[Peace-discuss] Matthew Hoh: And the Armies That Remained Suffer’d: Veterans, Moral Injury and Suicide

[David Green]

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Veterans, Moral Injury and SuicidePosted By Matthew Hoh On November 8, 2019
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Photograph Source: USAG- Humphreys – CC BY 2.0
<https://creativecommons.org/licenses/by/2.0/>

I was very pleased to see the *New York* *Times* editorial on November 1,
2019, *Suicide Has Been Deadlier than Combat for the Military*
<https://www.nytimes.com/2019/11/01/opinion/military-suicides.html>. 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
<https://www.va.gov/opa/docs/Suicide-Data-Report-2012-final.pdf> 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
<https://www.mentalhealth.va.gov/docs/data-sheets/2019/2019_National_Veteran_Suicide_Prevention_Annual_Report_508.pdf>
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
<https://www.cdc.gov/nchs/data/hestat/suicide/rates_1999_2017.htm>;
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
<https://www.mentalhealth.va.gov/docs/2016suicidedatareport.pdf>, 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*
<https://www.nytimes.com/2015/09/20/us/marine-battalion-veterans-scarred-by-suicides-turn-to-one-another-for-help.html>
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
<https://www.mentalhealth.va.gov/docs/data-sheets/2015/OMHSP_National_Suicide_Data_Report_2005-2015_06-14-18_508.pdf>,
including the Greatest Generation. A study in 2010
<https://news.yahoo.com/investigation-suicide-rates-soaring-among-wwii-vets.html>
 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
<https://www.mentalhealth.va.gov/suicide_prevention/data.asp>, show rates
for WWII veterans well elevated above their civilian peers. A 2012 VA study
<https://www.ncbi.nlm.nih.gov/pubmed/22505038> 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
<https://www.va.gov/opa/pressrel/pressrelease.cfm?id=5276>, 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
<https://www.militarytimes.com/veterans/2016/07/07/new-va-study-finds-20-veterans-commit-suicide-each-day/>.
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
<http://www.abrahamlincolnonline.org/lincoln/speeches/lyceum.htm> 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*
<https://www.revealnews.org/article/new-data-reveals-high-death-rates-for-iraq-afghanistan-vets-2/>
“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 <http://www.icasualties.org/> 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
<https://theconversation.com/how-ptsd-treatment-can-learn-from-ancient-warrior-rituals-69589>
 and Native American
<https://link.springer.com/chapter/10.1007/978-1-4899-0786-8_15> accounts,
tell of the psychological and psychiatric wounds of war, and what was done
for returning soldiers, while in both Homer
<https://www.simonandschuster.com/books/Odysseus-in-America/Jonathan-Shay/9780743211574>
 and Shakespeare
<https://matthewhoh.com/2014/07/11/shakespeare-ptsd-and-moral-injury/> 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
<https://opinionator.blogs.nytimes.com/2014/05/21/the-civil-war-and-p-t-s-d/>
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
<https://www.poetryfoundation.org/poems/45480/when-lilacs-last-in-the-dooryard-bloomd>”,
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 <https://save.org/about-suicide/suicide-facts/> and other sources
<https://afsp.org/about-suicide/suicide-statistics/> 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
<https://www.blogs.va.gov/VAntage/27677/facts-veteran-suicide/>, 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
<https://everytownresearch.org/those-who-serve-addressing-firearm-suicide-among-military-veterans/>.
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
<https://www.ncbi.nlm.nih.gov/pubmed/22505038> and US universities. In a 2015
meta-analyis by the University of Utah
<https://onlinelibrary.wiley.com/doi/abs/10.1111/sltb.12163> 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
<https://www.ptsd.va.gov/professional/treat/cooccurring/moral_injury.asp>.
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
<https://www.theatlantic.com/health/archive/2015/07/healing-a-wounded-sense-of-morality/396770/>
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
<https://matthewhoh.com/2018/04/28/update-to-last-weeks-post-on-suicide-and-combat-guilt/>.
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
<http://www.ncbi.nlm.nih.gov/pubmed/2018158> 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
<https://www.indiebound.org/book/9780806132808> of past wars showed the
majority of soldiers did not fire
<https://www.indiebound.org/book/9780316040938> 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 <https://taskandpurpose.com/5-reasons-soldiers-join-army>,
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
<https://www.youtube.com/watch?v=puAJcGfIq7U>, 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
<http://shakespeare.mit.edu/macbeth/full.html>:

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
<https://www.military.com/daily-news/2013/01/14/2012-military-suicides-hit-record-high-of-349.html>,
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
<https://academic.oup.com/milmed/article/183/suppl_1/396/4959986> 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.

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