War leaves PTSD scars on Native American vets
Ruben Ramirez earned a Bronze Star and three Purple Hearts as a World War II infantryman fighting Nazi troops in North Africa and Italy. The physical wounds he sustained in combat eventually healed. Not so his emotional injuries.
To this day, Ramirez, 86, a retired diesel mechanic and American Indian who traces his roots to the Apache nation, is tormented by recurrent nightmares of having witnessed his buddies being blown apart. He gets out of bed every few hours to patrol the perimeter of his house in Fresno.
However, it was not until 2008, after a broken marriage, a spotty employment record and more than 60 years of suffering, that Ramirez, one of an estimated 2,000 American Indian military veterans living in the Central Valley, finally sought treatment. Ultimately, he was diagnosed with post-traumatic stress disorder and received disability from the U.S. Department of Veterans Affairs.
"We were taught to be quiet," Ramirez said when asked to explain why it took him so long to seek counseling, which he continues to undergo weekly.
For a generation of older veterans like Ramirez, raised to keep their feelings in check, it is not uncommon to go years with untreated PTSD, or even to be aware that help is available through the VA.
But Ramirez's ethnic roots, American Indian activists say, may well have prolonged his agony.
While members of many American Indian tribes serve in the military in disproportionately higher numbers than other ethnic groups, studies suggest they also suffer PTSD with greater frequency.
A 1997 landmark study of American Indian veterans of the Vietnam War found that one-third lived with some form of PTSD a quarter-century after the war ended. That was twice the rate of white Vietnam veterans.
Although the study concluded that much of the difference may have resulted from American Indians' higher front-line duty in the war, it also raised the prospect that their subsequent social isolation may have played a role in the disparity.
Researchers have been stymied in drawing definitive conclusions about American Indians and PTSD, in part because of the relatively small numbers of Indians in the population.
But American Indian activists believe cultural traditions can make it particularly difficult for American Indian veterans to seek treatment for psychological issues stemming from their time in uniform.
Many also say the VA has been slow to expand outreach efforts and provide services that would resonate with American Indian veterans.
For example, the VA employs relatively few American Indians as counselors or spiritual advisers; only 28 of the VA's more than 4,600 psychologists are American Indian.
"The American Indian has a natural distrust of the white government," said James D. Cates, chairman of the National Native American Veterans Association. "You just can't send anyone out to educate them, either. The person who should do this should be Native American. They understand the traditions more than anyone."
How the government addresses PTSD victims has become more urgent with the end of the war in Iraq and President Barack Obama's plans to accelerate troop withdrawal from Afghanistan. About 30,000 U.S. forces pulled out of Iraq late last year, and Obama has said that 33,000 troops would leave Afghanistan by this summer.
Of more than 1.7 million veterans who have served in Afghanistan and Iraq, about 20% have PTSD or major depression, according to an American Psychological Association report released earlier this year.
California is home to 52,600 American Indian veterans, more than any other state. Nearly 740,000 American Indians reside in California, by far the nation's largest American Indian population. Moreover, California has vastly more reservations and Indian rancherias, and more federally recognized tribes (107) than any other state.
With such a large American Indian presence, many Indian veterans say they don't understand why the VA doesn't devote more resources to helping them. But with 8.3 million enrollees in the VA health care system, including more than 1.9 million in California alone, officials point out, there are only so many resources to go around.
Terry R. Bentley, a member of California's Karuk tribe, is one of four specialists hired last year to work with federally recognized American Indian tribes across the country -- part of the VA's new Office of Tribal Government Relations.
But, working alone in an office in Roseburg, Ore., and trying to cover six Western states, is a daunting task. "There is, honestly, so much work to be done," Bentley said. "We're really at the tip of the iceberg."
Officials at the VA Fresno, however, say they're making progress in responding to the particular needs of American Indian veterans suffering from PTSD.
The hospital has funding from the VA Office of Rural health to hire a Native American outreach worker and hopes to fill the position soon, said spokeswoman Dawn Golik. The hospital also is working with the American Indian Veterans Association in a rural health community collaborative, she said.
The Fresno VA now has two "peer specialist" volunteers, neither of them American Indians, who reach out to area American Indian veterans and attempt to help coordinate their care. One of those volunteers is former Fresno County sheriff's deputy John Howard, a decorated Purple Heart and Bronze Star recipient whose Army platoon leader died in his arms during combat in Vietnam.
Howard meets weekly with groups of local veterans, including American Indians, to talk through their emotional demons.
"I may have trust issues," Howard said of his own service-related demons, "but they're nothing like the ones Native Americans have. Until I got involved in all this, with my white boy eyes, I didn't understand their needs. Many of them are just not aware. They don't know it's OK to ask questions."
Operation Desert Storm veteran Rene Diaz Duran of Fresno speaks glowingly of the care he has received.
"The VA saved my life," said Diaz, an Apache and Pasqua Yaqui who came back from war unable to sleep, having survived multiple Iraqi rocket attacks in Saudi Arabia.
Fueled by alcohol and narcotics, Diaz got in a scrape with relatives after returning from war and soon found himself in trouble with the law. But instead of taking him to jail, he said, Fresno County sheriff's deputies took him to the Fresno VA hospital.
Diaz said he ended up in a VA psychiatric ward for four months, followed by 90 days in an inpatient recovery program. Along they way, he said, VA doctors prescribed him a "truckload" of anti-psychotics, sleep aids, mood stabilizers and other medications.
The treatment he has received, Diaz said, has helped him work through the inherent conflict he feels having served in the American military while being American Indian.
"Before, we were fighting against this country, now we're fighting for it," Diaz said. "It's ironic, but I'm proud to be a vet, and I'm proud to be Native. I'd do it all again if I had to."
Veterans Affairs officials and many veterans themselves say the VA's Veterans Health Administration has strived greatly in recent years to improve mental health care for all service veterans, including American Indians. The VA as of last year employed about 21,000 counselors and other mental health professionals -- up from nearly 14,000 in 2005.
Still, there is no shortage of critics who contend that the agency remains ill-equipped to handle the growing number of fighting men and women who suffer from traumatic brain injuries and combat-related mental problems.
The agency is particularly challenged in persuading veterans to see a psychologist. Army records show that only about 40% of soldiers who are identified as having serious emotional problems stemming from combat service voluntarily seek professional counseling.
American Indian veterans, advocates say, may be particularly reluctant because of an inherent distrust of government based on the way their ancestors often were persecuted.
"I have dreams of hitting people with my rifle, of children crying, of doing the same things that were done to my people," says Michael Roman, 32, of San Jose, a member of the Pima and Apache tribes who was among the first wave of Marines to enter Iraq during the 2003 invasion. "There's a lot of guilt there."
Access to care can be a particular problem because so many veterans live in rural areas.
Nearly 30% of the nation's 22 million veterans live in rural areas; for American Indian vets, the rural proportion is even higher.
And only about 10% of psychologists and psychiatrists, and 20% of masters-level social workers, practice in rural areas, according to the National Organization of State Offices of Rural Health.
The Fresno VA recently hired a telemedicine psychologist to provide mental health/PTSD services to veterans in rural areas.
Richard Gonzales, an Apache who fought with the 101st Airborne Division in Vietnam, says he sees progress.
Gonzales, who heads the Central California chapter of the American Indian Veterans Association, said Fresno VA Medical Center officials have begun meeting regularly with Indian vets to help them resolve complaints.
He said a confrontational attitude in the early sessions had eased. But the going remains tough. "You could tell," he said, "there's not a lot of understanding of the cultural differences."