After the War: Implications for Policy, Providers, and our Personal Lives

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After the War Implications for Policy,
Providers, and our Personal Lives Presented to
the CARE-NET Governors ConferenceJune 4,
2008Charleston, WV
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• Hilda R. Heady, MSW
• 2005 PresidentNational Rural Health
  AssociationAssociate Vice President for Rural
  HealthRCB HSC WVU
• Executive and State Program Director, WVRHEP/AHEC

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The Message

• There is a never-changing role of rural people in
  the military
• Rural people are disproportionately represented
  among all US veterans
• Therefore, rural veterans and their families
  should be a special concern.

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• Americans have an ambivalent relationship with
  their military and their veterans

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• Americans have to learn to separate their
• political views on War
• from their feelings
• toward their Warriors.

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Let those West Virginian hillbillies go get
shot, they wont take me. Unidentified college
student The Washington Monthly/April 1972
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Country boys just go to war.
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Rural people value service to others and military
service is just another way to serve
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• To care for him who shall have borne the battle,
  and for his widow, and his orphan.
• Abraham Lincoln
• Second Inaugural Address
• March 4, 1865

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Memorial Day 2005in Huntington, WV

• We heard a man say to his grandson, When you are
  in a crowd of veterans, you are in a crowd of all
  kinds of Americans. Pay attention to that.

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The Big Picture

• 26 million veterans or 12.7 US pop.
• Highest concentrations in rural and non-metro
  counties
• Vietnam Vets represent the largest vet population
  at 8.4 million or 31.7 of the total veteran
  population (average age is 61)

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The Big Picture

• Data on military recruits show that more than 44
  come from rural areas and 14 come from major US
  cities.
• Young people living in zip codes in sparse rural
  areas are 22 more likely to join the Army than
  their large city counterparts.
• Most enlistees come from the South (40) and the
  West (24)

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The Big Picture

• 70 million potentially eligible for VA service
  (vets and their families)
• Only roughly 1/3 of vets (7.8 million) receive VA
  services
• Leaving 2/3 in the civilian health care system
• 60 million American live in rural areas (75 of
  countries underserved areas.
• 9 of nations physicians practice in Rural
  American

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especially Rural Americans
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• Every American Generation that goes to War
  believes passionately that theirs is a unique
  experience

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• While there are unique features and social
  dynamics for each generation, war is still war
  and its impact to warriors and their families can
  be long lasting

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Our Current War

• Twenty-seven percent (27) of those who have been
  killed in Iraq are from rural areas while only
  19 of our nations populations live in rural
  areas and small towns.

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Carsey Institute Study

• According to their study, the death rate for
  rural soldiers is 60 percent higher than the
  death rate for those soldiers from cities and
  suburbs. Of rural areas, Vermont has the highest
  rate of casualties, followed by Delaware, South
  Dakota, and Arizona. Only eight of our states
  have higher urban than rural death rates

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So who are our Veterans?
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SF-36 Physical and Mental Health of Veterans,
Rural VS Urban
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Veterans and Signature Damage (Source Craig
Hyams, Veterans Health Administration)

• Each war has a signature wound
• Military physicians note signature wounds and
  researcher study them
• Many veterans suffer these wounds

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Signature Damage or Wounds

• Medical science learns and benefits from treating
  such wounds over time
• The longer veterans live with such wounds, the
  greater the contribution to the medical science
  knowledge base

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World War I doughboys in the infirmary line
after being gassed
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Traumatic Brain Injury
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Army Study of Warfront Soldiers(OIF/OEF)

• Depression, anxiety, acute stress
• 20.5 in 2006
• 18.2 in 2007
• PTSD
• 17 in 2004

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Rand Corp.s Health and National Security
Research Division Report

• Invisible Wounds of War Psychological and
  Cognitive Injuries, Their Consequences, and
  Services to Assist Recovery. Released 4-17-08
• Largest civilian study conducted to date thus far
  includes 1,965 respondents across US (WV study
  includes 1,000)

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Rand Report

• Study estimates 300,000 w PTSD or depression
  and 320,000 w TBI
• VA reports approximately 120,000 w mental health
  problems and 60,000 receiving treatment
• About 7 percent reported a probable brain injury
  and current PTSD or major depression.
• Only 43 percent reported ever having been
  evaluated by a physician for their head injuries.

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Rand Report

• Only 53 percent with PTSD or depression sought
  help during the past year.
• Reasons for not getting help
• worried about the side effects of medication
• believe family and friends could help them with
  the problem
• feared seeking care might damage their careers.
• Rates of PTSD and major depression were highest
  among women and reservists.

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U.S. Army Study Mental Health Issues
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Suicide Among Vets/Returning Soldiers

• Steven L. Rathbun, University of Georgia "In
  2005 ... in just th 45 states, there were at
  least 6,256 suicides among those who served in
  the armed forces. That's 120 each and every week,
  in just one year.ltGWOTgt Veterans aged 20 to
  24, had the highest suicide rate among all
  veterans, estimated between two and four times
  higher than civilians the same age."

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Suicide Among Vets/Returning Soldiers

• VA's Mental Health Division, Dr. Ira Katz,
• "'Our suicide prevention coordinators are
  identifying about 1,000 suicide attempts per
  month among the veterans we see in our medical
  facilities.

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Pre and Post Deployment Studies of OIF/OEF
Soldiers

• Exposure to combat
• Doubles the rate of PTSD
• Increases major depression
• Substance Abuse
• Impairment in social functioning (family)
• Impairment in ability to work
• Increases use of health care services

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Pre and Post Deployment Studies

• Pre and Post studies showed increase rate of
  mental disorders from 9.3 to 16
• Rate of PTSD directly correlates to intensity of
  wartime experience
• Rates are likely to be understated

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Veterans with Active Mental Health Issues

• 38 lack trust in mental health professionals
• 41 are embarrassed to seek help
• 50 felt seeking help would damaged their careers
• 65 feared being labeled as weak

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Males with Active Mental Health Issues

• 30 male civilians seek treatment
• Less than 20 servicemen seek treatment

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Implications for Families of Veterans

• War related PTSD can impair parenting (long
  distant parenting, emotional distancing, abuse,
  etc.)
• Rates of suicide of children of PTSD war veterans
  increases (Australian studies showed 3 times
  civilian rates)
• Divorce rates four times average rate for
  civilian population

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Traumatic Brain Injury

• High tech body armor is saving lives and
  resulting in TBI and possibly PTSD
• TBI can present life-long impairments and
  disabilities physical, cognitive, behavioral,
  emotional, and social

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TBI Complications

• Cognitive issues may impact treatment of other
  diseases and injuries
• Cumulative effect as the veteran may experience
  additional TBI or emotional trauma
• TBI and PTSD can go hand in hand
• Potential increased risk of Alzheimers due to
  interaction of the susceptibility gene (ApOE 4)
  and TBI

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TBI Services

• Defense and Veterans Brain Injury Center
• TBI care network to augment VA services
• 10 national centers (9 VA and 1 civilian)
• VHA TBI Case managers network

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Defense and Veterans Brain Injury Center Network
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• Those of us in the caring professions need to be
  concerned about the impact of signature and all
  wounds of war on our warriors and their families.

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Who provides their care?

• VA hospitals and medical centers
• Vet Centers
• Small rural hospitals
• Community Health Centers
• CBOCs
• Private Providers

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States with Higher than the National Average of
Veterans (200012.7) and VA facilities (2008)
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States with Higher than the National Average of
Veterans (200012.7) and VA facilities (2008)
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The Face of the New American Military Family
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African American Women

• Make up 12.7 of US population
• Make up 37.5 of all women serving in the US
  military forces

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Its Not Your Fathers VA

• Currently, women make up approximately 15 percent
  of the active force, are serving in all branches
  of the military, and are eligible for assignment
  in most military occupational specialties except
  for direct combat roles.
• By the year 2010, the women veteran population is
  projected to be over 10 percent of the total
  veteran population.
• (Source Center for Women Veterans -
  http//www1.va.gov/womenvet/ )

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Estimate 700,000 Children of deployed Parents Thei
r average age is 6
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The Bottom line.

• VA services are not enoughthere are too many to
  serve and too many are hidden
• The sticking point is skepticism among military
  personnel that the use of mental health services
  can remain confidential.

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What Rural Professionals Can Do

• Learn about TBI, PTSD, etc. utilize appropriate
  screening tools and know referral resources
• Remember to interview and care for vets family
  members as they may be his or her only system of
  support and care. Dont forget the rural vets
  family needs also.
• Help spread the word and knowledge about the
  needs of rural veterans

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• Contact your congressional delegation in support
  of legislation to address the needs of rural
  veterans
• Learn about local veteran organizations and other
  local community organizations and the services
  they provide to veterans and their families.
• Include seminars and workshops at your
  conferences on rural vets needs and issues.

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What More Can I Do?

• Join NRHA, a VSO, or other national or local
  organization for information and get involved
• Share your knowledge and awareness with
  colleagues in your service area
• Thank all vets you know and see

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As long as we choose warto solve our social,
political, and economic problems, we have the
social, ethical, and moral responsibility to
address the costs of this choiceHilda R.
Heady
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THANK YOU!

• Hilda R. Heady, MSW
• hheady_at_hsc.wvu.edu
• 304.293.4996
• www.NRHArural.org
• www.wvrhep.org/presentations/