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In my over thirty years of service as a clinician and mental health administrator in VHA, which included responsibility for directing all mental health and homeless services in VISN10, as well as national roles such as Co-Chair of the Committee on the Care of Severely Mentally Ill Veterans, and mental health representative on the national Task Force for Evidence Based Practice, and this past year as a CARES Commissioner, I have had the opportunity to observe closely and be part of VHA’s efforts to fight and prevent homelessness among veterans. I have met and worked with many homeless veterans. They are not always well understood; their characteristics and challenges buried in important but dry statistical data. It is their perspective that I shall try in some inadequate manner to communicate to you in these few minutes I have today.

Joe is an army Vietnam veteran with a chronic, persistent substance use disorder, one of the 776,000 veterans that the President’s National Drug Control Policy estimates need treatment. Seeing him on the streets of a major city it is easy to think of him as just another substance abuser, but he is a member of a unique subset of persons with this disease. He served his country honorably, succeeded in the structure and rigors of the Army, and got his habit in a jungle, coping with the stress of an increasingly unpopular war. It’s not the only thing that keeps him homeless today, 35 years later, but it has to be attended to before any other rehabilitation efforts will work. If he had read the paper he used to cover his head on a park bench over a year ago, he may have seen a story about the President, with sincerity, announcing a government wide initiative to improve substance abuse treatment. If VA had at least given him a copy of its 2003 report to Congress on maintaining Capacity he would have read that the very next year VHA again DECREASED its investment in substance abuse treatment, treating 5% fewer veterans than the year before. He wanders the streets in a VISN that has reduced the number of substance abusers it treats by 40% since 1996 when the Congress mandated there would be no decrease and spends barely a third of the funds on substance abuse treatment it did six years ago. One of 20 out of the 21 that have reduced services.

John is a navy Gulf War veteran with schizophrenia, one of the 117,000 service connected for psychoses the most severely debilitating of mental disorders, that emerges at a time of life when the stress of military service is in play. He sleeps in a shelter, fearful, having been trans-institutionalized to the streets and jails. He was the obviously distressed and dispossessed poster child on CBS news many years ago that raised public awareness about homelessness, but the VA Homeless programming parade is an emperor without clothes for him, they focus on higher functioning patients, most treat very few severely mentally ill, some none. This might not matter if he had access to Intensive Community Case Management, an evidence based, expensive intervention that works, but he lives on the wrong side of a state boundary. One state over VA has teams in every major city, in his state they have none at all.

Harry is a marine sergeant, discharged honorably, but in his view always a marine. He was lucky, he survived the retreat from the reservoir in Korea. Still, in his dreams, hears the voices of wounded men left behind to be slaughtered by the advancing Chinese. But he’s been lucky, again, enrolled in one of the handful of PTSD programs in VA specifically targeted to his age cohort, part of a larger, well organized PTSD program at his VA. He isn’t even one of the 180,000 veterans service connected for PTSD, he never applied for compensation. He tries still to keep track of his squad, and he worries about Gene, whose depression and nightmares have dominated the hidden side of his life, and are now throwing him off the track of respectability as he ages. He has few resources, has burned most bridges of support, will be homeless soon, but lives in a city where VA does many wonderful things, but doesn’t provide state of the art treatment for war related trauma, especially not for Korean vets.

So, what do we all need to hear from veterans like these. VA provides some excellent homeless programs, and mental health and vocational rehabilitation programs that support them, some staffed by VA and some through partnerships. But when a veteran unpacks his gear and cleans the jungle rot, or sand, out her boots whether she can access services to keep from being or remaining homeless depends not just on what she needs but where she returned home to. This is a current American tragedy.

What is the problem and what can be done? I believe the problem is more than one of funding. It is a failure of management in VHA to ensure that a consistent, adequate array of services are available across the system. Decentralization has had many benefits for transforming VHA, but top management in VHA has abdicated its responsibility to assure there is not unacceptable variability.

This is a time of great opportunity. The Secretary has underscored this issue in his recent CARES decision memorandum, stating that “it is not acceptable that the availability of mental health services be dependent on geographic location”, and a national effort for mental health strategic planning is just beginning, but I fear the moment will be lost if there is not firm committed leadership and oversight. I hope that in selecting the next Undersecretary for Health close scrutiny will be given to the willingness and ability of the candidates to provide firm, decisive leadership in assuring consistent mental health services. Without that we will lose this opportunity to assure that all the Joe, Harry, John and Marys out there now, or coming back from our current war, get what they deserve. I commend you for holding this hearing as a step in the oversight process.