Women Warriors : After Decades of Poor Funding, Breast Cancer Research Has a New, Rich and Most Unlikely Patron--the Defense Department. And Fran Visco and Col. Irene Rich Paln to Keep It That Way

They never should have met.

Fran Visco spent her life railing at injustice, both political and personal. The oldest of four children in an Italian Catholic family in Philadelphia, Visco always dreamed of being a lawyer--and if her parents didn’t have the money to send her to law school, if most girls in the mid-’60s had more-traditional goals, too bad; she simply worked her way through. She protested the Vietnam War, using the free time she did not have, between work and classes, to march and stuff envelopes. When she became a lawyer, she got involved in the women’s movement, demanding equal rights and equal pay.

She married twice before she found the right guy, and then, at 38, embarked on life as a working mother. As far as Fran Visco was concerned, the world order had a question mark at the end. Reality was there to be challenged.

Irene Rich led a more dutiful life. While Visco was marching against the war, Rich, then Irene Meyers, was sitting in her dad’s car waiting for him to get off work at Elmendorf Air Force base in Anchorage, Alaska, where he was employed by the Federal Aviation Administration. She was a nursing student at the University of North Carolina, but summers she came home--and since the Meyers were a one-car family, she had to pick up her dad every afternoon.

She sat in the parking lot and watched the same ritual over and over again: A plane came in from Vietnam bearing wounded soldiers, and the ones who were too weak to make the next leg of the trip were taken off. Then a truck drove up, and men loaded onto the plane for the journey stateside the coffins of boys who had died in the hospital. Injured soldiers off, dead soldiers on, day after day.

Irene Rich had always planned to be a nurse. Watching that sorry parade, she decided to be an Army nurse. To the dismay of her parents, who feared for her safety, and the ridicule of her friends, who questioned her sanity, she enlisted in 1971. If there were any logic to life, they would have grown old without ever being aware of the other’s existence. But in September, 1987, Fran Visco’s life abruptly stopped making sense. On her way in to work, she had her first baseline mammogram--and that afternoon the doctor called to say that the mass the radiologist saw on the film was almost certainly malignant. Thirty-nine-year-old Fran Visco had breast cancer.

She had a lumpectomy and radiation, as well as chemotherapy. And she did what she always had done: she got angry, at how little was known about the disease that threatened her. She joined a local advocacy group, but it quickly became clear to her that the first generation of advocates spent most of their energy campaigning for improved methods of early detection. Visco was more ambitious. She wanted a cure, or at least some decent information about prevention strategies.

In 1991, she attended a meeting of like-minded women called by Dr. Susan Love, now director of the Revlon/UCLA Breast Center. In May of that year, Love and a core group founded the National Breast Cancer Coalition, with Visco as its first president. The NBCC held hearings to determine what the price tag was for enough research to break medicine out of its standard regimen of surgery, radiation and chemotherapy. Then Visco started knocking on Congressional doors and testifying in front of appropriations committees.

She was asking for a lot--$300 million added to an existing annual research budget of only $90 million--but as far as she was concerned, it was reparations for decades of neglect.

*

Almost six years later, Fran Visco and Irene Rich are unlikely allies. Together they have established a controversial new source of funding for national breast cancer research--the Department of Defense. In fiscal 1993, an election-year Congress, eager to prove its commitment to women’s health, drafted the Army into the war on breast cancer, to the tune of $210 million. It was intended as a one-time expenditure, but Visco, a troop of lobbyists and a handful of sympathetic politicians have parlayed the original windfall into an ongoing program, with $25 million to sustain the two-year program in 1994, $150 million in fiscal 1995 and $75 million earmarked for fiscal 1996.

Visco, the tireless lobbyist, has each year pushed the appropriation in the halls of Congress. Rich, now Col. Irene Rich, is the program’s determined administrator. They are mismatched both in appearance and attitude: Visco a short, stocky brunette whose pugnacious attitude belies an eager sweetness; Rich a tall, rawboned woman at home in olive drab, a dignified full-bird colonel whose one concession to vanity is a formidable set of deep-pink fingernails. Visco talks to anyone who will listen and has elevated the pointed interruption to an art form. Rich, who has spent most of her career as an obstetrics and gynecological nurse, is precluded by military etiquette from saying anything critical about this, or any other, Administration, but she cries in front of a stranger when she recalls a young mother who died of breast cancer before her child reached kindergarten.

They have managed to sustain the program money at a time when traditional government sources of research funding are feeling the budget squeeze, but there is no time to celebrate. The clock ticks loudly: Every year, 182,000 women are diagnosed with breast cancer and 46,000 die--more casualties than all the American battle deaths of the Vietnam War. And the Defense Department program is hardly a safe haven. It faces adversaries in Congress, within the department itself and in the scientific community. Each appropriation has been a cliffhanger--particularly this year’s, thanks to attacks from both the new Republican Congress, which tried unsuccessfully to rescind last year’s appropriation, and Secretary of Defense William Perry, who announced his intention to withhold funds set aside for breast cancer and AIDS research, a statement that elicited a swift letter of reprimand from presidential Chief of Staff Leon Panetta.

Next year’s money has not officially been approved, since Congress turned down the proposed defense budget the first time around. But for once, breast cancer is not the debated issue, and Visco is guardedly optimistic. “We’re going to assume, and are working very hard to make sure, that the breast cancer money is safe. It’s just the latest in a series of crises,” she says. “It’s ongoing.”

Visco and Rich know that they are dancing at the edge of the abyss, always a vote away from defeat.

*

When Fran Visco set out on her quest for money, she found herself at the end of a long line of people who wanted funds from the National Institutes of Health, the federal government’s medical research center in Bethesda, Md. The Senate appropriations subcommittee that doled out money to the NIH found an extra $80 million, nowhere near what Visco was asking for, and gave her the same explanation everyone got: There was no way to give her more of the pie without taking it away from other, equally deserving programs.

Visco did not want to hear that the pie wasn’t big enough. “Everyone before me went up there hat in hand,” she recalls. “When it was my turn, I said something like, ‘You managed to find the money when it was time to bail out all those white guys in suits, from the savings and loan crisis. Are you saying now that you can’t find the money to fight breast cancer? You’ll just have to get a bigger pie.’ ”

Then she got lucky, and in a single evening, everything changed. Sen. Tom Harkin (D-Iowa) had been trying for three years to shift $4.2 billion in defense funds to pay for domestic social programs that would benefit women and children, and this year, at the National Breast Cancer Coalition’s request, he included a $210 million appropriation for breast cancer research. But the amendment violated a 1990 “fire wall” regulation that prevented such transfers, and overriding it required a two-thirds majority. The amendment failed, as it had twice before.

Visco’s colleague, Susan Love, was in Washington for a board meeting of the coalition, so Visco next approached Sen. Alfonse D’Amato (R-N.Y.), with a new tack. With no precedent, D’Amato introduced legislation to transfer 1% of the Defense Department research and development budget, an amount of $382 million, to fight breast cancer. That lost, too, but by a smaller margin.

Harkin quickly introduced what then-legislative director Ed Long referred to as a “stealth amendment,” appropriating $210 million for breast cancer research but leaving it within the Defense Department budget, which meant that it would require only a simple majority to carry. In the past, the military has conducted medical research deemed necessary to maintain a healthy defense force, but no one had ever stepped in to tell the Defense Department what to do with its money. Long has a framed copy of the vote tally on the wall of his office; he likes to show visitors how many Senators abstained at first, then shifted their votes to “yes.” No one wanted to be on record as voting against breast cancer research in an election year.

Suddenly Visco had her money.

“Then war broke out,” she says, with a wry smile. “The money was going to stay there? Who was going to get it? Who was going to administer it? Nobody was prepared--because no one believed we would get the money. Except us.”

*

Irene Rich had built a formidable career in the military. With a Ph.D. in nursing science, she had served as both a combat nurse and a women’s health specialist. In 1991, she was named head nurse, gynecology, gynecological oncology and plastic surgery at Walter Reed Army Medical Center and a year later she was named assistant chief of the Nursing Research Service . In early 1994, she was working on a research project on pregnancy among enlisted women when the call came. The general originally in charge of the breast cancer program had decided to retire, and Rich had been chosen to take over as of March.

She had no time to get acclimated. The program was late getting underway because the Army legally could not solicit applications until funds had been deposited in the Army Medical Research and Materiel Command account; but by the terms of the appropriation, the money would go back to the U.S. Treasury if it was not spent by Sept. 30, 1994. The AMRMC had already received 2,700 grant applications totaling $2 billion, and a private contractor had just completed a review to determine the proposals’ scientific merit. Now the Army had barely seven months to finish choosing deserving applicants and negotiate contracts with them.

The program’s framework was a report that the Army commissioned from the Institute of Medicine, a public policy advisory group established in 1970 by the National Academy of Sciences. The institute’s committee ran the philosophical gamut, from Berkeley geneticist Mary-Claire King, who has devoted her career to the pursuit of the gene for heritable breast cancer, to Dr. Harold Varmus, a Nobel laureate for his work on retroviruses and oncogenes. But the 12 members of the committee managed to agree on three priorities: This country needed to invest in the training of new doctors and scientists (up to $27 million), infrastructure enhancement to establish a foundation for future research (up to $21 million) and research projects (at least $151.5 million).

Basically, the nation lacked the fundamentals--tumor registries, DNA resources for research, computerized information systems--upon which it could build an orchestrated assault. Established researchers needed money, new researchers had to be wooed to the field, and the next generation needed to be recruited.

Rich had one additional weapon in her arsenal: No history. Visco is vocally impatient with the National Institutes of Health for spending too little money and focusing on basic science instead of targeted research. Rich is infinitely more diplomatic. “I could not do what I do were it not for the infrastructure known as the NIH, the premier and preeminent funder of science,” she says. But she relishes her position as an outsider. “I’m the new kid on the block,” she says. “I have not been raised and socialized into the NIH model.”

A newcomer and an activist; the combination fairly guaranteed change.

*

Ft. Detrick, Md., is a brooding, gray compound at the bottom of a boulevard that rolls along, innocently enough, past mini-malls and manicured shrubs, until it dead-ends at the base’s gate. This is the place where killer viruses sit in security tombs, and in the late afternoon it is frighteningly devoid of any signs of human activity. A tiny yellow-brick bungalow sits like an afterthought at the left edge of the base--the headquarters of the Army Medical Research and Materiel Command Research Area Directorate VI, which houses the main office of the breast cancer research program.

Rich assumed control of the program just two weeks before the first working session of the Integration Panel, a group composed of doctors, researchers and, for the first time, breast cancer patients such as Visco. It was their job to review the eligible grants to determine relevance--or, as Rich puts it, “how the community of breast cancer patients could best be served.” Their first meeting promised to be a collision of contradictory outlooks and criteria, and their choices would shape the direction the program took.

So she sent each member of the panel a letter introducing herself--and because it was a headstrong group, she says, made up of people “used to getting their own way,” she also included a copy of the book, “Getting to Yes: The Art of Negotiation.”

On the first morning of deliberations, the panel assembled around a U-shaped table, with Army representatives sitting at the edges of the room. Rich still chuckles at her first encounter with Visco.

“I ended up sitting behind Fran--I didn’t know her at all yet--and when I sat down, she turned around to me and said: ‘Colonel Rich, am I the only person you sent this book to?’ I think she’s aware of her reputation as a tough negotiator.”

For her part, Visco was still getting used to the notion that someone in uniform could be on her side. Ft. Detrick felt uncomfortably like enemy turf, and on her first visit, she wondered whether the officers she met were as skeptical of her as she was of them. “I thought: ‘They’ve got my records, all the anti-war stuff, and they’re never going to let me out of here.’ ”

But in Irene Rich she found someone whose ambition was, in its own properly disciplined way, as outsized as Visco’s. It is Rich’s job to wage war effectively--and after more than 20 years in the military, she likes to think she can do a better job than those who have been at it longer. She chooses to disregard the depressing results of a century’s effort-- mortality rate that obstinately refuses to budge--and no good way to predict who will, or won’t respond to treatment. Dr. Love tells women: “The way you know your breast cancer is cured? You die at 95 of a stroke.”

Visco considers her Rich “perfect” for her job, because she knows how to be an administrator without being an autocrat. “She has the ability to lead,” Visco says, “but the ideas don’t have to be hers.”

What that meant for the program was innovation, in terms both of process and product. The National Institutes of Health traditionally conducts a scientific review and then awards grants from the top score on down, until the money runs out. Defense Department applicants are similarly rated, but the Army awards from the top only if the integration panel feels that the grants live up to their criteria of relevance. The panel never dips below the cutoff score for scientific merit, but it has skipped over deserving grants that seem redundant in favor of a study with a slightly lower score that plows new ground.

“With our program, we laid up the frame of the Institute of Medicine guidance, what was needed for breast cancer, and we didn’t draw any lines in the traditional sense,” Rich says. “If we had 12 of something, we considered how could the community best be served? So we avoided duplication a lot.”

The Army also set aside $7.77 million--3% of the research funds for IDEA grants, for young researchers who had not yet managed to break into the National Institutes of Health or for speculative studies that seemed promising. This is the part of the program that Rich likes to brag about, because it broadens the field. Doctors such as Susan Love came to the Defense Department with ideas that could not find a home at the NIH--in Love’s case, a ductascope, a hairbreadth instrument that she planned to insert into the milk ducts of the breast to try to map the ductal system and look for early markers of disease.

But longtime breast cancer researchers, such as UCLA’s Dr. Dennis Slamon, believe that the Defense Department has managed an even more lasting contribution with its infrastructure grants. Slamon received two large grants from the department in the program’s first year, one for a tissue bank that will be a shared resource between UCLA and USC--but he can recall the days in the not-so-distant past, when pathologists would go begging to surgeons, asking them not to discard human tissue after surgeries. Now he and USC’s Dr. Michael Press have almost $1 million for a four-year effort to establish a bank of both malignant and healthy tissues, as well as fat tissue and bone marrow tissue, which can yield information about environmental factors in the disease.

He is understandably supportive of the program, but not just because he happened to profit from it. There is a Catch-22 to most medical research funded by the National Institutes of Health: You have to have early data to qualify for a grant, and to get early data, you need money. For the last five years, Slamon has received private funding from Revlon’s Ronald Perelman which has enabled him to move forward as quickly as he has. He Slamon knows firsthand how difficult it is to qualify for the NIH money without an ancillary source of cash.

“It’s almost impossible to get funded without preliminary data” at the institute, Slamon says, “and unless it’s really cheap to get that preliminary data, how do you get it without funds?” The Defense Department broke that cycle. It can provide start-up money--and is generally perceived as funding a broader range of research than the NIH does.

The first 334 grants were awarded a year ago. This June, the Defense Department sent out its second Broad Agency Announcement requesting applications. This time, the notion of relevance was refined even further: A questionnaire went out to the first group of grant recipients, asking them to explain exactly what aspect of prevention, treatment or cure their studies addressed. Rich’s goal with the second set of grants, to be announced next March, was to fill gaps in knowledge--to review all the applicants with an eye toward finding the ones who could plug holes.

“I’m a nurse, I’m a junior scientist, that’s all the Army has,” Rich says. “Not the traditionally groomed director of a major research program. The fact of the matter is, we scare the socks off traditional scientists. Our greatest potential? We’re making people who have perhaps been mired in status-quo-ism say ‘Whoa!’ ”

For Visco, there is no joy short of a medical breakthrough. She recalls a meeting, right after the Defense Department appropriation was awarded in late 1992, with Dr. Samuel Broder, then director of the National Cancer Institute, which had also received increased funds for breast cancer research: “A group of us met with a group from the NCI. At one point I said: ‘You know, we feel we have for the first time ever gotten a significant amount of money in the NCI for breast cancer research. What are you now going to do differently?’ There was dead silence for several seconds, and then Dr. Broder started talking about the NCI being a huge battleship that you just can’t turn on a dime.”

“The NIH’s problem is not just financial,” Visco says now. “It’s a vision crisis, a leadership crisis. There’s a level of mediocrity blanketing the scientific community; the same old people, the same sorts of programs being funded.”

When she spoke to the Institute of Medicine committee that devised a framework for the Defense Department program, she made sure they understood just what the department represented. “This is our opportunity,” she said. “We get to design a whole new battleship--and now we can make certain it can turn on a dime.”

*

Not everyone wants a new battleship, though, which is one of the reasons that Visco and Rich spend so much of their time on the stump. The Defense Department program has foes everywhere. The Army worries that programs such as Rich’s will dilute the country’s military readiness. Politicians resist blurring the lines between domestic and defense spending, fearing that once the gates are open, a flood of supplicants will demand their fair share. And influential members of the research community--including Dr. Harold Varmus, who was named director of the NIH in November, 1993--insist that the key to progress is basic scientific research, not earmarked programs.

“No one likes this program,” Visco says. “The National Cancer Institute, the National Institutes of Health, they don’t like this program because it’s competition. They believe they should have all this money. The Defense Department, the Pentagon, they don’t like it because they’re not medical people. There were members of Congress who were very strongly opposed to this program.”

This past year has been a frustrating mix of hanging onto last year’s appropriation while fighting for another year’s money. In the spring, Visco and Rich appeared at a Congressional Forum luncheon sponsored by Rep. Barbara Vucanovich [R-Nev.] and together they presented the yin and yang of the issue: Visco, too soon out of a hospital bed after the cab she was in was broadsided by another car, tentative and in some pain but determined to make an emotional appeal; Rich, the model of military efficiency, proudly touting the Army’s no-nonsense approach.

For all their combined energies, though, they cannot silence the ongoing debate within the scientific community, which is deeply divided on the issue of earmarked programs. Varmus, who lost his mother and grandmother to breast cancer, is sympathetic to the program’s goal but skeptical of targeted research. “It’s a mistake to get into thinking that there are people who work on a real-life problem and people who work on basic research,” he says.

Varmus believes in what he calls “creative chaos.” He thinks that scientists do their best work when left to their own investigative devices, not when they are given preemptive guidelines about what to look for.

“If you look at what has happened in cancer research generally, and breast cancer research specifically, many of the things that make us feel reasonably optimistic come not from studying breast cancer specifically but from trying to understand cells and genes and how certain kinds of cells behave under certain conditions,” Varmus says. “The general field of cell biology, genetics and molecular biology, when pursued with vigor and adequate support, can allow you to learn things that are relevant to disease.”

Dr. Larry Norton, director of the Evelyn Lauder Breast Center at Memorial Sloan Kettering Cancer Center in New York City, applauds the increase in funds but worries that politics may undercut progress, that too little emphasis has been placed on basic science.

“Targeted research cuts out a lot of possibilities,” he says. “The point that is frequently made is that if you want an advance this year, targeted research is where you get it. If you want an advance forever, then freedom is what you want. You just want to get the best minds producing, and then you see where it goes.”

Even Health and Human Services Secretary Donna Shalala, a vocal proponent of the program, admits that it raises tricky issues about funding priorities, as well as the role of the consumer. The success of AIDS activists has encouraged groups like the National Breast Cancer Coalition to demand recognition, but it also has spawned what Shalala calls “disease-of-the-month politics.”

She is wary of advocates “who are walking up to members of Congress and whispering in their ear, ‘Our disease is just as important as their disease.’ ” Shalala, whose three paternal aunts had breast cancer, simply doesn’t have the funds to satisfy everyone. “My job is to make sure they don’t cut each others throats and destroy our investment in basic science, which we have to continue.”

But because of special circumstances--the woeful under-funding of women’s health research that she encountered when she took her job--Shalala wants the Defense Department program to continue and lauds whatever increases the National Cancer Institute can manage. The National Institutes of Health spent $100 million in fiscal 1991, and in fiscal 1993, when the Defense Department program began, it was up to $229 million. A March, 1994, Congressional report noted that 20-year funding totals for breast cancer were higher than for lung or colorectal cancer, which kill more Americans each year than breast cancer.

Shalala is comfortable with the discrepancy--in part because breast cancer, unlike the other two diseases, continues to elude attempts to find a cause or propose a preventive strategy. More money is not enough if researchers do not have answers. Until there is parity for women’s health, there is no such thing as too much earmarked research.

“We have so underinvested in women’s diseases that I want to make sure we’re tilting toward bringing up our investment,” she says. “It’s complicated politics.”

*

Ironically, even some of the program’s biggest supporters have a problem with it. At a time when medicine sits on the brink of tremendous breakthroughs, budget cuts are strangling medical research. In that context, some members of the medical community worry that the Defense Department program fosters a false sense of complacency. They’re happy to have the money, so long as no one thinks it is enough.

In late October, the NIH was operating at $1 billion below its fiscal 1995 appropriation of $11 biullion, held hostage by a prolong congressional budget skirmish that Varmus called “really irritating. The budgets now encrusted with all these other amendments,” he says, “it’s not the process at its best.” The House recommendes a generous increase to $11.9 billion, but the Senate wants to spend only $11.6 billion. Since the NIH has an obligation to existing multiyear studies, what would suffer is new research. “When the NIH gets its budget every year, 80% of it is already committed to allocations made in previous years,” the NIH’s Varmus says. “There isn’t that much money you’d really call discretionary. The money simply runs out before the NIH can get around to paying for more-innovative projects.”

Doctors are quick to point out that there is more than self-interest at work here. They insist that short funds will have an effect for generations to come--at a time when enough money could result in remarkable progress.

“We should be throwing money at medical research,” says the Lauder center’s Norton, who believes that genetic research will revolutionize medicine. Creative people come in generations,” he says. “You can’t cut down funding now and in five years say: ‘OK, we got more money; let’s step up the research.’ Once you start the ball rolling, you not only have cut out the people who are doing the work but those who are also the next teacher generation as well. There’s enormous danger here.”

“We are probably entering the worst funding era for biological research that we’ve ever had,” agrees Dr. Marc Lippman, director of the Vincent T. Lombardi Cancer Center at Georgetown University. “I think this will be a hideous time. Two reasons: No question that federal funding will almost certainly decline. And secondly, most academic institutions are in the worst financial situation they’ve ever been in.

“Paradoxically, when we know the most and can do the most about cancer, when the most exciting work is there to be done, the process is going to be tremendously slow,” he says. “And it’s a tremendous misunderstanding to assume that the slack will be picked up by the biotech companies, who are understandably interested in their own products. While private money is really generous, it isn’t anything compared to the NIH budget.”

The budget for fiscal 1996 calls for $426 million for breast cancer research, a $49-million increase over 1995, plus $75 million for the Army. The country’s largest private donor, the American Cancer Society, invests between $5 million and $8 million annually in breast cancer research. There are other, smaller government programs and numerous other sources of private money, but these represent the bulk of this country’s resources.

Shalala knows how great the need is, but the realities of balancing the budget force her to make painful choices. “My job is like Solomon’s,” she says, “and I don’t have any easy things to lop off . . . . I will protect every dime of breast cancer money we have. I will try to ratchet it up. But I’m operating in a world that is really quite terrifying.”

The consequences of tight money are already evident, even at the exalted level of Mary-Claire King. The Berkeley geneticist always depended on NIH funding, but last spring, to the horror of the younger researchers in her lab, she decided not to apply for a particular grant. The field was simply too crowded, and she believed there was little chance her effort would pay off.

“If I were 29 and not 49, I’m sure I could not get funded now,” she says. “I was funded because it was the War on Cancer and it was OK to take a risk. I wasn’t believed for the first 16 years of the work.

“It’s a crapshoot now,” she says. “It’s not that we’re funding excellent work and poor proposals are not getting money. We’re funding excellent work, but other excellent work is not getting funded.” How far short has the budget fallen? King thinks that the NIH could productively invest a 50% increase in its budget, an additional $5 billion, and still be funding quality work.

She warns against being too pleased with the Defense Department appropriation: When taken in context, that money is small change.

“All we’re doing is hanging on by our fingernails in the Defense Department,” King says. “It’s absurd. We’re not really doing anything toward curing breast cancer.”

“If you’re funding one in 12,” she says, referring to the percentage of grant applications that the NIH can pay for, “the chances for a young researcher are worse than the chance that a woman will develop breast cancer.”

*

Fran Visco and Irene Rich both know that. This year the Army Medical Research and Materiel Command received 2,200 grant applications for its $150 million appropriation, and Rich is negotiating for a revised Institute of Medicine report, one that will refine the definition of “relevance,” based in part on information gaps that show up on the first grant list. Her office is where hope resides--not enough money, nowhere near certainty about the future, but for the moment the one place within the federal government where everybody is working on breast cancer.

The two women have changed their lives to make sure the program continues. Last spring, Visco stood mournfully in the lobby of her Washington hotel between meetings--tired, despondent, wondering how she was going to do battle one more time with a newly hostile Congress. She had just quit her law practice to devote herself to full-time lobbying and was about to launch Project Lead, an intensive four-day educational program for future activists, held during the summer in Los Angeles and three other cities. She hardly ever gets to see her husband and son these days, and yet she was haunted by the notion that she was going to fall short.

“I haven’t done anything yet,” she said, tears welling up in her eyes. “I haven’t done anything.”

Col. Rich, ever the good soldier, must watch the political skirmishes from the sidelines, but she knows how fragile the future is, how many of her professional peers would like to see her program fold. The woman who enlisted in the middle of the anti-war movement has yet again set herself apart as an outsider.

For her part, though, it seems the only reasonable response to too much suffering: Send in more troops to defeat the enemy. “I have sat at the deathbed of too many women as they’ve died with cancer,” she says quietly. “They wanted to live so badly. And I would think: ‘Somebody needs to help them really fight.’ So it was an honor to come to this program.”