Dr. Agarwal [Dr. Madhulika Agarwal, Deputy Under Secretary for Health Policy and Services], thank you for that kind introduction and for inviting me to address this conference. Let me also acknowledge:
Good morning. I am honored to be here. My thanks, once again, for the invitation to join you. Someone recently sent me a survey of responses to the question, "What is love?" That was asked of some youngsters. The responses were, I thought, quite enlightening about the powers of observation in young children and their conclusions about something as ambiguous as love:
Author and lecturer Leo Buscaglia once talked about a contest he was asked to judge. The purpose of the contest was to find the most caring child. The winner was a four-year old child whose next door neighbor was an elderly gentleman who had recently lost his wife.
Upon seeing the man cry, the little boy went into the old gentleman's yard, climbed onto his lap, and just sat there.
When his mother asked what he had said to the neighbor, the little boy said, "Nothing, I just helped him cry."
I will confess that I've wrestled some with what to say to you today. Mental health is not familiar terrain for me, so it's a bit of a challenge.
Some key terms seem, to me at least, to wash into one another. Mental Health, Mental Illness. Is one merely the absence of the other? The answer, I think, is 'No', but how so?
Happiness, sadness. Emotions, to be sure, yet where do they fit into the objectives of this conference? If one emotion is the absence of the other, is one positive and the other a negative or is there value to being able to experience sadness? It is often a trait anthropologists look for in animal species as a distinguishing characteristic.
What about fear and courage? You meet very few people who don't experience fear in combat. And the ones who claim not to be afraid are the ones who tend to take unusual risks. Does fear play a function in military units, and is courage the conquest of fear? And does this interaction between fear and courage suppress the 'Hooah factor' and give rise to the reluctant warrior: Fight as a last resort, minimize damage, protect the innocent, care for the injured—no matter, which uniforms they wear? Does the spiritual matter here, or is it all science and survival and pure analytics?
Much of my study in the military profession was about the doctrine of applying force. And though you hear, from time to time, the use of terms like "precision" as in "precision attack," or "surgical" as in "surgical strike," we are really a blunt instrument designed to force others to yield to our will.
And in that doctrine, as in most professions, there is a science to the use of force and then there is the art of doing it. There is a difference between the coercive use of force and the decisive use of it, and that's about as much clarity as you get sometimes. However, the effects of the military's application of force are immense, both on our adversaries and, at times, on our own young people, as well.
I've mentioned before that I carry with me two very distinct images of the men and women who have worn our Nation's military uniforms; two incongruent images that are always with me.
The first image is this—and it is one most familiar to everyone in this audience. Each year, something around 60 percent of high school graduates go on to colleges, universities, community colleges—some version of higher education. Of the remaining 40 percent or so, some undergo vocational training, and some immediately enter the workforce. Fewer others, still, join the less than one percent of Americans who volunteer to serve in our Nation's armed forces. Most young people today have no memory of a draft Army.
More than five million Americans have volunteered to serve in the military during the past decade. Three million of them joined after 9/11, knowing that they would probably be deploying to combat.
After enlisting, they undergo weeks of rigorous physical training and mental preparation for a disciplined life of values, standards, and accountability. Following graduation from basic training, they join a wide variety of units: platoons, ships, squadrons, and detachments.
When they reach those first units, they quickly become valued and trusted members of high-performing teams—tough, motivated, and extremely dedicated; maybe the highest performing teams they will ever be a part of. With excellent leadership, they go forward, each and every day, to perform the complex, the difficult, and the dangerous missions.
On some days, they are asked to do the impossible. Think of what they've been asked to do, and what they've accomplished, with unwavering commitment and without complaint, these last ten years in Afghanistan, and the last eight in Iraq—unseating the Taliban, pushing al Qaeda from its sanctuaries, capturing Saddam Hussein, delivering justice to Osama bin Laden, and preparing Iraqi and Afghan forces to defend their own countries.
But there is a second image: Veterans suffer disproportionately from homelessness, depression, substance abuse, and suicides. And they are well up there in joblessness, as well. Tens of thousands live in the streets of our Nation or are released from prison each year.
What's wrong with these disparate images? To be sure, there are fewer, a much, much smaller number, in the second image than the first, but they are the same youngsters who marched across the same high school graduation stages.
How did we fail to continue the kinds of successes they achieved while in uniform? How do we keep them from entering that downward spiral of depression, substance abuse, failed relationships, and joblessness that often leads to homelessness and, sometimes, to suicide?
This most visible aspect of this second image, image number two, is the homeless Veteran. At VA, our goal is to never allow those in image number one to become part of image number two, and to return those in image number two to lives as productive as possible. This is not about them; this is about us, and whether we have the skills, knowledge, and attributes; the determination; the courage; and whether we care enough to take on image number two, and all that it represents to us as healthcare professionals, as Veterans, and as a Nation. What have we wrought through our shortcomings—our shortcomings? So long as we think they are the problem or that the problem is theirs, we are unlikely to answer this question decently.
You are at this conference because you are expert at what I am merely prattling on about. I am the novice here. Whether you are a VA psychiatrist, psychologist, nurse, social worker, clinician, researcher, administrator, or educator, you know that VA healthcare works the physical, the mental, and the spiritual aspects of Veteran well-being.
Your several objectives for the next two days are clear and challenging. They are all well chosen and important and outlined in your conference materials. I would highlight two of them for you; we need your help especially in these areas:
The handbook is about standards—getting them in place all across VA. The integrated mental health strategy is about VA/DoD collaboration and teamwork, something we should be striving to do as a matter of routine. Very little of what we do at VA originates in VA. Much of what we end up treating or studying begins in DoD. We share the same patients, just at different times in their lives. If there is any value to standards of care and continuity of care, it does not reside cubby-holed in either department; standards, collaboration, and teamwork are precious principles in today's healthcare delivery models.
In this year's commencement address at Harvard medical school, Dr. Atul Gawande cited Dr. Lewis Thomas' observation that surviving a hospital stay in the pre-penicillin era before World War II was more the result of a disease running its own course than anything done medically by the hospital staff. Still, everyone was just as busy then, as now. Gawande goes on to say, since World War II, medicine has traveled an unfathomable distance. "We now have treatments for nearly all of the tens of thousands of diagnoses and conditions that afflict human beings. We have more than six thousand drugs and four thousand medical and surgical procedures . . . . Medicine's complexity," he says, "has exceeded our individual capabilities as doctors."
Gawande continues, "The core structure of medicine—how healthcare is organized and practiced—emerged in an era when doctors could hold all the key information patients needed in their heads and manage everything required themselves. . . . But you can't hold all the information in your head any longer, and you can't master all the skills." By the way, the title of his speech is "Cowboys and Pit Crews." With a little imagination, you can see where he is headed in trying to reach these young, graduating physicians on one of the more momentous days in their lives.
Gawande goes on to explain that the values of pit crews are not the values of cowboys. Pit crews, he says, are about "humility, discipline, and teamwork," which collide with the "autonomy, independency, and self-sufficiency" of cowboys."
For all of you, as well, success lies in your willingness to collaborate across the broad landscape of mental health care. How are we doing at creating our "pit crews" within each medical care facility? And you are not limited by the walls of the medical center. How are we doing at "pit crewing" our Medical Centers with our Vet Centers, and mobile clinics with our rural mental health initiatives and home-based telemental health care?
And what about VA/DoD collaboration? That should be a medical dream team or crew. You see, for the "pit crew," it's all about putting the driver in the best position to win. What about us? Are we working together to put our driver—our Veteran—in the best position to win?
The statistics show that VA's mental health care workload is steadily increasing. From 2005 to 2010, Veterans treated for any mental health diagnosis in any setting rose from a little over 1.4 million Veterans to just under 1.9 million. At the same time, the total number of VA mental health staff rose from around 13,000 to over 20,000 nationwide
While these are tight times for all federal budgets—which are being squeezed—thanks in large measure to the President's commitment and the support of the Congress, funding for VA's mental health programs has increased from $2.24 billion in FY 2005, to $6.15 billion projected for FY 2012—just short of a three-fold increase.
But money alone is not a panacea. What counts is what you do with the resources, and your challenge is to achieve more, to increase access for Veterans in need of mental health care today, and simultaneously, prepare for the very real future of increased case loads as the wars in Iraq and Afghanistan wind down and more servicemembers—drivers—come home.
This conference, with its diverse opportunities for sharing knowledge, probing new ideas, starting dialogues about innovative pathways to best approach mental healthcare, presents each one of you with an exciting and productive venue for advancing the state of the art. I urge you to take advantage of every moment you have here, and to take what you will learn back to your hospitals, clinics, Vet Centers, and communities and add this experience to your already impressive credentials.
Since last December, with input and recommendations from a variety of panels, work groups, and VA senior leaders, we settled on five core values that underscore the moral obligations inherent in VA's mission: integrity, commitment, advocacy, respect, excellence -- "I Care."
More than mere words, these values constitute promises we make, individually and collectively, to Veterans and other beneficiaries about our commitment to the mission of serving them.
Though the stories of every individual you touch and treat are different, in some ways, they are also similar—they are stories about caring, compassionate mental healthcare professionals all across VA who, in the words of a suicide prevention coordinator, live what they preach—"that people can, and do, change when they are supported in feeling dignified, respected, and valuable to themselves and others." That is what you do. That is why I am so proud of the men and women who bring to VA's mental healthcare programs energy, vitality, commitment, and caring; sounds like love to me. "You care," and sometimes that makes all the difference—like that most-caring four year old: "I just helped him cry."
I do know how hard you work, and I appreciate your dedication to the men and women I've devoted much of my life to. I don't know them individually, but I know them because I know their missions and what it took for them to prevail. I also know how many uncredited hours you put in when it would be just as easy to close your doors and go home. But you know there are Veterans still sitting patiently in the waiting room for you. So, you keep your doors open, and you welcome them in as if they were the first patient of the day. That's what "I Care" is all about. It marks the best in us, and I appreciate what you do and how you do it. In accepting his Nobel Prize for literature in 1950, William Faulkner observed, "I believe that man will not merely endure; he will prevail. He is immortal, not because he alone among creatures has an inexhaustible voice, but because he has a soul, a spirit capable of compassion and sacrifice and endurance."
Soul, spirit, compassion, sacrifice, endure, prevail. These six words, and all that they encompass, describe the mothers of the Veterans you treat. Some of them belong to the "Blue Star Mothers." In many respects, these six words also describe what you do for our Veterans: soul, spirit, compassion, sacrifice, endure, prevail. I commend you for your dedication and your compassion. Soldiering is said to be an affair of the heart, and so is bringing our Veterans home—all the way home—in body, mind, and spirit.
God bless those who serve and have served our Nation. And may God continue to bless this great country of ours.