Killing by the Numbers – The Use of Snipers in the Iraq War

May 9, 2008 – Genei Nesir Khudair al-Janabi, an Iraqi vegetable farmer, walked down to the ramshackle pump house along the banks of the Euphrates. Each day at midmorning, he would start the seven-horsepower pump to water his crops.

Khudair passed through the tall grass and palm trees of his farm in Jurf as Sakhr, a predominantly Sunni area 30 miles south of Baghdad dominated by sprawling patches of farmland, irrigation canals and regular eruptions of lethal violence. Daytime temperatures had lately been over 115 degrees, and it was already sweltering as he crossed the 500 meters for the last time.

As Khudair approached the pump house on May 11, 2007, he stumbled upon a team of five sweat-soaked U.S. Army snipers, dazed with heat and fatigue, hidden in the grass of a small hill. It’s hard to say who was more surprised, the Iraqi or the American troops. The sniper on guard at the “hide” was so shocked to see Khudair wander up to his position that he froze for a moment, staring. Then he approached Khudair and pointed a 9 mm pistol at the farmer’s head.

Meanwhile, Khudair’s 17-year-old son, Mustafa, was at the family home when he learned that a cousin had been killed in an accident. Mustafa hurried from the house to find his father in the fields and tell him the horrible news.

But as Mustafa approached, an American sniper popped out of the brush and waved him closer. Struck with fear, he entered the snipers’ hide to find his father, alive, face down on a patch of dirt with the corner of a plastic Army poncho over his head. Two soldiers were standing over him. They forced Mustafa to lie down, with his head close to his father’s in an “L” on the ground, and then pulled the corner of the poncho over his head too.

A half-hour passed. Khudair complained about the heat. The soldiers suddenly hoisted Mustafa up and signaled that he was free to go, but his father was still on the ground under the poncho. As he left the hide, Mustafa motioned toward Khudair and tried, in broken English, to tell the Americans who their prisoner was: “Father, father.”

Mustafa had just gotten back to the family home, 15 minutes later, when he heard two gunshots.

Three snipers with exemplary military records from the 1st Battalion of the 25th Infantry Division’s 501st Regiment were charged in Khudair’s killing. They were tried by the military judicial system in Iraq beginning in 2007. But the most important question raised by his death remains unanswered. Why would these elite American soldiers kill an unarmed prisoner in cold blood? The answer: pressure from their commanding officers to pump up a statistic straight out of America’s last long war against an intractable insurgency.

A review of thousands of pages of documents from the legal proceedings obtained by Salon shows that in the months prior to Khudair’s death, the young snipers, already frustrated by guerrilla tactics, were pressed to their physical limits and pushed by officers to stretch the bounds of the laws of war in order to increase the enemy body count. When the United States wallowed in Vietnam’s counterinsurgency quagmire decades ago, the same pressure placed on soldiers resulted in some of the worst atrocities of that war. A paratrooper who remembered the insidious influence of body counts in Vietnam warned Salon in 2005 that the practice could also ensnare good soldiers in Iraq. “The problem is that in Iraq, we are in a guerrilla war,” said Dennis Stout. “How do you keep score? How do you prove you are winning?”

The pressure from above for more bodies was also toxic in Iraq, where the isolated, outnumbered and outgunned snipers of the 1st Battalion had to make split-second life-or-death decisions. When those decisions landed them in a military court, it was the lowest-ranking soldiers, not the brass, who paid the price, and a sergeant who said he was pushed into taking a fatal shot who wound up with a long prison sentence. It was battalion commander Lt. Col Robert Balcavage, who pushed for a higher body count, who initiated the prosecution of three of the battalion’s snipers. “Yes, the chain of command deserves to burn in hell,” one sniper who served with the unit wrote Salon in an e-mail. “But I am not going on record saying that, well, cause I am still in the fucking Army.”

The body-count pressure on the 1st Battalion’s sniper section began to build in early 2007. In an insurgency like Vietnam or Iraq, it’s hard to point to achievement of a military objective or conquest of a town or region as success. Instead, commanders find themselves relying on numbers, which is how body counts began to creep into the Iraq war, despite their explicit disavowal by former Defense Secretary Donald Rumsfeld in 2003 (“We don’t do body counts”). In need of a positive metric, commanders of the 1st Battalion reached for body counts, since the metrics they did have were moving in the wrong direction. At the time, U.S. casualties from invisible roadside bombs were mounting. In the six months before the snipers arrived in country from Alaska in late October 2006, 426 U.S. service members had died in Iraq. In the six months between the 1st Battalion’s arrival and the day Khudair was killed, May 11, 2007, nearly 590 service members died in Iraq. It was one of the bloodiest periods of the Iraq war. At the time there was a new commander in Iraq, Gen. David Petraeus, who was talking about winning hearts and minds. The snipers’ commanders were talking about bodies. The battalion commander, Lt. Col. Balcavage, and top noncommissioned officer Command Sgt. Maj. Bernie Knight sent a clear message to the battalion’s snipers. Spc. Alexander Flores, a sniper, described it this way in a hearing: “Get more bodies. Raise the morale of the battalion.”

The résumé of Staff Sgt. Mike Hensley made the battalion leadership think he would be the leader who could produce the bodies. It wasn’t just that during a previous tour in Afghanistan, he refused to leave his unit despite contracting malaria, or that in Iraq he insisted on inspecting bridges personally for road bombs to keep his soldiers out of harm’s way, though that helped. He combined that commitment to the mission and to his men with a reputation for lethality. He was a competition-winning sniper. “The rest of the sniper section love Staff Sgt. Hensley,” Sgt. Alexander Anuschat, a sniper who reported to Hensley, would later testify. “He was the perfect man for the job.”

Officers hand-picked Hensley to lead the sniper section in early 2007. Hensley immediately suggested beefing up his new section from seven to 13 snipers, that in the field would operate in teams of about six men per mission. The men Hensley commanded also included Sgt. Evan Vela, Spc. Jorge Sandoval, Pvt. David Petta and Spc. Alexander Flores. Vela was a father of two from Idaho, married to his high school sweetheart. Sandoval, of Laredo, Texas, had never seen snow before being stationed in Fort Richardson in Alaska prior to Iraq. Petta and Flores would later start the investigation of the sniper section’s actions by reporting questionable shootings to their commanding officers.

Officers were pleased when, under Hensley’s lead, the snipers started racking up kills. But soon, the snipers were pushing the envelope. The decision of when to shoot and when not to shoot is often vexing for snipers, but following the rules of engagement became still more difficult for the snipers after commanding officers encouraged a loose interpretation of the rules to increase the likelihood of a kill.

The Law of Armed Conflict requires soldiers to identify “hostile intent” before pulling the trigger. “You have to decide if the individual you are looking at is a combatant or a civilian,” explained Scott Silliman, executive director of the Center on Law, Ethics and National Security at Duke Law. “You must conclude that the individual is a combatant.” There is no requirement that a target be armed, but he can’t be hors de combat — injured, surrendering or detained.

The nature of guerrilla warfare makes it difficult, however, to nail down exactly what that means on the battlefield. Lt. Matthew Didier, the officer directly in charge of the snipers, offered a tautology in one hearing late last year, explaining that the snipers could shoot if they had “reasonable certainty that the military target is, in fact, a military target.” Knight, the senior noncommissioned officer in the battalion, told Army investigators who later looked into the killing of unarmed Iraqis that the snipers were instructed that they could fire when they had “reasonable certainty that someone is committing acts of violence against coalition forces or Iraqis.”

The snipers remained nervous because, at best, the guidelines they were getting from their commanders were nebulous. The snipers felt they were being pressured to interpret “hostile intent” loosely to justify kills. During testimony, sniper Spc. Joshua Michaud said that Lt. Col. Balcavage and Command Sgt. Maj. Knight “constantly pushed for ‘If you feel threatened, you know, obviously eliminate the threat.’ But they kind of said it in a manner in which a lot of us took it like, ‘Hey, you need to go out there and you guys gotta start getting kills.'”

At worst, the rules explicitly allowed the killing of unarmed Iraqis under certain circumstances, a particularly dicey concept given an enemy that does not wear a uniform and hides among civilians. Specifically, the snipers were allowed to shoot unarmed people running away from explosions or firefights. The chain of command was particularly frustrated by insurgents fleeing after attacks from roadside bombs, called improvised explosive devices. The notes from Army agents who later investigated the shootings said the battalion leaders, Balcavage and Knight, worried that the snipers had “let a lot of guys go after IED explosions.” The snipers called these fleeing, sometimes unarmed Iraqis “squirters.” Of course, it’s not unusual for innocent people to run from explosions.

Didier, who has since been promoted to captain, said that “if that individual makes contact with you and then breaks contact of their own accord and disarms themselves while they are breaking contact, they are still an engageable target because they are not wounded, nor did they surrender.” He explained, “They are only breaking contact so that they can engage coalition forces at a later time.” In court, Sgt. Anthony Murphy, one of the snipers who was responsible for a questionable kill, testified that he interpreted this order about breaking contact so they can engage at a later time as: “Engage fleeing local nationals without weapons.”

In addition to the vague rules of engagement and pressure to boost the body count, a furtive Pentagon unit, the Asymmetric Warfare Group, further blurred the soldiers’ perceptions of what was acceptable. The covert program run by the Pentagon and supported by another “government agency” supplied the snipers with materiel to place on the battlefield, like explosives and ammunition, that might interest insurgents.

The Washington Post reported in September 2007 that the items were part of a “baiting” program and that the purpose was to shoot Iraqis who picked them up. Pulling the trigger, however, was never part of the operation, according to testimony and people with knowledge of the program.

The idea of “baiting,” or putting out items and shooting Iraqis who picked up the materiel, was actually developed at the platoon level, according to the testimony of Didier, the officer in charge of the platoon. It is unclear if the tactic was ever used in the field.

Only a handful of the snipers were informed of the materiel’s real purpose, which remains secret but has nothing to do with shooting people on sight. Because equipment was distributed equally among their packs, some soldiers who were not aware of the materiel’s purpose were still forced to lug it. Soon, confused about the extra equipment’s true purpose, they were imagining other explanations, and their confusion seems to have contributed to their willingness to bend the rules of engagement. The two snipers who eventually alerted authorities to the questionable kills and spurred an investigation believed the items were “drop weapons” to be placed on unarmed Iraqis after an illegal kill.

The killing of Genei Nesir Khudair al-Janabi took place on May 11, and it was the final kill for which snipers were prosecuted. But Khudair was, in fact, at least the fourth unarmed Iraqi the snipers had killed in the short time since Hensley took over leadership of the sniper section in March 2007. Each incident illustrates the ways in which the rules of engagement, the pressure to produce, the mysterious extra equipment, and the inherent difficulties of their jobs landed the snipers in court.

The first incident occurred on April 7, 2007. Sgt. Anthony Murphy’s sniper team was hiding in a shallow ravine. Through his rifle scope, Murphy watched a lone Iraqi man approaching through some bushes, his figure distorted by a heat mirage. The man appeared and then disappeared again, winding through nearby ravines. Soon, he was 50 meters away and Murphy was sure the man had spotted the team’s satellite communications gear through the brush.

In sniper talk, they had been “compromised.” Being compromised, or seen while on a mission, was particularly chilling, especially in areas where there had been significant insurgent activity. Three days earlier, a seemingly innocent goatherd had spotted one of the sniper teams in the same location. Within minutes, mortars were raining down on them.

Even a handful of insurgents could easily overrun one of the small, autonomous sniper teams. “They are all around us,” Murphy said during a court hearing. “We are put into their environment, their backyard.”

On April 7, even after the Iraqi man had apparently seen the snipers’ gear, he continued to move forward, alarming Murphy. “When people see us, they freak out,” Murphy explained in a hearing. “They leave. They get scared. They stop. They start screaming.” This Iraqi kept moving closer.

Murphy could see through the bushes that the man also had something in his hands, he just couldn’t make out what it was. Murphy did not wait to find out. He pulled the trigger, killing the man with one bullet.

When it turned out that the Iraqi was carrying a 3-foot piece of pipe, the snipers got nervous. Murphy later testified that Sgt. 1st Class Steven Kipling worried that higher-ups might question the legitimacy of the shooting and asked Murphy if they should place a weapon on the body to make him look “more guilty.”

Murphy refused. “I did the right thing,” he said, and then cited the rules of engagement. “Hostile intent. Hostile act. End.”

Murphy’s aggressive commanders agreed. Notes from Army special agents who later investigated the snipers show the chain of command had looked into the April 7 shooting and “concluded Sgt. Murphy correctly determined hostile intent and engaged the individual with a single shot.” The words “hostile intent” would show up again and again in thousands of pages of sworn testimony about the incidents that were reviewed by Salon.

In such a dangerous area, seeing an Iraqi eyeing U.S. troops with binoculars, or just digging a ditch, was enough to create a belief in “hostile intent.” On April 14, a sniper team was monitoring a power substation when Hensley, the sniper section leader, told other snipers that he had spotted an Iraqi man who appeared to be laying command wire for a roadside bomb. But Hensley couldn’t get in a clean shot and lost sight of the man.

A little before 5 p.m. Hensley received an order to keep an eye on a nearby house while incoming infantry troops performed a search there. According to the notes of Army investigators, this irritated Hensley, who asked for two volunteers. Hensley, Pvt. David Petta and Sgt. Richard Hand walked directly down a road toward the home.

Hand and Petta flanked Hensley as they approached the house. There were women and children outside and an unarmed Iraqi man, Mutham Nia Hussein Alwan, working on a water pump. At about 120 meters away, Hensley said, “That’s the guy.” Hand and Petta split off to the left. According to the investigating agents’ notes, when the snipers were 50 meters away from the house, a little more than half a football field, Hensley raised his weapon, then lowered it. They continued to close in.

Then a single shot rang out from Hensley’s M14 sniper rifle. At that moment, Sgt. Hand’s weapon was trained on one of the women. “As soon as the shot happened, she became hysteric [sic],” Hand would later testify. “She started going crazy. I mean, obviously, somebody she loved or cared for had just died. She became my No. 1 priority, because I was afraid I was going to have to shoot her.”

The body was later tested with EXPRAY, a field test kit used to detect explosives. It came up positive. But there is some evidence that Hensley might have been worried that the chain of command would still balk at the kill. Kipling testified that earlier that day he had found a length of detonation wire, balled it up, and given it to Hensley to bring back to base. A balled-up section of detonation wire was found on the body. Kipling said in court that he was “80 percent sure” the wire on the body was the same wire he had given Hensley. If Kipling is to be believed, the snipers had moved from merely talking about “drop weapons” to using them.

Two weeks later, on April 27, the loose rules for shooting unarmed, fleeing Iraqis — “squirters” — contributed to a death. Didier, the snipers’ immediate superior officer, radioed to Hensley that a squirter was headed his way.

An Iraqi army unit was investigating a weapons cache site when they were attacked by two insurgents dressed in dark track suits who quickly broke contact and fled east. Didier had set up Hensley and other snipers a half-mile in that direction. He radioed Hensley and described the two men en route.

A half-hour later, Hensley replied that he had “got eyes on” a man who fit that description moving east, according to hearing transcripts. “[Hensley] said [the man] was no longer armed. But he asked if he could still engage the individual,” Didier recalled. “I said yes, based on the current ROE, he could.”

The sniper team was hidden in a 3-foot-deep dry creek bed. Hensley and another sniper, Spc. Jorge Sandoval, watched through some trees as a man in dark clothing walked into an olive grove, squatted and began cutting the knee-high grass with a sickle. Hensley told Sandoval to grab his weapon and the two men moved 150 to 200 meters south along the creek bed to the edge of the tree line that had been blocking their shot.

Even from the new position, 200 meters away, only the man’s head appeared intermittently in Sandoval’s rifle scope through the tall grass. Hensley asked Sandoval if he had the shot. Sandoval stood to get a better angle. Hensley asked twice more. The third time, Sandoval fired. He quickly chambered another round, but Hensley told him he wouldn’t need it.

Sandoval drew his sidearm as the two snipers approached the body. The man had been shot in the head. Other snipers from the team approached as well and recognized the Iraqi as a man they had detained and released just days earlier. “You could tell by some of his face that was left,” Michaud, one of the other snipers there that day, said in a hearing.

As shocking as it might seem to shoot an unarmed Iraqi cutting grass, many times the snipers had seen insurgents feign farming or other harmless activity after attacking U.S. troops. Michaud said in one hearing that “they’ll run and pick up some farm equipment, or they might run to their house and start working on their vehicle, or they basically try to do anything they can to throw you off to make you think that, ‘Hey I was not part of that.'”

Even though the snipers had seen squirters’ tricks before — and this shot had been approved by Didier — Hensley and Sandoval apparently worried officers would not see the April 27 shooting as a clean kill. Sandoval testified that when he and Hensley first stood over the mutilated corpse, Hensley handed him command wire and told him to put it next to the body.

The snipers, however, did not use the Pentagon’s secret equipment as drop weapons. The use of drop weapons by Hensley was freelance. The presence of the unexplained equipment, however, may have encouraged the belief among soldiers that drop weapons were acceptable. If drop weapons were standard operating procedure, where was the line between right and wrong?

The events leading to the killing of Genei Nesir Khudair al-Janabi began three days earlier, on May 8. The snipers awoke at 4 a.m. to begin preparations for a mission that night. The team finally left Patrol Base Jurf at 11:30 p.m., bearing packs that weighed more than 100 pounds. They moved slowly through the night to avoid detection. It took them 90 minutes to travel three miles. The snipers finally reached their “hide” at 4 a.m.

They spent the next day hidden in reeds by a canal, while the temperature climbed past 115. That afternoon, Murphy drank 12 quarts of water in six hours and still needed two IVs. He checked his pulse and counted 120 beats per minute. “Once you feel like you are cooking inside, your heart begins to race,” he later testified.

The snipers stayed in position until 8 p.m. that night. For part of the march back to the patrol base, the snipers joined an infantry company headed in the same direction. One soldier from the company who was not even carrying a rucksack passed out from heat exhaustion. Medics gave him three IVs when the men reached the base at 11:30.

The snipers ate, debriefed and changed their clothes. Some got a few hours of sleep. Hand, who had been awake for 45 hours, testified that he slept from 3 a.m. to 7 a.m. then “scrounged together enough coffee” to have a cup.

The snipers spent a restless, sleep-deprived May 10 cleaning equipment and preparing for the next mission outside the wire, scheduled for that night. “In terms of the patrol base,” Hand testified, “you really can’t sleep, there is too much movement, too much noise and there is no shade unless you make some.”

Murphy, still recovering from the previous day’s dehydration, told Hensley, the leader of the sniper section, he could not make that night’s mission. Another sniper, Sgt. Robert Redfern, volunteered to take Murphy’s place.

Murphy, whom Vela later described as “like a brother to me,” saw Vela just before the mission. Vela was readying his gear. He looked drained. Murphy asked Vela, “Are you good, man?”

Hensley, Vela, Sandoval, Hand and Redfern left Patrol Base Jurf at around 10 p.m. and arrived at their “hide” at 2 a.m. on the morning of May 11. The hide was a grassy hill next to a run-down pump house on the banks of the Euphrates. An infantry company soon began raiding a nearby house in a futile effort to locate insurgent rockets.

In the field, snipers sleep in shifts, or “rest cycles,” with one man keeping guard while the others try to rest. By 10 a.m. the next morning, the guard on duty was Vela.

Vela testified that he remembered looking over a nearby berm and then in another direction at some children playing a few hundred meters away. When he turned back around toward the berm, Khudair, the vegetable farmer, “was just there.”

Vela froze. Sandoval, who had been woken by the sound of the Iraqi’s approach, motioned toward Vela’s gun. Taking the signal, Vela pointed the 9 mm pistol at the farmer’s face.

Sandoval woke up Redfern. Redfern and Vela waved the Iraqi into the hide, forced him down on his stomach and put the corner of the plastic poncho over his head. Vela stood over the man with the pistol, while Redfern ran his hands over Khudair’s shoulders, arms, sides, back and chest in a cursory search. No weapons.

Vela woke Hensley and told him an unarmed Iraqi was in the hide. Hensley stood up, walked over to the Iraqi — and from a standing position dropped a knee into his back with the full force of his body.

Khudair threw his head back, gasping for wind. “Staff Sgt. Hensley grabbed him by the mouth,” Vela testified, “and told him to shut up or he was going to kill him.”

Hensley wrapped parachute cord around the Iraqi’s hands and Redfern dragged him deeper into the snipers’ hide. At this point, Redfern spotted a boy approaching and waved him into the hide site as well. The snipers put him on his stomach, so the two Iraqis formed an L-shape on the ground with both of their heads under the corner of the poncho.

Hensley then dispatched Sandoval and Redfern to the pump house, 15 to 20 meters away, to provide security. Vela handed his pistol to Sandoval, who was armed with a bolt-action rifle that could only hold five rounds without reloading.

Vela said Hensley sat down on the berm for a moment. He then got up and radioed their superior officer, Didier. Hensley reported that he had spotted an Iraqi nearby armed with an AK-47. But Vela couldn’t see anyone who matched that description. Vela alerted Hand, who was fading in and out of sleep on a nearby berm, that Hensley “might have seen something.” Then Hensley ordered Vela to retrieve his pistol from Sandoval in the pump house.

A half-hour after the 17-year-old Iraqi boy entered the hide, Sandoval and Redfern saw him pass by their position in the pump house as he walked home. Thinking that both Iraqis had been released, Sandoval peered around the pump house wall to look into the hide. Khudair was still there. Vela was sitting on his rear, with one leg cocked up and an elbow resting on his knee, holding the pistol in one hand.

Inside the hide, Hensley radioed Didier a second time, saying an insurgent was moving closer to their position. Hensley asked permission to do a “close kill” to avoid being compromised.

Vela then looked around, but still didn’t see any armed insurgent. “I was just really confused about what he was saying,” Vela testified.

Hensley untied the Iraqi. “I thought we were going to let him go,” Vela told the Army court.

“Are you ready?” Hensley allegedly asked Vela.

Hensley stepped aside. “Shoot,” he said.

Vela claimed during testimony that he doesn’t remember pulling the trigger. “It took me a second to realize that the shot had come from the pistol and it was in my hand.”

Hensley radioed to Didier that the snipers had killed an insurgent. Meanwhile, the Iraqi’s body convulsed. Hensley “kind of laughed” at the spectacle, according to Vela. Hensley then “[punched] the guy in the throat, and said, ‘Shoot him again,’ which I did.”

Vela testified that after he shot the man for the second time, Hensley pulled an AK-47 out of his rucksack and placed it on the body. The snipers then agreed on a story about the shooting consistent with Hensley’s radio calls.

Murphy, the soldier who had stayed behind because of dehydration, was sitting on a Humvee when the snipers trailed back into Patrol Base Jurf. The men were so soaked with sweat that Murphy thought they had waded through a canal.

“Hey, what’s up, man?” Murphy asked Vela. But Vela just walked past his friend in silence. In testimony Murphy described Vela as “detached, somber, serious.”

In late June 2007, less than two months after Khudair’s death, Flores and Petta informed military authorities that the sniper section might be using drop weapons. That led to investigation of the circumstances of several of the unit’s kills, which led in turn to the arrest of Sandoval, Hensley and Vela.

Sandoval was charged with murder for the deaths on April 27 and May 11, but convicted only of planting command wire in connection with the April 27 killing. He served about a month and a half in prison. The Army charged Hensley with three murders for the shootings of April 14, April 27 and May 11. He was convicted of planting a weapon, for placing the AK-47 next to Khudair, and insubordination. He was sentenced to time served and busted down to sergeant.

On February 10, 2008, however, Vela was sentenced to 10 years in a military prison for the murder of Khudair.

Top battalion leaders, who had to sign off on the charges, have faced no serious questions about whether their demand for more bodies, their vague rules of engagement or the confusion sown by the secret program might have contributed to the events of spring 2007. U.S. Army Alaska spokesman Lt. Col. Jonathan Allen said Balcavage and Knight were unavailable for an interview.

Hand, one of the snipers in the hide on May 11, later testified that he believes his “main responsibility is to take care of my subordinates.” But the battalion leaders, he said, “have been very lax in their care of anybody except themselves.”

“If you have never been outside the wire, you really have no basis [to judge],” said Hand. “You’ve never been in a life-or-death situation where you have had to count on the guy to your left and right … You see stuff out there that no one back here is going to see.”

Hensley, meanwhile, is back on active duty. Now a sergeant, he is stationed in Georgia, where he is an instructor for Army Rangers.

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Pentagon Drops Post in Pakistan for Top General

May 9, 2008, Washington, DC – When the Pentagon announced in March that Maj. Gen. Jay W. Hood would become the senior American officer based in Pakistan, it reflected the military’s aim to put a crisis-tested veteran in a critical job at a pivotal time in the fight against Al Qaeda and the Taliban in Pakistan’s tribal areas.
But nearly two months later, the military has quietly canceled the assignment of General Hood, a 33-year Army veteran who was excoriated in the Pakistani news media for one of his previous jobs: commander of the United States prison at Guantánamo Bay, Cuba.

During General Hood’s command from 2004 to 2006, military authorities force-fed with tubes detainees who were engaging in hunger strikes at the Guantánamo prison, a step they justified as necessary to prevent the prisoners from committing suicide to protest their indefinite confinement. Also during General Hood’s tenure, reports that an American guard may have desecrated a Koran stirred wide protests in the Islamic world.

The decision to withdraw General Hood’s assignment has not been announced, but it appears to reflect the widening shadow that the military prison at Guantánamo is casting over American foreign policy. While the United States considers Pakistan a close ally in its counterterrorism efforts, the accounts by Pakistanis who have returned to Pakistan after being held at Guantánamo Bay have added to anti-American sentiment in the country.

Several leading Pakistani military and foreign affairs commentators denounced General Hood’s selection in recent weeks, calling on their new government to block his appointment. In interviews this week, American military officials said they had reluctantly concluded that General Hood’s effectiveness could be seriously hindered, and that his personal safety might even be at risk if he were to take up the post.

About 65 detainees at Guantánamo Bay have been repatriated to Pakistan, according to Cmdr. Pauline Storum, a military spokeswoman.

It is not clear whether Pakistan’s new government requested that the appointment be canceled. But on Thursday, a spokesman for the Pakistani Foreign Ministry, Mohammed Sadiq, told reporters that the government was “fully cognizant of the public sentiments and sensitivities regarding the reported transfer of General Hood to Islamabad,” and he added, “We hope to address this matter of public interest in the best possible manner.”

Asked about the withdrawal of the appointment, an American military spokesman sought Thursday to put the best face on an awkward situation. “General Hood is being considered for a different, equally important job in the Centcom headquarters,” said Capt. James Graybeal, chief spokesman for the United States Central Command, which oversees military affairs in Pakistan.

General Hood did not return e-mail messages or a telephone call to his office on Thursday.

General Hood, who served in the 1991 Persian Gulf war and in Kosovo, had been expected to become chief of a division of the United States Embassy in Islamabad known as the Office of the Defense Representative to Pakistan. The office has about two dozen people and oversees military relations with Pakistan, including training and equipment.

Until a few years ago, a colonel typically directed the office. But in a sign of Pakistan’s strategic importance in the Bush administration’s campaign against terrorism after the Sept. 11, 2001, attacks, the job was upgraded to that of a two-star general. The current head of the office, Maj. Gen. James R. Helmly, had been scheduled to leave at the end of May. No replacement for General Hood has been named.

Two senior Defense Department officials, who spoke on condition of anonymity because the issue involves personnel decisions, expressed chagrin that General Hood’s selection had not been evaluated more carefully.

Under General Hood’s command, and after consultations with senior Pentagon officials, American guards at Guantánamo Bay used forceful methods in dealing during 2006 with detainees who engaged in hunger strikes. They strapped them into “restraint chairs,” sometimes for more than two hours at a time, to feed them through tubes and prevent them from deliberately vomiting afterward.

General Hood, who took command of the detention center at Guantánamo Bay in March 2004, shortly before the Abu Ghraib scandal in Iraq broke, sought to put a more human face on it. He was credited by lawyers for the prisoners and human rights groups with having improved the treatment of detainees, and it was soon after he took over that some of the most severe interrogation methods were curtailed.

But he also had to deal with the fallout of a report in Newsweek asserting that a military inquiry was expected to find that a Koran had been flushed down a toilet at the detention center. The magazine later retracted the article, but the military inquiry concluded that a soldier had inadvertently splashed urine on a Koran. The magazine’s original assertion led to riots in Pakistan and Afghanistan that left at least 17 people dead.

Criticism of General Hood in the Pakistani news media was unrelenting after the Pentagon announced on March 13 that he would take over the post.

“Guantánamo Bay itself has become a symbol of injustice, torture and abuse of Islam, and sending a commanding officer from there to Islamabad begs the question: What is the message coming out of the Pentagon for Pakistanis by this insensitive act?” Shireen M. Mazari, director general of the Institute of Strategic Studies, a research group in Islamabad financed by Pakistan’s foreign office, wrote on March 20 in The News, one of the largest English-language newspapers in Pakistan.

Dr. Mazari added, “Equally important, given that host governments always have a choice of refusing a nominee — and many Western countries have exercised that right in the diplomatic nominees of the Pakistan government — why has the Pakistan government chosen to silently accept what the U.S. military dishes out, with no thought to the sensitivities of its own people?”

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Battle of the Hawks

May 6, 2008 – In the increasingly unlikely event of a McCain-Clinton election, folks who care about the peace issue would have serious reason to worry. Both of these candidates are inveterate hawks, and what we would be up against is a choice between the neoconservatives and the neoliberals as to who could be more adventurous in getting us into unjustifiable foreign wars.

Both not only voted to authorize President Bush’s irrational invasion of Iraq but also have failed to apply those lessons to the real challenges we face, particularly concerning Iran. On the one hand, we have Sen. John McCain’s wildly inane “bomb, bomb, bomb, bomb, bomb Iran” singing refrain, and on the other, Sen. Hillary Clinton’s commitment to “totally obliterate” Iran in response to any nuclear attack by Tehran on Israel.

Clinton has stood by her implicitly genocidal threat against the 70 million innocent Iranians, who have no effective control over their government’s policy, a threat made in response to a question raised in the heat of primary day in Pennsylvania. She later extended the threat to include retaliation on behalf of Saudi Arabia, Kuwait and other Arab countries if they were attacked by Iran.

Her statement extending the U.S. “nuclear umbrella” far beyond the threat to retaliate against a Soviet nuclear attack during the Cold War was greeted with a yawn by the media, which interpreted it as an election-day ploy to appear tough and pro-Israel. The Washington Post referred to “Clinton’s apparent effort to distinguish herself from her rival for the Democratic nomination … by offering a more hawkish approach to world affairs.” That rival, Barack Obama, has called for negotiations with Iran’s leaders and condemned Clinton’s proposal as saber rattling.

But the Washington Post story provided evidence that Hillary’s hawkishness is not merely a campaign posture, as evidenced by her two key foreign policy advisers, who the Post reports helped come up with the “obliterate Iran” idea. One of them is Martin S. Indyk, the former Clinton administration ambassador to Israel, who was as strong as any of the neoconservatives in advocating the invasion of Iraq. In an article he co-wrote with Kenneth M. Pollack for the Los Angeles Times three months before the Iraq invasion, which cited their insider status as former government officials who “had access to the most sensitive U.S. intelligence on Iraq,” the two claimed that Iraq had “thousands of tons of precursor chemicals for chemical warfare agents, thousands of liters of biological warfare agents. …” That “insider” information was false.

The Clinton campaign’s national security director, Lee Feinstein, is another leading Democratic hawk and Clinton administration alum who promoted the threat to obliterate Iran. Feinstein, like Indyk, had strongly disparaged the work of the U.N. inspectors before the invasion. And even a month after the U.S. occupation began, as U.S. troops scoured all of the suggested weapons locations, Feinstein argued, “I believe they will find weapons of mass destruction.”

The dark irony here is that the unjustifiable invasion of Iraq has elevated Iran to a position of enormous power over events in the region, beginning with its influence over the puppet government in Iraq’s Green Zone, many of whose key members, including the prime minister, spent many years in exile in Tehran, where they were trained. The ability of Iran to make life miserable for the American occupation is the main counterweight to a tougher stance on Iran’s nuclear program, and that is the direct consequence of a war for which Clinton and McCain both voted.

Clinton seems to be far more hawkish than her husband, and her increasingly bellicose remarks support that perception. If she is chosen as the Democratic Party’s standard-bearer, she can be expected to tack further in that direction, once the primaries are over and the peace vote has been counted out.

I do not think this a matter of a female candidate having to prove that she is capable of being a macho commander in chief, although there is a whiff of Margaret Thatcher here, so proud of taking her nation to unneeded war. With Clinton, as with Thatcher, quite apart from gender, there seems to be a more basic philosophical commitment to using military force before other options have been seriously explored.

That the force cited by Clinton portends the “total obliteration” of another people raises the prospect of the United States, the only nation that has ever used nuclear weapons, doing so again. It suggests that such weapons of mass destruction are not heinous inventions but rather instruments of rational policy when in the hands of the virtuous. That is a message that we dare not deliver to the world.

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Mental Health Care Needed for Our Servicemen, Women

May 7, 2008 – Sometimes it amazes me how little logic the military really applies to the men and women who wear the uniform. Not just the individual branches, but the overall Department of Defense as well. Why should it take an independent agency doing a research study to inform DoD that our overburdened troops are suffering from unprecedented mental health issues?

To me, it should be obvious if you use some good old-fashioned common sense.

You have young adults, in their late teens and up, spending three and four tours in a combat zone within the span of a few years. How can that not affect the mental health of a normal person?

If it doesn’t, I would start to worry about the state of our young people as a whole.

An Associated Press article I read several weeks ago quoted numbers from a study done by the Rand Corporation that indicated up to 20 percent of our troops who have served in Iraq and Afghanistan are suffering from major depression or post-traumatic stress.

And when I say combat vets, I don’t just mean those soldiers and Marines out on foot patrol. Every person who is sent into the war zone is exposed to life and death conditions every day, regardless of what their occupational specialty is.

No longer is the front line “out there” ahead of the column of troops — it is everywhere, on all sides. Even the supposedly safe areas are vulnerable to rocket and mortar attacks or to suicide bombers.

Soldiers who drive trucks are exposed to combat situations every time they convoy outside the wire.

Communications personnel and military police officers and supply troops who are off-duty are snatched up to provide extra security on convoys or to fill out squads on patrol because there aren’t enough infantry troops to cover it.

Nurses and medics are in the thick of battle, saving lives and risking their own.

And all these personnel are male and female. Gender has truly become irrelevant in the combat zone.

Women are winning the Silver Star for bravery in the face of battle. They are driving trucks, flying support missions, manning checkpoints and pulling security duty. This isn’t your father’s and grandfather’s war anymore. And that is truly my point here.

These are real people, such as the young mother who cannot drive during a thunderstorm because the noise terrifies her, bringing back images of mortar attacks and exploding bombs.

There is the vet who is panicked by the sound of a loud alarm going off. Perhaps saddest of all to me is the young Marine still on active duty who has been to Iraq four times at last count, twice because he volunteered to go back with units other than his own, because he is more comfortable there in the “sandbox” than he is back home.

The mental health issues facing this generation of warriors is unprecedented. So, the real question has to be: Are the DoD and the VA equipped to handle it?

I see Operation Iraqi Freedom vets every week in my office who are trying to cope with the struggles of being home, in a normal life. They are hesitant to reach out for mental health treatment because of the stigma that still is associated with it.

Not only must the branches of service address this, but we as a society must change our perceptions so that these vets do not feel ostracized.

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Veteran Suicide Rates Questoned

May 6, 2008, Washington, DC – Lawmakers are questioning whether the Department of Veterans Affairs has been accurately reporting the number of veterans who commit suicide or if it’s covering up the data.

At a hearing held by the House Veterans’ Committee today, chairman Bob Filner, D-Calif., said he thought there was “criminal negligence” and “clear evidence of a bureaucratic coverup” in the VA’s handling of mental health findings.

“If you have a thousand, and you said it could be more, of suicide attempts per month, we’ve got some real difficult issues,” Filner said to Secretary of Veterans Affairs Dr. James Peake.

But most of the committee’s time was spent on a report aired by CBS News last year that said the VA was under-reporting the magnitude of suicides among veterans by manipulating the data.

Filner said there was clear evidence of a bureaucratic cover-up and asked the VA secretary if anyone involved would lose their job because of it.

“I think that we owe appropriate, validated numbers to this committee,” Peake said. “We’re absolutely committed to try to do the right thing by all of our service members, our veterans, and not worry as much about whether this is a little above, or a little below, some national average.”

Dr. Ira Katz, a VA mental health officer who came under fire at the hearing, said it was his recollection that CBS asked him for information, about attempts or completed suicides, from medical records.

During interrogation by committee members, Katz was asked why he questioned a CBS claim that 6,200 veterans had committed suicide in 2005.

Then, three days later, he wrote in an e-mail that there were about 18 suicides a day, or about 6,570 per year, among America’s veterans.

Asked today if he intentionally withheld information from CBS, Katz responded that he was “concerned about their findings with respect to very young veterans, not the entire veterans population.

“If you’re interested in whether there’s an epidemic related to the war, you would also want to see what the rates were before the war,” Katz said. “CBS never addressed that. I have concerns about the CBS report.”

Also testifying today was Stephen Rathbun, an associate professor of biostatistics at the University of Georgia, who analyzed the data used in the CBS report.

Rathbun told the committee he was confident of the results of his analysis, though he also said that CBS asked him to destroy the data once his analysis was completed, and that the work was not peer reviewed. CBS did not pay him for the work, he said.

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Editorial Column: Returning Vets: Shh! Don’t Worry

May 7, 2008 – It looks as though the head of the Department of Veterans Affairs plans to keep Ira Katz on as mental health director. Katz tried to keep the alarming rate of veteran suicides quiet with a “Shh!” e-mail sent to staff.

Sen. Patty Murray is among the group of lawmakers outraged at Katz’s conduct. In April, Murray asked for Katz to resign after hearing how he handled news that 12,000 vets attempt suicide per year while under VA treatment. According to CBS, Katz describes his e-mail as “unfortunate.” On behalf of all the vets who died at their own hands or are suffering the sort of mental anguish that continues to lead so many of them down the dark path of suicide, we find his e-mail unacceptable.

How can department head James Peake justify keeping Katz on, especially given that Thomas Insel, director of the National Institute of Mental Health, has already sounded the alarm that post-war suicides might exceed the number of combat deaths in Afghanistan and Iraq?

Bloomberg.com reported that Insel’s claims “echoed a Rand Corp. study published last month that found about 20 percent of returning U.S. soldiers have post-traumatic stress disorder or depression, and only half of them receive treatment.” The story estimates that based on the fact that about 1.6 million troops have served in Iraq and Afghanistan since 2001, we might well be looking at an avalanche of people suffering from depression, post-traumatic stress disorders, developing substance abuse problems.

Do we really want to gamble on how many of those vets will try to kill themselves? If so, are we to remain satisfied with a VA that just tries to sweep the whole tragic situation under the rug?

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VA Official On Veterans’ Attempted Suicides: ‘Shh!’

May 7, 2008 – The director of mental health at the VA yesterday told the House Veterans Affairs Committee he made a poor choice when he wrote ‘Shh!’ in an email to colleagues discussing veterans’ suicide attempts. The line “was an error and I apologize for that,” Ira Katz told the committee, the Associated Press reports.

The email said 12,000 veterans a year attempt suicide while under department treatment. “Is this something we should (carefully) address ourselves in some sort of release before someone stumbles on it?” the email asked.

Veterans Affairs Secretary James Peake also apologized to the committee yesterday for the email, which came to light in a trial in San Francisco over the quality of mental health care delivered to veterans.

Peake said the figures in the email were not released because of concerns about accuracy, the AP reports. Of nearly 500,000 veterans who fought in Afghanistan and Iraq and then left the military between 2002 and 2005, 144 have committed suicide, Peake said. He added that the rate is slightly higher than what would be expected in the general population, but the difference isn’t statistically significant.

House Veterans Affairs Committee Chairman Bob Filner (D-Calif.) blasted Katz and the VA. “This is not a bureaucratic situation with numbers. This is life or death,” Filner said, according to a report in Stars and Stripes. “I think there is clear evidence of a cover-up, and I think there is criminal negligence here.”

An investigation by CBS News last year revealed a “suicide epidemic” among veterans. Those findings, which helped set the stage for the latest hearings, were disputed by the VA at the time. But “e-mails made public last month show [Katz] and other researchers had more confidence in those figures than first revealed, and uncovered additional data supporting CBS’ claims over the following weeks, “Stars and Stripes writes. CBS explains its methodology here.

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May 8: Pentagon Deployed 43,000 Medically Unfit Soldiers to Iraq and Afghanistan Wars

May 8, 2008, Washington, DC — More than 43,000 U.S. troops listed as medically unfit for combat in the weeks before their scheduled deployment to Iraq or Afghanistan since 2003 were sent anyway, Pentagon records show.

This reliance on troops found medically “non-deployable” is another sign of stress placed on a military that has sent 1.6 million servicemembers to the war zones, soldier advocacy groups say.

Please see articles featuring VCS on this issue:

     – Jan. 17, 2008: Medically Unfit Soldiers at Fort Carson Ordered Back to Iraq War: http://www.veteransforcommonsense.org/ArticleID/9151

     – Feb. 10, 2008: Fort Carson Forcibly Removed Soldier from Mental Hospital and Deployed Him to Iraq War: http://www.veteransforcommonsense.org/articleid/9321

     – Apr. 8, 2008: Deployed for Third Time with Both PTSD and TBI, A Fort Carson Soldier Died of Drug Overdose in Iraq: http://www.veteransforcommonsense.org/articleid/9771

“It is a consequence of the consistent churning of our troops,” said Bobby Muller, president of Veterans For America. “They are repeatedly exposed to high-intensity combat with insufficient time at home to rest and heal before redeploying.”

The numbers of non-deployable soldiers are based on health assessment forms filled out by medical personnel at each military installation before a servicemember’s deployment.

According to those statistics, the number of troops that doctors found non-deployable, but who were still sent to Iraq or Afghanistan fluctuated from 10,854 in 2003, down to 5,397 in 2005, and back up to 9,140 in 2007.

The Pentagon records do not list what — or how serious — the health issues are, nor whether they were corrected before deployment, said Michael Kilpatrick, a deputy director for the Pentagon’s Force Health Protection and Readiness Programs.

A Pentagon staffer examined 10,000 individual health records last year to determine causes for the non-deployable ratings, Kilpatrick said. Some reasons included a need for eyeglasses, dental work or allergy medicine and a small number of mental health cases, he said.

This is the first war in which this health screening process has been used, the Pentagon said.

Most of the non-deployable servicemembers are in the Army, which is doing most of the fighting in Iraq and Afghanistan. Between 5{cd9ac3671b356cd86fdb96f1eda7eb3bb1367f54cff58cc36abbd73c33c82e1d} and 7{cd9ac3671b356cd86fdb96f1eda7eb3bb1367f54cff58cc36abbd73c33c82e1d} of all active-duty, National Guard and Reserve soldiers slated for combat were found medically unfit due to health problems each year since 2003, according to statistics provided to USA TODAY.

Unit commanders make the final decision about whether a servicemember is sent into combat, although doctors can recommend against deployment because of a medical issue, Army spokeswoman Kim Waldron said.

“The commander consults with health care professionals to determine whether the treatment a soldier needs is available in theater,” said Army Col. Steven Braverman of the Army Medical Command.

At Fort Carson, Colo., Maj. Gen. Mark Graham ordered an investigation into deployment procedures for a brigade deployed to Iraq late last year. At least 36 soldiers were found medically unfit but were still deployed, Graham told USA TODAY.

For at least seven soldiers, treatment in the war zone was inadequate and the soldiers were sent home, he said, and at least two of them should never have been deployed.

In testimony before the Senate Armed Services Committee in February, the panel’s chairman, Sen. Carl Levin, D-Mich., asked Army leaders about an e-mail from the surgeon for the Fort Carson brigade that said medically “borderline” soldiers went to war because “we have been having issues reaching deployable strength.”

“That should not be happening,” Army Secretary Pete Geren told the committee. “I can’t tell you that it’s not, but it certainly should not be happening.”

Meanwhile, soldiers with medical problems have also deployed to Iraq and Afghanistan from Fort Drum in New York and Fort Stewart and Fort Benning, both in Georgia, according to Brenda Farrell, who is leading an investigation into the practice for the Government Accountability Office.

A report from that investigation sought by members of the House Armed Services Committee is due in June.

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VA Blasted Over Veterans Suicides

May 6, 2008 – The chairman of the House Veterans Committee blasted the Veterans Affairs Department on Tuesday, accusing the agency of criminal failure to respond to evidence of rising suicide rates among former soldiers.

“This is a matter of life and death,” said Chairman Bob Filner, D-California, “and I think there was criminal negligence in the way this was handled.”

In a follow-up hearing on the veteran suicide issue, Filner insisted the VA either ignored critical suicide data or covered up the numbers.

“The pattern is deny, deny, deny,” Filner told Veterans Secretary Jim Peake, “then when facts seemingly come to disagree with the denial, you cover up, cover up, cover up.”

The committee was reacting to a December hearing in which Ira Katz, the VA’s chief for mental health, insisted suicide data reported in the media had been exaggerated.

Three days after his testimony, Filner said, the agency indicated some alarming statistics could, in fact, be correct.

Peake responded with a list of statistics by age and gender, insisting such data can be incomplete and easily manipulated.

He confronted one of the most heated figures, an estimate that 1,000 veterans a month are attempting suicide.

“I can appreciate that the number of 1,000 suicide attempts a month might be shocking,” he said, “but in a system as large as ours … and consistent with the literature, we might well expect a larger number of attempts than that.”

Peake denied there was any attempt to downplay the numbers on suicides among veterans.

“I believe that Dr. Katz was not trying to obfuscate,” Peake told reporters afterward, “I have no intention of relieving Dr. Katz.”

Peake, answering questions in a hallway after his testimony, said “maybe we should have been looking at this sooner, but we didn’t have that infrastructure in place.”

He described the data as “erratic,” and said “it means nothing until we start to refine it, and make sure we have good data. And that’s what the American public deserves, is good data.”

In earlier testimony, Peake repeatedly testified he would not condone a cover-up.

“Our intent is to be forthcoming,” he told the committee. “If we’ve got something to hide, we shouldn’t be hiding it. We should be doing something about it.”

Anger was evident across the hearing room Tuesday.

Rep. Harry Mitchell, a Democrat from Arizona was particularly irate at what he sees as stonewalling by the VA. He said he has spent four months requesting specifics on what resources the agency needs to handle the suicide issue.

“That’s not just an insult to me, it’s an insult to me and our veterans,” he said.

He was told to file a Freedom of Information Act request, a method more commonly reserved for the public and media, not congressional committee members, he said.

“I’ve tried to be reasonable,” Mitchell told the committee, “I’ve tried to work with Secretary Peake’s office, but Mr. Chairman, my patience is at an end.”

Mitchell told Peake that if he does not receive the documents by Friday, he will push for a committee subpoena.

In the past, Peake has denied the agency suppressed or ignored key suicide records.

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Testimony of Dr. James Peake, VA Secretary

May 6, 2008 – The purpose of this testimony is to provide information on the issues related to veterans suicide: what VA knows, including the sources of information we use; what we do not know, and what we intend to do about that problem; and what we have been doing to directly address the issues of suicide from a clinical perspective, and how we are expanding our outreach, even as we seek better ways to measure the problem.

The language used to talk about suicide is complex. Suicidal behavior exists along a continuum; from thinking about ending one’s life, to developing a plan to do so, to non-fatal suicidal behavior, to actually ending one’s own life. The Centers for Disease Control (CDC) has come up with some definitions of suicidal behavior which the Department of Veterans Affairs (VA) has adopted.

CDC has defined suicidal ideation as having thoughts of harming or killing oneself; a suicide attempt is a non-fatal, self-inflicted destructive act in which a person has either an explicit or an inferred intent to die; self-inflicted injuries are suicidal and non-suicidal behaviors such as self mutilation; and suicide itself refers to a fatal self-inflicted destructive act in which there is an explicit or an inferred intent to die.

Suicide is a relatively infrequent act. Although suicide is the 11th leading cause of death among Americans of all ages, when studying any group over short periods of time the number of actual suicides will be low. Only very large studies conducted over long periods of time allow the accumulation of enough observations to make meaningful comparisons.

Suicide risks vary by age, gender and other factors. For Americans in general, the highest rates of suicide are among older men, but middle-aged veterans appear to take their own lives in greater proportions than their elders.

Suicides often occur in close proximity, especially after media attention. This kind of behavior is called “copycat behavior,” or the “Werther effect,” after a wave of suicides in 18th century Europe following the publication of a book by Goethe. It can be difficult to tell when a cluster represents a temporary trend, or a sustained trend.

Official suicide rates based on death certificate data can be incomplete. There are regional differences in how suicides are defined; how ambiguous cases are classified; and how thoroughly coroners or medical examiners investigate causes of death. In some areas religious traditions, life insurance policies, or legal sanctions may lead to underreporting. The increased awareness of the relationship between mental illness and suicide may cause an apparent increase in the reported number of suicides—without the rates actually differing.

And finally, reconstructing the events leading up to a death is difficult. Death certificates provide only a limited amount of information about actual causes of death, so researchers need to contact those closest to the victim to understand the true circumstances of death, and the factors that contributed to a death. Family members and others can often provide inaccurate or incomplete information.

The way researchers determine incidences for suicide is to express the number of suicides in a population per hundred thousand people per year. Because suicide rates vary by age, with both older and younger people at higher risk, any rates that attempt to make comparisons across different populations by year must be adjusted to allow for accurate comparisons. One way to do so is to look at age specific rates of suicides and compare them to the U.S. population as distributed by age. CDC uses the U.S. population census figures for 2000 to do this.

Another method of adjustment is called the standardized mortality ratio. This ratio compares the number of observed deaths in a defined group with the number of deaths that would be expected if that group had the same age-specific rates as a standard population.

Finally, there are sophisticated statistical techniques which can be used to derive a relative risk that take into account multiple characteristics of individuals, such as gender, race and ethnicity, medical conditions and other factors.

Each of these methods of adjustment has their strengths and their weaknesses. Each is potentially misleading when comparing populations with very different age or gender distributions. A careful analysis of suicide rates that is age and gender specific is both necessary and appropriate.

Because of this, VA has long subjected its own data, that of the Department of Defense, and data from nationally-accepted statistical sources to careful and painstaking analysis to obtain the truth about veterans’ suicide.

A suicide rate is normally calculated by describing the number of cases occurring in a defined group over a specific period of time. These are called incidences of suicide, and to avoid expressing incidences as very small fractions, suicide rate is typically expressed in terms of the number of suicides per 100,000 persons per year.

To make accurate comparisons of suicide rates, such as trends over time or comparisons among veterans and non-veterans, three important elements are needed. First is an accurate count of events for both groups, called the numerator. Second is an accurate estimate of the total population at risk, called the denominator. And third, as already mentioned, there needs to be an adjustment for age and gender differences between populations.

HOW VA COLLECTS SUICIDE DATA
VA relies on multiple sources of information to identify deaths that are potentially due to suicide. This includes VA’s own Beneficiary Identification and Records Locator Subsystem, called BIRLS; records from the Social Security Administration; and data compiled by the National Center for Health Statistics in its National Death Index.

This is a painstaking and difficult process for VA and for others, best illustrated by the fact that suicide data from the Centers for Disease Control and prevention are available only through 2005. Calculating suicide rates specifically for veterans is made even more difficult by the fact that the National Death Index does not include information about whether a deceased individual is a veteran or not.

The National Death Index is simply a central computerized index of death record information on file in the vital statistics offices of every state. The Index is compiled from computer files submitted by State vital statistics offices. Death records are added to the file annually, about twelve months after the end of a calendar year. CDC uses this data to compile its statistics on American death rates.

Given that the NDI does not indicate veteran status, VA regularly submits requests for information to NDI. Because the system contains a list of all Americans who have died, and because of the capabilities of its Electronic Health Record system, VA is able to send NDI a list of all patients who have not been treated at any VA medical centers in the past twelve months and before, to see if they are still among the living.

NDI checks this list against their records, and tells VA which veterans have died, and the cause of their death as listed on the veterans’ death certificates. From this information, VA is able to learn the approximate number of veterans under its care who have died of suicide, and to use that information to make comparisons on rates of suicide among those veterans and all other Americans.

This information tells VA about the suicide rates among veterans under its care, but says nothing about the rates of suicide among veterans who are not currently in the system. For those veterans, an even more complicated process has to be followed in order to estimate rates. VA obtains regular updates from the Department of Defense’s Defense Manpower Data Center on soldiers separating from the military. Those new veterans immediately become part of total population and suicide calculations.

In 2002, the CDC established the National Violent Death Reporting System, or NVDRS. NVDRS today is fully implemented in 16 states, and collects data on violent deaths, including suicides. NVDRS collects data on violent deaths from a variety of sources, including death certificates, police reports, medical examiner and coroner reports, and crime laboratories. Veteran status is included in the database.

Together, these sources offer a comprehensive picture of the circumstances surrounding homicides and suicides. This, too, is a time-consuming and difficult task, and standard reports from NVDRS are available only through 2005.

Because NVDRS is a comprehensive source of data, and because it indicates whether or not a coroner has indicated that the deceased is a veteran, VA is able to obtain counts of the number of suicides among all veterans in the sixteen stats that have fully implemented this system, broken down by sex, age, race and state. To summarize, determining suicide rates among veterans is a challenging puzzle. Multiple data sources must be used, and data must be carefully checked and rechecked. Each system helps obtain a piece of the complicated puzzle that constitutes the process of accurately estimating rates of veteran suicides.

These are time-consuming processes—but they are the best ways VA knows to obtain aggregate data on suicide. The weaknesses inherent in this method are clear.

First, the CDC’s manual for completion of death certificates states that the determination of whether or not someone is a veteran should usually be done by funeral directors. The information available to directors is limited, and their willingness to investigate the question of veteran status varies. Generally, these directors allow families to self-certify their response to the question of whether their loved one was a veteran; an approach fraught with pitfalls. In addition, funeral directors may not be clear on whether a young person died on active duty, or shortly after leaving the service.

Second, the classification of a death as suicide is dependent on the work of coroner’s offices throughout America. This paper has already discussed issues related to coroner determinations: regional differences in definitions; the manner in which ambiguous cases are classified; the level of investigative determination; religious traditions, and legal sanctions all create difficulties in data reliability.

And third, data takes a very long time to assemble. Neither NDI nor NVDRS has released reports of data newer than 2005—and it is midway through 2008 at present.

There are actions VA can take, and is taking, to improve the reliability and the speed of the data the Department is obtaining and providing to Congress. First, VA has begun negotiations with NVDRS staff that will provide information from all of NVDRS’ sources (death certificates, police reports, medical examiner and coroner reports, and crime laboratories) on a monthly and quarterly basis, as they are received by NVDRS.

VA will not be able to determine when there is sufficient information to provide full and publishable data—only NVDRS can do that—but will be able to examine and analyze these reports in a way that will allow the Department to spot suicide trends by age, sex and even region more quickly and to take action in those areas.

The Department will also systematically assess its efforts to inform funeral directors about the importance of determining whether or not a person who has died of suicide is or is not a veteran, and what sorts of information to consider in making that determination.

VA will also investigate working directly with state vital records offices, as the NDI does, to obtain information on veteran suicides directly from them.

And finally, VA has a new way of obtaining information on both suicides and suicide attempts: the Department’s suicide prevention coordinators.

Until VA committed itself last year to providing full time suicide prevention coordinators at each of its 153 hospitals, it could provide no useful number of attempted suicides among patients. Last October, a standardized definition of suicide attempts was developed and coordinators were asked to begin to count the number of such attempts of which they were aware.

VA’s definition of a suicide attempt included any behaviors that might have potentially allowed veterans to injure themselves, when there was evidence that the veteran had the intent to kill himself or herself—whether or not he or she was actually injured. The definition also included events in which a veteran was rescued, an attempt thwarted, or a veteran changed his or her mind after taking an initial action.

On February 13, 2008, an internal email from VA’s Deputy Chief of Patient Care Services for Mental Health discussed the existence of this information. In this email, he suggested 1,000 veterans a month under VA care were being reported as attempting suicide, and was concerned about disclosing the information.

The data was not sent to CBS because of his concerns.

The number of attempts referenced was based on only three months worth of data, too short a time period to determine if it was reliable.

The data was demonstrably not accurate. Even now, six months after collecting data began, the reports indicate that a number of states have suspiciously low reporting rates—and there is remarkable variability among individual VA facilities throughout the United States, due either to regional variability in suicide rates, differences in the manner in which individual suicide coordinators reported data, or both.

VA’s suicide prevention coordinators were new to their jobs, and new to their tasks. There was a great deal of uncertainty over “borderline calls,” and many of them were just beginning to make the community and in-hospital contacts that are essential in making an accurate count of the number of suicide attempts among patients.

VA is addressing the problem of the accuracy of suicide coordinators’ data in a number of important ways; by regularly reviewing the data the Department receives, and educating coordinators on the proper way to collect and report this information;

And VA is regularly reviewing difficult “calls” with its suicide coordinators—and encouraging them to meet the right people in their communities to obtain additional data.

In the near future, the Department intends to ask suicide prevention coordinators for the names of all those in their facility who have attempted suicide. This will allow further refinement of this data by checking the electronic medical records of individual veterans whose names have been reported as having attempted suicide. VA will learn how this information has been entered into the health record, and how practitioners have incorporated this information into the treatment plan for the individual whose record is being reviewed—with important implications for preventing suicide throughout VA’s system.

VA’s suicide coordinators are providing another important service; they are providing an additional source of data on the number of completed suicides at their facilities. This data, too, has significant problems: while VA can tell with considerable accuracy how many veterans commit suicide within its facilities, suicide coordinators have both limited time and contacts among coroners and funeral directors to provide accurate counts of the numbers who have died of suicide in the community.

While coordinators will be encouraged to continue to make those contacts, and to attempt to refine the accuracy of the numbers of dead they submit, VA believes that the focus of suicide prevention coordinators must be on preventing suicide among the living. Epidemiologists and researchers, using the data sources described above, will be the ones to learn more from those who have been lost.

Before turning to the actual data, here is a brief explanation of some data which has been widely attributed to VA, but which, in fact, is not the Department’s. On March 20, 2008, CBS aired a story on veterans’ suicide which included a statement in which the network said it had “obtained from VA” the information that there had been 790 attempted suicides among veterans under the Department’s care in all of 2007.

VA has since reviewed its records to try to understand where CBS might have gotten their information, and believes the number stemmed from a response to a Freedom of Information Act Request CBS made to the Veterans Health Administration’s Freedom of Information Act Officer on December 20, 2007; a request that was subsequently modified on January 29, 2008. VA provided CBS with the information they asked for–information in the Department’s National Patient Care Data base for the years 2000 through 2007, broken down by year, state, age group, gender and race.

This data provides a breakdown of why veterans were seen in VA’s hospitals and clinics by International Classification of Diseases code. Once such code is “Suicide and other Self-Inflicted Injuries.” CBS apparently counted the total number of veterans for whom that code was entered—and came up with 790 attempts for 2007.

That number, unfortunately, is not at all useful if the purpose of the count is to determine the total number of suicides and attempts among veterans under VA’s care. Some people who attempt suicide, but do not die, do not then present directly to VA for care. Others do not admit that their injuries were due to suicide attempts until a counselor discusses their situation with them. And still others treat their own wounds without seeing a clinician; the attempt is only revealed later, during counseling. CBS’s number, while arithmetically correct, is actually misleading.

VA’s DATA ON SUICIDES AND ATTEMPTS
To review what we do know specifically, let us compare veterans’ rates of suicide to non-veterans rates. The source of the base data is the National Death Index, a product of the National Center for Health Statistics of the Department of Health and Human Services. The most current complete data in this area is from 2005; 2006 data should be released soon. The overall rates of suicide for men and women from 2001 through 2005 are shown in Tables 1 and 2. It is important to separate the rates for men and women. By doing so, we see that men have a higher rate of suicide than women; a rate that is statistically significant. It is also important to separate these figures by age groupings, because there are significant differences in that area as well. These tables provide that information as well.

Table 1: Suicide Rates Per 100,000 Male U.S. Citizens by Fiscal Year and Age

 2001
 2002
 2003
 2004
 2005
 
All men
 23.18
 23.63
 23.20
 23.20
 23.19
 
18-29
 20.14
 20.08
 19.38
 20.21
 19.35
 
30-64
 22.45
 23.10
 23.13
 23.00
 23.19
 
65+
 31.42
 31.81
 29.76
 29.01
 29.53
 

Table 2: Suicide Rates Per 100,000 Female U.S. Citizens by Fiscal Year and Age

 2001
 2002
 2003
 2004
 2005
 
All women
 5.22
 5.44
 5.42
 5.81
 5.65
 
18-29
 3.40
 3.67
 3.56
 3.91
 3.90
 
30-64
 6.28
 6.47
 6.57
 7.09
 6.78
 
65+
 3.88
 4.09
 3.79
 3.79
 3.99
 

Source: CDC’s WISQARS Injury Reporting System and CDC’s National Center for Health Statistics’ National Death Index

Tables 3 and 4 provide overall rates of suicide for male and female Veteran VA users, broken down into three age groups: 18 to 29; 30 to 64; and 65 and older.

Table 3: Suicide Rates Per 100,000 Male Veteran VA Users by Fiscal Year and Age

 2001
 2002
 2003
 2004
 2005
 
All Male VA users
 36.49
 41.58
 32.92
 35.40
 37.19
 
18-29
 27.75
 36.54
 35.64
 42.54
 26.94
 
30-64
 41.37
 46.32
 39.57
 38.44
 40.66
 
65+
 32.03
 37.03
 26.77
 32.09
 34.27
 

Table 4: Suicide Rates Per 100,000 Female Veteran VA Users by Fiscal Year and Age

 2001
 2002
 2003
 2004
 2005
 
All Female VA users
 9.87
 12.49
 9.00
 12.28
 13.59
 
18-29
 2.12
 15.75
 5.93
 7.41
 7.81
 
30-64
 11.99
 11.17
 10.76
 14.88
 13.96
 
65+
 6.58
 15.66
 3.95
 4.31
 17.60
 

Source: CDC’s National Center For Health Statistics’ National Death Index

These tables show that men, whether or not they are veterans, have a higher rate of suicide than women, in numbers that can be considered statistically significant. In addition, there are significant differences by age groupings. VA is able to make these comparisons, because it is able to match the names of veterans under our care whom we have not recently seen against the National Death Index. The Death Index then provides information on which of these men and women have died, and the cause of their death, including suicide.

What cannot be learned from this table is how the rates of suicide compare among all veterans, not only those in the VA system, to the general population. Doing so would require matching the full list of 24.5 million veterans against the National Death index to see how many of them have committed suicide. That currently is not possible. However, VA has matched up general population rates of suicide in the sixteen states reporting to NVDRS in 2005 against the rate of veteran suicide in those states.

Table 5: Suicide Rates per 100,000 in 16 States Among General Population vs. Veteran Population (Males) in 2005

 18-29
 30-64
 65+
 
All male VA users
 53.18
 36.85
 36.00
 
All male veterans
 44.99
 25.60
 31.52
 
All men
 20.36
 23.28
 30.51
 

Table 6: Suicide Rates per 100,000 in 16 States Among General Population vs. Veteran Population (Women) in 2005

 18-29
 30-64
 65+
 
All female VA users
 25.02
 15.81
 —
 
All female veterans
 15.35
 11.41
 3.66
 
All women
 4.35
 7.04
 3.63
 

Sources:

General Population: CDC’s Web-based Injury Statistics Query and Reporting System

OEF/OIF: DoD’s Defense Manpower Data Center

Suicide Data: CDC’s National Center for Health Statistics National Death Index and CDC’s National Violent Death Reporting System

At this time, there is no firm explanation of the reason for the disparity in rates between VA’s patients and other Americans. However, the veterans VA serves—as opposed to the overall population of American veterans—are older, sicker, and poorer than the general population of the United States. VA researchers believe this may account for at least some of the apparent differences.

VA’s summary of this data from 2001 through 2005 yields the following hypotheses:

Male veterans commit suicide at a somewhat higher rate than other men, but with varying statistical significance by age and over different years.
Within the group of male veterans there are differences in the age at which veterans die of suicide compared to what is seen in the general population—especially in the ages between 30 and 64, at which ages veterans have a statistically significant higher rate. This finding is reproducible over time.
Male veterans commit suicide at a higher rate than female veterans.
Within the group of female veterans, there is nearly a twofold increase over the rate of suicide for women in the general population, which is also variably statistically significant over the years and by age.
Clearly, returning service men and women represent a group of particular interest to the Nation. VA has a particular sense of urgency to understand why these men and women might be taking their own lives—and to intervene to prevent even a single suicide. To better understand suicide in this particular cohort, Dr. Han Kang of VA’s Environmental Epidemiological Service conducted a study that matched those service members who had served in the theater of operations, and who separated from service between 2002 and 2005 against the National Death Index.

Using this method, Dr. Kang found that 144 out of 490,346 separated OEF/OIF servicemembers committed suicide during that time, for an overall rate of 21.9 per 100,000. These are deaths only of men and women who separated from the military, and the data does not include any suicides while a servicemember was on active duty.

To compare this to other national norms, Dr. Kang looked at this cohort against the national averages discussed above. For OIF/OEF veterans who had deployed and separated from 2002-2005, the rate was slightly higher than would be expected in an age, gender and race matched general population, but not by a statistically significant amount. (Standardized mortality Ratio of 1.15 (p>.05.)

Dr. Kang also examined this data for differences in suicide rates between those who have used VA for care and those who have not. He found that 17.0 of every 100,000 OEF/OIF veterans who use VA for care take their own lives, compared to 24.0 of every 100,000 OEF/OIF veterans who do not use VA for care. This apparent advantage of VA care, though encouraging, is not statistically significant. In this group, the same is true for vet center users.

Male veterans 18-29 who used VA care took their own lives at a rate of 21.0 per 100,000, compared to veterans of that age who did not use VA for care, a group which died of suicide at a rate of 30.4 per 100,000—a statistically significant difference. Male veterans aged 30-64 who used VA for care died of suicide at a rate of 17.5 per 100,000, compared to a rate of 22.8 per 100,000 for their fellow veterans who did not use VA for care—not a statistically significant difference. Since only 3 women OEF/OIF veterans died of suicide through 2005, accurate rates within age groups cannot be calculated.

VA statisticians have worked with this now-older data in anticipation of follow-on data when the updated National Death Index information is available. Some of the insights they have found include the knowledge that there appears to be little variation in suicide risk by branch of service. Statisticians also found that a diagnosis of a mental disorder predicted a nearly 1.8 times higher suicide risk than the general population. This is consistent with what has been published in research journals regarding the non-veteran population, and emphasizes the importance of the Department’s mental health efforts.

All of this data comes from national data for suicide against those who are known, from VA’s data sources or from Department of Defense records, to be veterans. These national numbers must be used because VA’s clinical records do not capture, in any reliable or complete way, such events as suicides or suicide attempts.

The National Death Index, a national roll-up of information from coroners through the states, offers the most complete compilation of deaths among veterans and their causes—since VA may not know of a death even if it occurs in an area in which the Department has a facility. Because information on deaths continues to be updated as reports come in over time, confidence in the completeness of those numbers only comes after several years of data collection. VA is awaiting at this time the release of National Death Index compilations for 2006 for further analysis.

Regarding inpatient deaths: from 2000 through 2007, exactly 50 VA inpatients took their own lives while under the Department’s care, based on root cause analyses of the deaths received by VA’s Office of Patient Safety. That number varies from a high of 14 such suicides in 2002, to a low of 2 in 2007, when Veterans Health Administration officials demanded that all facilities pay special attention to improving their environment of care to reduce opportunities for suicide.

VA’s SUICIDE PREVENTION EFFORTS
The steps VA is taking to prevent suicide among veterans are important and significant. All VA employees have been given the message that even strong and resilient people can develop mental health conditions; care for those conditions is readily available and should be immediately provided; and treatment works.

VA has held two National VA Suicide Prevention Awareness Days throughout its system to focus all 200,000 health care employees on this issue. The first event focused on enhancing overall awareness of the issue. The second coincided with National Suicide Prevention Awareness Week. During that week, VA staff was trained on how to work with available prevention resources, including the hotline and the suicide prevention coordinators. VA will continue participating in Suicide Prevention Awareness Week activities every year, with a special focus on veterans and ways VA can continually improve its suicide prevention efforts.

The Department is in the process of adding 23 new vet centers throughout the Nation to provide more individual, group and family counseling to veterans of all wars who have served in combat zones, bringing the total number of vet centers to 232.

VA’s suicide prevention program includes two centers that conduct research and provide technical assistance in this area to all locations of care. One is the Mental Health Center of Excellence in Canandaigua, New York, which focuses in developing and testing clinical and public health intervention related to suicide risk and prevention. The other is the VISN 19 Mental Illness Research Education and Clinical Center in Denver, which focuses on research in the clinical and neurobiological sciences with special emphasis on issues related to suicide risk.

VA’s system of care also includes a suicide prevention call center, also located in Canandaigua, and the suicide prevention coordinators previously discussed, who are located at each of VA’s 153 hospitals. Altogether, VA has more than 200 mental health providers whose jobs are specifically devoted to preventing suicide among veterans.

To develop the suicide prevention call center, the Department has partnered with the Lifeline Program of the Substance Abuse and Mental Health Services Administration. Those who call 1-800-273-TALK are asked to press “1” if they are a veteran, or are calling about a veteran.

Unlike other such hotlines, VA’s hotline is staffed solely by mental health professionals—24 hours a day, seven days a week. Hotline staff is trained in both crisis intervention strategies, and in issues relating specifically to veterans, such as traumatic brain injury and post traumatic stress disorder. In emergencies, the hotline contacts local emergency resources such as police or ambulance services to ensure an immediate response.

Cards, pamphlets and posters—even refrigerator magnets—bearing the number are distributed by suicide prevention coordinators to at-risk veterans and their family members.

In addition, posters with hotline information are located throughout VA medical centers and clinics, and in all residential rehabilitation programs there are stickers on phones and by doors with the hotline number. Vet Centers also make this information available.

If the caller is a veteran enrolled with VA for care, the hotline staff is able to use the veteran’s electronic medical record during the call, if the veteran is a VA patient and willing to identify himself or herself. These records provide information that is invaluable during a crisis, including information on medications; the patient’s treatment plan; and who to contact during this emergency.

Staff can talk directly to the facility that is treating the veteran. They can place consults in the patient’s medical record, and are able to make arrangements to directly refer veterans to a Medical Center or Community-based outpatient clinic to be seen if that’s appropriate.

And hotline staff follows up on these referrals. They check patient’s records to see if consultations were completed; actions are taken; and follow-ups are ongoing. If the record does not show this information, the suicide prevention coordinator is called, ensuring that no referral is lost in the process.

From its beginnings in July, 2007 through the end of April, 16,414 calls have come to the hotline from veterans and 2125 family members or friends have called. These calls have led to 3464 referrals to suicide prevention coordinators and 885 rescues involving emergency services. 493 active duty servicemembers have also called.

Besides keeping track of veterans who have tried to take their own lives, suicide prevention coordinators receive referrals of those at risk for suicide from both the hotline and from providers in their facilities. They also ensure that care for these veterans is appropriate for their situations.

Coordinators educate their colleagues, veterans and families about risks for suicide. They provide enhanced treatment monitoring for veterans at risk and ensure that any missed appointments are followed up on. The coordinators work with the entire staff of their medical centers to maintain awareness of those who have previously attempted suicide, and ensure their care is enhanced to reduce the risk of renewed attempts.

They also work with patient safety officers to conduct quarterly safety inspections of inpatient psychiatry units, and coordinate staff education programs about suicide prevention. These coordinators are in the process of organizing a system of flags in the electronic medical record system to alert providers about those at high risk. They are also conducting training for community members who have frequent contact with veterans to help them recognize those at risk and encourage them to seek treatment.

There is a large body of scientific literature on suicide. Over the years, VA has been a prime contributor to the knowledge that has been developed in the scientific community on this issue. Our research has helped us target our efforts to reduce suicide. Some of the information our researchers have developed includes:

Among veterans receiving care from VA who died from suicide, almost 60{cd9ac3671b356cd86fdb96f1eda7eb3bb1367f54cff58cc36abbd73c33c82e1d} of those under age 65 had a mental health or substance abuse diagnosis on their medical records—but only 24{cd9ac3671b356cd86fdb96f1eda7eb3bb1367f54cff58cc36abbd73c33c82e1d} of those 65 or over had such a diagnosis.
There is significant variability in suicide rates among veterans by geography. In general, rates are lowest in the Northeast and highest in the West.
Firearms are the most common means used by veterans who died of suicide, accounting for nearly two-thirds of all deaths.
There appears to have been an increase in suicide rates among Vietnam veterans during the first two years after these veterans returned home. After a few years, however, Vietnam veterans’ rates of suicide were comparable to those of the general population.
There was no increase in suicide rates among veterans who returned from the first Gulf War.
Those veterans who are wounded in combat are at higher risk of suicide.
5. FUTURE ACTIVITIES

In the near future, the Department will continue to educate its employees; through additional Suicide Prevention Days; through posters identifying the warning signs of suicide; and through its continuing Employee Education process to identify those at possible risk of suicide to ensure they get proper care. As new data on suicide rates, risk factors for suicide and regional variations become available, VA will use that data to refine its programs, and to better evaluate their level of success.

VA will increasingly reach out to the newest generation of veterans, by using communications outlets familiar to them. VA now has a virtual office on “Second Life;” and recently collaborated with MTV on a video on readjustment issues for returning veterans that can be found on their web site.

VA will continue its efforts to meet the mandate of the President’s New Freedom Commission to reduce the stigma that surrounds mental illness.

VA will also continue the expansion of its mental health program that has enabled the Department to hire more than 3800 new mental health employees in the past three years, and expand hours of operation for mental health clinics beyond normal business hours. These efforts to better identify and treat mental illness will help prevent contemplation of suicide and suicide attempts—and will help ensure that veterans in crisis are already involved in VA’s system and have somewhere to turn when they need help.

The Department will aggressively follow up on patients in mental health and substance abuse programs who miss appointments to ensure they are not lost to follow up care. VA will also monitor the standards the Veterans Health Administration has set for itself: to provide initial evaluations of all patients with mental health issues within 24 hours, provide urgent care immediately when that evaluation indicates it is needed, and to complete a full evaluation and initiate a treatment plan within 14 days for those not needing immediate crisis care.

On May 2, VA began contacting nearly 570,000 combat veterans of the Global War on Terror to ensure they know about VA medical services and other benefits. The Department will reach out and touch every veteran of the war to let them know it is here for them. The first of those calls are going to an estimated 17,000 veterans who were sick or injured while serving in Iraq or Afghanistan. If any of these 17,000 veterans do not now have a care manager to work with them to ensure they get appropriate health care, VA will offer to appoint one for them.

All case managers for OEF/OIF veterans will be trained in suicide risk recognition and management for their patients, and encouraged to establish a personal relationship with those veterans to support their health care needs.

I have also directed the creation of a work group on suicide prevention in the veteran population. This work group will look at all matters relating to VA’s ability to prevent suicide among veterans. They will be given all the data VA has, and access to the best experts VA knows.

The work group will be asked to provide a report within fifteen days of the completion of their meeting on how VA can better approach suicide prevention, suicide research, and suicide education.

All work group members will come from outside the Department of Veterans Affairs. Some will be DoD specialists; others will be from other government agencies. Nationally recognized clinical treatment, research and public health experts on suicide and suicide prevention will augment them. The work group will provide an additional level of advice and oversight to all the issues described above.

There is nothing more tragic than the loss of even one of those great men or women who have served this nation. The VA is committed to doing all that we can to serve the individual while we continue to try to understand a very complicated problem that is also a national problem. We owe this committee and the nation accurate information and carefully studied, thoughtful conclusions while we provide the “best care anywhere” to our Veterans.

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