When I first moved to Georgia from the Boston area, one of the things I kept in mind was my proximity to a VA Medical Center, and according to my trusty GPS, my new home was only about an hour from the Atlanta VA hospital in Decatur. The VA Hospital I’d grown accustomed to in Rhode Island was certainly busy and I’d be lying if I said I never had reason to complain, but I understood the nature of the challenge facing VA employees: they’re consistently under-staffed and overworked with no real hope of that changing in sight. When dealing with the VA, many veterans like myself adopt a shoulder-shrugging “it is what it is” mentality… because, depending on your circumstance, it may well be the only option available to you.

Of course, my GPS may have been telling the truth about how long it would theoretically take to drive to Decatur under perfect circumstances, but the reality of Atlanta means the drive would never take less than a full two hours. As near as I can tell, Atlanta was designed specifically to maximize traffic congestion, leading many locals to regularly joke that Atlanta is an hour from Atlanta. As a result, I tried my best to avoid the trip whenever I could, but a few years ago I began suffering from Central Serous Chorioretinopathy, or CSC, which is a condition that leads to swelling in my retinas that leaves me temporarily blind from time to time.

I called the VA and told them that I had woken up without vision in my right eye and that I was terrified. They told me they could fit me in to their eye clinic four hours later (a miracle by VA standards) and that I should start making arrangements to get there immediately. As I later recounted in a piece, I received incredible care from the Atlanta VA Eye Clinic that day, with some doctors staying well after their shifts trying to figure out what had happened to my eye. I had been boxing the night before, so the first assumption was a detached retina — and it took a great deal of testing to finally make a determination. Unfortunately, the diagnoses came with no clear path for treatment (through no fault of the staff), and I was told all we could do was wait and see how my vision turned out.

On my follow up visit, the waiting room was standing room only. I stood for the first two hours until a chair opened up, but only kept my seat for about fifteen minutes before an older veteran, clearly more in need of a rest, found himself waiting with us. Two more hours would pass before I had my pupils dilated and waited some more (for my eyes to adjust) just to have a doctor give them a quick glance, tell me there was nothing he could do, and send me on my way. By then, CSC had become an issue in both of my eyes, but there was still no course of treatment to be had (again, that’s not the VA’s fault at all from what I understand). Because I was too blind to drive myself, my poor wife and two-year-old daughter eventually chose to wait it out in the car, driving laps around the parking lot as I stood in the waiting room. All told, I left the VA six hours after my appointment was scheduled — and depressingly, with no course of treatment.  I was frustrated, depressed, and it turns out… lucky.

Other patients, I’ve since come to learn, have had far worse experiences with the Atlanta VA.

A 2017 report on the Atlanta VA Medical Center found a laundry list of basic cleanliness and safety issues in the facility, leading directly into a 2018 report filed by the VA’s Office of Inspector General that noted another series of issues and infractions, including failing to give patients mammograms for years. Another subsequent report found the VA had the worst staffing issues in the nation. It only got worse from there.

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In October of 2018, the Atlanta VA had its Veterans Affairs quality rating dropped from 3 out of 5 stars to just 1 out of 5 stars — the lowest possible rating the VA system provides and making the Atlanta VA ranked among the lowest 10% of VA hospitals in the nation. The VA further noted that the Atlanta facility often failed to conduct criminal background checks or drug screenings on employees in a timely manner. Soon thereafter, they were also fined for improperly storing hazardous waste on the hospital’s grounds. Following these announcements, the facility changed directors, but the trouble kept coming.

In April of this year, a 68-year-old veteran who had been seeking care at the Atlanta VA Medical Center returned to his car in the same parking lot my wife and daughter spent the day waiting for me in, produced a pistol, and shot himself. It was one of two veteran suicides at Georgia VA facilities that month and served as yet another tragic reminder of what can happen when troubled veterans do not have access to the mental healthcare that they need.

In July of this year, it was revealed that the Atlanta VA, in an effort to clear their massive backlog of health care applications, had chosen to simply eliminate 208,272 applications citing clerical errors on the patient’s behalf. Many of these claims were simply thrown out over missing signatures or because some boxes had been left blank. The VA sent just one letter to each rejected applicant, prompting veteran’s groups to protest the lack of communication and what seemed to be a decision based on improving the VA’s statistics, rather than helping veterans that are seeking care. Some of those patients had been waiting on a response to their application since 1998.

Which brings us to the recent and tragic story of Vietnam veteran Joel Marrable, who died after a long fight with cancer at the Atlanta VA Medical Center earlier this month. In the days leading up to his death, Marrable’s daughter found her dying father covered in ants with hundreds of ant bites. When she told the nurses, they responded that “they thought he was dead,” before removing him from the bed, changing the sheets and cleaning the room. When Marrable’s daughter returned the next day, however, she once again found her weak father, who was unable to get out of bed unassisted, covered in ants and new bites. She had him immediately removed from that room and placed in a new one. An hour later, he died.

“I felt very small in the world Saturday when my dad died,” Marrable’s daughter, Laquana Ross, said. “Now I am able to share his story and my dad matters to someone beyond me and my family. Now the world knows and the world cares that this happened.”

The Atlanta VA Medical Center is far from the only VA facility in the country with issues, but it seems that most of the issues affecting the VA as a whole can be found represented in this one troubled facility. My first-hand experiences tell me that there are responsible, professional, and caring employees on the staff in Decatur, though they seem too overwhelmed to offer much in the way of real care. A six hour wait followed by a five-minute consultation just isn’t a feasible healthcare option for veterans that have to maintain jobs.

This nation chose to go to war and these men and women were sent to fight it. The suffering should be over when they get home. No one deserves to die like Joel Marrable.