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Submission For The Record of Marsha Four, John Rowan, National President, Chair, Women Veterans' Committee, and, Vietnam Veterans of America

Good morning Chairman Michaud, Chairman Hall, and Ranking Member Miller, Ranking Member Lamborn and distinguish members of these subcommittees.  Thank you for giving Vietnam Veterans of America (VVA) the opportunity to offer our comments for the record on the issues facing Women Veterans.

WOMEN’S HEALTH ISSUES

According to figures supplied by the Department of Defense (DoD), 20% of new recruits are women, almost 15 percent of America’s active duty military is women, and nearly half of them have been deployed to Iraq and Afghanistan (i.e., one in seven Americans deployed to Iraq is a woman).  This has particularly serious implications for the VA healthcare system because the VA itself projects that by 2010, over 14 percent of all veterans will be women, compared with two percent in 1997.  The VA has made vast improvements in treating women veterans since 1992. However, this increase in potential health care system “users” coupled with returning female OIF and OEF veterans, who, in particular, face a variety of co-occurring ailments and traumas heretofore unseen in the VA healthcare system, we believe that the VA is in need of ramping up its efforts to bring into modern times, the delivery of its medical and mental health care to women veterans.   Even today, some women continue to report a less than “accepting”, “friendly”, or “knowledgeable” attitude or environment both within the VA and/or by its third party vendors. This may, in part, be the result of a system that has evolved principally on the medical needs of the male veteran.  Reports also indicate that in mixed gender residential programs women remain fearful and unsafe. 

Compounding the emotional turmoil for women are wounds and injuries that range from life-changing -- the loss of limbs and brain injuries -- to temporary, such as infections and rashes.  Although some of the short-term health problems are likely tied to the harsh realities of war, where women can go weeks without a shower and spend months hauling gear and lifting heavy weapons in triple-digit heat, the VA has found 29 percent of the women veterans it evaluated returned with genital or urinary system problems, 33 percent had digestive illnesses and 42 percent had back troubles, arthritis and other muscular ailments.

This obviously points up the need for a well-conceived and well-implemented long-range plan for healthcare services and delivery for our women veterans.  To VVA’s knowledge there is no such plan that exists today.  As we have already noted, the VA has taken great strides in the past 15 years toward improvement of the quality of care for female veterans, but there is always room for improvement.  While it is fair to say that the quality of care at most VA facilities is equal to that of any other medical system in the world, it does not help women veterans who cannot access that fine care because it’s not available.

DELIVERY OF SERVICES

Providing care and treatment to women veterans by professional staff that have a proven level of expertise is vital in delivering appropriate and competent gender-specific care.  It is not sufficient to simply have training in internal medicine.  Women’s health care is a specialty recognized by medical schools throughout the country. Providers who have both a knowledge base and training in women’s health are able to keep current on health care and its delivery as it relates to gender.  In order to maintain proficiency in delivering care and performing procedures, these providers must meet experience standards and maintain an appropriate panel size. This cannot occur if women veterans are lost in the general primary care setting.  It is critical that women receive care from a professional who is experienced in women’s health.  If attention is not given to defining qualified providers, it will be a detriment to the quality of care provided to women veterans.

VVA does, however, feel comprehensive women’s health care clinics are most desirable where the medical center populations indicate because comprehensive consolidated delivery systems present increased advantage to the patients they serve. 

Vietnam Veterans of America (VVA) believes women’s health care is not evenly distributed or available throughout the VA system.  Although women veterans are the fastest growing population within the VA, there seems to remain a need for increased focus on women health and its delivery. It seems clear that although VACO may interpret women’s health as preventative, primary and gender specific care, this comprehensive concept remains ambiguous and splintered in its delivery throughout all the VA medical centers. Many view women’s health as only a GYN clinic. As you are aware, throughout medical schools across the country and in the current health care environment, women’s health is viewed as a specialty onto itself and involves more that gender specific GYN care.  VVA is hopeful that the revision of VHA Services for Women Veterans, Handbook 1330.1, and its recommendations for an integrated primary care/mental health model of service delivery will pass concurrence.  Additionally, that after concurrence it will be strongly supported and recommended to all medical centers in the VHA system.

VVA supported VHA’s past creation of “Centers of Excellence” for women veterans’ health. We believe these should be evaluated for standard compliance and re-established.  These Centers of Excellence are an investment in innovative health care delivery specifically addressing the unique needs of women, serving as a model in prevention, education, outreach, and research programs. This emphasis could lead to the creation of VA training fellowships in women’s healthcare.  These centers could also assist in the recruitment and retention of women healthcare specialists. 

There are increasing numbers of women veterans of childbearing age.  More than 62 percent of all women veterans are under 45, and of women veterans seeking health care from the VA, 56 percent are under 45.  Providing for the cost of maternity services but not providing newborn care for a reasonable post-delivery period presents an unfair financial burden to the woman veteran. It could additionally compromise adequate health care for her newborn.   VVA seeks legislation to provide contract care, for up to 14 days post-delivery, for infants born to women veterans who receive delivery benefits through the VA and are in need of this extended care.

WOMEN VETERAN PROGRAM MANAGERS

The duties, responsibilities, advocacy, oversight and reporting of the VA Women Veteran Program Managers, as defined in their handbook (1330.2), are substantial.  As such, it is not difficult to understand why VVA stands with a firm resolve to call for the VA to provide the Women Veteran Program Managers with a minimum of 20 hours per week to accomplish the responsibilities of the position.  VVA believes that these significant duties and responsibilities are essential and should not be minimized in light of the collateral duties they usually must perform.  `Further, we believe that while each VISN must designate, support, and utilize one of its Medical Center Woman Veteran Program Managers as the VISN Women Veteran Program Manager, we believe additional time must be allocated for these increased duties and responsibilities. 

PTSD AND SUBSTANCE ABUSE 

The VA counts PTSD as the most prevalent mental health malady (and one of the top illnesses overall) to emerge from the wars in Iraq and Afghanistan, but the VA is facing a wave of returning veterans who are struggling with memories of a war where it's hard to distinguish innocent civilians from enemy fighters and where the threat of suicide attacks and roadside bombs hovers over the most routine mission.  Moreover, the return of so many veterans from Afghanistan and Iraq is squeezing the VA's ability to treat yesterday's soldiers from Vietnam, Korea, the Cold War, and World War II.  Top VA officials have said that the agency is well-equipped to handle any onslaught of mental health issues and that it plans to continue beefing up mental health care and access under the administration’s budget proposal released in mid-February. 

Yet according to a GAO report issued in November 2006, the VA did not spend all of the extra $300 million budgeted to increase mental health services and failed to keep track of how some of the money was used.  The VA launched a plan in 2004 to improve its mental health services for veterans with PTSD and substance-abuse problems.  To fill gaps in services, the department added $100 million for mental health initiatives in 2005 and another $200 million in 2006.  That money was to be distributed to its regional networks of hospitals, medical centers, and clinics for new services.  But the VA fell short of the spending by $12 million in 2005 and about $42 million in fiscal 2006, said the GAO report.  It distributed $35 million in 2005 to its 21 health care networks but didn't inform the networks the money was supposed to be used for mental health initiatives.  VA medical centers returned $46 million to headquarters because they couldn't spend the money in FY’06. 

More troubling, however, is the fact that the VA cannot determine to what extent about $112 million was spent on mental health services improvements, or new services in 2006.  In September 2006, the VA said that it had increased funding for mental health services, hired 100 more counselors for the Vet Center program, and was not overwhelmed by the rising demand.  That money is only a portion of what VA spends on mental health.  The VA planned to spend about $2 billion on mental health services in FY’06.  But the additional spending from existing funds on what the VA dubbed its Mental Health Care Strategic Plan was trumpeted by VA officials as a way to eliminate gaps in mental health services now and services that would be needed in the future. 

Furthermore, an investigation by McClatchy Newspapers in early February of this year found that even by its own measures, the VA isn't prepared to give returning veterans the care that could best help them overcome destructive, and sometimes fatal, mental health ailments.  For example, the McClatchy report found that VA mental health care is extremely inconsistent and highly variable from state to state and from facility to facility.  In some places, there is no mental health care, while at others, veterans may get individual psychotherapy sessions, or in others, they meet mostly for group therapy. 

Some veterans are cared for by psychiatrists; others see social workers.  Some veterans get in quickly.  Others wait.  Once they're in the door, some veterans get visits of 75 to 80 minutes, while others get 20 to 30-minute appointments.  In other words, the VA's mental health system is nonexistent for many of the veterans it is supposed to be serving.

Lastly, the nature of the combat in Iraq and Afghanistan is putting service members at an increased risk for PTSD.  In Iraq, close-quarters urban combat is unpredictable, with a constant risk of roadside bombs.  Troops end up feeling out of control of their surroundings, a major risk factor for PTSD.  Service members are serving multiple tours, and the intensity of the conflict is constant. 

In these wars without fronts, “combat support troops” are just as likely to be affected by the same traumas as infantry personnel.  This has particularly important implications for our female soldiers, who now constitute about 16 percent of our active-duty fighting force.  Returning female OIF and OEF troops face ailments and traumas of other sorts.  For example, studies conducted at the Durham, North Carolina Comprehensive Women’s Health Center by VA researchers have demonstrated higher rates of suicidal tendencies among women veterans suffering depression with co-morbid PTSD.  And according to a Pentagon study released in March 2006, more female soldiers report mental health concerns than their male comrades:  24 percent compared with 19 percent.  In addition, roughly 40 percent of these women warriors have musculoskeletal problems that doctors say likely are linked to carrying too-heavy and ill-fitted equipment.  A considerable number -- 28 percent -- return with genital and urinary system infections.  In addition, there are gender-related societal issues that make transitioning tough.

For example, women are more likely to worry about body image issues, especially if they have visible scars or amputations, and their traditional roles as caregivers in civilian life can set them back when they return.  They are the ones who have traditionally had the more nurturing role within our society, not the ones who need nurturing.  Although the VA has, after much prodding by Congress, finally come to implement services to women to treat PTSD and other after-effects of military sexual trauma at VA medical centers, there are very few clinicians within the VA who are prepared to treat combat situation-induced PTSD as opposed to MST-induced PTSD.  Additionally, there are already cases where returning women service personnel have a combination of the two etiologies, making it extremely difficult for the average clinician to treat, no matter how skilled in treating either combat-incurred PTSD in men, or MST-induced PTSD in women.  Because of the number of women who are now de facto combat veterans and because of the nature of the conflicts in both Afghanistan and particularly Iraq, VVA believes that we have entered a whole new world of mental health needs for our veterans.

Furthermore, VVA believes there is a need for increased VA research specifically focused on women veterans’ healthcare issues.   For example, as of August 2006 VA data showed that 25,960 of the 69,861 women separated from the military during fiscal years 2002-06 sought VA services.  Of this number approximately 35.8 percent requested assistance for “mental disorders” (i.e., based on VA ICD-9 categories) of which 21 percent was for post traumatic stress disorder or PTSD, with older female vets showing higher PTSD rates.  Also, as of early May 2007, 14.5 percent of female OEF/OIF veterans reported having endured military sexual trauma (MST).  Although all VA medical centers are to have MST clinicians, very few clinicians within the VA are prepared to treat co-occurring combat-induced PTSD and MST.  These issues singly are ones that need address, but concomitantly create a unique set of circumstances that demonstrates another of the challenges facing the VA.  The VA will need to directly identify its ability and capacity to address these issues along with providing oversight and accountability to the delivery of services in this regard.  VVA believes that the VA has twelve programs that address PTSD in women veteran, but they are not exclusively for MST (some are general PTSD programs), and not all are gender specific programs.

As previously mentioned, studies conducted at the Durham, North Carolina Comprehensive Women’s Health Center by VA researchers have demonstrated higher rates of suicidality among women veterans suffering depression, substance abuse and co-occurring PTSD.  But at the present time there are only three VA women’s residential treatment centers for PTSD and substance abuse in the country (i.e., a fourth with eight beds is scheduled to open later this summer in the Boston area).

VVA calls upon this committee to appoint a task force within the VA to begin work to produce a reasonable and practical plan of how VA can best reach this ever increasing veteran cohort in the coming years, providing them a delivery model of inclusive comprehensive and integrated care. 

Few of us can know the dark places in which those who have suffered as the result of rape and physical violence must live every day for the rest of their lives.  It is a very long road to find the path that leads them to some semblance of “normalcy” in order to feel the free, outside of the secluded, lonely, fearful, angry corner into which they have been hiding. A concern for the environment of the delivery of services also exists in the residential programs of the VA. Most, if not all residential programs, are designed for treatment of mental health problems. The veterans of these programs are a very vulnerable population. This was particularly brought to our attention in regard to women veterans, who, in light of the high incidence of past sexual trauma, rape, MST, and domestic violence find it difficult, if not impossible, to share residential programs with male veterans.  They openly discuss their concern for a safe treatment setting, especially on units where the treatment unit layout does not provide them with a physically segregated, secured area. They also discuss the need for gender specific group sessions, in light of the nature of some of their personal and trauma issues. VVA asks that all residential treatment areas be evaluated for the ability to provide and facilitate this environment and that medical center facilities develop cost plans to address this accommodation.

This submission points to the need for a well-conceived and well-implemented long-range plan for medical and mental healthcare services and delivery for our women veterans.  VVA has not been made aware that any such inclusive comprehensive plan exists today.  As we have already noted, the VA has taken great strides in the past 15 years toward improvement of the quality of care for female veterans, but there exists a need for increased attention, followed by enhancement of programs and services, in a concerted effort to meet the increasing demand and complexity of women’s health.  This enhancement will certainly put a demand on the ever-present budget.  VVA respectfully requests that women’s health care be evaluated for budgetary consequences and that Congress considers this when determining the dollars required to meet these needs. VVA also respectfully requests that continued oversight be requested of the VA in regard to the issues of this submission and those of others during this hearing. While it is fair to say that the quality of care at most VA facilities is equal to that of any other medical system in the world, it does not help women veterans who cannot access that fine care because it’s not available.

Vietnam Veterans of America thanks the committee for this opportunity to provide submitted testimony.