[The only way to prevent veterans from killing themselves is to
prevent them from going to war.] [[link removed]]

AND THE ARMIES THAT REMAINED SUFFER’D: VETERANS, MORAL INJURY AND
SUICIDE  
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Matthew Hoh
November 11, 2019
Common Dreams
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*
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*
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*
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_ The only way to prevent veterans from killing themselves is to
prevent them from going to war. _

Think now of young men or women home from Iraq or Afghanistan,
Somalia or Panama, Vietnam or Korea, the woods of Europe or the
islands of the Pacific, what they have done cannot be undone, all the
words of assurance that their actions were not murder cann, U.S.
Marine Corps/Lance Cpl. Robert Reeves

 

I was very pleased to see the _New York_ _Times_ editorial on November
1, 2019, _Suicide Has Been Deadlier than Combat for the Military_
[[link removed]].
As a combat veteran myself and someone who has struggled with
suicidality since the Iraq war I am grateful for such public attention
to the issue of veteran suicides, particularly as I know many who have
been lost to it. However, the _Times_ editorial board made a serious
error when it stated “Military officials note that the suicide rates
for service members and veterans are comparable to the general
population after adjusting for the military’s demographics,
predominantly young and male.” By incorrectly stating veteran
suicide rates* are comparable to civilian suicide rates the _Times
_makes the consequences of war seem tragic yet statistically
insignificant. The reality is that deaths by suicide often kill
veterans at a level greater than combat, while the primary reason for
these deaths lie in the immoral and ghastly nature of war itself.

To the _Times’_ discredit annual suicide data provided by the
Veterans Administration (VA) since 2012
[[link removed]]
clearly notes that veteran suicide rates when compared with the
civilian population are adjusted for age and sex. In the 2019 National
Veteran Suicide Prevention Annual Report
[[link removed]]
on pages 10 and 11 the VA reports that adjusted for age and sex the
suicide rate for the veteran population is 1.5 times that of the
civilian population
[[link removed]];
military veterans make up 8% of the US adult population, but account
for 13.5% of the adult suicides in the US (page 5).

As one notes the differences in populations of veterans, specifically,
between veterans who have seen combat and those that have not seen
combat, one sees a much higher likelihood of suicide among veterans
with combat exposure. VA data shows among veterans that had deployed
to Iraq and Afghanistan, those in the youngest cohort
[[link removed]], i.e.
those most likely to have seen combat, had suicide rates, again
adjusted for age and sex, 4-10 times higher than their civilian peers.
Studies outside the VA that focus on veterans who have seen combat,
because not all veterans who deploy to a war zone are engaged in
combat, confirm higher rates of suicide. In a 2015 _New York Times_
[[link removed]]
story a Marine Corps infantry unit that was tracked after coming home
from war saw suicide rates among its young men 4 times greater than
other young male veterans and 14 times that of civilians. This
increased risk of suicide for veterans who served during war holds
true for all generations of veterans
[[link removed]],
including the Greatest Generation. A study in 2010
[[link removed]]
by _The Bay Citizen_ and New America Media, as reported by Aaron
Glantz, found the current suicide rate for WWII veterans to be 4 times
higher than for their civilian peers, while VA data, released since
2015 [[link removed]],
show rates for WWII veterans well elevated above their civilian peers.
A 2012 VA study [[link removed]] found
that Vietnam veterans with killing experiences had twice the odds of
suicidal ideation than those with lower or no killing experiences,
even after adjusting for post-traumatic stress disorder (PTSD),
substance abuse and depression.

The VA’s Veterans Crisis Line (VCL), one of many programs of support
unavailable to previous generations of veterans, is a good measure of
how intense the current struggle with veteran suicide is for the VA
and caregivers. Since its opening in 2007 through the end of 2018
[[link removed]], VCL
responders “have answered more than 3.9 million calls, conducted
more than 467,000 online chats and responded to more than 123,000
texts. Their efforts have resulted in the dispatch of emergency
services nearly 119,000 times to Veterans in need.” Putting that
last statistic into context more than 30 times a day VCL responders
call police, fire or EMS to intervene in a suicide situation, again a
service that was not available prior to 2007. The VCL is just one part
of a larger support system for suicidal veterans and there are
undoubtedly many more than 30 needed emergency interventions for
veterans each day, just note the oft mentioned number of 20 veteran
suicides a day
[[link removed]].
That number of men and women who die by suicide each day, without end,
brings the true costs of war: bodies buried, families and friends
destroyed, resources expended, back to a nation that has always
thought itself protected from war by its two protecting oceans. How
tragic do Abraham Lincoln’s words
[[link removed]] now
sound when the thought of the consequences of the wars the US has
brought to others return home to us:

Shall we expect some transatlantic military giant to step the ocean
and crush us at a blow? Never! All the armies of Europe, Asia, and
Africa combined, with all the treasure of the earth (our own excepted)
in their military chest, with a Bonaparte for a commander, could not
by force take a drink from the Ohio or make a track on the Blue Ridge
in a trial of a thousand years. At what point then is the approach of
danger to be expected? I answer. If it ever reach us it must spring up
amongst us; it cannot come from abroad. If destruction be our lot we
must ourselves be its author and finisher. As a nation of freemen we
must live through all time or die by suicide.

This high rate of suicide in veterans leads to a total number of
deaths of combat troops at home that surpasses the totals killed in
war. In 2011, Glantz and _The Bay Citizen_
[[link removed]]
“using public health records, reported that 1,000 California
veterans under 35 died from 2005 to 2008—three times the number
killed in Iraq and Afghanistan during the same period.” The VA data
tells us that close to two Afghan and Iraq veterans die by suicide
each day on average, meaning the estimated 7,300 veterans who have
killed themselves since just 2009, after coming home from Afghanistan
and Iraq, are greater in number than the 7,012 service members killed
[[link removed]] in those wars since 2001. To visually
understand this concept that the killing in war does not end when the
soldiers come home, think of the Vietnam Veterans Memorial in
Washington, DC, The Wall, with its 58,000 names. Now visualize The
Wall but lengthen it by some 1,000-2,000 feet to include the 100,000
to 200,000 plus Vietnam veterans who are estimated to have been lost
to suicide, while keeping space available to continue to add names for
as long as Vietnam veterans survive, because the suicides will never
stop. (Include the victims of Agent Orange, another example of how
wars never end, and The Wall extends past the Washington Monument).

The mental, emotional and spiritual injuries that come with surviving
war are not unique to the United States or the modern age. Disparate
historical sources, such as Roman
[[link removed]]
and Native American
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accounts, tell of the psychological and psychiatric wounds of war, and
what was done for returning soldiers, while in both Homer
[[link removed]]
and Shakespeare
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we find clear references to the lasting invisible wounds of war.
Contemporary literature and newspapers of the post Civil War era
chronicled the consequences of that war on the minds, emotions and
health of Civil War veterans by documenting the prevalence of
afflicted veterans in cities and towns
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all across the United States. Estimates are that hundreds of thousands
of men died in the decades after the Civil War from suicide,
alcoholism , drug overdoses and the effects of homelessness induced by
what they had done and seen in the war. Walt Whitman’s “When
Lilacs Last in the Dooryard Bloom’d
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primarily an elegy to Abraham Lincoln, pays tribute to all who
suffered after the war was over on the battlefields, but not in minds
or memories:

And I saw askant the armies,

I saw as in noiseless dreams hundreds of battle-flags,

Borne through the smoke of the battles and pierc’d with missiles I
saw them,

And carried hither and yon through the smoke, and torn and bloody,

And at last but a few shreds left on the staffs, (and all in silence,)

And the staffs all splinter’d and broken.

I saw battle-corpses, myriads of them,

And the white skeletons of young men, I saw them,

I saw the debris and debris of all the slain soldiers of the war,

But I saw they were not as was thought,

They themselves were fully at rest, they suffer’d not,

The living remain’d and suffer’d, the mother suffer’d,

And the wife and the child and the musing comrade suffer’d,

And the armies that remain’d suffer’d.

Digging further into the data on veterans suicide provided by the VA
one finds still another chilling statistic. It is difficult to truly
ascertain an exact ratio of suicide attempts to death by suicide.
Among US adults the CDC
[[link removed]] and other sources
[[link removed]] report that there
are roughly 25-30 attempts for each death. Looking at information from
the VA it appears that this ratio is much lower, perhaps in the single
digits
[[link removed]],
perhaps as low as 5 or 6 attempts for each death. The primary
explanation for this seems to be that veterans are much more likely to
use a firearm for suicide than civilians; it’s not hard to
understand how using a gun is a much more likely way to kill oneself
than by other methods. Data shows the lethality of using a firearm for
suicide is above 85%, while other methods of death by suicide have
only a 5% success rate
[[link removed]].
This does not satisfy the question though as to why veterans have a
stronger intention of killing themselves than civilians; why do
veterans reach a place of distress and despair in their suicidality
that initiates such a serious determination to end their lives?

Multiple answers have been offered to this question. Some suggest
veterans struggle to reintegrate into society, while others believe
the culture of the military dissuades veterans from asking for help.
Other thoughts extend to the idea that because veterans are trained in
violence they are more likely to turn to violence as a solution, while
another line of thinking is that because a high number of veterans own
guns the solution to their problems is in their immediate possession.
There are studies that show of predispositions to suicide or the
relationship between opiates and suicide. In all these suggested
answers there are elements that are partiality true or complement a
larger reason, but they are incomplete and are ultimately belied,
because if these were the reasons for elevated veteran suicides then
the entire veteran population should respond in a similar manner.
However, as noted above, veterans who have been to war and who have
seen combat have higher rates of suicide than veterans who did not go
to war or experience combat.

The answer to this question of veteran suicide is simply there is a
clear link between combat and suicide. This link has been confirmed
over and over again in peer reviewed research by the VA
[[link removed]] and US universities. In
a 2015 meta-analyis by the University of Utah
[[link removed]] National
Center for Veteran Studies researchers found 21 of 22 previously
conducted peer reviewed studies investigating the link between combat
and suicide confirmed a clear relationship between the two.** Titled
“Combat Exposure and Risk for Suicidal Thoughts and Behaviors Among
Military Personnel and Veterans: A Systematic Review and
Meta‐Analysis”, the researchers concluded: “The study found a 43
percent increased suicide risk when people were exposed to killing and
atrocity compared to just 25 percent when looking at deployment [to a
war zone] in general.”

There are very real connections between PTSD and traumatic brain
injury and suicide, both conditions often being the result of combat.
Additionally, combat veterans experience high levels of depression,
substance abuse and homelessness. However, the primary cause of
suicidality in combat veterans I believe is not something biological,
physical or psychiatric, but rather something that in recent times has
come to be known as moral injury
[[link removed]].
Moral injury is a wounding of the soul and spirit caused when a person
transgress against her or his values, beliefs, expectations, etc. Very
often moral injury
[[link removed]]
occurs when someone does something or fails to do something, eg. I
shot and killed that lady or I failed to save my friend from dying
because I saved myself. Moral injury can also occur when a person is
betrayed by others or by an institution, such as when one is sent to a
war based on lies or is raped by their fellow soldiers and then denied
justice by their commanders.

An equivalent for moral injury is guilt, but such an equivalence is
too simple, as the severity of moral injury transmits to not just a
blackness of the soul and spirit, but also to a deconstruction of
one’s own self. In my own case it was as if the foundations of my
life, my existence, were cut out from underneath me. This is what
drove me to suicidality
[[link removed]].
My conversations with fellow veterans inflicted with moral injury
attest to the same.

For decades the importance of moral injury, whether or not this exact
term has been utilized, has been understood in literature examining
suicide among veterans. As early as 1991 the VA identified
[[link removed]] the best predictor of
suicide in Vietnam veterans as being “intensive combat related
guilt”. In the aforementioned meta-analysis of studies examining the
relationship of combat and suicide by the University of Utah, multiple
studies speak to the importance of “guilt, shame, regret, and
negative self-perceptions” in the suicidal ideation of combat
veterans.

Killing in war does not come natural to young men and women. They have
to be conditioned to do so and the US government has spent tens of
billions of dollars, if not more, perfecting the process of
conditioning young men and women to kill. When a young man enters the
Marine Corps to become a rifleman he will go through 13 weeks of
recruit training. He will then go for six to eight weeks of additional
weapons and tactics training. During all these months he will be
conditioned to kill. When receiving an order he will not say “yes,
sir” or “aye, sir” but will respond with the yell “Kill!”
This will last for months of his life in an environment where the self
is replaced with unquestioning group think in a training environment
perfected over centuries to create disciplined and aggressive killers.
After his initial training as a rifleman, this young man will report
to his unit where he will spend the rest of his enlistment,
approximately 3 ½ years, doing only one thing: training to kill. All
of this is necessary to ensure the Marine will engage and kill his
enemy with certainty and without hesitation. It is a non-stop,
academically and scientifically proven process unmatched within
anything in the civilian world. Without such conditioning men and
women will not pull the trigger, at least not as many of them as the
generals want; studies [[link removed]]
of past wars showed the majority of soldiers did not fire
[[link removed]] their weapons in
battle unless they were conditioned to do so.

Upon release from the military, upon returning from war, the
conditioning to kill no longer serves a purpose outside of combat and
the bubble of military life. Conditioning is not brain washing and
like physical conditioning such mental, emotional and spiritual
conditioning can and will atrophy. Faced with himself in society,
allowed to view the world, life and humans as he once knew them a
dissonance between what he was conditioned to in the Marine Corps and
what he once knew of himself now exists. Values he was taught by his
family, his teachers or coaches, his church, synagogue or mosque;
things he learned from the books he read and the movies he watched;
and the good person he always thought he was to be return, and that
dissonance between what he did in war and what and who he believed
himself to be results in moral injury.

Although there are many reasons people join the military, such as the
economic draft
[[link removed]], the
majority of young men and women who join the US Armed Forces do so
with the intention of helping others, they view themselves, rightly or
wrongly, as being someone with a white hat on. This role of hero is
further inculcated through military training
[[link removed]], as well as through our
society’s near-deification of the military; witness the continued
and unquestioning reverence of soldiers whether it be at sporting
events, in movies, or on the political campaign trail. However, the
experience of veterans at war is often that the people who were
occupied and to whom the war was brought didn’t view US soldiers as
wearing white hats, but rather black ones. Here, again, a dissonance
exists within a veteran’s mind and soul, between what society and
the military tells him and what he has truly experienced. The moral
injury sets in and leads to a despair and distress to which, in the
end, only suicide seems to provides relief.

I mentioned Shakespeare before and it is to him I often return when I
speak of moral injury and death by suicide in veterans. Remember Lady
MacBeth and her words in Act 5, Scene 1 of MacBeth
[[link removed]]:

Out, damned spot! Out, I say!—One, two. Why, then, ’tis time to do
’t. Hell is murky!—Fie, my lord, fie! A soldier, and afeard? What
need we fear who knows it, when none can call our power to
account?—Yet who would have thought the old man to have had so much
blood in him…

The thane of Fife had a wife. Where is she now?—What, will these
hands ne’er be clean?—No more o’ that, my lord, no more o’
that. You mar all with this starting…

Here’s the smell of the blood still. All the perfumes of Arabia will
not sweeten this little hand. Oh, Oh, Oh!

Think now of young men or women home from Iraq or Afghanistan, Somalia
or Panama, Vietnam or Korea, the woods of Europe or the islands of the
Pacific, what they have done cannot be undone, all the words of
assurance that their actions were not murder cannot be justified, and
nothing can clean the haunting blood from their hands. That in essence
is moral injury, the reason why warriors throughout history have
killed themselves long after coming home from war. And that is why the
only way to prevent veterans from killing themselves is to prevent
them from going to war.

NOTES

*With regards to active duty military suicides
[[link removed]],
active duty suicide rates are comparable to civilian rates of suicide,
when adjusted for age and sex, however, it is important to note that
prior to the post 9/11 years
[[link removed]]
suicide rates were as little as half that of the civilian population
among active duty service members (the Pentagon did not start tracking
suicides until 1980 so data on previous wars in incomplete or
non-existent for active duty forces).

**The study that did not confirm a link between suicide and combat was
inconclusive due to methodology issues.

MATTHEW HOH [[link removed]] is a
member of the advisory boards of Expose Facts, Veterans For Peace and
World Beyond War. In 2009 he resigned his position with the State
Department in Afghanistan in protest of the escalation of the Afghan
War by the Obama Administration. He previously had been in Iraq with a
State Department team and with the U.S. Marines. He is a Senior Fellow
with the Center for International Policy.

*
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