Hispanic veterans health

1. Hispanic veterans health A Hispanic Veteran’s Perspective LTC (fmr. sel) Louis DiBernardo, MD, MPH US Army Medical Corps

2. Overview • Defining a “Veteran” • Hispanics in the US military • Common healthcare issues for Veterans • Specific healthcare issues for Hispanic Veterans • Potential solutions for healthcare issues

3. What is a Veteran? • Federal Definition • Under U.S. law, a veteran is someone who has served in the Armed Forces of the United States. The soldier must have served and been discharged honorably. • State Definition • Each state has its own definition for a soldier. For example, South Dakota state laws have a variety of criteria to consider a solider a veteran. Although the federal government identifies the soldier a veteran after one day of service, South Dakota classifies a soldier as a veteran relative to war-time service or if they received a medal of honor during a wartime conflict. • Misconceptions • Former or current members of the Armed Forces Reserves or National Guard don't qualify unless they were active duty in the Army or other Armed Forces (Marines, Air Force, Navy or Coast Guard). The exception to this rule is if the President of the United States calls reservists to service by executive order. The presidential order qualifies reservists as veterans. • Benefits • The federal government's Department of Veteran Affairs offers veterans a variety of benefits. This includes pensions and disability for retirees and soldiers permanently injured during their service. Home loans, vocational training, and life insurance are also available to veterans.

4. Therefore… Many differences exist between whether one is (was) on regular Active Duty, Reservist, or National Guard (and each branch has it’s own subtle differences of these titles), and what they imply in terms of benefits after being discharged. Simply having been in the service doesn’t necessarily qualify one for VA benefits

5. Historically Speaking… • We currently have the largest all-volunteer military force since the Revolutionary War • The total US military makes up about 1% of the total US population, and there are presently about 26 million US Veterans (about 10% of the population) • As a country, there is culturally a greater lack of understanding towards Veterans simply because there are relatively so few of us now compared to the rest of the population. (a function of numbers)

6. Hispanics in the US military • Have been involved in United States military campaigns since the Revolutionary War • We hold our share of Medal of Honor recipients since its inception • Our valor and heroism is accredited in part to our culture • Historically our culture has fought on “both sides” of the US military • In 1976 Mexican American Richard E. Cavazos made military history by becoming the first Hispanic to attain the rank of Brigadier General in the United States Army. Less than 20 years later, the native Texan would again make history by being appointed the Army's first Hispanic four-star general.4 • Veterans History Project – Library of Congress2

7. Variations in military experience make for challenges in provider understanding: • Active Duty vs. Reservist • Army vs. Navy vs. Marines vs. Air Force vs. Coast Guard vs. National Guard • Combat vs. Non-Combat experience • Retired vs. “short stint”

8. Common Health Issues for Veterans include:8 • Traumatic Brain Injury (mild vs. “not so mild”) • Amputations, blindness, disfigurement • Post-Traumatic Stress Disorder • Insomnia, Depression, and Suicide • Depleted Uranium exposure • Chemical, fume, and toxin exposures (Agent Orange, DU, chlorine gas, plasticized sewage) • NOTE: Some conditions don’t happen or appear for years after being out of the service. • The good news: Because military medicine has advanced, 9 in 10 injuries now survive7

9. Air Evac Trauma patient

10. Blast Injury

11. Wound to elbow and forearm

12. Shrapnel Fragment Injury

13. IED Injury

14. Andrew Steele makes an adjustment on the prosthetic leg of Army Staff Sgt. Ryan Kelly of Abilene, Texas.7

15. Specific Healthcare Issues for Hispanic Veterans

16. Hispanic Veteran Health Issues • Where’s the Hispanic/Latino VA physician? • Social isolation from family members that don’t “speak military”, or even speak English • Culturally speaking, male Hispanic/Latino patients don’t like going to the doctor----this seems to be amplified several times over for many Hispanic Veterans • Hispanic female Veterans don’t have enough of anything (OB/GYN VA docs, supportive spouses, culturally sensitive female Veteran outreach) • Anger management/”machismo”/fear of “taboo” labels in Mental Health • There are currently debates going on about whether or not multi-linguistic competence is necessary in the VA (after all, if one has served in the US military, one needs to have been able to read, write, speak, and follow orders in English, right?)

17. Medically speaking… • Just as there has been a shortage of physicians in the Active Duty and Reserves military, so too goes the lack of providers in the VA that are “prior service” • The argument has been made for years that there aren’t enough physicians of color to provide culturally competent healthcare to underserved minority communities. The same can be said about the lack of Veteran physicians in the VA system who can deliver the same quality of “militarily experienced cultural” healthcare to Veterans • Having said that, how much more of a need can one now begin to recognize when it comes to finding Hispanic Veteran physicians to take care of Hispanic Veteran patients???

18. Returning Home • For those that have been to a combat zone, there are stresses associated with every stage of the deployment---Before, During, and After • The stresses vary, as do the abilities of the soldier and the soldier’s family to cope with those stresses---this is irrespective of whether or not the mission was combat related or not • Even a deployment that went well is stressful • Veteran attitudes can create isolationism • No matter how disciplined a person is, the stress of adjusting to civilian life can lead to drugs or excessive drinking.1

19. When should VA outreach begin? • Right after initial enlistment! • Do NOT use the recruiters as a way to “promise” VA benefits • Minority Veteran programs need to be marketed, and the database for interested “future Veterans” needs to be created from this initial outreach • Just as in the civilian sector of healthcare, the VA needs to market it’s providers (as well as improve their provider numbers, experience, and diversity)!!!

20. Sample Pamphlets Offer lots of information: Education Health benefits Home Loan Programs Work-study benefits The 800 number for Minority Veterans is listed on one of the sheets

21. Advisory Committee for Minority Veterans • According to the VA’s own website as of 2/17/11: • Shows 12 members total: • 4 African-Americans • 2 Asian-Americans • “1 ½” Native Americans • 1 Pacific Islander • “3 ½” Hispanic/Latino Americans One RN, one PA student, one Physician (none of whom are Hispanic)5

22. Center for Minority Veterans • The Center for Minority Veterans is part of the Office of the Secretary. The Center assists eligible veterans in their efforts to receive benefits and services from VA. The Center acts only as a mediator and facilitator -- As such the Center does not process claims, handle equal employment complaints, or employee relation problems. The Center is dedicated to ensuring that all veterans are aware of benefits, services, and programs offered by VA.6

23. So the questions… • How does the VA overcome the challenges that mainstream society has had for over 70 years when it comes to the racial and ethnic disparities of healthcare? • Where is the scientific literature to demonstrate and support any evidence that such disparities exist to a lesser (or greater) degree among Veterans? • Where’s the exposure?

24. Some microcosm examples… • Not all Veterans choose to go to the VA for their healthcare---in part because the VA limits what you can go there for (again, it’s based on the Veteran’s qualification status) • History of negative stigma for the VA (especially in the wake of the Active Duty WRMC scandal; word of mouth plays a big role) • Medicare qualified Veterans prefer Medicare/HMO clinics to the VA • Many new generation Veterans prefer Tricare

25. Persistent issues that need work: • 1. In general, with as far as we’ve come, there is much to still be accomplished in the world of minority Veterans’ health • 2. Currently, no hard data exists on multi-cultural approaches within the VA to improving minority health care delivery • 3. On the Active Duty medical side, multi-cultural approaches to healthcare for our own soldiers and their families do not exist---so how can there be any such transition to the VA side of healthcare? • 4. There is no overlay between Active Duty medicine and VA medicine when it comes to minority related health issues • 5. Competent healthcare for Veterans must take on a cultural as well as a military medical perspective in order to be truly effective at attracting diverse Veteran groups • 6. Future challenges: finding Hispanic/Latino physicians with a military background who want to return to the VA system to deliver healthcare, and the challenge of getting the VA to extend to such physicians an attractive offer of employment that will fulfill the mission of delivering culturally competent care • 7. If the interest is not there, such needs will only worsen

26. Potential Solutions? • Research, research, research! The data is there, but opportunity from WITHIN the VA system must be created to make the data viable, usable, and more likely to affect policy (e.g. VA sponsored grants, research programs, Needs Assessments, etc.) • The Advisory Committee for Minority Veterans needs to expand, and it needs funding • The VA system needs to target Hispanic Veteran nurses, physicians, and other medical personnel for employment!!!!! • In the bigger picture of things, Hispanics/Latinos overall need to continue to push towards higher education---our under-representation in society in general leads to an even bigger under-representation when it comes to government and medical leadership

27. References • 1. Association of Gospel Rescue Missions, Statistics & Studies: Homeless Veteran Survey, October 1997 • 2. Library of Congress • 3. U.S. Latino Patriots: From the American Revolution to Afghanistan, An Overview • By Refugio I. Rochin and Lionel Fernandez • 4. biography.jrank.org/.../Cavazos-Richard-E-1929-U-S-Army-General.html • 5.www.va.gov/CENTERFORMINORITYVETERANS/Advisory_Committee.asp • 6. www.va.gov/centerforminorityveterans/ • 7. Protection, fast treatment key to highest-ever survival rateThursday, December 9, 2004 Posted: 12:07 PM EST (1707 GMT) • 8. Quinlan, J., et al, “Care of the Returning Veteran”, American Family Physician, July 1, 2010, Vol 82, No 1, pp 43-49