15 April, 2019 06:48

New York Times: V.A. Officials, and the Nation, Battle an Unrelenting Tide of Veteran Suicides
By Jennifer Steinhauer | April 14, 2019
WASHINGTON — Three veterans killed themselves last week on Department of Veterans Affairs health care properties, barely a month after President Trump announced an aggressive task force to address the unremitting problem of veteran suicide.
Mr. Trump’s executive order was a tacit acknowledgment of what the deaths rendered obvious: The department has not made a dent in stemming the approximately 20 suicide deaths every day among veterans, about one and a half times more often than those who have not served in the military, according to the most recent statistics available from the department.
A 2015 measure that required officials to provide annual reviews of mental health care and suicide prevention programs has found that veterans often receive good mental health care at many Department of Veterans Affairs centers — but that has not decreased suicide rates. A relatively new program, known as the Mayor’s Challenge, that helps city and state governments reach more veterans through more public health programs via Veterans Affairs partnerships has shown some promise, but no data exists yet demonstrating suicide reductions.
While the V.A. has been the public face of the issue, veterans are in many ways an amplification of the same factors that drive suicide in the broader American population: a fragmented health care system, a shortage of mental health resources, especially in rural areas, a lack of funding for suicide research and easy access to guns. All of these contribute to the drastically increased suicide rate among all Americans, which rose 33 percent from 1999 to 2017.
High rates of homelessness, traumatic brain injuries, post-traumatic stress and a military culture that can be resistant to seeking help are all aggravating factors for veterans, whose rates of suicide have been the subject of numerous hearings on Capitol Hill.
“We are not even at the Sputnik stage of understanding problems with mental health,” said Robert Wilkie, the secretary of veterans affairs. “I have said this is the No. 1 clinical priority that is made manifest by the president putting V.A. as the lead for this national task force.”
Some programs to address veteran suicide are showing promise.
A study of nine V.A. emergency rooms found 45 percent fewer suicidal behaviors among patients who received follow-up outreach after suicide attempts; as a result of this study, all V.A. medical centers have put into place the Safety Planning Intervention program.
Since the department in 2017 began tracking suicides at Veterans Affairs facilities — among the most high-profile of veteran suicides — there have been more than 260 suicide attempts, 240 of which have been interrupted, department officials say.
Yet about 70 percent of veterans do not regularly use the V.A., access to a federal department that may be viewed as central to suicide prevention.
“The vast majority of veterans that die by suicide are not seeking services,” said Julie Cerel, a professor at the University of Kentucky and president of the American Association of Suicidology. “So the V.A.s are kind of at a loss of how to serve this group of people. Yet when they do end their lives, it becomes the responsibility of the V.A.,” in the viewpoint of critics, she said.
Leadership turmoil — a consistent trait of the Trump administration — has complicated the V.A.’s attempt to address suicide. The agency’s director of its prevention office, Caitlin Thompson, resigned in 2017 after tangling with political appointees. According to a Government Accountability Office report last year, the office has essentially languished. Most notably, the office spent $57,000 of its $6.2 million media budget, and its presence on social media declined 77 percent from the levels of 2015, the report found. Lawmakers expressed outrage.
Although Veterans Affairs officials blamed miscommunication at the time, Keita Franklin, the department’s new executive director of suicide prevention, said that the program had been delayed to come up with a more targeted marketing campaign, called #BeThere. It will try to “talk more specifically with targeted audiences,” she said, noting campaigns focused on 18- to 24-year-olds might focus on texting a friend in trouble while the over-60 crowd would be encouraged to have coffee. Some advertisements would be honed for women, for example, or for veterans in rural communities.
Yet myriad political, structural and cultural impediments exist far beyond the administration’s walls.
Many suicide experts believe that a lack of proper training in suicide prevention in the broader mental health field, hobbled by a lack of research into a matter that has stymied so many public health officials, is central to the issue.
In 2017, the suicide rate in the United States reached 14 per 100,000 people, according to the Centers for Disease Control and Prevention; it is the nation’s 10th leading cause of death. Yet only $68 million is expected to be spent on suicide research this year, according to the National Institutes of Health. In comparison, breast cancer will receive about $709 million in research funding and $243 million is expected to be spent this year researching prostate cancer.
“There has been tremendous research on breast cancer and AIDS, which lowered mortality rates on diseases we once thought once insurmountable,” Dr. Cerel said. “However, we have not had comparable research into suicide.”
Guns are used in the majority of veteran suicides, in large part because gun ownership is high for that group. Last year, about 80 percent of suicides among veterans in Montana were by firearms, said Claire R. Oakley, the director of health promotion at RiverStone Health, a community provider attached to the Mayor’s Challenge in Billings, Mont., which has had among the highest rates of suicide in the nation.
“Awareness is important but it does take funding and there is no capacity funding to do this work,” she said, noting that volunteers had filled many of the gaps.
Proper storage techniques and training friends and family to know when to try to remove guns from vulnerable veterans are still lacking. Lawmakers who move to reduce gun access to suicidal veterans often face resistance.
“By reducing access to firearms you see a drop right away,” said Jane Pearson, chairwoman of the Suicide Research Consortium at the National Institute of Mental Health. “We have to think of a way forward that is fair, that does not take away weapons unfairly.”
Several states have enacted “extreme risk protection order” laws, which help law enforcement and family members temporarily remove guns from, or prohibit their purchases by, people who may be a threat to themselves.
Perhaps most vexing is a military culture that emphasizes discipline and perseverance, which can backfire when a veteran is suicidal.
“People who join the military have this sense of boot straps, ‘I can do it,’” Dr. Franklin said. “Then you become a vet and they say come in and get mental health care, and inwardly they don’t feel good doing it.”
Mr. Trump’s executive order would also task multiple federal agencies — like the Agriculture Department in rural areas — to pitch in on veteran suicide prevention and to give grants to local governments to work with health care partners to better reach veterans.
“There is no single cause of suicide,” Dr. Franklin said. “When we pull a thread, we see a complex situation with 25 factors playing. We can’t prevent suicide from where we sit in the V.A. by ourselves.”
Allowing local governments to join with health care providers has also shown promise. The Massachusetts Coalition for Suicide Prevention, for instance, works through 10 regional coalitions to provide veterans with mental health services as well as things like entrepreneurship training.
A major complication is reaching the veterans to start. Many use both V.A. and community providers; providers outside the system have varied forms of insurance coverage.
“There are a lot of things the V.A. have done right,” Dr. Pearson said. “The issue is the challenge in our health care system with people jumping from one system to another.”
The Mayor’s and Governor’s Challenges — which team governments with community health care providers to better reach and service veterans — show promise in connecting veterans to needed services inside and outside the Department of Veterans Affairs.
Brent Arnspiger, the suicide prevention coordinator for the Michael E. DeBakey V.A. Medical Center in Houston, works with a local provider to send veterans who are not eligible for V.A. services to that provider’s facilities, and vice versa. “We have a warm handoff instead of just giving someone a phone number,” he said. “In the last three months, we have given 30 consults there,” he said of the health centers, “and they brought five to us.”
Other states are eagerly embracing the same challenge. “The Commonwealth of Virginia has one of the largest populations of veterans, service members and their families in the nation,” said Carlos Hopkins, the Virginia secretary of Veterans and Defense Affairs, “which gives us a particularly keen awareness of the importance of tackling this national epidemic head on.”

Military Times: Vet gets his foot cut off because VA made administrative errors*
By: Leo Shane III | 3 days ago
Administrative errors at an Indianapolis Veterans Affairs health center jeopardized the health of numerous patients and forced at least one to lose his foot to a medical amputation, federal investigators announced on Wednesday.
Advocates worry the incidents, which took place two years ago, are indicative of lingering systemic communications problems at the federal bureaucracy. They’re calling for VA leaders to take a closer look at internal communication and oversight protocols.
“Too many veterans have lost their limbs on the battlefield. They should not be losing limbs due to bureaucratic malpractice,” American Legion National Commander Brett Reistad said in a statement released Thursday morning.
Officials from the U.S. Office of Special Counsel said the mistakes — brought to light by VA whistleblowers — have prompted a series of reforms at the local VA facility and to the larger regional network. But the mistakes did not result in the firing of any officials; one social work assistant chief was reassigned, and a senior chief retired in lieu of reprimand, officials said.
At issue was a decision by VA officials to have social workers stop recording home health care consults into a VA’s patient record system. The move was made due to concerns that the work was outside the responsibilities of the staffers.
But as a result, department officials acknowledged, “this decision led to a system breakdown, as the transition was not implemented with key services in a collaborative and cohesive manner.”
Follow-up visits to veterans after major surgeries and other periodic home check-ups ended up delayed or dropped altogether.
Investigators found in one case, a veteran who had been discharged from the Indianapolis hospital after a diabetes treatment was left to change the dressings on his foot wound himself for several days, even though VA staffers were supposed to do that.
“[His] worsening infection … and subsequent amputation appears to have been related to the delay of the dressing changes by the home care agency,” their report states.
VA investigators completed their report on the issue last summer, but the Office of Special Counsel released their report on problems this week. VA officials said they have updated procedures to allow social workers once again to update information into the patient record system, and trained staff on the proper procedures.
In a letter to the special counsel, VA Secretary Robert Wilkie acknowledged the mistakes constitute “gross mismanagement” by staffers but said the corrective actions should prevent future problems.
In a letter to the White House, Special Counsel Henry Kerner acknowledged those changes but stated that “I am nonetheless distressed that such a situation occurred in the first place.”
Reistad echoed that concern. He praised the whistleblowers who exposed the problems and said VA officials need to do a better job to “identify critical needs and share best practices” within the system.

Defense News: Is it already time to worry about the Pentagon budget?
By: Joe Gould | 2 days ago
WASHINGTON — With six months before the first budget deadline, it may be already time to panic.
Lawmakers’ worries the budget fight between President Donald Trump and Democrats will cause a deadlock were on full display this week. If the two sides can’t reach a deal to ease statutory budget caps, a stopgap continuing resolution, or CR, could freeze the Pentagon’s budget at last year’s level, or leave the department in a worse state — automatic sequestration cuts could slash its budget by $71 billion.
After Congress’ spring recess, Democrats and Republicans must quickly work to settle sharp disagreements over spending for the Pentagon, domestic programs and the president’s wall at the southern border. They have until Oct. 1 to avoid a continuing resolution and until January to avoid sequestration.
Republican lawmakers have been using budget hearings to warn that unless negotiations get into high gear, there’s potential to erase the military readiness gains enabled by the last two years of strong defense budgets. While common at this point in the budget cycle, the potential audiences for that message this time around will range from left-leaning Democrats to the White House.
Earlier this month, Politico reported that the White House wants to boost its leverage in the high-stakes talks with Democrats and Senate Republicans by delaying negotiations until after both the 2019 budget and the debt ceiling expire at the end of September. That suggests the fiscal year will start on a CR.
Because the already high chances of an impasse over funding for the president’s border wall increase in proximity to 2020 electoral politics, it’s possible lawmakers will abandon negotiations for easing spending caps and punt to a full-year continuing resolution, said Rick Berger, a former Senate Budget Committee staffer with the American Enterprise Institute.
“From the perspective of the Senate GOP, this is not a good idea because the longer we go without a deal, the higher the chance that everybody throws up their hands and just takes a full-year CR,” Berger said. “This then goes from ‘how do we thread the needle on a caps deal’ to ‘how do we blame the hell out of each other for the 2020 race.’ Once that momentum gathers, it’s going to be really hard to stop.”
At an April 4 budget hearing, Senate Armed Services Committee Chairman Jim Inhofe, R-Okla., asked Air Force Secretary Heather Wilson to outline the impact of sequestration on her service, if there’s no deal. She said the resulting $29 billion cut would be “absolutely devastating in scope and scale.”
“That would be no F-35s, cut all of the KC-46s, stop the B-21 program, no ground-based strategic deterrent, no research, development, test and evaluation for any space system, most of the fourth- and fifth-generation [fighter jet] modifications, and all of science and technology,” she said. “Or, $29 billion means all of weapons systems sustainment, all flying hours, all base operations and airfield support, and all munitions, together, make $29 billion.”
In the same vein, AirLand Subcommittee Chairman Sen. Tom Cotton, R-Ark., prompted the Air Force’s chief, Gen. David Goldfein, to spell out how a full-year continuing resolution would do much the same thing.
“Sequester would be the worst thing, but it’s hard to imagine we’d go back to the actual sequester levels. But a proposal that’s being batted around — a full-year continuing resolution — is almost the worst thing imaginable?” Cotton asked, to which Goldfein replied: “Yes, sir.”
One significant and positive sign this week is that Senate Majority Leader Mitch McConnell, R-Ky., announced this week that talks have begun at the staff level. The impact of those talks is unclear for now.
House Democrats failed to pass a 2020 spending plan this week amid internal divisions, but they did pass a measure that sets the overall spending cap at $1.3 trillion for 2020, about a $350 billion increase from 2019. That in turn allows House appropriators to begin drafting their 2020 spending bills.
The House bill that was scuttled Tuesday aimed to reset spending limits for defense at $733 billion for fiscal 2020 and $749 billion for fiscal 2020. The nondefense side of the budget also would come in well-above statutory budget caps, at $631 billion and $646 billion, respectively.
Progressive Democrats balked because the defense side was too high and the nondefense side was too low. Still, House Speaker Nancy Pelosi, D-Calif., may use the coming weeks to sway her members, and if that fails, to team with Republican leaders — just as former GOP House Speakers John Boehner and Paul Ryan had to team with Pelosi to pass bills their Tea Party wing wouldn’t accept.
“I don’t participate in the German word ‘Schadenfreude,’ taking delight in other people’s misery, but these things can become miserable,” Rep. Jeff Fortenberry, R-Neb., a member of the Appropriations Committee, told the Washington Examiner. “Shoe’s on the other foot.”
In spite of the fears on display in Congress, Center for Strategic and International Studies defense budget analyst Todd Harrison was skeptical Washington would stumble into a full-year CR — “It’s never happened because it’s impractical” — much less a sequester, which happened once, in 2013.
“Democrats don’t want a sequester either because if it gets triggered, you’re talking massive cuts to nondefense programs as well as defense programs,” Harrison said.
After border wall funding is subtracted from the defense budget, it’s about $742 billion, which is less than a 1% difference from the president’s budget request and theoretically an easy gap to bridge. “So why would anyone let the budget caps stay where they are and sequester be triggered?” Harrison asked.
Indeed, why are lawmakers even bringing it up?
“Old habits die hard,” Harrison said. “What folks have become accustomed to doing with these hearings is saying: ‘We have to scare everyone about sequestration,’ right? ‘Scare everyone about a full-year CR.’ ”
In a roundtable with reporters, the House Armed Services Committee’s ranking member, Rep. Mac Thornberry, R-Texas, said he believes Congress has a center mass that wants a strong defense budget. The nightmare scenarios can’t be ruled out given the last few years of dysfunction, but they’re unlikely.
“Both parties have a political interest in continuing to make the progress that we’ve begun to make on readiness and other things,” Thornberry said. “Even though there’s some fringe elements in both parties, the mass of both parties know that both of us have a responsibility to help defend the country as the Constitution requires us to do.”
If the resistance is in the White House, it can be overcome, but Congress must unify on a spending deal.
“Obviously the president can sign it or not, but I think you can have a genuine bipartisan effort in the Capitol that would result in a very strong vote,” Thornberry said. “That would send a strong message to the president. That’s our job. We ought to do it.”

Associated Press: The chill in US-Russia relations has some worried about stumbling into a military conflict
By: Robert Burns, The Associated Press | 18 hours ago
WASHINGTON — It has the makings of a new Cold War, or worse.
The deep chill in U.S.-Russian relations is stirring concern in some quarters that Washington and Moscow are in danger of stumbling into an armed confrontation that, by mistake or miscalculation, could lead to nuclear war.
American and European analysts and current and former U.S. military officers say the nuclear superpowers need to talk more. A foundational arms control agreement is being abandoned and the last major limitation on strategic nuclear weapons could go away in less than two years. Unlike during the Cold War, when generations lived under threat of a nuclear Armageddon, the two militaries are barely on speaking terms.
"During the Cold War, we understood each other’s signals. We talked," says the top NATO commander in Europe, U.S. Army Gen. Curtis Scaparrotti, who is about to retire. "I’m concerned that we don’t know them as well today."
Scaparrotti, in his role as Supreme Allied Commander Europe, has met only twice with Gen. Valery Gerasimov, the chief of the Russian general staff, but has spoken to him by phone a number of other times.
"I personally think communication is a very important part of deterrence," Scaparrotti said, referring to the idea that adversaries who know each other’s capabilities and intentions are less likely to fall into conflict. "So, I think we should have more communication with Russia. It would ensure that we understand each other and why we are doing what we’re doing."
He added: "It doesn’t have to be a lot."
The United States and Russia, which together control more than 90 percent of the world’s nuclear weapons, say that in August they will leave the 1987 treaty that banned an entire class of nuclear weapons. And there appears to be little prospect of extending the 2010 New Start treaty that limits each side’s strategic nuclear weapons.
After a period of post-Cold War cooperation on nuclear security and other defense issues, the relationship between Washington and Moscow took a nosedive, particularly after Russian forces entered the former Soviet republic of Georgia in 2008. Tensions spiked with Russia’s annexation of the Crimea in 2014 and its military intervention in eastern Ukraine. In response, Congress in 2016 severely limited military cooperation with Russia.
The law prohibits "military-to-military cooperation" until the secretary of defense certifies that Russia "has ceased its occupation of Ukrainian territory" and "aggressive activities." The law was amended last year to state that it does not limit military talks aimed at "reducing the risk of conflict."
Relations frayed even further amid U.S. allegations that Russia interfered in the 2016 U.S. presidential election, although President Donald Trump has doubted Russian complicity in what U.S. intelligence agencies assert was an effort by Moscow to boost Trump’s chances of winning the White House. After a Helsinki summit with Putin in July, Trump publicly accepted the Kremlin leader’s denial of interference.
Marine Gen. Joseph Dunford, chairman of the Joint Chiefs of Staff, said in an interview Friday that Russian behavior is to blame for the strained relationship.
"It’s very difficult for us to have normal relationships with a country that has not behaved normally over the last few years," Dunford said. "There are major issues that affect our bilateral relationship that have to be addressed, to include where Russia has violated international laws, norms and standards."
Dunford said he speaks regularly with Gerasimov, his Russian counterpart, and the two sides talk on other levels.
"I’m satisfied right now with our military-to-military communication to maintain a degree of transparency that mitigates the risk of miscalculation," he said. "I think we have a framework within to manage a crisis, should one occur, at the senior military-to-military level."
James Stavridis, a retired Navy admiral who was the top NATO commander in Europe from 2009 to 2013, says the West must confront Russia where necessary, including on its interventions in Ukraine and Syria. But he believes there room for cooperation on multiple fronts, including the Arctic and arms control.
"We are in danger of stumbling backward into a Cold War that is to no one’s advantage," he said in an email exchange. "Without steady, political-level engagement between the defense establishments, the risk of a true new Cold War rises steadily."
No one is predicting a deliberate Russian act of war in Europe, but the decline in regular talks is a worry to many.
Moscow says it is ready to talk.
"Russia remains open for interaction aimed at de-escalating tension, restoring mutual trust, preventing any misinterpretations of one another’s intentions, and reducing the risk of dangerous incidents," the Russian Ministry of Foreign Affairs said in a statement last week in response to NATO’s 70th anniversary celebration.
Sam Nunn, who served in the Senate as a Democrat from Georgia from 1972 to 1997, argues that dialogue with Russia is too important to set aside, even if it carries domestic political risk.
"You can’t call time out," he said in an interview. "The nuclear issues go on, and they’re getting more dangerous."
Nunn co-wrote an opinion piece with former Secretary of State George Shultz and former Defense Secretary William Perry arguing that the U.S. and its allies and Russia are caught in a "policy paralysis" that could lead to a military confrontation and potentially the first use of nuclear weapons since the U.S. bombed Japan in August 1945.
"A bold policy shift is needed," they wrote in the Wall Street Journal on Thursday, "to support a strategic re-engagement with Russia and walk back from this perilous precipice. Otherwise, our nations may soon be entrenched in a nuclear standoff more precarious, disorienting and economically costly than the Cold War."
A group of U.S., Canadian, European and Russian security experts and former officials in February issued a call for talks with Russia on crisis management.
"The risks of mutual misunderstanding and unintended signals that stem from an absence of dialogue relating to crisis management … are real," the Euro-Atlantic Security Leadership Group said in a statement.
It said this could lead to conventional war with Russia or, in a worst case scenario, “the potential for nuclear threats, or even nuclear use, where millions could be killed in minutes.”