Through Veterans' Eyes

by Larry Minear

  * * *

  In New Hampshire, the needs discovered in one-on-one debriefings were so extensive that the New Hampshire Guard’s commanding officers, who (along with soldiers’ families) had originally fiercely resisted delaying reunions with families by an extra day or two, ended by expressing gratitude for mandatory individualized screenings. Mandating individual sessions seemed particularly essential to National Guard officials inasmuch as Guard personnel, unlike active-duty forces, quickly disperse, many to communities lacking adequate mental health services. How many families would pick up the warning signs of serious emotional problems when they first appeared? How many rural health practitioners would be familiar with PTSD or knowledgeable about the experiences that had made the condition so prevalent among returning veterans? “My family doctor from childhood tried to help with meds and treatment, but [dealing with] veterans was a completely new thing for him,” said Jennifer Pacanowski, an Iraq veteran whose PTSD waited two and a half years to be diagnosed and then waited another nine months for treatment charges to be reimbursed.13 “The nature of the National Guard itself,” observed one New Hampshire social service provider, “involves one person here, one person there.”

  The return of active-duty contingents confirmed the correlation established by the New Hampshire Guard authorities. The 4th Combat Brigade, stationed at Fort Carson, Colorado, offers a case in point. In fierce fighting in places such as Fallujah and Ramadi, Baghdad and Sadr City, the 3,500-strong brigade experienced 113 deaths, with hundreds more wounded. One therapist who treated soldiers upon their return to Fort Carson commented, “It got to the point I stopped asking if they have deployed, and started asking how many times they have deployed.” Over a three-year period, nine current or former Brigade members were charged with killings. Families of returning veterans also experienced higher levels of domestic violence.14 Disturbed by such incidents, an Army task force was established in 2008 to search for explanations.15

  The intensive screening and follow-up approach implemented in New Hampshire served as a model for other state National Guard units and for the active-duty military. In late 2008, the director of health services at the Army’s Fort Campbell in Kentucky noted that “for the first time, every soldier returning home will have an individual meeting with a behavioral health specialist and then go through a second such session ninety days to 120 days later.”16

  Annual reviews by a DOD Mental Health Advisory Team (MHAT) beginning in early 2003 serve as a barometer of the impacts of exposure in Afghanistan and Iraq on U.S. military personnel. The fourth MHAT report, based on Operation Iraqi Freedom surveys conducted in mid-2006 and released in November 2006, concluded, “the level of combat is the main determinant of a Soldier’s or Marine’s mental health status.” Soldiers who had deployed more than once reported higher acute stress levels. “Only five percent of soldiers reported taking in-theater Rest and Relaxation, even though the average time deployed was nine months.” MHAT-IV recommended more extended time between deployments, “Battlemind Warrior Resiliency Training” before deployment, and more intensive positioning of mental health resources.17

  A report of the DOD Task Force on Mental Health in mid-2007, noted in Chapter 1, identified the nationwide universe of need. The report analyzed data from a Post-Deployment Health Reassessment, administered to veterans 90 to 120 days following their return from the Afghanistan and Iraq theaters. The survey found that “38 percent of Soldiers and 31 percent of Marines report psychological symptoms. Among members of the National Guard, the figure rises to 49 percent…. Further, psychological concerns are significantly higher among those with repeated deployments, a growing cohort.”18

  The fifth MHAT report, released in March 2008 and based on data collected in 2007, confirmed the findings of earlier studies—those who deployed three and four times demonstrated higher stress levels than those deployed once or twice—and provided comparisons between the two theaters. The levels of combat exposure in Afghanistan had increased while those in Iraq had decreased. Morale had improved among the troops in Iraq from 2006 to 2007; there was a higher incidence of mental health problems in Afghanistan in 2007 than in 2005. Yet the rates of stress in the two theaters were generally comparable. While some officials described the latest findings as “a ‘good news’ story,” the data themselves remained sobering.19

  New Hampshire authorities also found a link between reentry and homelessness, a major problem among veterans across the nation. “On any given night,” Leslie Kaufman of the New York Times wrote about veterans from America’s wars, “a virtual army of one hundred and fifty thousand veterans are homeless across the nation, including an estimated twelve hundred in New York City.”20 Veterans for America, which placed the total of homeless veterans at just under 200,000 in Fiscal Year 2006, has noted that “Vets from Afghanistan and Iraq appear to be seeking out mental health services at higher rates than vets from other conflicts.” The director of a San Diego vet center remarked in late 2007, “We anticipate that it’s going to be a tsunami.”21 The Veterans for America’s Survival Guide for veterans counsels, “If you are moving around, ask to receive mail and phone calls for the short term at a local drop-in center, shelter, the VA regional office or clinic, local veterans’ service organization, or your church.”22

  “No one keeps track of how many of the troops who have been deployed to Iraq or Afghanistan since 2001 are homeless,” noted the Boston Globe’s Anna Badken in mid-2007. But there has been a significant change since the days of reentry following Vietnam. She continued: “The approximately seventy thousand veterans of the war in Vietnam who became homeless usually spent between five and ten years trying to re-adjust to civilian life before winding up in the streets. Veterans of today’s wars who become homeless end up with no place to live within eighteen months after they return from war.”23 Iraq and Afghanistan Veterans of America urged the Obama administration in its first hundred days to give priority to the needs of homeless veterans from Afghanistan and Iraq, of whom it said there were already 2,000.24 Veterans for Common Sense linked homelessness to delays in federal processing of veterans’ disability benefit requests.25

  Responding to massive need for health and social services has been complicated by a shortage of facilities and health care personnel. One DVA official noted that a nationwide shrinkage in medical infrastructure following the end of the Cold War—he himself had seen a reduction from 129 to 79 facilities during the years 1987–1995—meant that Guard personnel and others had fewer treatment options and had to travel greater distances to access them. In most rural states, he said, soldiers had access to only a single DVA facility. As the conflicts proceeded, however, the DVA’s budget for mental health matters, including PTSD, was significantly increased and additional mental health clinicians were hired.26

  The experience of Marine Sgt. Luis Almaguer (whose photograph appears in Chapter 4) illustrates the problems that some have faced. Returning from Iraq with eighty percent disabilities, he moved his family first from his home in the small town of Del Rio, Texas, along the Rio Grande River (population 36,000) to San Antonio, two and a half hours away, to be closer a major veterans facility. From San Antonio, he traveled for extended treatments to San Diego, where TBI treatments are administered at Camp Pendleton’s Defense and Veterans Brain Injury Concussion Clinic and at the Navy Medical Center in San Diego.

  A number of well-publicized false starts undermined veterans’ confidence in the institutional reentry process. The suspicion that veterans were getting the run-around seemed confirmed by an e-mail to staff from a VA team leader in Temple, Texas, in May 2008. “Given that we are having more and more compensation-seeking veterans,” wrote Norma J. Perez, a PTSD program coordinator in an internal memo, “I’d like to suggest that you refrain from giving a diagnosis of PTSD straight out” and consider instead “a diagnosis of Adjustment Disorder.” The suggestion was immediately rejected by the national DVA head as representing the misguided view of “a single staff member,
out of the VA’s two hundred and thirty thousand employees, in a single medical facility.”27

  In January 2008, Army officials reportedly instructed the DVA employees not to help returning veterans, as they had in the past, with the preparation of paperwork necessary to process health care and disability payments. One veteran described his feeling of being “tossed aside like a worn-out pair of boots.”28 Delays in receiving prompt and quality medical and mental health treatment have been a recurring problem. In a number of highly publicized incidents, veterans seeking help have been rebuffed or put on a waiting list. “Told to Wait, a Marine Dies: VA Care in Spotlight after Iraq War Veteran’s Suicide,” read one Boston Globe headline in February 2007.29

  A series of reports on National Public Radio beginning in December 2006 highlighted incidents in which veterans were returned to Iraq and Afghanistan before their medical and psychological problems had been fully addressed. Sgt. Metz Duites, who served in Iraq for a year and one of whose photos appear in Chapter 6, required surgery for a torn rotator cuff, which the DVA arranged. However, the Army, unaware of an injury that rendered him no longer able to throw a grenade, sent him back to Iraq.30 Some veterans came to believe that the imperative to get them suited up and redeployed in the global war on terror was not matched by a commitment to see that their needs were met upon returning.31

  Veterans were also outraged by a change in regulations, instituted by the Bush administration in March 2008, which narrowed the injuries qualifying for reimbursable treatment to only those sustained directly in combat. The Disabled American Veterans condemned the change as embodying a “shocking level of disrespect for those who stood in harm’s way.”32 Some suspected DVA medical personnel of attributing wounds to preexisting conditions as a device for limiting the scope of insurance coverage.

  The two needs among returning veterans that have caused greatest concern in terms of incidence, on the one hand, and the lack of institutional capacity, on the other, have been the “signature injuries” of the wars in Afghanistan and Iraq: PTSD and TBI. A 2008 study entitled “Invisible Wounds of War” by the RAND Corporation concluded that an estimated 300,000 service personnel from Iraq and Afghanistan were suffering from PTSD or major depression, an estimated 320,000 from TBI. The RAND report found that only about half of those affected had sought help, with about half receiving “minimally adequate treatment.”33 “We’ve come a long way,” said one DOD official in commenting on the report, “but we still have a long way to go.”34

  Mental health professionals are bracing for a major upsurge in demand for PTSD services and in the overall costs of providing them. Although the DVA had treated more than 52,000 Iraq veterans for PTSD as of mid-2007, “the greatest effect of those mental health issues has yet to be experienced,” according to Medscape Medical News. Estimates of the cost of treating the identified number of 300,000 PTSD cases over the lifetimes of those involved are placed at some $660 billion.35 PTSD is also linked to a doubling in recent years in the suicide rate among active-duty personnel returning from Afghanistan and Iraq.36

  The TBI outlook is also daunting. Reflecting in particular the status of roadside bombs as the weapon of choice of the insurgents, soldiers in Iraq and Afghanistan are in greater danger of sustaining TBI than their predecessors in other recent conflicts. “The IEDs have added a new dimension to battlefield injuries,” observes Ronald Glasser of the Washington Post. “Wounds and even deaths among the troops who have no external signs of trauma but whose brain has been seriously damaged.”37 The Dole-Shalala commission reported 2,726 TBI cases among those who had served in Iraq.38

  Experts are cautious in quantifying the TBI numbers of such injuries since some 70 percent are not identified as such through normal magnetic resonance imagery screening.39 In addition, the late onset nature of TBI means that for some of those affected, symptoms do not manifest themselves until years after an injury was sustained. “The Department of Veterans Affairs is now planning for the large influx of veterans with TBIs from the current conflicts who will need continuing care during the coming years,” writes one of the officials involved. “These patients because of the nature of their brain injuries can be the ones at highest risk of falling through the cracks.”40

  The gravity of the psychological impact of the wars in Afghanistan and Iraq on those involved has been flagged in alarming terms by DVA officials such as Dr. Matthew J. Friedman. He has concluded that “most people who have survived this experience will be changed by it, whether crossing some psychiatric threshold or not.” In his judgment, “the wars in Afghanistan and Iraq are likely to produce a new generation of veterans with chronic mental health problems associated with participation in combat.”41

  In a strange twist, fresh wounds from the global war on terror have brought new attention to still-festering wounds from Vietnam. Dr. Gonzalo Vera, chief of mental health programs at the VA hospital in Northampton, Massachusetts, has noted that “of his caseload of 120 psychiatric patients who have fought predominantly in Vietnam but also in the Gulf War and elsewhere, ‘virtually every single patient has been affected by the Iraq war and has experienced a retriggering of trauma.’”42 Global War on Terror veterans express particular appreciation for the support of other veterans, whether from earlier conflicts or from Afghanistan and Iraq.

  STEPS FORWARD

  Dissatisfaction with the inadequacies of the institutional system for reentry spiked following the Washington Post exposé in early 2007 on conditions at the Walter Reed Army Medical Center. The uproar led to the firing of the commander of Walter Reed, resignation of the secretary of the Army, and creation by President Bush on March 8 of a Commission on Care for America’s Returning Wounded Warriors. Following hearings and testimony from more than 1,700 veterans, the commission, headed by former Senator Bob Dole and former Health and Human Services Secretary Donna Shalala, issued a report entitled “Serve, Support, and Simplify.”

  In what it termed a “bold blueprint for action,” the commission made six recommendations seeking “to ensure that those who have served in Iraq and Afghanistan are able to successfully transition back to civilian life or active duty service.” The recommendations included a complete restructuring of disability determination and compensation systems, the development of individualized patient-centered recovery plans, and aggressive prevention and treatment of PTSD and TBI. Acknowledging the systemic shortcomings such as those flagged by individual veterans, Shalala commented on unveiling the report: “The system should work for the patient, instead of the patient working for the system.”43

  Once again, states played an innovative role. New Hampshire early on had formed an interagency task force that conducted a statewide survey of social services. It concluded that some 80 percent of the services needed already existed; the remaining 20 percent would have to be devised or adapted. The process also sought to anticipate future needs rather than waiting for them to materialize. Soldiers readying themselves for future deployment were encouraged, by New Hampshire social service guidelines, to think in terms of “your boots, your belt, your shirt—and your pre-deployment social worker.” One DOD-funded New Hampshire initiative, the Joint Family Support Assistance Program, involves meeting with individual soldiers and families at every stage of the process, from predeployment to reentry. In 2008, the legislature created a commission, originally for three months but later extended to two years, to coordinate the statewide effort.44

  * * *

  The Commission acknowledges the heroic services veterans from Iraq and Afghanistan have rendered to our country, and cannot state strongly enough the obligation our nation and New Hampshire owes to those men and women who have been injured as a result of their service. Through extensive meetings and presentations, the Commission has learned that the hidden injuries of combat, including post-traumatic stress disorder and traumatic brain injury, can be severe and lifelong, and require a comprehensive, coordinated, and funded system of services and supports. While there are promising new and
existing programs to assist veterans with TBI and PTSD, and their families, in general resources are fragmented. Some veterans don’t know about, and have trouble accessing, treatment and services, and some veterans fall through the cracks.

  —Interim Report, Commission on PTSD and TBI*

  * * *

  The state of Minnesota, which has also contributed large numbers of National Guard troops to the conflicts in Afghanistan and Iraq, has also played a lead institutional role with its Beyond the Yellow Ribbon program. This, too, is an interagency effort in which government at every level joins with private agencies to assist newly returned Guard members in the reentry process. Focusing on the period after yellow ribbons expressing solidarity with the troops have been taken down, the program reconvenes veterans at regular thirty-day intervals to check on such concerns as mental health, anger management, domestic relations, and employment. Having assisted several thousand veterans throughout the state since it was launched in 2005, the Minnesota program is poised to become a national undertaking.45

  A similar effort has been initiated in New York State, home to unusually large numbers of veterans from Afghanistan and Iraq, to assess their needs and the capacity of existing institutions to meet them. Underwritten by the New York State Health Foundation, the undertaking seeks to provide a more detailed analysis of a situation in which “returning veterans who do not receive timely and appropriate care for mental health issues seem to be at risk for chronic illness, substance use issues, family life challenges, domestic violence, unemployment, homelessness, and even suicide.”46

  Comparable initiatives are also taking shape at the national level. A provision in the FY08 National Defense Authorization Act—one in which then-Senator Barack Obama played a lead role—mandates a nationwide assessment of the needs of soldiers who have served in Afghanistan and Iraq, and the needs of their families. The survey will be conducted by the Institute of Medicine of the National Academies, with the initial hearings conducted in February 2009. Also at the federal level, passage of the Dignity for Wounded Warriors Act of 2008 increases the amount of treatment provided for medical needs related to military service.