By Hilda R. Heady, MSW 2005 NRHA President Associate Vice President for Rural Health West Virginia University Our Invisible Heroes-Rural Veterans: A Special Concern for Rural Health Advocates

The Message 1.There is a never-changing role of rural people in the military and rural people are disproportionately represented among veterans. 2.Community based services vary across the country for these rural veterans and there are training implications for the healthcare workforce to serve these veterans. 3.We need to be concerned about the availability and quality of community based services

“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

“Let those West Virginian hillbillies go get shot, they won’t take me.” Unidentified college student The Washington Monthly/April 1972

“PTSD is the price of war. Its cost to everyone involved is chronic in nature. At the least, those affected deserve intensive therapy without fear of reprisal.” Mike Magee, Health Politics, September 1, 2004

Rural people value service to others and military service is just another way to serve

So who are our Veterans?

States with % of Veterans > the National Average of 12.7%, %Colorado15%Arizona* 14.2%South Carolina15.1%Virginia 14.2%Arkansas15.1%Washington 14.4%West Virginia15.1%Oregon 14.5%South Dakota15.3%Florida 14.7%New Mexico15.9%Maine 14.8%Oklahoma16%Wyoming 14.8%Idaho16.1%Nevada 15%New Hampshire16.2%Montana

SF-36: Physical and Mental Health of Veterans, Rural VS Urban Mental Health Physical Health All U.S. Adults Urban Veterans Rural Veterans Average Score for 8 Measurements of Physical and Mental Health

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

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

World War I “doughboys” in the infirmary line after being gassed

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

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 Alzheimer’s due to interaction of the susceptibility gene (ApOE 4) and TBI

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

Defense and Veterans Brain Injury Center Network

The Face of the New American Military Family

“IT’S NOT YOUR FATHER’S 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 - )

Community Based Approaches Need to include self-help organizations for veterans and their families

Who provides their care? VA hospitals and medical centers Vet Outreach Centers Community Health Centers CBOCs Private Providers

Number of Vet Centers, CBOCs, VAMCs by States with Highest Veteran Populations State Vet Pop CBOCsVet CtrsVAMCs Montana16.2%1021 Nevada16.1%432 Wyoming16%722 Maine15.9%551 Florida15.3%31136 Oregon15.1%942 Wash.15.1%855 Virginia15.1%543 Arizona15%1553

Number of Vet Centers, CBOCs, VAMCs by States with Highest Veteran Populations State Vet Pop CBOCsVet CtrsVAMCs N Hampshire15%511 Idaho14.8%331 Oklahoma14.8%232 New Mexico14.7%1331 So Dakota14.5%833 W Virginia14.4%594 Arkansas14.2%913 So Carolina14.2%932 Colorado14.1%1162

Budget Considerations Baby Boomer veterans are aging and putting pressure on all systems of care We are continuing to create veterans From 1996 to 2004 the VA experienced an increase of vets seeking care by 134% The VA’s budget from 1996 to 2004 increased by 44%

Iraq KIA Disproportionately from Non-metro counties Between March 2003, and March 2004, 29% of the 600 soldiers killed in action in Iraq were from non-metro counties By contrast, 19% of the population years of age live in 2,396 non-metro counties and 81% live in 836 metro counties

Killed in Iraq as of 2/2/04 519TOTAL 156> 100, ,000 – 50, ,000 – 100, ,000 – 40, ,000 – 90, ,000 – 30, ,000 – 80, ,000 – 20, ,000 – 70, ,000 – 10, ,000 – 60, – 1,000 Total Killed Hometown Population Range Total Killed Hometown Population Range

PTSD Study, 1988 Vietnam Veterans with PTSD –15.2% of male Vietnam Veterans –8.5% of female Vietnam Veterans Estimated number of Vietnam Veterans with full or partial PTSD = 1.5M

VA Commissioned PTSD Study by the Institute of Medicine June 16, 2006 “The committee wrote that because all veterans deployed to a war zone are at risk for the development of PTSD, it would be prudent for health professionals to query veterans about their wartime experiences and their symptoms, when presenting at primary care and other health facilities (inpatient or outpatient).”

U.S. Army has begun to Study Mental Health Issues 21.5Suicide rate, U.S., persons 18-34, Suicide rate, U.S. civilian population, Suicide rate for whole U.S. army, Suicide rate for whole U.S. army, Suicide rate for soldiers in Iraq and Kuwait, 2003 Rate per 100,000 Suicide

Pre and Post Deployment Studies of Iraq 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

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

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

Males with Active Mental Health Issues 30% male civilians seek treatment Less than 20% servicemen seek treatment

Implications for Families of Vietnam Veterans War related PTSD impairs parenting (long distant parenting, emotional distancing, abuse, etc. Rates of suicide of children of PTSD war veterans increases (Australian study showed 3 times civilian rates) Divorce rates four times average rate for civilian population

The Bottom line…. VA services are not enough…there 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.”

And they are aging Vietnam era veterans represent the largest veteran population at 8.4 million or 31.7% of the total veteran population

Veterans Integrated Service Networks

NRHA is working to bring this issue to the American conscience

NRHA Efforts NRHA now over 10, 000 members, was the first on March 29, 2001 US Senate Special Committee on Aging, “Healthy Aging in Rural America” testimony to include concerns for aging rural veterans April 19, 2004 Congressional staff hearing Congressional Rural Caucus July 2004 Rural Health Policy passes policy paper on rural veterans

NRHA Efforts November 11, 2004 NRHA press campaign regarding rural veterans in observance of Veterans Day NRHA leadership delivers national speeches on rural veterans’ issues January 31, 2006 Press release on TBI and rural veterans

NRHA Efforts Technical Assistance to non-VA health care providers responding to VA requests for proposals Currently producing a manual on contracting with the VA Staff and leadership maintain contact with congressional staff and other organizations on this issue.

So what can I do? If you have a veteran in your family, thank him or her. If you don’t know, find out if you do, and then thank him or her. Help spread the word and knowledge about the needs of rural veterans

So What Can I Do? Contact your congressional delegation asking for a congressional hearing on the needs of rural veterans Contact local veteran organizations and let them know that NRHA cares about rural veterans Include workshops at your conferences on rural vets’ needs and issues.

So What Can I Do? Join NRHA or a veterans group and get involved Don’t forget the rural vet’s family members who need support and knowledge, as they may be his or her only system of support and care.