National Security

The Reckoning

The scars from today’s wars amount to a national pathology. America could take a generation to heal.

** ADVANCE FOR MONDAY NOV. 29 ** U.S. soldiers carry Spc. Jeremy Kuehl,  24, of Altoona, Iowa, from the 1-320th Alpha Battery, 2nd Brigade of the 101st Airborne Division, to a medical evacuation helicopter after he was seriously wounded by stepping on an improvised mine near COP Nolen, in the volatile Arghandab Valley, Kandahar, Afghanistan, Friday, July 30, 2010. (AP Photo/Rodrigo Abd)
AP Photo/Rodrigo Abd
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James Kitfield
Sept. 8, 2011, 11 a.m.

The troops come home from war much the way they left, largely in­vis­ible to a dis­trac­ted na­tion. Re­turn­ing units are typ­ic­ally met at an air­field by buses that shuttle them to a gated mil­it­ary base. On a parade ground, a com­mand­er re­minds the as­sembled, some of the more than 2.3 mil­lion ser­vice mem­bers de­ployed dur­ing the past dec­ade of war, of all that they ac­com­plished. He re­calls the broth­ers in arms who didn’t make it back and the memor­ies that unite those who did. The shared hard­ships, the mo­ments of ter­ror and ela­tion, the con­stant jok­ing that held the aw­ful­ness at bay. The un­bear­able mel­an­choly that des­cends at the play­ing of “Taps.”

The com­mand­er dis­misses the form­a­tion, and the troops real­ize that the ties that bound their lives to­geth­er are break­ing. The mar­ried ser­vice mem­bers run in­to the open arms of their fam­il­ies, hus­bands hold­ing ba­bies they’ve nev­er met, uni­formed wo­men hug­ging young chil­dren they can hardly re­cog­nize. Even be­fore the smiles and tears sub­side, spouses sense the vast gulf that now lies between them and won­der how to get across. Single troop­ers head for the bar­racks, crack­ing wise but of­ten wish­ing that they, too, had fam­ily to wel­come them home. And, in­ev­it­ably, there are the strag­glers — young sol­diers shuff­ling and chain-smoking, un­sure of where to go or what to do next. Hav­ing come of age on dis­tant bat­tle­fields, they are sud­denly lost in Amer­ica.

Even Col. Dav­id Suth­er­land, a dec­or­ated com­mand­er who served in Ir­aq, was shocked by the dizzy­ing sense of ali­en­a­tion he felt on reentry. “Nev­er in the his­tory of our Re­pub­lic have so few been asked to do so much for so long. And yet, when sol­diers re­turn home, they feel acutely this dis­con­nect between the mil­it­ary and a ci­vil­ian so­ci­ety that doesn’t even seem to be at war,” says Suth­er­land, the Joint Staff’s spe­cial as­sist­ant in charge of the War­ri­or and Fam­ily Sup­port pro­gram. “We fall in­to the same trap of our fath­ers from World War II or Vi­et­nam, which is to keep the memor­ies of those sac­red mo­ments on the bat­tle­field to ourselves. That’s how they be­come secrets, and secrets are not healthy.”

Tens of thou­sands of oth­er troops re­turn home on the aeromed­ic­al-evac­u­ation flights that land routinely at An­drews Air Force Base in Mary­land or Trav­is Air Force Base in Cali­for­nia, where the buses wait­ing to meet them bear large red crosses. The crit­ic­ally wounded emerge from the massive C-17 trans­ports first, nearly in­vis­ible be­neath band­ages, a jungle of med­ic­al equip­ment strapped to their gurneys. Next out are the less-dire cases, car­ried on stretch­ers. Fi­nally, the am­bu­lat­ory pa­tients shuffle single file to the wait­ing buses. In the past dec­ade, Air Mo­bil­ity Com­mand has flown more than 35,600 aeromed­ic­al-evac­u­ation sorties, trans­port­ing more than 177,000 wounded or ill ser­vice mem­bers home.

Staff Sgt. Dan Nev­ins was one of those pa­tients who landed on the tar­mac at An­drews in 2005 cling­ing to life. Hav­ing already lost one leg, he fought through 18 months and 30 sur­ger­ies at Wal­ter Reed Army Med­ic­al Cen­ter try­ing in vain to save the oth­er. “In ret­ro­spect, fi­nally let­ting go of my oth­er leg and get­ting on with my life was the best de­cision I ever made,” says Nev­ins, who now works for the non­profit Wounded War­ri­or Pro­ject help­ing oth­er in­jured vet­er­ans try to get on with their lives.

Thou­sands of oth­er troop­ers have re­turned home in flag-draped coffins at Dover Air Force Base in Delaware. Last month, Pres­id­ent Obama and oth­er seni­or of­fi­cials traveled to Dover to hon­or the 30 Amer­ic­an troops killed in Afgh­anistan on Aug. 6 after their heli­copter was shot down, the worst single-day loss of the long Afghan war. Their names joined the hon­or roll of more than 6,000 fallen ser­vice mem­bers from Ir­aq and Afgh­anistan. The deaf­en­ing si­lence of the dead con­tin­ues to send shock waves through a land­scape of grief in­hab­ited by their fam­il­ies and com­rades — the col­lat­er­al wounded of these wars.

“A death in the mil­it­ary is un­like any oth­er loss in our so­ci­ety, be­cause there are so many com­plic­at­ing factors,” says Bon­nie Car­roll, founder and pres­id­ent of the Tragedy As­sist­ance Pro­gram for Sur­viv­ors, or TAPS, which reaches out to griev­ing mil­it­ary fam­il­ies with “peer pro­fes­sion­als” who have so­cial work de­grees and have also lost loved ones in the mil­it­ary. Be­cause deaths of­ten hap­pen on long com­bat de­ploy­ments, Car­roll says, griev­ing spouses some­times trick them­selves in­to think­ing that a miss­ing ser­vice mem­ber will still walk through the front door someday. Oth­er times, the man­ner of death is so trau­mat­ic that fam­il­ies re­ceive mul­tiple sets of re­mains. “When a death is so hor­rif­ic in nature, and the spouse hears about it re­peatedly in the me­dia or third-party ac­counts, they can cre­ate a memory that leads to their own post-trau­mat­ic stress dis­order.”

Every war leaves its im­print on those who fight it and on the na­tion­al psyche. At the 10-year mark, the wounds and men­tal scar tis­sue from Afgh­anistan and Ir­aq have amassed in­to something like a patho­logy unique to these con­flicts — one that will af­flict this coun­try for a gen­er­a­tion.

Due largely to ad­vances in com­bat medi­cine, rap­id aeromed­ic­al evac­u­ation, and body ar­mor, the wars have proven to be the least leth­al in mod­ern U.S. his­tory. Ac­cord­ing to Dr. Ron­ald Glass­er, a Vi­et­nam-era Army sur­geon and the au­thor of the re­cent book, Broken Bod­ies, Shattered Minds: A Med­ic­al Odys­sey from Vi­et­nam to Afgh­anistan, for every bat­tle­field death, 16 ser­vice mem­bers sur­vived their wounds. The ra­tio in Vi­et­nam, he said, was 2.4 wounded for every death. In the Civil War, the ra­tio was less than 1-to-1, with few sol­diers sur­viv­ing bat­tle­field wounds.

In his book, Glass­er warns that the na­tion will face a mor­al and eco­nom­ic reck­on­ing in caring for so many wounded vet­er­ans. “Be­cause of body ar­mor there have been re­l­at­ively few of the pen­et­rat­ing chest wounds or ab­dom­in­al in­jur­ies that caused so many battle deaths in past wars,” he tells Na­tion­al Journ­al. “But no one was really pre­pared for the num­ber of ser­i­ously wounded sur­viv­ors.” Ac­cord­ing to the Pentagon, 168,000 ser­vice mem­bers wounded or in­jured in these wars are graded “60 per­cent dis­abled” or high­er, and the VA faces a 492,000-case back­log of dis­ab­il­ity claims. More than 508,000 vet­er­ans of today’s wars have already been treated at VA hos­pit­als and clin­ics. The Con­gres­sion­al Budget Of­fice es­tim­ates that the med­ic­al costs as­so­ci­ated with today’s vet­er­ans could come to $40 bil­lion to $55 bil­lion over the next dec­ade.

Just as the cur­rent wars have dragged on, with tac­tics and geo­graphy shift­ing over the years, the patho­logy of these wounds has also mutated over time. Early on in Afgh­anistan, for in­stance, small arms caused many in­jur­ies. A few years in­to the fight­ing in Ir­aq — as in­sur­gent bombs got big­ger and the ar­mor on U.S. mil­it­ary vehicles got thick­er — troops ab­sorbed blast waves through their seats, caus­ing a spike in spin­al-cord in­jur­ies, con­cus­sions, and brain trauma. Over the last 18 months in Afgh­anistan, the pro­file has changed again.

“As Afgh­anistan has turned primar­ily in­to a war of dis­moun­ted in­fantry, our poly­trauma wards have seen a huge in­flux of troop­ers with really massive in­jur­ies from ab­sorb­ing blasts while on foot patrol, in­clud­ing mul­tiple am­pu­ta­tions, really severe brain in­jury, and the emo­tion­al wounds that go with all of that,” says Dr. Shane Mc­Namee, the chief of phys­ic­al medi­cine and re­hab­il­it­a­tion at the VA’s Poly­trauma Re­hab­il­it­a­tion Cen­ter in Rich­mond, Va. “In the past five years, I can’t tell you how many times we have regeared to tail­or our care de­liv­ery to sub­sequent waves of ser­vice mem­bers with dif­fer­ent kinds of wounds.”

But im­pro­vised ex­plos­ive devices, the en­emy weapon of choice in both con­flicts, have caused their sig­na­ture wounds, cre­at­ing more than 1,300 am­putees, nu­mer­ous burn vic­tims, and un­known num­bers who suf­fer from trau­mat­ic brain in­jury. Ac­cord­ing to the ad­vocacy group Vet­er­ans for Com­mon Sense, more than 190,000 troops have suffered a con­cus­sion or brain in­jury. There is also grow­ing evid­ence of links between TBI and posttrau­mat­ic stress dis­order. “They both in­jure sim­il­ar areas of the brain and ex­hib­it sim­il­ar symp­toms,” says Mc­Namee. “The lines between them are pretty gray.” Ac­cord­ing to a 2008 Rand sur­vey, one in five vet­er­ans of these wars — some 300,000 people — are suf­fer­ing either from ma­jor de­pres­sion or PTSD, while 320,000 have suffered con­cus­sions or TBI.

Those grow­ing num­bers are sig­ni­fic­ant. By al­low­ing the Vi­et­nam War — and the phys­ic­al and emo­tion­al trauma it caused — to re­cede from our na­tion­al con­scious­ness, Amer­ica in­her­ited an epi­dem­ic of vet­er­ans suf­fer­ing from the at­tend­ant ills of PTSD. Today, the post-9/11 gen­er­a­tion of vo­lun­teers faces the same risk. “When a lot of us Vi­et­nam vet­er­ans re­turned from war, it took us a dec­ade or even two be­fore we would even talk about what happened, and we bottled up a lot of an­ger and hurt,” says Tom Mitchell, a state dir­ect­or for U.S. Vets, a non­profit that works to get home­less vet­er­ans off the streets. “A lot of us are de­term­ined not to let that hap­pen with this new gen­er­a­tion of com­bat vet­er­ans from Ir­aq and Afgh­anistan.”

Today’s wars are the first ex­ten­ded con­flicts to be fought not by draftees but by a re­l­at­ively small co­hort of vo­lun­teers. That partly ex­plains why the patho­lo­gies spe­cif­ic to this war have been so hard to pre­dict. Like pre­vi­ous gen­er­a­tions, however, today’s vet­er­ans gen­er­ally keep the tox­ic af­teref­fects of war to them­selves; they are simply too pain­ful to ad­mit or con­front.

The small size of the all-vo­lun­teer force, for in­stance, has ne­ces­sit­ated mul­tiple com­bat de­ploy­ments with in­ad­equate breaks in between, which men­tal-health ex­perts be­lieve greatly in­creases the propensity for PTSD and its ef­fects: de­pres­sion, drug ab­use, failed mar­riages, and emo­tion­al dis­tress. The De­fense De­part­ment’s Task Force on Men­tal Health found in 2007 that 38 per­cent of all act­ive-duty ser­vice mem­bers have re­por­ted psy­cho­lo­gic­al symp­toms after their tours. In some months this year, the sui­cide rate for act­ive-duty ser­vice mem­bers has ex­ceeded com­bat deaths, and in April, the VA’s sui­cide-pre­ven­tion hot­line re­ceived more than 14,000 calls — the most ever re­cor­ded in a single month. Dr. Robert Pet­zel, the VA un­der­sec­ret­ary of health, says that doc­tors have be­come ex­pert at re­cog­niz­ing and treat­ing PTSD. “It’s prob­ably true that mul­tiple com­bat de­ploy­ments in­crease the like­li­hood of PTSD,” he warns, “though we don’t have ad­equate re­search to prove that yet.”

Today’s all-vo­lun­teer force is also older than its draft-era coun­ter­part, with more mar­ried ser­vice mem­bers and a lar­ger num­ber of uni­formed wo­men (14.6 per­cent of the act­ive-duty total). More than 220,000 wo­men have served in Ir­aq and Afgh­anistan, mean­ing that they’ve borne a high­er share of the bur­den than in past wars. After 9/11, the mil­it­ary di­vorce rate climbed from 2.6 per­cent per year in 2001 to 3.6 per­cent in 2010. And 7.8 per­cent of wo­men in the mil­it­ary di­vorced in 2010. (Be­cause the mil­it­ary does not track over­all di­vorce rates, count as di­vorced those ser­vice mem­bers who re­marry in a giv­en year, or fol­low up on the di­vorce rate of mil­it­ary per­son­nel a year or two after they leave ser­vice, many ex­perts be­lieve the Pentagon un­der­es­tim­ates the ac­tu­al rate of mil­it­ary di­vorce.) “Over­all di­vorce rates in the mil­it­ary could climb to as high as 80 per­cent for first mar­riages, which would mean that ser­vice in the mil­it­ary is be­com­ing a pre­curs­or for di­vorce,” says Leti­cia Dreil­ing, a Hou­s­ton Vets Cen­ter mar­riage and fam­ily ther­ap­ist.

Ac­cord­ing to the VA, about one in five fe­male vet­er­ans, or 20 per­cent, have also tested pos­it­ive for posttrau­mat­ic stress re­lated to “mil­it­ary sexu­al trauma,” a catch-all cat­egory that in­cludes everything from sexu­al har­ass­ment to rape. “I ac­tu­ally think the mil­it­ary sexu­al trauma among wo­men is much high­er than the of­fi­cial fig­ures, be­cause we find that a lot of wo­men ser­vice mem­bers feel guilty even talk­ing about it,” says Ju­dith Broder, a clin­ic­al psy­cho­lo­gist who star­ted The Sol­diers Pro­ject, which of­fers free men­tal-health coun­sel­ing to re­turn­ing vet­er­ans. “Wo­men vet­er­ans of­ten feel like it’s a be­tray­al of their unit to speak about sexu­al trauma, so they tend to carry that wound a long time in si­lence, which in­creases the like­li­hood that it will de­vel­op in­to com­bat-stress dis­order.” Wo­men are also the fast­est grow­ing sub­set of the home­less-vet­er­an pop­u­la­tion in Amer­ica, ac­cord­ing to Broder. Some land on the streets with their chil­dren.

As a per­cent­age of the over­all de­ployed force, the Na­tion­al Guard and Re­serves have also shouldered more of the bur­den in Afgh­anistan and Ir­aq than in wars past. Yet as cit­izen-sol­diers, re­serv­ists are less pre­pared for the stresses of a long com­bat tour. In­deed, the Task Force on Men­tal Health found that 49 per­cent of Na­tion­al Guards­men re­por­ted ex­per­i­en­cing psy­cho­lo­gic­al troubles after their de­ploy­ments.

With the wars now wind­ing down, the Pentagon es­tim­ates that as many as 1 mil­lion ser­vice mem­bers are likely to leave act­ive duty in the next five years. They will enter a strug­gling eco­nomy where the job­less rate for young (ages 18 to 24) male vet­er­ans of Ir­aq and Afgh­anistan was 21.9 per­cent last year, and where vet­er­ans make up an es­tim­ated 20 per­cent of the home­less pop­u­la­tion. Many ex­perts be­lieve that the na­tion is simply un­pre­pared for that ap­proach­ing army of suf­fer­ing.

“There are com­bat wounds you can see, and oth­ers that are in­vis­ible un­til symp­toms de­vel­op long after ser­vice mem­bers re­turn home, and we’re see­ing an in­crease in vir­tu­ally all of the met­rics that track them,” says clin­ic­al psy­cho­lo­gist Bar­bara Van Dah­len, the founder and pres­id­ent of the non­profit Give an Hour, which con­nects vet­er­ans to a net­work of 6,000 men­tal-health pro­fes­sion­als for free treat­ment.

Des­pite im­prove­ments in the mil­it­ary and VA health care sys­tems — and the co­oper­a­tion of nearly 5,000 non­profits that serve mil­it­ary per­son­nel — Van Dah­len sees a pop­u­la­tion at severe risk. “We should have learned from Vi­et­nam, be­cause all you have to do is study the home­less pop­u­la­tion today to un­der­stand that an aw­ful lot of those vet­er­ans nev­er really made it all the way home,” she says. “If we don’t get ahead of the chal­lenge, we will risk los­ing this gen­er­a­tion of vet­er­ans.”

The odys­sey be­gins on a day like any oth­er, log­ging duty in a faraway and un­fa­mil­i­ar land. Dan Nev­in’s began in Ir­aq in a Hum­vee that was boun­cing down a dusty road out­side the Sunni-in­sur­gent strong­hold of Fal­luja. Without warn­ing, his vehicle struck a road­side bomb. In an in­stant, Nov. 10, 2004, be­came the day that changed his life forever. By the time Nev­in ar­rived at the U.S. mil­it­ary hos­pit­al in Land­stuhl, Ger­many, 12 hours later, he had already lost one leg. Even­tu­ally, he lost the oth­er to a bone in­fec­tion.

In 2004 and 2005, the in­sur­gen­cies that would even­tu­ally drive Ir­aq to the brink of civil war grew; cor­res­pond­ingly, the num­ber of crit­ic­ally wounded ser­vice mem­bers pour­ing in­to the mil­it­ary med­ic­al sys­tem spiked. Nev­in had to wait a week to get space on one of the crowded med­ic­al flights from Ger­many, and when he ar­rived at Wal­ter Reed Army Med­ic­al Cen­ter, the staff was nearly over­whelmed. The care “was ab­so­lutely world-class,” he says. But the care­givers “just couldn’t handle all of the wounded. Those guys worked day and night, but it was a con­stant battle to get ap­point­ments if you needed a modi­fic­a­tion to your pros­thet­ic leg. And when you did get an ap­point­ment, you could wait hours.”

Lead­ers of the mil­it­ary health care sys­tem were also be­gin­ning to real­ize the com­plex­ity of provid­ing life-sav­ing and re­hab­il­it­at­ive care for so many severely wounded troops. Nev­in’s Re­serve ac­tiv­a­tion had forced him to take a ma­jor pay cut from his job selling phar­ma­ceut­ic­als in Cali­for­nia. Be­cause his wife couldn’t af­ford to leave her own job, he could only see her one week­end every six weeks or so, put­ting more strain on their mar­riage. Yet com­pared to some of the young­er act­ive-duty pa­tients who were told they were too in­jured to con­tin­ue serving — mean­ing forced sep­ar­a­tion from the only job and cul­ture they had known as adults — he felt lucky. “As a re­serv­ist, I had a col­lege de­gree, a good job, and a sup­port­ive fam­ily to go home to,” Nev­in says. “Some of those young kids joined the mil­it­ary right out of high school, however, and they didn’t have any of that to fall back on. So they found every ex­cuse ima­gin­able not to be re­leased from Wal­ter Reed. I thought they were crazy at the time, but later I real­ized that those young guys barely in­to their 20s were para­lyzed with fear about what came next.”

By 2007, the prob­lems at Wal­ter Reed ex­ploded in­to a full-blown scan­dal when The Wash­ing­ton Post pub­lished a series of art­icles de­tail­ing neg­lect, over­worked case man­agers, and shoddy in­fra­struc­ture. The com­mand­er of Wal­ter Reed and the sec­ret­ary of the Army resigned. But the scan­dal helped show the Pentagon and VA that their un­der­staffed and stovepiped med­ic­al fa­cil­it­ies were still un­pre­pared for the wounded and maimed pa­tients of­ten trans­ition­ing back and forth between their sys­tems. For the Army, the res­ult was the cre­ation of the War­ri­or Trans­ition Com­mand. From the be­gin­ning, its mis­sion was to pro­tect sub­sequent waves of re­turn­ing wounded sol­diers from the para­lyz­ing fears that haunted young troop­ers at Wal­ter Reed — the no­tion that the mil­it­ary was abandon­ing them at their mo­ment of greatest need.

Lt. Col. Danny Dudek, who now works for the War­ri­or Trans­ition Com­mand, real­ized how pre­cari­ous he felt when his own odys­sey began in 2007. While trav­el­ing north of Bagh­dad just three months earli­er, a pen­et­rat­ing ex­plos­ive hit his ar­mored Stryker fight­ing vehicle. The blast killed the sol­dier next to him and caused a spin­al-cord in­jury in Dudek that left him para­lyzed be­low the knee. With­in days, he had been through sur­gery at Wal­ter Reed; with­in a few months, he was sent to the VA hos­pit­al in Seattle to re­cov­er near his fam­ily. The care was ex­cel­lent, but Dudek felt bereft of the ca­marader­ie and sup­port struc­tures that he had come to de­pend on in his unit and some­what lost in the VA bur­eau­cracy. “We over­looked all the oth­er stuff that goes in­to be­ing a sol­dier, like be­ing able to rely on strong lead­er­ship, show­ing up for form­a­tion, know­ing that our fam­il­ies are taken care of,” Dudek says. “I think the Army real­ized that we can’t just treat wounded sol­diers like pa­tients. We need to con­tin­ue to treat them like sol­diers, too.”

That epi­phany led to the es­tab­lish­ment in 2007 of 29 com­munity-based War­ri­or Trans­ition Units for all sol­diers whose care re­quires at least six months of com­plex med­ic­al treat­ment. The units blend the ef­forts of a primary-care doc­tor, a nurse case man­ager, and a squad lead­er. Sol­diers help shape their own com­pre­hens­ive trans­ition plans, which in­clude ca­reer and em­ploy­ment goals; Sol­dier and Fam­ily As­sist­ance Cen­ters aid their fam­ily mem­bers.

Still, the chal­lenges are so com­plex that even this well-in­ten­tioned pro­gram ini­tially went awry in some places. Me­dia in­vest­ig­a­tions of vari­ous units showed con­flicts between the med­ic­al and mil­it­ary staff, over­crowding, and an over­re­li­ance on med­ic­a­tion. An Army In­spect­or Gen­er­al’s re­port is­sued in Janu­ary es­tim­ated that up to a third of all sol­diers in War­ri­or Trans­ition Units last year were over­med­ic­ated, hooked on drugs, or ab­us­ing il­leg­al sub­stances.

The Army has in­vest­ig­ated the charges but hasn’t backed away from the concept. “We did have some in­ex­per­i­enced lead­ers in War­ri­or Trans­ition Units who didn’t fully un­der­stand the com­plex­ity of tail­or­ing a treat­ment re­gime to each sol­dier, and some sol­diers do feel that mil­it­ary drills get in the way of their re­cov­ery,” says Dudek, who com­manded a trans­ition unit in Seattle. “There were also some con­flicts between nurse case man­agers and squad lead­ers. But with good lead­er­ship, that or­gan­iz­a­tion­al fric­tion usu­ally gets quickly re­solved.” He adds that “the last thing we need to do is come back wounded and just “˜take a knee.’ What I told my sol­diers is that you have to fight to over­come the pain, the apathy, and the fear of an un­cer­tain fu­ture. And for me and a lot of them, it is the hard­est fight of our lives.”

When Lance Cpl. Nancy Schiliro was med­ic­ally dis­charged from the Mar­ine Corps in 2005 after los­ing an eye in a mor­tar at­tack in Ir­aq, there was no long coun­sel­ing ses­sion or trans­ition unit. They hadn’t been cre­ated yet. One day she was liv­ing in the 24/7 bubble of life as a Mar­ine — be­ing told what to do, where to go, when to eat, and who to hang out with — and the next day she was home and that bubble had burst. The whole ex­per­i­ence was so dis­or­i­ent­ing that, for six months, Schiliro didn’t even real­ize that she was suf­fer­ing from PTSD. “I wasn’t sleep­ing. I jumped at loud noises. I ba­sic­ally stayed to my­self and stopped in­ter­act­ing with people. I just wasn’t me,” she says. Fi­nally, her broth­er’s fath­er-in-law, him­self a former Mar­ine, called a friend at a loc­al vet­er­ans’ cen­ter, who reached out. “It’s taken me awhile to learn how to man­age my dis­ease, and it’s got­ten bet­ter,” she says. “But I don’t think I’ll ever be totally cured.”

Cases like Schiliro — vet­er­ans who need care but fall in­to the gap between mil­it­ary med­ic­al treat­ment and VA fol­low-on care — have driv­en re­forms de­signed to make the trans­ition more seam­less. The Pentagon and the VA es­tab­lished a Joint Ex­ec­ut­ive Coun­cil that is­sued 26 ini­ti­at­ives to stand­ard­ize treat­ment and eval­u­ation sys­tems. For in­stance, mil­it­ary treat­ment fa­cil­it­ies today typ­ic­ally don’t re­lease a wounded ser­vice mem­ber un­til he or she has sched­uled ap­point­ments in the Vet­er­ans Health Ad­min­is­tra­tion sys­tem. If re­ques­ted, one of a hun­dred VA “trans­ition pa­tient ad­voc­ates” will even travel with ser­vice mem­bers as they move from ma­jor mil­it­ary hos­pit­als to VA hos­pit­als closer to home. An­ti­cip­at­ing de­mand, the VA also hired 7,000 men­tal-health of­fi­cials in re­cent years, ex­pan­ded sui­cide-pre­ven­tion hot­lines, and es­tab­lished care­giver pro­grams that provide sti­pends and travel al­low­ances for fam­ily mem­bers who care for ser­i­ously wounded vet­er­ans. “The de­part­ments of De­fense and Vet­er­ans Af­fairs have gone from a re­l­at­ively low-level of in­ter­ac­tion in 2001 to a de­gree of co­oper­a­tion that is his­tor­ic­ally un­pre­ced­en­ted,” says Pet­zel, the VA health un­der­sec­ret­ary.

Hun­dreds of thou­sands of vet­er­ans of Afgh­anistan and Ir­aq have or will soon re­join the ci­vil­ian world.

For all of those ad­vances, however, ma­jor prob­lems per­sist. Des­pite the move to a joint dis­ab­il­ity eval­u­ation pro­cess de­signed to stream­line claims pro­ced­ures, some vet­er­ans are still wait­ing up to 400 days for a de­cision on wheth­er they will re­ceive pay­ments and at what levels, and a back­log of nearly 500,000 late claims have gone bey­ond the 125-day stand­ard at the VA. Un­til dis­ab­il­ity pay­ments be­gin, eas­ing some of their fin­an­cial bur­dens, wounded vet­er­ans are sus­cept­ible to al­co­hol or drug ab­use — or worse — to al­le­vi­ate their suf­fer­ing. “I know that VA and DOD have big chal­lenges,” Sen­ate Vet­er­ans’ Af­fairs Com­mit­tee Chair­wo­man Patty Mur­ray, D-Wash., said at a hear­ing earli­er this year. “But ser­vice mem­bers and vet­er­ans con­tin­ue to take their own lives at an alarm­ing rate. Wait times for be­ne­fits con­tin­ue to drag on for an av­er­age of a year or far more.”

An­oth­er sign of trouble: Des­pite ag­gress­ive out­reach, only about half of the Ir­aq and Afgh­anistan vets have even re­gistered with the VA, mean­ing there is a vast at-risk pop­u­la­tion. “A chief les­son of Vi­et­nam was that we need to get new vet­er­ans help as early as pos­sible, be­fore their lives spir­al in­to crisis,” says Fern Taylor, su­per­visor of a clin­ic for re­turn­ing vet­er­ans at a VA hos­pit­al in Hou­s­ton. “Too of­ten, our first con­tact with a vet­er­an is in the emer­gency room, through the crim­in­al-justice sys­tem, or on our sui­cide-pre­ven­tion hot­line.”

Kathy Molit­or, the sui­cide-pre­ven­tion co­ordin­at­or at a VA post-de­ploy­ment clin­ic in Hou­s­ton, has no doubt that many vets need help. In 2007, the VA’s sui­cide hot­line re­ceived 9, 400 calls, she says, and the next year, it jumped to 67,400. In 2009, it reached 119,000, and last year it was up to 135,000. Just listen­ing to the calls for help can in­duce sec­ond­ary trau­mat­ic stress: I feel like an an­im­al, un­fit for civ­il­ized so­ci­ety.”¦ My hus­band only wants to hang out and drink and do drugs with his bud­dies.”¦ I can’t talk to my wife be­cause she might be in­fec­ted with my dis­ease.”¦  My hus­band barks or­ders at our chil­dren like they were sol­diers.”¦  After watch­ing my buddy blown to bits, I’m angry all the time.”¦  Why does Daddy want to go back to war? “¦ Our son is con­stantly clean­ing his gun in his room alone, and we can’t get him to stop.”¦  I’m not/she’s not/he’s not the same per­son any­more “¦

The es­sen­tial mes­sage that Molit­or and the oth­er hot­line ther­ap­ists try to con­vey to callers is simple: War is haz­ard­ous to your men­tal health. “It’s really no sur­prise that these vet­er­ans have posttrau­mat­ic stress, be­cause these are hard is­sues for hu­mans to deal with on top of all of life’s oth­er stresses and dif­fi­culties,” she says. “On the phone, we try and let them know that these are nor­mal re­ac­tions to what are really ab­nor­mal ex­per­i­ences.”

On a re­cent swel­ter­ing day, Os­kar Gonza­lez-Yet­zirah of the non­profit U.S. Vets trolled be­neath one of Hou­s­ton’s count­less high­way over­passes, of­fer­ing bottles of wa­ter to the ragged men and wo­men gathered there. He had a simple ques­tion for any takers.

“You a vet?”

U.S. Vets is one of roughly 5,000 non­profits na­tion­wide that aid mil­it­ary per­son­nel and vet­er­ans. In a sense, they are Amer­ica’s catch­ers in the rye — the last line of help for vet­er­ans poised on the pre­cip­ice of a cliff. The vet­er­ans whom Gonza­lez-Yet­zirah finds un­der the over­pass have already hit rock bot­tom, join­ing some 3,500 home­less vet­er­ans in Hou­s­ton and 150,000 na­tion­wide. Al­most all are job­less; many are sub­stance ab­users or men­tally ill.

He tries to coax the vets in­to gov­ern­ment or non­profit as­sist­ance sys­tems. U.S. Vets has a 72-bed fa­cil­ity in down­town Hou­s­ton, but it is over­booked by 30 spaces. Gonza­lez-Yet­zirah and his boss would have to work the phones to find an open slot at an­oth­er shel­ter. He knows that many vet­er­ans who suf­fer from PTSD would rather sleep out­side than sub­ject their frayed nerves to the chaos of a home­less shel­ter. He also knows from ex­per­i­ence that if red tape keeps him from log­ging the vet­er­ans in­to the sys­tem be­fore night­fall, they will al­most surely slip through his fin­gers and dis­ap­pear onto the streets again.

As a former Mar­ine who served in Ir­aq, Gonza­lez-Yet­zirah him­self has also struggled with PTSD and re­ad­just­ment is­sues. In his first job back — wait­ing tables — he al­most clocked his boss, a pimply 18-year-old, for or­der­ing him around. That might have landed him in the Har­ris County Jail, where he runs group-ther­apy ses­sions for the 400 to 600 jailed vets be­ing held there on any giv­en day. He now sees a new wave of vets ap­proach­ing the pre­cip­ice, just one sim­il­ar out­burst away from join­ing their broth­ers in jail or un­der the bridge. “I run in­to a lot of [re­cently re­turned] vet­er­ans in my work who are not home­less yet, but they are at the stage of run­ning from place to place, sleep­ing on a buddy’s couch, liv­ing paycheck to paycheck and barely mak­ing ends meet,” Gonza­lez-Yet­zirah says.

Many are mar­ried to young wives who have little edu­ca­tion and are caring for ba­bies, even as the vet­er­ans struggle against their PTSD to hold down jobs. They tend to fol­low a pat­tern, he says: Soon, their fam­il­ies will break apart and the vets will end up on the streets. “I’ve seen that enough times to un­der­stand how it hap­pens. I just don’t un­der­stand how we as a coun­try can al­low those people who fought for our freedoms to stay home­less.”

Like pre­vi­ous gen­er­a­tions of vet­er­ans be­fore them, the post-9/11 vo­lun­teers are com­ing home from war burdened by wounds and sor­rows. Only this time it’s not too late to help them carry that weight.

The sol­diers sent to fight on our be­half are not vic­tims; they don’t want our pity, and they have much to con­trib­ute and even to teach us. But com­bat vet­er­ans strug­gling to re­gain a sense of nor­malcy in every­day life need and de­serve the same as­sur­ances at home that their bud­dies gave them on faraway bat­tle­fields: They need to know that someone has their back. 

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