was a primitive defense against the fear of leaving the only home I had ever known on an Army base.

I recently finished reading Michael Bliss’s seminal biography of Sir William Osler (1848-1919), the great Anglo-American physician and medical educator.² Bliss found few blemishes on Osler’s character or missteps in his stellar career, but one of the few may be his views on retirement. The epigraph is from an address Osler gave before leaving Johns Hopkins for semiretirement in Oxford, England. The farewell speech caused a media controversy with his comments reflecting attitudes that seem ageist today, when many people are active, productive, and happy long past the age of 60 years.³ I do not endorse Osler’s philosophy of aging, nor his exclusion of women (if I did, I would not be around to write this editorial). Not even Osler himself followed his advice: he was active in medicine almost until his death at 70 years old.²

Yet like many of my fellow federal health care practitioners (HCPs), I have been thinking about and planning for retirement earlier than expected, given the memos and directives about voluntary early retirement, deferred resignation, and reductions in force.^4,5 The COVID-19 pandemic sadly compelled many burned-out and traumatized HCPs to cross the retirement Rubicon far sooner than they imagined.⁶

A Google search for information about HCP retirement, particularly among physicians, produces a cascade of advisory articles. They primarily focus on finances, with many pushing their own commercial agenda for retirement planning.⁷ Although money is a necessary piece of the retirement puzzle, for HCPs it may not be sufficient to ensure a healthy and satisfying retirement. Two other considerations may be even more important to weigh in making the retirement decision, namely timing and meaning.⁸

For earlier generations of HCPs, work was almost their sole identity. Although younger practitioners are more likely to embrace a better work-life balance, it is still a driving factor for many in the decision to retire.⁹ It is not just about the cliché of being a workaholic, rather many clinicians continue to enjoy lifelong learning, the rewards of helping people in need, and professional satisfaction. HCPs also spend a longer time training than many other professions; perhaps since we waited so long to practice, we want to stay a little longer.¹⁰ For those whose motivation for federal practice was a commitment to service, these may be even more powerful incentives to continue working.

When a nurse, physician, pharmacist, or social worker no longer finds the same gratification and stimulation in their work, whether due to unwelcome changes in the clinical setting or the profession at large, declining health or emotional exhaustion, or the very human need to move onto another phase of life (what Osler likely really meant), then that may be a signal to think hard about retiring. Of course, there have always been—and will continue to be—professionals of all stripes who, even in the most agreeable situation, just cannot wait to retire. Simply because there are so many other ways they want to spend their remaining energy and time: travel, grandchildren, hobbies, even a second career. Because none of us knows how far out our life extends, it is prudent to periodically ask what is the optimal path that combines both purpose and well-being.

All of us as HCPs, and even more as human beings with desires and duties far beyond our respective professions, face a dilemma: a choice between 2 goods that cannot both be fulfilled simultaneously. This is likely why HCPs frequently do what is technically called a phased retirement, a fancy name for working part-time, or retiring from 1 position and taking up another. This temporizes the decision and tempers the bittersweet emotional experience of leaving the profession in one way, and in another, it delays the inevitable.

Over the last few years, I have learned 2 important lessons while watching many of my closest friends retire. First, for those who are still working and those who are retired may seem to inhabit a separate country; hence, special efforts must be made to both appreciate them while they are in our immediate circle of concern and to make efforts to stay in contact once they are emeriti. It is almost as if after being a daily integral aspect of the workplace they have passed into a different dimension of existence. In terms of priorities and mindsets, many of them have. Second, what makes retirement a reality with peace and growth rather than regret and stagnation is owning the decision to retire. There are always constraints: financial, medical, and familial. However, those who retire on their own terms and not primarily in response to fear or uncertainty appear to fare better than those feeling the same pressures who give away their power.¹¹ Having read about retirement in the last months, the best advice I have seen is from Harry Emerson Fosdick, a Protestant minister in the early 20th century: “Don’t simply retire from something; have something to retire to.”¹²

I have not yet decided about my retirement. Whatever decision you make, remember it is solely yours. After a lifetime of caring for others, retirement is all about caring for yourself.

The uselessness of men above sixty years of age and the incalculable benefit it would be in commercial, in political, and in professional life, if as a matter of course, men stopped working at this age.

Sir William Osler¹

The first time I remember hearing the word retirement was when I was 5 or 6 years old. My mother told me that my father had been given new orders: either be promoted to general and move to oversee a hospital somewhere far away, or retire from the Army. He was a scholar, teacher, and physician with no interest or aptitude for military politics and health care administration. Reluctantly, he resigned himself to retirement before he had planned. I recall being angry with him, because in my solipsistic child mind he was depriving me of the opportunity to live in a big house across from the parade field, where the generals lived or having a reserved parking spot in front of the post exchange. As a psychiatrist, I suspect that the anger was a primitive defense against the fear of leaving the only home I had ever known on an Army base.

I recently finished reading Michael Bliss’s seminal biography of Sir William Osler (1848-1919), the great Anglo-American physician and medical educator.² Bliss found few blemishes on Osler’s character or missteps in his stellar career, but one of the few may be his views on retirement. The epigraph is from an address Osler gave before leaving Johns Hopkins for semiretirement in Oxford, England. The farewell speech caused a media controversy with his comments reflecting attitudes that seem ageist today, when many people are active, productive, and happy long past the age of 60 years.³ I do not endorse Osler’s philosophy of aging, nor his exclusion of women (if I did, I would not be around to write this editorial). Not even Osler himself followed his advice: he was active in medicine almost until his death at 70 years old.²

Yet like many of my fellow federal health care practitioners (HCPs), I have been thinking about and planning for retirement earlier than expected, given the memos and directives about voluntary early retirement, deferred resignation, and reductions in force.^4,5 The COVID-19 pandemic sadly compelled many burned-out and traumatized HCPs to cross the retirement Rubicon far sooner than they imagined.⁶

A Google search for information about HCP retirement, particularly among physicians, produces a cascade of advisory articles. They primarily focus on finances, with many pushing their own commercial agenda for retirement planning.⁷ Although money is a necessary piece of the retirement puzzle, for HCPs it may not be sufficient to ensure a healthy and satisfying retirement. Two other considerations may be even more important to weigh in making the retirement decision, namely timing and meaning.⁸

For earlier generations of HCPs, work was almost their sole identity. Although younger practitioners are more likely to embrace a better work-life balance, it is still a driving factor for many in the decision to retire.⁹ It is not just about the cliché of being a workaholic, rather many clinicians continue to enjoy lifelong learning, the rewards of helping people in need, and professional satisfaction. HCPs also spend a longer time training than many other professions; perhaps since we waited so long to practice, we want to stay a little longer.¹⁰ For those whose motivation for federal practice was a commitment to service, these may be even more powerful incentives to continue working.

When a nurse, physician, pharmacist, or social worker no longer finds the same gratification and stimulation in their work, whether due to unwelcome changes in the clinical setting or the profession at large, declining health or emotional exhaustion, or the very human need to move onto another phase of life (what Osler likely really meant), then that may be a signal to think hard about retiring. Of course, there have always been—and will continue to be—professionals of all stripes who, even in the most agreeable situation, just cannot wait to retire. Simply because there are so many other ways they want to spend their remaining energy and time: travel, grandchildren, hobbies, even a second career. Because none of us knows how far out our life extends, it is prudent to periodically ask what is the optimal path that combines both purpose and well-being.

All of us as HCPs, and even more as human beings with desires and duties far beyond our respective professions, face a dilemma: a choice between 2 goods that cannot both be fulfilled simultaneously. This is likely why HCPs frequently do what is technically called a phased retirement, a fancy name for working part-time, or retiring from 1 position and taking up another. This temporizes the decision and tempers the bittersweet emotional experience of leaving the profession in one way, and in another, it delays the inevitable.

Over the last few years, I have learned 2 important lessons while watching many of my closest friends retire. First, for those who are still working and those who are retired may seem to inhabit a separate country; hence, special efforts must be made to both appreciate them while they are in our immediate circle of concern and to make efforts to stay in contact once they are emeriti. It is almost as if after being a daily integral aspect of the workplace they have passed into a different dimension of existence. In terms of priorities and mindsets, many of them have. Second, what makes retirement a reality with peace and growth rather than regret and stagnation is owning the decision to retire. There are always constraints: financial, medical, and familial. However, those who retire on their own terms and not primarily in response to fear or uncertainty appear to fare better than those feeling the same pressures who give away their power.¹¹ Having read about retirement in the last months, the best advice I have seen is from Harry Emerson Fosdick, a Protestant minister in the early 20th century: “Don’t simply retire from something; have something to retire to.”¹²

I have not yet decided about my retirement. Whatever decision you make, remember it is solely yours. After a lifetime of caring for others, retirement is all about caring for yourself.

The uselessness of men above sixty years of age and the incalculable benefit it would be in commercial, in political, and in professional life, if as a matter of course, men stopped working at this age.

Sir William Osler¹

The first time I remember hearing the word retirement was when I was 5 or 6 years old. My mother told me that my father had been given new orders: either be promoted to general and move to oversee a hospital somewhere far away, or retire from the Army. He was a scholar, teacher, and physician with no interest or aptitude for military politics and health care administration. Reluctantly, he resigned himself to retirement before he had planned. I recall being angry with him, because in my solipsistic child mind he was depriving me of the opportunity to live in a big house across from the parade field, where the generals lived or having a reserved parking spot in front of the post exchange. As a psychiatrist, I suspect that the anger was a primitive defense against the fear of leaving the only home I had ever known on an Army base.

I recently finished reading Michael Bliss’s seminal biography of Sir William Osler (1848-1919), the great Anglo-American physician and medical educator.² Bliss found few blemishes on Osler’s character or missteps in his stellar career, but one of the few may be his views on retirement. The epigraph is from an address Osler gave before leaving Johns Hopkins for semiretirement in Oxford, England. The farewell speech caused a media controversy with his comments reflecting attitudes that seem ageist today, when many people are active, productive, and happy long past the age of 60 years.³ I do not endorse Osler’s philosophy of aging, nor his exclusion of women (if I did, I would not be around to write this editorial). Not even Osler himself followed his advice: he was active in medicine almost until his death at 70 years old.²

Yet like many of my fellow federal health care practitioners (HCPs), I have been thinking about and planning for retirement earlier than expected, given the memos and directives about voluntary early retirement, deferred resignation, and reductions in force.^4,5 The COVID-19 pandemic sadly compelled many burned-out and traumatized HCPs to cross the retirement Rubicon far sooner than they imagined.⁶

A Google search for information about HCP retirement, particularly among physicians, produces a cascade of advisory articles. They primarily focus on finances, with many pushing their own commercial agenda for retirement planning.⁷ Although money is a necessary piece of the retirement puzzle, for HCPs it may not be sufficient to ensure a healthy and satisfying retirement. Two other considerations may be even more important to weigh in making the retirement decision, namely timing and meaning.⁸

For earlier generations of HCPs, work was almost their sole identity. Although younger practitioners are more likely to embrace a better work-life balance, it is still a driving factor for many in the decision to retire.⁹ It is not just about the cliché of being a workaholic, rather many clinicians continue to enjoy lifelong learning, the rewards of helping people in need, and professional satisfaction. HCPs also spend a longer time training than many other professions; perhaps since we waited so long to practice, we want to stay a little longer.¹⁰ For those whose motivation for federal practice was a commitment to service, these may be even more powerful incentives to continue working.

When a nurse, physician, pharmacist, or social worker no longer finds the same gratification and stimulation in their work, whether due to unwelcome changes in the clinical setting or the profession at large, declining health or emotional exhaustion, or the very human need to move onto another phase of life (what Osler likely really meant), then that may be a signal to think hard about retiring. Of course, there have always been—and will continue to be—professionals of all stripes who, even in the most agreeable situation, just cannot wait to retire. Simply because there are so many other ways they want to spend their remaining energy and time: travel, grandchildren, hobbies, even a second career. Because none of us knows how far out our life extends, it is prudent to periodically ask what is the optimal path that combines both purpose and well-being.

All of us as HCPs, and even more as human beings with desires and duties far beyond our respective professions, face a dilemma: a choice between 2 goods that cannot both be fulfilled simultaneously. This is likely why HCPs frequently do what is technically called a phased retirement, a fancy name for working part-time, or retiring from 1 position and taking up another. This temporizes the decision and tempers the bittersweet emotional experience of leaving the profession in one way, and in another, it delays the inevitable.

Over the last few years, I have learned 2 important lessons while watching many of my closest friends retire. First, for those who are still working and those who are retired may seem to inhabit a separate country; hence, special efforts must be made to both appreciate them while they are in our immediate circle of concern and to make efforts to stay in contact once they are emeriti. It is almost as if after being a daily integral aspect of the workplace they have passed into a different dimension of existence. In terms of priorities and mindsets, many of them have. Second, what makes retirement a reality with peace and growth rather than regret and stagnation is owning the decision to retire. There are always constraints: financial, medical, and familial. However, those who retire on their own terms and not primarily in response to fear or uncertainty appear to fare better than those feeling the same pressures who give away their power.¹¹ Having read about retirement in the last months, the best advice I have seen is from Harry Emerson Fosdick, a Protestant minister in the early 20th century: “Don’t simply retire from something; have something to retire to.”¹²

I have not yet decided about my retirement. Whatever decision you make, remember it is solely yours. After a lifetime of caring for others, retirement is all about caring for yourself.

Express Scripts, the contractor that manages the pharmacy benefit for Tricare, the military health insurance program, announced in 2021 that after a 5-year absence, CVS Pharmacy was once more in the network. In 2023, CVS had the largest profits of any pharmacy chain in the United States, about $159 billion, and generated a quarter of the overall revenue of the US pharmacy industry.¹ Tricare officials heralded the return of CVS as a move that would offer US Department of Defense (DoD) beneficiaries more competitive prices, convenient access, and overall quality.²

DOJ Files Lawsuit Against CVS

In December 2024, the US Department of Justice (DoJ) filed a lawsuit alleging that CVS violated both the Controlled Substances Act (CSA) and the False Claims Act (FCA).^3,4 The United States ex rel. Estright v Health Corporation, et al, filed in Rhode Island, charged that CVS “routinely” and “knowingly” filled invalid prescriptions for controlled substances violating the CSA and then billed federal health care programs for payment for these prescriptions, a breach of the FCA.⁵ The DoJ alleged that CVS pharmacies and pharmacists filled prescriptions for controlled substances that (1) lacked a legitimate medical purpose; (2) were not legally valid; and/or (3) were not issued in the usual course of medical practice. ⁶ CVS contests the charges and issued an official response, stating that it disputes the allegations as false, plans to disprove them in litigation, and has nonetheless fully cooperated with the investigation.⁷

The allegations involved prescriptions for drugs like opioids and benzodiazepines, primary culprits in the American overdose epidemic.⁸ The complaint notes that the prescriptions were early refills in excessive quantities and included what has been called the “holy trinity” of dangerous medications: opioids, benzodiazepines, and muscle relaxants. ^5,8 Even worse (if that is possible), as the complaint outlines, CVS had access to data from both inside and outside the company that these prescriptions came from notorious pill mills and were hence unlawful and yet continued to fill them, leading the DoJ to file the more serious charge that the corporation “knowingly” violated the CSA and “prioritized profits over safety in dispensing controlled substances.”^5,6

The Unholy Trinity

The infamous members of what I prefer to call the “unholy trinity” are a benzodiazepine, often alprazolam, an opioid, and the muscle relaxant carisoprodol. The combination amplifies each agent’s independent risk of respiratory depression. The latter is a schedule IV medication with an active metabolite, meprobamate, that also has this adverse effect. All 3 drugs have high abuse potential and, when combined, increase the risk of fatal overdose. The colloquial name holy trinity derives from the synergistic euphoria experienced when taking this triple cocktail of sedative agents.⁹ This pharmacological recipe for disaster is the house specialty of pill mills: infamous storefront practices that generate high profits and exploit persons with chronic pain and addiction by handing out controlled substances with little clinical assessment and even less oversight.¹⁰

When the Means Become the End

The DoJ allegations suggest that the violations resulted from “corporate-mandated performance metrics, incentive compensation, and staffing policies that prioritized corporate profits over patient safety.”⁶ If the allegations are true, why would a company reinvited by Tricare to serve the nation’s heroes seemingly engage in illegal practices? While CVS has not responded in court, their statement argued that “too often, we have seen government agencies and trial lawyers question the good-faith decisions made by pharmacists while a patient waits at the pharmacy counter, often in pain.”⁶

The DoJ complaint offers a cautionary warning for the US health care system, which is increasingly being micromanaged in the pursuit of efficiency. Like many practitioners in and out of the federal system, I get a cold chill when I read the word productivity. “CVS pharmacists described working at CVS as ‘soul crushing’ because it was impossible to meet the company’s expectations,” the complaint alleges, because “CVS set staffing levels so low that it was impossible for pharmacists to comply with their legal obligations and meet CVS’s demanding metrics.”⁵ Did top-down mandates drive the alleged activities by imposing unattainable performance metrics on pharmacists, offering incentives that encouraged and rewarded corner-cutting, and refusing to fund sufficient staffing to ensure patient safety? This may be what happens when the means (efficiency) become the end rather than a mechanism to achieve the goal of more accessible, affordable, high-quality health care.

Ethically, what is most concerning is that leadership intentionally “deprived its pharmacists of crucial information” about specific practitioners known to engage in illegal prescribing practices.⁶ CVS did not provide pharmacists with “information about prescribers’ prescribing habits that CVS routinely collected and reviewed at the corporate level,” and even removed prescriber blocks that were implemented at Target pharmacies before it was acquired by CVS.⁵ The first element of informed consent is providing patients with adequate information upon which to decide whether to accept or decline treatment. ¹¹ In this situation, however, CVS allegedly prevented “pharmacists from warning one another about certain prescribers.”⁶

If true, the company deprived frontline pharmacists of the information they needed to safely and responsibly dispense medications: “The practices alleged contributed to the opioid crisis and opioid-related deaths, and today’s complaint seeks to hold CVS accountable for its misconduct.”⁶ Though the cost in human life that may have resulted from CSA violations must absolutely and always outweigh financial considerations, the economic damage to Tricare from fraudulent billing and the betrayal of its fiduciary responsinility cannot be underestimated.

A Corporate Morality Play

CVS is not the only company, nor is pharmacy the only industry in health care, that has been the subject of watchdog agency lawsuits or variegated forms of wrongdoing, including violations of the CSA and FCA.^10,12 As of this writing, the DoJ case against CVS has not been heard, much less adjudicated in a court of law. It is ironic that both the DoJ claims and the CVS rebuttal describe the manifest conflict of obligation that pharmacists confront between protecting their livelihood and safeguarding patients’ lives as suggested in the epigraph that has been attributed to the 19th-century British physician and medical educator Peter Mere Latham. It is a dilemma that a growing number of health care practitioners face daily in a vocation becoming increasingly commercialized. It is all too easy for an individual physician, nurse, or pharmacist to feel hopeless and helpless before the behemoth might of a large and looming entity. Yet, it was a whistleblower whose moral courage led to the DoJ investigation and subsequent charges.¹³ We must all never doubt the power of a committed person of conscience to withstand the pressure to mutate medications into poison and stand up for the principles of our professions and inspire a community of colleagues to follow their example.

Express Scripts, the contractor that manages the pharmacy benefit for Tricare, the military health insurance program, announced in 2021 that after a 5-year absence, CVS Pharmacy was once more in the network. In 2023, CVS had the largest profits of any pharmacy chain in the United States, about $159 billion, and generated a quarter of the overall revenue of the US pharmacy industry.¹ Tricare officials heralded the return of CVS as a move that would offer US Department of Defense (DoD) beneficiaries more competitive prices, convenient access, and overall quality.²

DOJ Files Lawsuit Against CVS

In December 2024, the US Department of Justice (DoJ) filed a lawsuit alleging that CVS violated both the Controlled Substances Act (CSA) and the False Claims Act (FCA).^3,4 The United States ex rel. Estright v Health Corporation, et al, filed in Rhode Island, charged that CVS “routinely” and “knowingly” filled invalid prescriptions for controlled substances violating the CSA and then billed federal health care programs for payment for these prescriptions, a breach of the FCA.⁵ The DoJ alleged that CVS pharmacies and pharmacists filled prescriptions for controlled substances that (1) lacked a legitimate medical purpose; (2) were not legally valid; and/or (3) were not issued in the usual course of medical practice. ⁶ CVS contests the charges and issued an official response, stating that it disputes the allegations as false, plans to disprove them in litigation, and has nonetheless fully cooperated with the investigation.⁷

The allegations involved prescriptions for drugs like opioids and benzodiazepines, primary culprits in the American overdose epidemic.⁸ The complaint notes that the prescriptions were early refills in excessive quantities and included what has been called the “holy trinity” of dangerous medications: opioids, benzodiazepines, and muscle relaxants. ^5,8 Even worse (if that is possible), as the complaint outlines, CVS had access to data from both inside and outside the company that these prescriptions came from notorious pill mills and were hence unlawful and yet continued to fill them, leading the DoJ to file the more serious charge that the corporation “knowingly” violated the CSA and “prioritized profits over safety in dispensing controlled substances.”^5,6

The Unholy Trinity

The infamous members of what I prefer to call the “unholy trinity” are a benzodiazepine, often alprazolam, an opioid, and the muscle relaxant carisoprodol. The combination amplifies each agent’s independent risk of respiratory depression. The latter is a schedule IV medication with an active metabolite, meprobamate, that also has this adverse effect. All 3 drugs have high abuse potential and, when combined, increase the risk of fatal overdose. The colloquial name holy trinity derives from the synergistic euphoria experienced when taking this triple cocktail of sedative agents.⁹ This pharmacological recipe for disaster is the house specialty of pill mills: infamous storefront practices that generate high profits and exploit persons with chronic pain and addiction by handing out controlled substances with little clinical assessment and even less oversight.¹⁰

When the Means Become the End

The DoJ allegations suggest that the violations resulted from “corporate-mandated performance metrics, incentive compensation, and staffing policies that prioritized corporate profits over patient safety.”⁶ If the allegations are true, why would a company reinvited by Tricare to serve the nation’s heroes seemingly engage in illegal practices? While CVS has not responded in court, their statement argued that “too often, we have seen government agencies and trial lawyers question the good-faith decisions made by pharmacists while a patient waits at the pharmacy counter, often in pain.”⁶

The DoJ complaint offers a cautionary warning for the US health care system, which is increasingly being micromanaged in the pursuit of efficiency. Like many practitioners in and out of the federal system, I get a cold chill when I read the word productivity. “CVS pharmacists described working at CVS as ‘soul crushing’ because it was impossible to meet the company’s expectations,” the complaint alleges, because “CVS set staffing levels so low that it was impossible for pharmacists to comply with their legal obligations and meet CVS’s demanding metrics.”⁵ Did top-down mandates drive the alleged activities by imposing unattainable performance metrics on pharmacists, offering incentives that encouraged and rewarded corner-cutting, and refusing to fund sufficient staffing to ensure patient safety? This may be what happens when the means (efficiency) become the end rather than a mechanism to achieve the goal of more accessible, affordable, high-quality health care.

Ethically, what is most concerning is that leadership intentionally “deprived its pharmacists of crucial information” about specific practitioners known to engage in illegal prescribing practices.⁶ CVS did not provide pharmacists with “information about prescribers’ prescribing habits that CVS routinely collected and reviewed at the corporate level,” and even removed prescriber blocks that were implemented at Target pharmacies before it was acquired by CVS.⁵ The first element of informed consent is providing patients with adequate information upon which to decide whether to accept or decline treatment. ¹¹ In this situation, however, CVS allegedly prevented “pharmacists from warning one another about certain prescribers.”⁶

If true, the company deprived frontline pharmacists of the information they needed to safely and responsibly dispense medications: “The practices alleged contributed to the opioid crisis and opioid-related deaths, and today’s complaint seeks to hold CVS accountable for its misconduct.”⁶ Though the cost in human life that may have resulted from CSA violations must absolutely and always outweigh financial considerations, the economic damage to Tricare from fraudulent billing and the betrayal of its fiduciary responsinility cannot be underestimated.

A Corporate Morality Play

CVS is not the only company, nor is pharmacy the only industry in health care, that has been the subject of watchdog agency lawsuits or variegated forms of wrongdoing, including violations of the CSA and FCA.^10,12 As of this writing, the DoJ case against CVS has not been heard, much less adjudicated in a court of law. It is ironic that both the DoJ claims and the CVS rebuttal describe the manifest conflict of obligation that pharmacists confront between protecting their livelihood and safeguarding patients’ lives as suggested in the epigraph that has been attributed to the 19th-century British physician and medical educator Peter Mere Latham. It is a dilemma that a growing number of health care practitioners face daily in a vocation becoming increasingly commercialized. It is all too easy for an individual physician, nurse, or pharmacist to feel hopeless and helpless before the behemoth might of a large and looming entity. Yet, it was a whistleblower whose moral courage led to the DoJ investigation and subsequent charges.¹³ We must all never doubt the power of a committed person of conscience to withstand the pressure to mutate medications into poison and stand up for the principles of our professions and inspire a community of colleagues to follow their example.

Express Scripts, the contractor that manages the pharmacy benefit for Tricare, the military health insurance program, announced in 2021 that after a 5-year absence, CVS Pharmacy was once more in the network. In 2023, CVS had the largest profits of any pharmacy chain in the United States, about $159 billion, and generated a quarter of the overall revenue of the US pharmacy industry.¹ Tricare officials heralded the return of CVS as a move that would offer US Department of Defense (DoD) beneficiaries more competitive prices, convenient access, and overall quality.²

DOJ Files Lawsuit Against CVS

In December 2024, the US Department of Justice (DoJ) filed a lawsuit alleging that CVS violated both the Controlled Substances Act (CSA) and the False Claims Act (FCA).^3,4 The United States ex rel. Estright v Health Corporation, et al, filed in Rhode Island, charged that CVS “routinely” and “knowingly” filled invalid prescriptions for controlled substances violating the CSA and then billed federal health care programs for payment for these prescriptions, a breach of the FCA.⁵ The DoJ alleged that CVS pharmacies and pharmacists filled prescriptions for controlled substances that (1) lacked a legitimate medical purpose; (2) were not legally valid; and/or (3) were not issued in the usual course of medical practice. ⁶ CVS contests the charges and issued an official response, stating that it disputes the allegations as false, plans to disprove them in litigation, and has nonetheless fully cooperated with the investigation.⁷

The allegations involved prescriptions for drugs like opioids and benzodiazepines, primary culprits in the American overdose epidemic.⁸ The complaint notes that the prescriptions were early refills in excessive quantities and included what has been called the “holy trinity” of dangerous medications: opioids, benzodiazepines, and muscle relaxants. ^5,8 Even worse (if that is possible), as the complaint outlines, CVS had access to data from both inside and outside the company that these prescriptions came from notorious pill mills and were hence unlawful and yet continued to fill them, leading the DoJ to file the more serious charge that the corporation “knowingly” violated the CSA and “prioritized profits over safety in dispensing controlled substances.”^5,6

The Unholy Trinity

The infamous members of what I prefer to call the “unholy trinity” are a benzodiazepine, often alprazolam, an opioid, and the muscle relaxant carisoprodol. The combination amplifies each agent’s independent risk of respiratory depression. The latter is a schedule IV medication with an active metabolite, meprobamate, that also has this adverse effect. All 3 drugs have high abuse potential and, when combined, increase the risk of fatal overdose. The colloquial name holy trinity derives from the synergistic euphoria experienced when taking this triple cocktail of sedative agents.⁹ This pharmacological recipe for disaster is the house specialty of pill mills: infamous storefront practices that generate high profits and exploit persons with chronic pain and addiction by handing out controlled substances with little clinical assessment and even less oversight.¹⁰

When the Means Become the End

The DoJ allegations suggest that the violations resulted from “corporate-mandated performance metrics, incentive compensation, and staffing policies that prioritized corporate profits over patient safety.”⁶ If the allegations are true, why would a company reinvited by Tricare to serve the nation’s heroes seemingly engage in illegal practices? While CVS has not responded in court, their statement argued that “too often, we have seen government agencies and trial lawyers question the good-faith decisions made by pharmacists while a patient waits at the pharmacy counter, often in pain.”⁶

The DoJ complaint offers a cautionary warning for the US health care system, which is increasingly being micromanaged in the pursuit of efficiency. Like many practitioners in and out of the federal system, I get a cold chill when I read the word productivity. “CVS pharmacists described working at CVS as ‘soul crushing’ because it was impossible to meet the company’s expectations,” the complaint alleges, because “CVS set staffing levels so low that it was impossible for pharmacists to comply with their legal obligations and meet CVS’s demanding metrics.”⁵ Did top-down mandates drive the alleged activities by imposing unattainable performance metrics on pharmacists, offering incentives that encouraged and rewarded corner-cutting, and refusing to fund sufficient staffing to ensure patient safety? This may be what happens when the means (efficiency) become the end rather than a mechanism to achieve the goal of more accessible, affordable, high-quality health care.

Ethically, what is most concerning is that leadership intentionally “deprived its pharmacists of crucial information” about specific practitioners known to engage in illegal prescribing practices.⁶ CVS did not provide pharmacists with “information about prescribers’ prescribing habits that CVS routinely collected and reviewed at the corporate level,” and even removed prescriber blocks that were implemented at Target pharmacies before it was acquired by CVS.⁵ The first element of informed consent is providing patients with adequate information upon which to decide whether to accept or decline treatment. ¹¹ In this situation, however, CVS allegedly prevented “pharmacists from warning one another about certain prescribers.”⁶

If true, the company deprived frontline pharmacists of the information they needed to safely and responsibly dispense medications: “The practices alleged contributed to the opioid crisis and opioid-related deaths, and today’s complaint seeks to hold CVS accountable for its misconduct.”⁶ Though the cost in human life that may have resulted from CSA violations must absolutely and always outweigh financial considerations, the economic damage to Tricare from fraudulent billing and the betrayal of its fiduciary responsinility cannot be underestimated.

A Corporate Morality Play

CVS is not the only company, nor is pharmacy the only industry in health care, that has been the subject of watchdog agency lawsuits or variegated forms of wrongdoing, including violations of the CSA and FCA.^10,12 As of this writing, the DoJ case against CVS has not been heard, much less adjudicated in a court of law. It is ironic that both the DoJ claims and the CVS rebuttal describe the manifest conflict of obligation that pharmacists confront between protecting their livelihood and safeguarding patients’ lives as suggested in the epigraph that has been attributed to the 19th-century British physician and medical educator Peter Mere Latham. It is a dilemma that a growing number of health care practitioners face daily in a vocation becoming increasingly commercialized. It is all too easy for an individual physician, nurse, or pharmacist to feel hopeless and helpless before the behemoth might of a large and looming entity. Yet, it was a whistleblower whose moral courage led to the DoJ investigation and subsequent charges.¹³ We must all never doubt the power of a committed person of conscience to withstand the pressure to mutate medications into poison and stand up for the principles of our professions and inspire a community of colleagues to follow their example.

If I can stop one heart from breaking, I shall not live in vain.
Emily Dickinson¹

The celebration of Valentine’s Day has made the association of hearts with the month of February almost automatic. There is, though, another commemoration of hearts in the second month of the year with special significance for federal practice: American Heart Month. President Lyndon B. Johnson proclaimed February as American Heart Month in 1964 to raise awareness of the enormous human and economic cost of cardiovascular diseases (CVD) that impact many Americans in their prime.

The Centers for Disease Control and Prevention estimates that 1 in 5 deaths in the United States is due to CVD, which includes coronary artery disease, heart failure, heart attack, and stroke.² American Heart Month aims to increase public attention to heart disease prevention and promote research to develop better diagnostic treatment methods for the leading cause of death in most populations.

Forty years after this proclamation, the American Heart Association launched Go Red for Women. On the first Friday of American Heart Month, Americans are encouraged to wear red to draw attention to CVD as the leading cause of death among women as well as men.^2,3 A 2024 report from the American Heart Institute and McKinsey Health Institute attributed at least one-third of the overall health care disparities between men and women to inequities in CVD care. These detrimental differences in the management of heart disease in women encompass both diagnostic misadventures and failure to promptly employ effective therapeutics. CVD morbidity and mortality data for Black women are even higher due to multiple and overlapping social determinants of health.⁴

Higher rates of hypertension, hyperlipidemia, and smoking in women veterans compared with civilians have resulted in an increased risk of heart disease and a 26% higher rate of CVD-related mortality. One in 10 women enrolled in US Department of Veterans Affairs (VA) health care has CVD. Research shows that these women are less likely compared to male veterans to receive counseling about exercise or to be prescribed medications such as statins, even when evidence-based treatment guidelines are followed. The increased rates of heart disease and its complications in women veterans are in part due to risk factors related to military service such as posttraumatic stress disorder (PTSD) and depression, which exceed the rates of nonveteran women.⁵

The heart has a long association with psychological health. For millennia, philosophers and physicians alike believed the heart was the center of the self and the locus of sentience. Even William Harvey, whose discovery of the circulation of blood earned him the title of the father of cardiology, viewed the heart as the life force.⁶ The heart has been explicitly linked to American military trauma since the Civil War era diagnosis of Soldier’s Heart. More recently, mutual genetic vulnerabilities to PTSD and CVD have been posited.⁷ Indeed, research with male combat veterans helped establish the association.

Until recently, there has been a dearth of research to establish the same connection between CVD and PTSD in women veterans, who have elevated rates of PTSD in part due to higher rates of homelessness and military sexual trauma.⁵ Due in large part to the work of a group of VA and US Department of Defense (DoD) researchers, this is starting to change. A research group conducted a retrospective longitudinal study using electronic health record data from nearly 400,000 women veterans to determine the propensity scores of associations between a PTSD diagnosis and the incidence of heart disease over nearly 5 years. The hazard ratio (HR) for the incidence of CVD in women with trauma was 1.44 (compared with matched controls) and even higher in younger women (HR, 1.72).⁸ Researchers also compared CVD mortality in civilian and veteran women and found a concerning trend: not only were mortality rates higher in veterans, but they also did not benefit from an overall improved trend in deaths from heart disease over the past 20 years.⁹

Two years later, the same VA/DoD research group conducted additional analysis on the dataset used in the prior study to examine potential mechanisms underlying the epidemiological link between CVD and PTSD in women veterans. Women with and without PTSD were matched on age and traditional CVD risk factor parameters. The findings demonstrated an association of PTSD with higher risks of diabetes, hypertension, hyperlipidemia, and smoking. However, these traditional risk factors only accounted for one-fourth of the total association. About 34% of the risk was attributed to depression, anxiety, and substance use disorders, as well as obesity and neuroendocrine disorders. This leaves slightly more than half of the elevated risk of CVD unexplained.¹⁰

This research, along with other studies, have identified several mechanisms elucidating the link. Promising translational research may lead to new diagnostic techniques or improved treatment modalities for CVD in women. The most established etiology is that veterans with PTSD have a higher prevalence of multiple CVD risk factors, including smoking, substance use disorders, obesity, poor diet, sleep disorders, depression, and inactivity. There is also increased recognition that PTSD involves neuroendocrine dysfunction in the stress-response that triggers a cascade of metabolic responses (eg, chronic inflammation) that contribute to the onset and progression of heart disease.¹¹

This burgeoning scientific work on CVD and its close association with PTSD and the role of both traditional and nontraditional risk factors can inform VA efforts to educate frontline VA and DoD clinicians, leading to better care for women veterans. Whether a practitioner provides primary, specialty, or mental health care, this new knowledge can inform efforts to optimize prevention and treatment for both PTSD and CVD. For example, the VA/DoD researchers recommend prescribing antidepressants that are less likely to cause or worsen hypertension and to employ psychotherapies known to reduce the harmful CVD effects of increased stress acting through the hypothalamic-pituitary axis. These studies empower VA clinicians to realize Emily Dickinson’s aspiration to prevent trauma and reduce damage to both the psyche and the soma. The health of every veteran’s heart and mind matters, as does every effort of federal practitioners to protect and heal it.

If I can stop one heart from breaking, I shall not live in vain.
Emily Dickinson¹

The celebration of Valentine’s Day has made the association of hearts with the month of February almost automatic. There is, though, another commemoration of hearts in the second month of the year with special significance for federal practice: American Heart Month. President Lyndon B. Johnson proclaimed February as American Heart Month in 1964 to raise awareness of the enormous human and economic cost of cardiovascular diseases (CVD) that impact many Americans in their prime.

The Centers for Disease Control and Prevention estimates that 1 in 5 deaths in the United States is due to CVD, which includes coronary artery disease, heart failure, heart attack, and stroke.² American Heart Month aims to increase public attention to heart disease prevention and promote research to develop better diagnostic treatment methods for the leading cause of death in most populations.

Forty years after this proclamation, the American Heart Association launched Go Red for Women. On the first Friday of American Heart Month, Americans are encouraged to wear red to draw attention to CVD as the leading cause of death among women as well as men.^2,3 A 2024 report from the American Heart Institute and McKinsey Health Institute attributed at least one-third of the overall health care disparities between men and women to inequities in CVD care. These detrimental differences in the management of heart disease in women encompass both diagnostic misadventures and failure to promptly employ effective therapeutics. CVD morbidity and mortality data for Black women are even higher due to multiple and overlapping social determinants of health.⁴

Higher rates of hypertension, hyperlipidemia, and smoking in women veterans compared with civilians have resulted in an increased risk of heart disease and a 26% higher rate of CVD-related mortality. One in 10 women enrolled in US Department of Veterans Affairs (VA) health care has CVD. Research shows that these women are less likely compared to male veterans to receive counseling about exercise or to be prescribed medications such as statins, even when evidence-based treatment guidelines are followed. The increased rates of heart disease and its complications in women veterans are in part due to risk factors related to military service such as posttraumatic stress disorder (PTSD) and depression, which exceed the rates of nonveteran women.⁵

The heart has a long association with psychological health. For millennia, philosophers and physicians alike believed the heart was the center of the self and the locus of sentience. Even William Harvey, whose discovery of the circulation of blood earned him the title of the father of cardiology, viewed the heart as the life force.⁶ The heart has been explicitly linked to American military trauma since the Civil War era diagnosis of Soldier’s Heart. More recently, mutual genetic vulnerabilities to PTSD and CVD have been posited.⁷ Indeed, research with male combat veterans helped establish the association.

Until recently, there has been a dearth of research to establish the same connection between CVD and PTSD in women veterans, who have elevated rates of PTSD in part due to higher rates of homelessness and military sexual trauma.⁵ Due in large part to the work of a group of VA and US Department of Defense (DoD) researchers, this is starting to change. A research group conducted a retrospective longitudinal study using electronic health record data from nearly 400,000 women veterans to determine the propensity scores of associations between a PTSD diagnosis and the incidence of heart disease over nearly 5 years. The hazard ratio (HR) for the incidence of CVD in women with trauma was 1.44 (compared with matched controls) and even higher in younger women (HR, 1.72).⁸ Researchers also compared CVD mortality in civilian and veteran women and found a concerning trend: not only were mortality rates higher in veterans, but they also did not benefit from an overall improved trend in deaths from heart disease over the past 20 years.⁹

Two years later, the same VA/DoD research group conducted additional analysis on the dataset used in the prior study to examine potential mechanisms underlying the epidemiological link between CVD and PTSD in women veterans. Women with and without PTSD were matched on age and traditional CVD risk factor parameters. The findings demonstrated an association of PTSD with higher risks of diabetes, hypertension, hyperlipidemia, and smoking. However, these traditional risk factors only accounted for one-fourth of the total association. About 34% of the risk was attributed to depression, anxiety, and substance use disorders, as well as obesity and neuroendocrine disorders. This leaves slightly more than half of the elevated risk of CVD unexplained.¹⁰

This research, along with other studies, have identified several mechanisms elucidating the link. Promising translational research may lead to new diagnostic techniques or improved treatment modalities for CVD in women. The most established etiology is that veterans with PTSD have a higher prevalence of multiple CVD risk factors, including smoking, substance use disorders, obesity, poor diet, sleep disorders, depression, and inactivity. There is also increased recognition that PTSD involves neuroendocrine dysfunction in the stress-response that triggers a cascade of metabolic responses (eg, chronic inflammation) that contribute to the onset and progression of heart disease.¹¹

This burgeoning scientific work on CVD and its close association with PTSD and the role of both traditional and nontraditional risk factors can inform VA efforts to educate frontline VA and DoD clinicians, leading to better care for women veterans. Whether a practitioner provides primary, specialty, or mental health care, this new knowledge can inform efforts to optimize prevention and treatment for both PTSD and CVD. For example, the VA/DoD researchers recommend prescribing antidepressants that are less likely to cause or worsen hypertension and to employ psychotherapies known to reduce the harmful CVD effects of increased stress acting through the hypothalamic-pituitary axis. These studies empower VA clinicians to realize Emily Dickinson’s aspiration to prevent trauma and reduce damage to both the psyche and the soma. The health of every veteran’s heart and mind matters, as does every effort of federal practitioners to protect and heal it.

If I can stop one heart from breaking, I shall not live in vain.
Emily Dickinson¹

The celebration of Valentine’s Day has made the association of hearts with the month of February almost automatic. There is, though, another commemoration of hearts in the second month of the year with special significance for federal practice: American Heart Month. President Lyndon B. Johnson proclaimed February as American Heart Month in 1964 to raise awareness of the enormous human and economic cost of cardiovascular diseases (CVD) that impact many Americans in their prime.

The Centers for Disease Control and Prevention estimates that 1 in 5 deaths in the United States is due to CVD, which includes coronary artery disease, heart failure, heart attack, and stroke.² American Heart Month aims to increase public attention to heart disease prevention and promote research to develop better diagnostic treatment methods for the leading cause of death in most populations.

Forty years after this proclamation, the American Heart Association launched Go Red for Women. On the first Friday of American Heart Month, Americans are encouraged to wear red to draw attention to CVD as the leading cause of death among women as well as men.^2,3 A 2024 report from the American Heart Institute and McKinsey Health Institute attributed at least one-third of the overall health care disparities between men and women to inequities in CVD care. These detrimental differences in the management of heart disease in women encompass both diagnostic misadventures and failure to promptly employ effective therapeutics. CVD morbidity and mortality data for Black women are even higher due to multiple and overlapping social determinants of health.⁴

Higher rates of hypertension, hyperlipidemia, and smoking in women veterans compared with civilians have resulted in an increased risk of heart disease and a 26% higher rate of CVD-related mortality. One in 10 women enrolled in US Department of Veterans Affairs (VA) health care has CVD. Research shows that these women are less likely compared to male veterans to receive counseling about exercise or to be prescribed medications such as statins, even when evidence-based treatment guidelines are followed. The increased rates of heart disease and its complications in women veterans are in part due to risk factors related to military service such as posttraumatic stress disorder (PTSD) and depression, which exceed the rates of nonveteran women.⁵

The heart has a long association with psychological health. For millennia, philosophers and physicians alike believed the heart was the center of the self and the locus of sentience. Even William Harvey, whose discovery of the circulation of blood earned him the title of the father of cardiology, viewed the heart as the life force.⁶ The heart has been explicitly linked to American military trauma since the Civil War era diagnosis of Soldier’s Heart. More recently, mutual genetic vulnerabilities to PTSD and CVD have been posited.⁷ Indeed, research with male combat veterans helped establish the association.

Until recently, there has been a dearth of research to establish the same connection between CVD and PTSD in women veterans, who have elevated rates of PTSD in part due to higher rates of homelessness and military sexual trauma.⁵ Due in large part to the work of a group of VA and US Department of Defense (DoD) researchers, this is starting to change. A research group conducted a retrospective longitudinal study using electronic health record data from nearly 400,000 women veterans to determine the propensity scores of associations between a PTSD diagnosis and the incidence of heart disease over nearly 5 years. The hazard ratio (HR) for the incidence of CVD in women with trauma was 1.44 (compared with matched controls) and even higher in younger women (HR, 1.72).⁸ Researchers also compared CVD mortality in civilian and veteran women and found a concerning trend: not only were mortality rates higher in veterans, but they also did not benefit from an overall improved trend in deaths from heart disease over the past 20 years.⁹

Two years later, the same VA/DoD research group conducted additional analysis on the dataset used in the prior study to examine potential mechanisms underlying the epidemiological link between CVD and PTSD in women veterans. Women with and without PTSD were matched on age and traditional CVD risk factor parameters. The findings demonstrated an association of PTSD with higher risks of diabetes, hypertension, hyperlipidemia, and smoking. However, these traditional risk factors only accounted for one-fourth of the total association. About 34% of the risk was attributed to depression, anxiety, and substance use disorders, as well as obesity and neuroendocrine disorders. This leaves slightly more than half of the elevated risk of CVD unexplained.¹⁰

This research, along with other studies, have identified several mechanisms elucidating the link. Promising translational research may lead to new diagnostic techniques or improved treatment modalities for CVD in women. The most established etiology is that veterans with PTSD have a higher prevalence of multiple CVD risk factors, including smoking, substance use disorders, obesity, poor diet, sleep disorders, depression, and inactivity. There is also increased recognition that PTSD involves neuroendocrine dysfunction in the stress-response that triggers a cascade of metabolic responses (eg, chronic inflammation) that contribute to the onset and progression of heart disease.¹¹

This burgeoning scientific work on CVD and its close association with PTSD and the role of both traditional and nontraditional risk factors can inform VA efforts to educate frontline VA and DoD clinicians, leading to better care for women veterans. Whether a practitioner provides primary, specialty, or mental health care, this new knowledge can inform efforts to optimize prevention and treatment for both PTSD and CVD. For example, the VA/DoD researchers recommend prescribing antidepressants that are less likely to cause or worsen hypertension and to employ psychotherapies known to reduce the harmful CVD effects of increased stress acting through the hypothalamic-pituitary axis. These studies empower VA clinicians to realize Emily Dickinson’s aspiration to prevent trauma and reduce damage to both the psyche and the soma. The health of every veteran’s heart and mind matters, as does every effort of federal practitioners to protect and heal it.

On December 11, 2020, the US Food and Drug Administration (FDA) delivered the holiday gift America was waiting for—approval of the first COVID-19 vaccine. Following the recommendation of its expert advisory panel, the FDA issued its opening emergency use authorization (EUA) for the Pfizer and BioNTech product to be distributed and administered across the country.¹ A week after that historic announcement, the FDA issued an EUA to Moderna for a second COVID-19 vaccine.²

An EUA is a misunderstood concept that, like the development of the vaccine itself, appears almost like a magical federal deliverance to a nation at a time when almost every other public health effort has floundered. An EUA is a regulatory process to enable a public health emergency response with medical countermeasures including not only vaccines, but also medications. Earlier in 2020, hydroxychloroquine and remdesivir each received EUAs for treating patients with COVID-19.³ The EUA for hydroxychloroquine was later revoked when more data raised concerns for its efficacy.⁴ EUAs do not mean the drugs are experimental or that everyone receiving them is participating in a research trial; however, for the sake of safety and science, data continue to be collected and analyzed. Issuance of an EUA indicates that after rigorous examination and an independent advisory board review of data submitted by the manufacturer, the FDA has determined the product and situation meet key criteria: (1) There is a public health emergency that threatens health and life and requires expedited procedures; (2) there are no extant approved products able to treat or prevent the disease; and (3) the known and potential benefits of the product outweigh the known and potential risks.⁵

The public and even the professional press have celebrated the arrival of this technologic triumph over a virus that had vanquished staggering numbers of lives and livelihoods. Much of the media coverage aptly chose the word “hope” to capture the significance of this unprecedented accomplishment for which so many millions yearned. A Google search for “hope” on the morning of December 20, yielded 339,000,000 results. For example, a headline especially salient for Federal Practitioner readers from the New York Times read, “‘A Shot of Hope’ What the Vaccine is like for Frontline Doctors and Nurses.”⁶

I want to briefly argue why even though I believe hope in and for the vaccine is desperately needed if we are to survive this long, dark winter, trust in the vaccine can actually usher in the warmth of economic recovery and the light of saved lives. Trust is crucial in 3 main areas if the awe-inspiring hope of the vaccine the EUAs codify is to be fulfilled. The venerable moral and civic virtue of trust has been trivialized and commercialized mostly mentioned in advertising for insurance or real estate companies. Medical virtue-ethicists Edmund Pellegrino and David Thomasma describe trust as the binding force that keeps civilization intact. “Trust is ineradicable in human relationships. Without we could not live in society or attain even the rudiments of a fulfilling life, they explain. “Without trust we could not anticipate the future, and we would therefore be paralyzed into inaction. Yet to trust and entrust is to become vulnerable and dependent on the good will and motivations of those we trust. Trust, ineradicable as it is, is also always problematic.”⁷

The first area where that trust is the hardest to secure is in the federal government, the actions and messages of which have seemed so inconstant, unjust, and deceptive to many. For enough citizens to roll up their sleeves, they must believe the outgoing and the incoming administrations and legislators can make rational plans translated into sound public health policy that place the good of humanity above other interests and then mobilize the resources of the country to deliver that good with consistency, fairness, and transparency.

The second area is trust in medical science. Long before COVID-19, American attitudes toward vaccines reflected reasonable fears and ridiculous conspiracy theories—both of which are serious obstacles to the breadth of immunization required to achieve herd immunity. Ordinary people must believe that the health care professionals and scientists at the Centers for Disease Control and Prevention and the FDA will never compromise safety for political expediency. Recent polls have shown an increase in the percentage of the population willing to consider vaccination. A December Gallop poll found that 63% of Americans were willing to be vaccinated for COVID-19.⁸ To raise those numbers high enough to approach herd immunity will require Americans to believe that the scientists who discover the vaccines and the companies that develop them have placed people above profit and ranked the safety of society above individual scientific renown.

Groups that have been the historic objects of exploitation in research and contemporary disparities in health care understandably have more distrust of science and medicine. While public health officials insist that they have developed a system of vaccine distribution that is equitable and prioritizes the sick and old and those who care for them before the rich and powerful, we should not be surprised that our communication of this assurance is viewed with skepticism. As a recent Medscape article advised, public health officials may need to rely on, “trusted messengers” to help some communities to “overcome vaccine hesitancy.”⁹

Third we must trust in our fellow citizens to maintain the public health measures of social distancing and mask wearing even after there is widespread vaccination. If we are to reap the benefits of a safe and effective vaccine, we must be a community of immunity, not just isolated inoculated individuals. We as health care practitioners must do all we can to educate the public that the adverse reactions to the vaccine so prominently featured in the media are expected with any new and complex biological product and do not signal risk that outweighs the deadliness of the virus.¹⁰

Fourth, and finally, we must trust in ourselves as health care professionals and administrators. We in the DoD, VA, and PHS have the knowledge and skills to endure the onslaught of pain and suffering we will all experience in one way or another in these next long months. We must believe that our courage and compassion can turn a vaccine into vaccinations sufficient to relieve the COVID-19 siege of our hospitals and intensive care units. When that day comes, hope will have been a plan we could trust. 

On December 11, 2020, the US Food and Drug Administration (FDA) delivered the holiday gift America was waiting for—approval of the first COVID-19 vaccine. Following the recommendation of its expert advisory panel, the FDA issued its opening emergency use authorization (EUA) for the Pfizer and BioNTech product to be distributed and administered across the country.¹ A week after that historic announcement, the FDA issued an EUA to Moderna for a second COVID-19 vaccine.²

An EUA is a misunderstood concept that, like the development of the vaccine itself, appears almost like a magical federal deliverance to a nation at a time when almost every other public health effort has floundered. An EUA is a regulatory process to enable a public health emergency response with medical countermeasures including not only vaccines, but also medications. Earlier in 2020, hydroxychloroquine and remdesivir each received EUAs for treating patients with COVID-19.³ The EUA for hydroxychloroquine was later revoked when more data raised concerns for its efficacy.⁴ EUAs do not mean the drugs are experimental or that everyone receiving them is participating in a research trial; however, for the sake of safety and science, data continue to be collected and analyzed. Issuance of an EUA indicates that after rigorous examination and an independent advisory board review of data submitted by the manufacturer, the FDA has determined the product and situation meet key criteria: (1) There is a public health emergency that threatens health and life and requires expedited procedures; (2) there are no extant approved products able to treat or prevent the disease; and (3) the known and potential benefits of the product outweigh the known and potential risks.⁵

The public and even the professional press have celebrated the arrival of this technologic triumph over a virus that had vanquished staggering numbers of lives and livelihoods. Much of the media coverage aptly chose the word “hope” to capture the significance of this unprecedented accomplishment for which so many millions yearned. A Google search for “hope” on the morning of December 20, yielded 339,000,000 results. For example, a headline especially salient for Federal Practitioner readers from the New York Times read, “‘A Shot of Hope’ What the Vaccine is like for Frontline Doctors and Nurses.”⁶

I want to briefly argue why even though I believe hope in and for the vaccine is desperately needed if we are to survive this long, dark winter, trust in the vaccine can actually usher in the warmth of economic recovery and the light of saved lives. Trust is crucial in 3 main areas if the awe-inspiring hope of the vaccine the EUAs codify is to be fulfilled. The venerable moral and civic virtue of trust has been trivialized and commercialized mostly mentioned in advertising for insurance or real estate companies. Medical virtue-ethicists Edmund Pellegrino and David Thomasma describe trust as the binding force that keeps civilization intact. “Trust is ineradicable in human relationships. Without we could not live in society or attain even the rudiments of a fulfilling life, they explain. “Without trust we could not anticipate the future, and we would therefore be paralyzed into inaction. Yet to trust and entrust is to become vulnerable and dependent on the good will and motivations of those we trust. Trust, ineradicable as it is, is also always problematic.”⁷

The first area where that trust is the hardest to secure is in the federal government, the actions and messages of which have seemed so inconstant, unjust, and deceptive to many. For enough citizens to roll up their sleeves, they must believe the outgoing and the incoming administrations and legislators can make rational plans translated into sound public health policy that place the good of humanity above other interests and then mobilize the resources of the country to deliver that good with consistency, fairness, and transparency.

The second area is trust in medical science. Long before COVID-19, American attitudes toward vaccines reflected reasonable fears and ridiculous conspiracy theories—both of which are serious obstacles to the breadth of immunization required to achieve herd immunity. Ordinary people must believe that the health care professionals and scientists at the Centers for Disease Control and Prevention and the FDA will never compromise safety for political expediency. Recent polls have shown an increase in the percentage of the population willing to consider vaccination. A December Gallop poll found that 63% of Americans were willing to be vaccinated for COVID-19.⁸ To raise those numbers high enough to approach herd immunity will require Americans to believe that the scientists who discover the vaccines and the companies that develop them have placed people above profit and ranked the safety of society above individual scientific renown.

Groups that have been the historic objects of exploitation in research and contemporary disparities in health care understandably have more distrust of science and medicine. While public health officials insist that they have developed a system of vaccine distribution that is equitable and prioritizes the sick and old and those who care for them before the rich and powerful, we should not be surprised that our communication of this assurance is viewed with skepticism. As a recent Medscape article advised, public health officials may need to rely on, “trusted messengers” to help some communities to “overcome vaccine hesitancy.”⁹

Third we must trust in our fellow citizens to maintain the public health measures of social distancing and mask wearing even after there is widespread vaccination. If we are to reap the benefits of a safe and effective vaccine, we must be a community of immunity, not just isolated inoculated individuals. We as health care practitioners must do all we can to educate the public that the adverse reactions to the vaccine so prominently featured in the media are expected with any new and complex biological product and do not signal risk that outweighs the deadliness of the virus.¹⁰

Fourth, and finally, we must trust in ourselves as health care professionals and administrators. We in the DoD, VA, and PHS have the knowledge and skills to endure the onslaught of pain and suffering we will all experience in one way or another in these next long months. We must believe that our courage and compassion can turn a vaccine into vaccinations sufficient to relieve the COVID-19 siege of our hospitals and intensive care units. When that day comes, hope will have been a plan we could trust. 

On December 11, 2020, the US Food and Drug Administration (FDA) delivered the holiday gift America was waiting for—approval of the first COVID-19 vaccine. Following the recommendation of its expert advisory panel, the FDA issued its opening emergency use authorization (EUA) for the Pfizer and BioNTech product to be distributed and administered across the country.¹ A week after that historic announcement, the FDA issued an EUA to Moderna for a second COVID-19 vaccine.²

An EUA is a misunderstood concept that, like the development of the vaccine itself, appears almost like a magical federal deliverance to a nation at a time when almost every other public health effort has floundered. An EUA is a regulatory process to enable a public health emergency response with medical countermeasures including not only vaccines, but also medications. Earlier in 2020, hydroxychloroquine and remdesivir each received EUAs for treating patients with COVID-19.³ The EUA for hydroxychloroquine was later revoked when more data raised concerns for its efficacy.⁴ EUAs do not mean the drugs are experimental or that everyone receiving them is participating in a research trial; however, for the sake of safety and science, data continue to be collected and analyzed. Issuance of an EUA indicates that after rigorous examination and an independent advisory board review of data submitted by the manufacturer, the FDA has determined the product and situation meet key criteria: (1) There is a public health emergency that threatens health and life and requires expedited procedures; (2) there are no extant approved products able to treat or prevent the disease; and (3) the known and potential benefits of the product outweigh the known and potential risks.⁵

The public and even the professional press have celebrated the arrival of this technologic triumph over a virus that had vanquished staggering numbers of lives and livelihoods. Much of the media coverage aptly chose the word “hope” to capture the significance of this unprecedented accomplishment for which so many millions yearned. A Google search for “hope” on the morning of December 20, yielded 339,000,000 results. For example, a headline especially salient for Federal Practitioner readers from the New York Times read, “‘A Shot of Hope’ What the Vaccine is like for Frontline Doctors and Nurses.”⁶

I want to briefly argue why even though I believe hope in and for the vaccine is desperately needed if we are to survive this long, dark winter, trust in the vaccine can actually usher in the warmth of economic recovery and the light of saved lives. Trust is crucial in 3 main areas if the awe-inspiring hope of the vaccine the EUAs codify is to be fulfilled. The venerable moral and civic virtue of trust has been trivialized and commercialized mostly mentioned in advertising for insurance or real estate companies. Medical virtue-ethicists Edmund Pellegrino and David Thomasma describe trust as the binding force that keeps civilization intact. “Trust is ineradicable in human relationships. Without we could not live in society or attain even the rudiments of a fulfilling life, they explain. “Without trust we could not anticipate the future, and we would therefore be paralyzed into inaction. Yet to trust and entrust is to become vulnerable and dependent on the good will and motivations of those we trust. Trust, ineradicable as it is, is also always problematic.”⁷

The first area where that trust is the hardest to secure is in the federal government, the actions and messages of which have seemed so inconstant, unjust, and deceptive to many. For enough citizens to roll up their sleeves, they must believe the outgoing and the incoming administrations and legislators can make rational plans translated into sound public health policy that place the good of humanity above other interests and then mobilize the resources of the country to deliver that good with consistency, fairness, and transparency.

The second area is trust in medical science. Long before COVID-19, American attitudes toward vaccines reflected reasonable fears and ridiculous conspiracy theories—both of which are serious obstacles to the breadth of immunization required to achieve herd immunity. Ordinary people must believe that the health care professionals and scientists at the Centers for Disease Control and Prevention and the FDA will never compromise safety for political expediency. Recent polls have shown an increase in the percentage of the population willing to consider vaccination. A December Gallop poll found that 63% of Americans were willing to be vaccinated for COVID-19.⁸ To raise those numbers high enough to approach herd immunity will require Americans to believe that the scientists who discover the vaccines and the companies that develop them have placed people above profit and ranked the safety of society above individual scientific renown.

Groups that have been the historic objects of exploitation in research and contemporary disparities in health care understandably have more distrust of science and medicine. While public health officials insist that they have developed a system of vaccine distribution that is equitable and prioritizes the sick and old and those who care for them before the rich and powerful, we should not be surprised that our communication of this assurance is viewed with skepticism. As a recent Medscape article advised, public health officials may need to rely on, “trusted messengers” to help some communities to “overcome vaccine hesitancy.”⁹

Third we must trust in our fellow citizens to maintain the public health measures of social distancing and mask wearing even after there is widespread vaccination. If we are to reap the benefits of a safe and effective vaccine, we must be a community of immunity, not just isolated inoculated individuals. We as health care practitioners must do all we can to educate the public that the adverse reactions to the vaccine so prominently featured in the media are expected with any new and complex biological product and do not signal risk that outweighs the deadliness of the virus.¹⁰

Fourth, and finally, we must trust in ourselves as health care professionals and administrators. We in the DoD, VA, and PHS have the knowledge and skills to endure the onslaught of pain and suffering we will all experience in one way or another in these next long months. We must believe that our courage and compassion can turn a vaccine into vaccinations sufficient to relieve the COVID-19 siege of our hospitals and intensive care units. When that day comes, hope will have been a plan we could trust.