As we enter the second decade of a war on terrorism, with the war in Afghanistan coming to an end, now is a good time to have a candid discussion of how we will continue to address the future needs of those who have served in harm’s way—particularly our combat wounded and their families—and what lies ahead. Advances in medical practice, battlefield medicine, and complex casualty care have saved many who in earlier conflicts would have died of their wounds. Survival rates from combat-related injuries are the highest in history. That said, George Washington had it right: Our ability to attract and retain a quality volunteer force in the future depends, in part, on how well it is perceived we treat the current force, especially the combat wounded.
With more than 49,000 Americans wounded in combat in the past ten-plus years, what can we do to ensure the best possible future for those veterans? We should ask three questions:
• What future do we, as a nation, envision for combat wounded and their families?
• What is our national strategy to attain that future?
• What is the role of government?
Our efforts should steer us to a vision for the future supported by an overarching strategy. A coordinated execution plan is necessary to realize that future so we can correctly and wisely coordinate actions with resources—especially in the face of increasing fiscal challenges. Finally, roles and responsibilities must be clearly delineated to avoid redundancies or gaps.
What Future Do We Envision?
The outstanding support from senior leadership and the outpouring of support from Americans for those wounded in combat has never been greater. From our largest cities to rural America, the generosity and gratitude toward our military—especially our injured—is unprecedented. Yet, what future will all that good will support? Our national resolve must ensure that the same opportunities America offered these young men and women before their selfless sacrifice still remain despite any injures they may have sustained, be they visible or invisible.
We’ve all heard tragic stories of some Vietnam veterans who spiraled into the triad of homelessness, alcoholism, and substance abuse. That, I contend, was due to a lack of a national strategy or plan to reintegrate them into our society. We must not repeat the experience. The opportunity lost to our nation will be great in unrealized potential amongst these present day heroes.
So, how are we doing? According to the Veteran’s Village of San Diego (VVSD), a nonprofit organization that provides shelter, support, and substance-abuse rehabilitation to homeless veterans, of the roughly 160 individuals in the facility in 2010, two were veterans of Operation Iraqi Freedom or Operation Enduring Freedom. In 2011, on average that number exceeded 30, a 15-fold increase. And those are just the ones who swallowed their pride and asked for help. Many are suffering with alcoholism—despite treatment available before discharge in our highly successful Substance Abuse Rehabilitation Programs. This is also of particular concern when we realize most of those veterans attended mandatory Transition Assistance Program courses and left the service with marketable skills. Further, several reports have shown that joblessness among combat injured in particular is much higher than national unemployment rates. While we don’t have good statistics on how many OIF/OEF combat injured may be homeless, the VVSD experience is troubling.
At Naval Medical Center San Diego, to assist combat injured we established the Balboa Career Transition Center to provide on-site federal Department of Veterans Affairs (VA) support for disability ratings; U.S. Department of Labor vocational support to include resume writing, interview-technique clinics, and job fairs; and more through the “Coming Home to Work” initiative, which offers nonpaid internships and apprenticeships to give the wounded work experience beyond their military rating or occupational specialty. Finally, we partnered with California’s Education Development Department to maintain a college campus on base for convenient, continued education access for service members striving for a degree while going through their medical rehabilitation. That’s just one effort, and similar initiatives exist elsewhere, but an overarching national plan to link and grow those initiatives would be invaluable.
We must have a clear, precise, and articulated vision for these men and women, something that goes beyond just avoiding homelessness, alcoholism, and drug abuse. They represent the best of our youth, the proven mettle of sacrifice and dedication to a cause greater than themselves.
But, what vision for the future does all our government and community giving—financial and otherwise—support? How are those resources being coordinated to attain that vision? Those are important questions. History tells us that when conflicts end, resources become scarce or are diverted, national resolve can shift or wane, our attention gets focused elsewhere, or other priorities often emerge. But our combat-wounded will still awaken every day with scars of service, both physical and mental. Thanking them starts with clearly defining and helping to create a future for them, one to which we, as a nation, will commit for the long haul. That requires a whole-of-the-nation approach: individuals, communities, corporations, and government acting as a coalition, because so much is at stake.
What Is Our National Strategy?
Admiral Mike Mullen, while he was chairman of the Joint Chiefs of Staff, brought people together to determine what elements must be in place to support combat-injured service members and their families. Two of his staff officers, Army Colonel David Sutherland and Army Major John Copeland, in their landmark white paper “Sea of Goodwill,” defined three core elements:
• Access to healthcare for life
• Education
• Career-transition services
To that I add a fourth: Family support. Those four elements must be part of any national strategy to attain the same future we would wish for our children: a healthy, productive life that includes education, vocation, and the best quality of life possible for them and their families.
In the realm of healthcare, the VA has made significant headway in becoming a national model of service and support through such programs as My Health eVet, PTSD Coach, and others. The Military Healthcare System has likewise successfully transitioned from an acute-care system focused on either rapid return to active duty or rapid transition into a comprehensive program of longer-term support/rehabilitation and, at the deckplates, a model of interservice collaboration and cooperation. Communication between the Department of Defense (DOD) and the VA has also never been better in providing a coordinated handoff of patients from military to VA healthcare.
Further, partnerships with civilian healthcare centers of excellence are at an all-time high, ensuring the care given combat-injured is the best our nation can offer. The Integrated Disability Evaluation System currently is being streamlined to help the combat-injured get through the system as quickly as possible and proceed with their lives. All of that said, much progress in this area has been the result of congressional beneficence in the form of special funding. Sustainment of such gains will be a challenge in the tight fiscal environment ahead.
National healthcare capacity in some specialties also directly affects our combat-injured veterans. Prosthetics is just one area requiring a plan. Fewer than ten colleges in the United States train prosthetists, yet there is a baseline civilian demand for prosthetic services that extends well beyond wounded-warrior care: accident victims, patients with congenital abnormalities, and a growing number of patients requiring amputations due to advanced diabetes mellitus, as poignantly discussed by N. R. Kleinfield in his 2006 New York Times series on diabetes care in New York City as an example of a national trend. Nationally, we need a growth plan for training prosthetists to care for all such individuals.
At Naval Medical Center San Diego, we implemented a mentorship/internship program to train local civilian prosthetists to treat blast amputations. The goal is to equip them with the skills and experience needed to successfully treat these complicated and multifaceted cases so our wounded warriors will have access to the care and expertise they need after transition to the civilian sector.
National healthcare resource distribution is also a challenge and directly impacts our combat injured veterans. As a nation we’ve spent millions on healthcare services for wounded, ill, and injured service members. Federal expenditures and private donations clearly show our resolve. We nonetheless need an overarching national distribution plan to ensure we are matching resources to demand, driving service-provision to areas of greatest need, and doing so in ways that minimize inconvenience (to patients and their families) while maximizing patient support from family, friends, units, and local service-support organizations.
The medical literature is clear that family and friends play a vital role in patient recovery. For example, at NMCSD, the Comprehensive Combat and Complex Casualty Care program was established in 2007 to provide West Coast wounded warriors the opportunity for treatment and care nearer their families and units. This also allows those wounded warriors the opportunity to benefit from local vocational prospects during rehabilitation. If we drive resource distribution correctly we have an opportunity to align those resources so they can be reutilized for broader benefit when the last wounded warrior walks out the door. We have opportunities and national resolve as never before for developing an all-encompassing strategy to put resources where they are needed most in support of a national vision. To do otherwise could result in having to maintain underused, expensive healthcare facilities and resources in areas where they cannot be fully utilized.
Private generosity has produced two world-class healthcare facilities for wounded-warrior care: the Centers for the Intrepid at Bethesda, Maryland, and at San Antonio. The staffs at both locations are dedicated, compassionate, and fully committed toward the care of wounded warriors and their families. Both exist within the confines of a secure base, and both are DOD operations. However, as we move into the future, and as the number of combat-injured decrease, how do we continue to optimize and take advantage of these national treasures? Looming fiscal constraints and increasing attention to DOD healthcare costs may make sustaining those facilities a challenge, especially if they become underutilized.
Title X of the United States Code currently limits the ability to use the centers for civilian benefit, but leveraging those assets for the greater good would allow stroke victims, non-DOD patients with traumatic brain injuries (TBI) not related to combat, and others to benefit from the advances, experience, and resources brought to bear there now for the combat-injured. Further, if legislative relief permitted a partnership with the civilian sector for those and other cooperative opportunities, that could result in cost sharing the sustainment of those capabilities. In turn, that could lower healthcare expenses for DOD, creating a potential model for bending the DOD’s cost curve for healthcare in other areas while expanding care options and opportunities for all. Equally important, it would preserve those capabilities and competencies at lower cost for use in the next conflict.
Addressing Education Needs
In another realm, we’ve done moderately well with education efforts. College and university programs to provide any veteran with a post-secondary education are commonplace. Enhancements to the Montgomery G.I. Bill, tuition-assistance programs, state tuition discounts for military, and other initiatives have made getting a degree financially easier than ever. However, the dynamic challenges of our wounded warriors—many of whom are junior enlisted, married, or have children—require more consideration.
For example, the spouses of many wounded warriors also work. Many combat-wounded suffer from TBI, a signature symptom of which is short-term memory loss. A spouse may need to frequently take time off to drive his or her partner to appointments and other engagements. Childcare and other routine domestic tasks aside, adding a requirement of transporting a partner to classes becomes increasingly burdensome. If it is excessive and requires time off from work, it could put the spouse’s job at risk.
The simplest course of action is to not put that job (income) at risk and forgo college, which has a negative effect on long-term goals. It’s estimated that no more than 30 percent of G.I. Bill-eligible wounded warriors are enrolled in college, in part for some of the reasons just cited. Further, short-term memory is critical to academic success in college. We are only beginning to scratch the surface of adaptive technologies to compensate for short-term memory loss from TBI as an impediment to academic success. We all agree that going to college is good. But for many of our wounded veterans it sometimes comes down to a matter of being able to do so without putting the family income at risk and having the adaptive technologies to be successful. Addressing those challenges will be critical to providing educational opportunities for our wounded.
Career-Transition Efforts
In the area of career transition this nation has perhaps the most work to do. The services’ personnel departments tell us that significant numbers of veterans leave active duty and re-enter civilian life unemployed, numbers that include the combat-injured. In testimony last year to the House Armed Services Committee, former chairman of the Joint Chiefs of Staff Marine General Peter Pace said unemployment among wounded veterans might exceed 40 percent. Most veterans have technical skills necessary for employment. Further, there is no shortage of companies committed to hiring combat-wounded veterans and, if necessary, training them.
The key is linking those service members with employers. Employment in today’s job market is critically dependent on networking and narrowing the gap between employer and potential employee. Friends, high school or college pals, family, and others in the community all help civilian job seekers build networks and find job leads. But military personnel move frequently; most do not live in areas where friends or family are nearby to help. Further, the nature of military service frequently precludes developing a civilian network for job leads: It’s hard to develop such a network in a combat zone or when otherwise deployed. For our wounded service members, it is especially difficult because after those deployments, they come home to long, complex, and fully engrossing medical care, leaving few opportunities for networking.
DOD transition-assistance programs have done much to help service members, including the wounded, with résumé writing, interviewing, and related activities—all of which occur after a job lead has been identified and pursued. But the network must be developed for that lead to occur, so we need to narrow the gap between employers and wounded warriors. Career fairs help, but they are not universally available, are sporadic in nature, and do not represent all potential employers. A national partnership between DOD, other federal agencies, and corporate America to narrow the employer-veteran gap is crucial. Employer incentives of the types being introduced or proposed will be critical as well and must be part of our overarching plan.
Expanding our Focus on Family
Lastly, America needs a comprehensive approach to wounded-warrior family support, especially regarding mental health. A military lifestyle has no civilian equivalent. Further, caring for a wounded veteran, especially one with post-traumatic stress disorder (PTSD) or TBI, is very challenging—something most civilians have not experienced and can only vaguely imagine. Mental-health support for family members is essential, both during and after their loved ones’ service. Congress has allowed DOD to dramatically increase its mental-health-provider workforce over the past ten years. Yet, as stigma declines and need increases, most such providers are fully occupied caring for active-duty personnel.
Service-family support programs are invaluable, but family members needing professional mental-health care increasingly are referred to the civilian network of providers managed by TRICARE. As dedicated and caring as those providers may be, they are reflective of our nation as a whole—less than 2 percent have served in the military or have any military connections. Few have significant experience with PTSD. When a military spouse speaks of deployment stressors, Marine expeditionary forces, brigade combat teams, or the issues of living with a spouse with PTSD, the provider frequently cannot fully understand. It becomes very difficult to establish a therapeutic relationship when there is no common understanding of the stressors.
Education programs to orient civilian providers to the challenges of military life, as is done in San Diego, can help and should be part of the national strategy. For the combat-wounded re-entering civilian life the challenges are greater if they settle in areas lacking adequate mental- health services or resources—much less providers with military experience. In September 2011, the Department of Health and Human Services identified 3,684 areas in the United States as having insufficient mental-health services to meet the needs of the 90.3 million people living in those areas.
Further, unlike military medicine that has on-call mental-health providers continually available, many civilian providers do not offer appointments after normal working hours or on weekends. Consider the spouse who routinely takes time off to shuttle a loved one to medical appointments, therapy, classes, and the like—in addition to time off for unexpected, unrelated family matters, such as a child’s illness. Taking time off on top of all that to seek mental-health support for themselves can be challenging enough; it is made more so when an evening or weekend appointment is not an option. Likewise, for those who decide to seek care, not all mental-health care providers can see them right away, so the family member may have to wait some time for an appointment. But the time to treat mental-health concerns is when they arise—especially for this population.
There is a way ahead, however. By way of example, when the 3d Battalion, 5th Marine Regiment returned to Marine Corps Base Camp Pendleton in 2011 from a deployment with multiple combat casualties, the occasion was used to critically assess and implement expanded, more effective unit and family support for returning combat forces. For family mental health, there are approximately 880 civilian mental-health providers in the area surrounding Camp Pendleton. TriWest, the managed-care support contractor for the area, worked with the staff at Naval Hospital Camp Pendleton to identify those providers with military experience who also were willing to see family members after hours or on weekends—and would see them within a week’s time. Family members were then preferentially sent to the 62 providers meeting those criteria. That is just one effort, but it is one that could be a model for a much broader approach.
Much has been done. But there is much to do. A comprehensive national strategy that can be delineated, executed, and sustained will help. Focusing on coordinating the four critical areas of access to healthcare for life, education, career transition services, and family support is a strong first step.
What Is the Role of Government?
The need for a detailed vision for the combat-injured and their families has been articulated here. As part of a national strategy to realize that future we must define roles, responsibilities, and coordination priorities, especially in a time of fiscal constraint. As a result of our overwhelming national support, it is increasingly difficult to differentiate the role and responsibility of government from private sector. Colonel Sutherland and Major Copeland referred to such unprecedented support as a “sea of goodwill.” So how is that generosity coordinated and applied to need? For that matter, how is need identified and prioritized? How is determination made regarding the responsibility of government and the need for private-sector support?
A defined and articulated partnership between government and private sector is an ideal way ahead. It can be done—as seen in the case of the 5th Marines at Camp Pendleton. A summit among all concerned to define the needed relationships, responsibilities, and commitment would be a solid beginning.
What do the next ten years hold for the combat-injured and their families? It all depends. A great deal of good has been done in the past decade, but much of it has been the result of special funding initiatives, independent programs mandated by Congress, or acts of kindness by caring Americans, all without an overarching plan or coordination. Our war-tried heroes deserve a unified plan with a clearly articulated end-state vision, a strategy to achieve that vision, and defined roles and responsibilities. Uncoordinated generosity is no strategy for the future, and too much depends on our doing this right—or so George Washington might have reminded us. We cannot leave that to chance.