[Senate Hearing 109-376]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 109-376
 
       FIELD HEARING ON THE STATE OF VA CARE IN HAWAII: PART III

=======================================================================

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                       ONE HUNDRED NINTH CONGRESS

                             SECOND SESSION

                               __________

                            JANUARY 13, 2006

                               __________

       Printed for the use of the Committee on Veterans' Affairs


 Available via the World Wide Web: http://www.access.gpo.gov/congress/
                                 senate


                                 ______

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                     COMMITTEE ON VETERANS' AFFAIRS

                      Larry Craig, Idaho, Chairman
Arlen Specter, Pennsylvania          Daniel K. Akaka, Ranking Member, 
Kay Bailey Hutchison, Texas              Hawaii
Lindsey O. Graham, South Carolina    John D. Rockefeller IV, West 
Richard Burr, North Carolina             Virginia
John Ensign, Nevada                  James M. Jeffords, (I) Vermont
John Thune, South Dakota             Patty Murray, Washington
Johnny Isakson, Georgia              Barack Obama, Illinois
                                     Ken Salazar, Colorado
                  Lupe Wissel, Majority Staff Director
               D. Noelani Kalipi, Minority Staff Director


                            C O N T E N T S

                              ----------                              

                            January 13, 2006
                                SENATORS

                                                                   Page
Akaka, Hon. Daniel K., U.S. Senator from Hawaii..................     1
    Prepared statement...........................................     2

                               WITNESSES

Osman, Lieutenant General H.P. (Pete), U.S. Marine Corps, Deputy 
  Commandant for Manpower and Reserve............................     3
    Prepared statement...........................................    10
Mixon, Major General Benjamin, R., U.S. Army, Commanding General, 
  25th Infantry Division (Light), Schofield Barracks, Hawaii.....    14
    Prepared statement...........................................    17
Lee, Major General Robert G.F., Adjutant General, State of 
  Hawaii, Department of Defense..................................    19
    Prepared statement...........................................    21
Horn, Colonel Matthew, Deputy Commander, U.S. Army Reserve, 
  Commander, 9th Regional Readiness Command......................    22
    Prepared statement...........................................    23
Perlin, Hon. Jonathan B., M.D., Ph.D., Under Secretary for 
  Health, Department of Veterans Affairs, Accompanied by Robert 
  Wiebe, M.D., VA Network Director, VISN 21, Sierra Pacific 
  Network; James Hastings, M.D., Director, VA Pacific Islands 
  Health Care System; and Steven A. MacBride, M.D., Chief of 
  Staff, VA Pacific Islands Health Care System...................    24
    Prepared statement...........................................    26
Harlan, Jon, M.S.W., Team Leader, Hilo Vet Center................    43
    Prepared statement...........................................    46
Kunz, Kevin, M.D., M.P.H., FASAM, Past President, Hawaii Society 
  of Addiction Medicine..........................................    48
    Prepared statement...........................................    51
Lum Ho, Sergeant Greg, Hawaii Army National Guard................    54
    Prepared statement...........................................    56
King, Katherine, veteran.........................................    56
    Prepared statement...........................................    59

                                APPENDIX

Prepared statements:
Cook, Bud Pomaika'i, Ph.D........................................    67
Eaglin, Floyd D..................................................    67
Kekumu, Wendall E.K..............................................    95
Poulin, Guy......................................................    85
Ribbentrop, Master Sergeant Keith T. (Ret.), USAF, MBA...........    93
Tamlin, George...................................................    95
Wilson, Carolle Brulee...........................................    95


       FIELD HEARING ON THE STATE OF VA CARE IN HAWAII: PART III

                              ----------                              


                        FRIDAY, JANUARY 13, 2006

                               U.S. Senate,
                    Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 10:10 a.m., in 
Conference Room at the Department of Labor and Industrial 
Relations Building, 1990 Kinoole Street, Hilo, Hawaii, Hon. 
Daniel Akaka (Ranking Member) presiding.
    Present: Senator Akaka.

 OPENING STATEMENT OF HON. DANIEL K. AKAKA, U.S. SENATOR FROM 
                             HAWAII

    [Typed from Senator Akaka's prepared statement; the 
Senator's opening statement was not taped.]
    Senator Akaka. Aloha. Welcome to the fourth and final 
Senate Committee on Veterans' Affairs field hearing in Hawaii. 
It is a pleasure for me to leave our Nation's capital and 
conduct official Senate business here in my home State. We have 
had three successful and informative hearings this week, and 
I'm sure this hearing will be no different.
    At this time I would like to thank the staff at the Hilo 
and Kona Vet Centers and Clinics. All of you do a wonderful 
service for our veterans.
    The focus of this hearing will be on readjustment care for 
returning servicemembers. We are all aware that after Vietnam 
and other wars, some of our servicemembers who honorably served 
our Nation were not provided with the care and services they 
needed to reintegrate into society. Caring for returning 
servicemembers is part of the continuing cost of war.
    We must act now to assure adequate levels of care and 
services are available for those that may leave the Armed 
Forces after returning from overseas. The earlier a veteran 
receives care after separation from the military, the greater 
the likelihood the veteran will not have long-term problems.
    With this thinking in mind, I sponsored the Vet Center 
Enhancement Act, which recently passed the U.S. Senate. This 
legislation authorizes the Department of Veterans Affairs to 
hire more Global War on Terror outreach coordinators, gives VA 
authority to administer bereavement counseling at Vet Centers, 
and authorizes $180 million for Vet Centers. This legislation 
goes a long way to providing the care and services Hawaii's 
returning servicemembers desperately need. But we should not 
stop here.
    Today we will investigate what is working and what needs to 
be done better. We have wonderful witnesses today. Our first 
panel consists of high-ranking military and VA personnel. 
Lieutenant General Pete Osman is the Deputy Commandant for 
Manpower and Reserve, United States Marine Corps. Major General 
Benjamin R. Mixon is the Commanding General of the 25th 
Infantry Division. Major General Robert Lee is Adjutant General 
for the State of Hawaii. Colonel Matt Horn is the Deputy 
Commander, U.S. Army Reserve, Commander, 9th Regional Support 
Command.
    Lastly, Panel I has the Honorable Dr. Jonathan Perlin, 
Under Secretary for Health at VA. He is accompanied by Dr. 
Robert Wiebe, VA Director for the Sierra Pacific Network; Dr. 
James Hastings, Director of the VA Pacific Islands Health Care 
System; and Dr. Steven A. MacBride, Chief of Staff for the VA 
Pacific Islands Health Care System.
    The second and final panel is made up of John Harlan, Team 
Leader at the Hilo Vet Center; Dr. Kevin Kunz, President of the 
American Society of Addiction Medicine; Sergeant Greg Lum Ho of 
the Army National Guard; and a veteran, Katherine King. I want 
to thank you all for attending this hearing, and I look forward 
to your comments.
    Finally, I want to address the fact that there are many 
veterans who are here today and who want to testify. We want to 
hear from you. Unfortunately, we cannot accommodate everyone's 
request to testify. However, we are accepting written testimony 
for the record. You can rest assured that we will read your 
written testimony. If you have brought written testimony with 
you, please give it to the Committee staff who are located at 
the back of the room.
    If you do not have written testimony, but would like to 
submit something, my staff is in the back of the room to assist 
you. In addition, the Committee staff is joined by VA staff who 
can respond to the questions, concerns, and comments that you 
raise.
    Once again, mahalo to all who are in attendance today, and 
I look forward to hearing from today's witnesses.
    [The prepared statement of Senator Akaka follows:]

  Prepared Statement of Hon. Daniel K. Akaka, U.S. Senator from Hawaii

    Aloha. Welcome to the fourth and final Senate Committee on 
Veterans' Affairs field hearing in Hawaii. It is a pleasure for me to 
leave our Nation's capital and conduct official Senate business here in 
my home state. We have had three successful and informative hearings 
this week, and I am sure this hearing will be no different.
     At this time I would like to thank the staff at the Hilo and Kona 
Vet Centers and Clinics. All of you do a wonderful service for our 
veterans.
     The focus of this hearing will be on readjustment care for 
returning servicemembers. We are all aware that after Vietnam and other 
wars, some of our servicemembers, that honorably served our Nation, 
were not provided with the care and services they needed to reintegrate 
back into society. Caring for returning servicemembers is part of the 
continuing cost of war.
    We must act now to assure adequate levels of care and services are 
available for those that may leave the Armed Forces after returning 
from overseas. The earlier a veteran receives care after separation 
from the military, the greater the likelihood the veteran will not have 
long-term problems.
     With this thinking in mind, I sponsored the Vet Center Enhancement 
Act, which recently passed the U.S. Senate. This legislation authorizes 
the Department of Veterans Affairs (VA) to hire more Global War on 
Terror Outreach Coordinators; gives VA authority to administer 
bereavement counseling at Vet Centers; and authorizes $180 million for 
Vet Centers. This legislation goes a long way to providing the care and 
services Hawaii's returning servicemembers desperately need. But, we 
should not stop here.
     Today we will investigate what is working and what needs to be 
done better. We have a wonderful witness list today. Our first panel 
consists of high-ranking military and VA personnel. Lieutenant General 
Pete Osman is the Deputy Commandant for Manpower and Reserve, United 
States Marine Corps. Major General Benjamin R. Mixon is the Commanding 
General of the 25th Infantry Division. Major General Robert Lee is 
Adjutant General for the State of Hawaii. Colonel Matt Horn is the 
Deputy Commander, U.S. Army Reserve, Commander, 9th Regional Support 
Command.
    Lastly, panel one has the Honorable Dr. Jonathan Perlin, Under 
Secretary for Health at VA. He is accompanied by Dr. Robert Wiebe, VA 
Director for the Sierra Pacific Network; Sergeant James Hastings, 
Director of the VA Pacific Islands Health Care System; and Dr. Steven 
A. MacBride, Chief of Staff for the VA Pacific Islands System.
    The second and final panel is made up of John Harlan, Team Leader 
at the Hilo Vet Center; Dr. Kevin Kunz, President of the American 
Society of Addiction Medicine; Greg Lum Ho of the Army National Guard; 
and a veteran, Katherine King. I want to thank you all for attending 
this hearing and I look forward to your comments.
    Finally, I want to address the fact that there are many veterans 
who are here today and who want to testify. We want to hear from you. 
Unfortunately, we cannot accommodate everyone's request to testify. 
However, we are accepting written testimony for the record. You can 
rest assured that we will read your written testimony. If you have 
brought written testimony with you please give it to Committee staff 
who are located in the back of the room.
    If you do not have written testimony but would like to submit 
something, my staff is in the back of the room to assist you. In 
addition, the Committee staff is joined by VA staff who can respond to 
the questions, concerns, and comments that you raise.
    Once again, mahalo to all who are in attendance today and I look 
forward to hearing from today's witnesses.

STATEMENT OF LIEUTENANT GENERAL H.P. (PETE) OSMAN, U.S. MARINE 
       CORPS, DEPUTY COMMANDANT FOR MANPOWER AND RESERVE

    [Typed from General Osman's prepared statement; the 
General's testimony was not taped.]
    General Osman. Mr. Chairman, Senator Akaka, and 
distinguished Members of the Committee, I am grateful for this 
opportunity to appear before you today to discuss the 
interaction between the Marine Corps, DoD, and the Department 
of Veterans Affairs to care and support our returning 
servicemembers, including those from the State of Hawaii.
    The State of Hawaii has been the source of great help to 
the Marine Corps in the Global War on Terrorism. Marine Corps 
Base Hawaii, including the Kaneohe Bay and Camp H.M. Smith 
installations, is home to over 16,000 Marines, sailors, family 
members, and Marine Corps civilian employees. Tripler Army 
Medical Center in Honolulu is also an important facility for 
the Marine Corps, currently providing medical care to several 
injured Marines. The Spark M. Matsunaga VA Medical Center and 
the Oahu VA healthcare clinic are also resources for our 
injured servicemembers.
    The State of Hawaii has also witnessed its share of 
casualties and injuries during the Global War on Terrorism, 
with two Marines with Hawaii homes of record killed in combat 
and nine others injured. The Marine Corps is highly focused on 
caring for these and all injured Marines, ensuring that their 
family members are provided for and comforted in the wake of 
their injury, and, when necessary, assisting with their 
transition to civilian life.
    Supporting injured Marines and their families is a complex 
task. We do our best to tailor our support to fit their 
individual needs. This support comes from numerous Marine Corps 
initiatives designed to promote and provide treatment for the 
mental and physical well-being of all servicemembers and their 
families. These include community-based services, buddy care, 
non-medical support resources, chaplains, morale, recreation, 
and welfare programs, and the full spectrum of clinical care 
and patient movement of the military health system.
    There are also many joint VA/DoD programs whose goal is to 
help injured servicemembers transition from DoD to VA 
healthcare, convert from DoD to VA benefits systems, improve 
VA/DoD sharing of personnel and healthcare information, and to 
otherwise assist servicemembers who, for whatever reason, are 
transitioning to civilian life.
    Today, I'd like to touch upon several programs, many of 
which are the result of lessons learned from the Marine Corps' 
central role in Operation Iraqi Freedom and Operation Enduring 
Freedom. Many of these programs involve close communication and 
joint effort with VA. All of these programs are available to 
all Marines, including those stationed here in Hawaii; many 
have program liaisons based at Marine Corps Base Hawaii.
    Military leaders and medical professionals realize that 
many deployed servicemembers experience combat stress and that 
it affects some individuals more than others. The stress of 
current operations has affected not only those Marines deployed 
to a war zone, but also those remaining in garrison and their 
family members.
    To maintain the readiness of the Marine Corps as a war-
fighting force, we remain vigilant in watching our young, 
expeditionary, and vigorous members for signs of distress and 
to effectively manage operational stress at every level. The 
goal of this effort is to provide pre-deployment training, 
assistance when the stress is occurring, and post-combat 
monitoring and assistance to identify mental health problems 
early, so they will have the best chance of healing completely.
    Since the Marine Corps crossed the line of departure into 
Iraq in March 2003, we have continuously developed and improved 
our operational stress control programs based upon lessons 
learned. For example, in January 2004, we launched the 
Operational Stress Control and Readiness (OSCAR) program, which 
embed mental health professionals with ground units. OSCAR has 
been successful in helping Marines deal with the acute stress 
of combat. It also keeps Marines with low-level problems at 
their assigned duties and allows those with more severe 
conditions to immediately receive appropriate treatment.
    In addition, we learned that as we redeployed from OEF and 
OIF, that returning home from an operational deployment can be 
a stressor, not only for Marines, but for their family members. 
In response, in May 2003, we launched the Warrior Transition 
and Return and Reunion programs. These programs help Marines 
and their families cope with the stress of homecoming.
    Though we provide many prevention and treatment programs, 
we know that their success is dependent upon Marines 
confidently availing themselves of the support offered. As 
such, we consistently reassure Marines that the combat/
operational stress they are experiencing is not uncommon, and 
we urge use of available resources. We also emphasize that 
stress heals more quickly and completely if it is identified 
early and managed properly. With this in mind, over the past 2 
years we have greatly expanded our efforts to educate Marines 
and their family members about combat/operational stress 
control.
    To coordinate our efforts, we have established a Combat and 
Operational Stress Control (COSC) section in our Manpower and 
Reserve Affairs Department. The objectives of the Marine Corps' 
COSC program are to provide the tools to prevent, identify, and 
treat combat/operational stress injuries in war fighters and 
their family members before, during, and after deployment.
    To assist during the pre-deployment phase, Marine officers 
and staff NCOs are trained to prevent, identify, and manage 
stress injuries. Moreover, Marines are trained that stress is 
to be expected and how to monitor and manage personal stress 
levels. During deployment, in addition to OSCAR, there are 
mentorship programs and treatment services by chaplains.
    For our dedicated families who await the return of their 
Marine, we have counseling and referral services available 
through various venues. For example, the Key Volunteer Network 
supports the spouses of the unit Marines by providing official 
communications from the command about the welfare of the unit 
and other key status or information.
    We also have Marine Corps Community Services programs, and 
Military/MCCS One Source. Military/MCCS One Source is a 24/7/
365 information and referral tool for Marines and their 
families that provides counseling on virtually any issue they 
may face, from childcare to deployment stress to financial 
counseling.
    Additionally, in the case of mass casualties experienced by 
a command or unit, the Marine Corps' Critical Incident Stress 
management trained teams provide crisis management briefings to 
family members and friends of the command or unit. During 
crisis management briefings, Marine Corps personnel, chaplains, 
and Managed Health Network (MHN) counselors are available to 
provide information and answer questions concerning the 
casualties.
    MHN is an OSD-contracted support surge operation mechanism 
that allows us to provide augmentation counselors for our base 
counseling centers and primary support at sites around the 
country to address catastrophic requirements.
    After deployment, we help with readjustment by providing 
briefs for Marines and families on how to recognize problems 
and seek help, and by screening redeployed Marines for mental 
health problems. Marine officers and NCOs receive training 
close to the time of redeployment on the normal stress of 
readjusting to life in garrison and of reuniting with family 
members. They also are taught how to identify their Marines who 
are having problems, and how to get them help.
    We have begun screening all returned Marines and sailors 
for a wide variety of health problems after they have been back 
home for 90 to 180 days, and those who screen positive are 
evaluated and treated. Family members also receive redeployment 
stress briefs, including information about how to take care of 
their own stress as they reunite with their Marine spouses, and 
how to know whether their spouse is experiencing a stress 
problem that requires attention.
    To ensure COSC training participation, we have a system 
using the Marine Corps Total Force System for unit-level 
tracking by individual Marines during pre-deployment, re-
deployment, and post-deployment. We have also implemented the 
Department of Defense pre-deployment and post-deployment health 
assessments, which facilitates early identification and 
treatment of persistent stress problems.
    Another important component of COSC is our web-based 
information and referral too, the ``Leaders Guide to Managing 
Marines in Distress.'' The guide gives leaders the ability to 
help Marines at the point of greatest impact, Marine to Marine. 
It offers leaders, at all levels, information to resolve high-
risk problems faced by Marines that could be detrimental to 
personal and unit readiness.
    The faster and more effectively these problems are solved, 
the more time the individual and unit will have to focus on the 
mission. The guide is separated into 6 major categories: 
deployment, family, personal, harassment, substance use, and 
emotional. Within these categories, there are 16 main problem 
areas that include an overview of the problem, risk factors, 
why Marines may not seek help, prevention strategies, 
resources, and Marine Corps guidance. The guide can be accessed 
at http://www.usmc-mccs.org/leadersguide.
    The Marine Corps appreciates the Committee's attention to 
this important issue, and I commend your steadfastness in 
ensuring that servicemembers receive appropriate care in terms 
of both prevention of combat stress and treatment. I can assure 
you of the Marine Corps' commitment to the mental and emotional 
well-being of our force remains strong. We will continue to 
seek validation of our COSC program and closely interact with 
commands to capture lessons learned and best practices for 
future improvements and adjustments.
    Care for Injured Marines: The Marine Corps has a long 
history of caring for its fallen and injured Marines. Many of 
the Marines and sailors who have suffered extremely serious 
combat injuries would not have survived in previous wars. Due 
to improved combat equipment, forward-deployed trauma stations, 
and post-injury medical care, they are fortunately still with 
us.
    Nevertheless, their trauma still has a potentially 
devastating impact on them, their families, and their future. 
Therefore, the Marine Corps places top priority on the health 
care of our returning injured Marines.
    Marine Casualty Services: Marines who are seriously wounded 
in Iraq or Afghanistan, once stabilized, are ordinarily 
transported first to National Naval Medical Center (NNMC) in 
Bethesda, Maryland. Based on lessons learned from the treatment 
and processing of servicemembers injured during OIF/OEF, we 
established a Marine Casualty Services (MCS) patient 
administration team at that facility under the leadership of a 
Marine officer.
    MCS at Bethesda is a team of 27 professionals dedicated to 
assisting every admitted Marine. The team is composed of 
surgeons, mental health specialists, nurses, case management 
specialists, and a VA benefits coordinator. The team helps with 
all facets of the servicemembers' care--from assisting with 
family members' travel and lodging, to filing all appropriate 
claims for entitlements, to ensuring medical records are 
transferred in a timely fashion.
    They collaborate with the hospital staff, family members, 
and VA Medical Center staff on a daily basis to ensure a 
seamless transition of care and services. Intensive case 
management is a key component for post-discharge and follow-up 
care. Continued communication and coordination between the 
Marine Corps medical treatment facility case manager, Veterans 
Health Administration/DoD liaison, VA Medical Center OIF/OEF 
case manager, and the Marine for Life--Injured Support 
representative, is absolutely crucial as our injured Marines 
proceed through their recovery.
    To enhance continuity, clinical outcomes, and improve 
family support, the trauma team doctors at NNMC conduct weekly 
teleconferences with primary VA transfer sites. Because of the 
importance of the MCS, the Marine Corps has established teams 
at Andrews Air Force Base to meet all incoming medevac flights, 
a team at Walter Reed to provide onsite support for Marines 
receiving amputee rehabilitation, and personnel augmentation to 
the Joint Personnel Effects Division at Aberdeen. These teams 
remain actively involved with the day-to-day care of our 
injured Marines and do their best to support and advocate for 
our Marines and families even after they transfer to a VA 
Medical Center or other facility.
    Marine for Life--Injured Support is a formal program 
instituted by our Commandant to assist injured servicemembers 
and their families. The concept of Injured Support gives 
renewed meaning to ``Once a Marine, Always a Marine,'' and 
assures all Marines that they never truly leave the Corps.
    The goal of this program is to bridge the difficult gap 
between military medical care and transition to VA. The key is 
to ensure continuity of support through transition and, in 
combination with Office of the Secretary of Defense Military 
Severely Injured Center, to provide case management tracking 
for several years forward.
    As our injured Marines continue with their recovery, 
potentially transfer from active to veteran status, and 
assimilate back into their communities, Marine for Life--
Injured Support will be their greatest supporter and advocate. 
This program has been in operation since last January with 
features that include advocacy within both DoD and external 
agencies, assistance with military disability processing and 
physical evaluation boards, assistance with employment, and 
improved VA handling of healthcare and benefit cases.
    On average, 30 percent of our discharged injured Marines 
who have been contacted request and receive assistance. Injured 
Support representatives interact with Marine Casualty Services 
on a weekly basis to provide program information and contact 
numbers to hospitalized Marines and family members. Marine for 
Life--Injured Support is living proof of our motto--``Semper 
Fidelis.''
    Health Insurance Portability and Accountability Act 
(HIPAA): While the Marine Corps is not a keeper of 
servicemembers medical records, it wants to make sure that MCS 
and Marine for Life--Injured Support follow the law's mandates. 
As such, these personnel have received training from the NNMC 
HIPAA compliance specialist, as well as online follow-up 
training. Moreover, all injured Marines receiving healthcare at 
DOD and VA installations are counseled on their HIPAA rights 
and provided the necessary disclosure forms. In June 2005, DoD 
and VA signed a MOU on the sharing of information, called the 
HIPAA MOU.
    Transition Assistance: Our hope is that many of our injured 
Marines will be able to return to duty. Clearly, in many cases, 
this is not possible. Consequently, the Marine Corps and DoD, 
along with the help of VA, has developed several initiatives to 
assist servicemembers who, for whatever reason, transition back 
to civilian life.
    Seamless Transition Program: The Marine Corps is an active 
participant in the DoD/VA Joint Seamless Transition program. VA 
established the program in coordination with the services to 
facilitate and coordinate a more timely receipt of benefits for 
injured servicemembers while they are still on active duty.
    There are VA social workers and benefit counselors assigned 
at eight Military Treatment Facilities (MTFs) that serve the 
highest volume of severely injured servicemembers, including 
Walter Reed Army Medical Center and National Naval Medical 
Center in Bethesda. VA staff stationed at these MTFs brief 
servicemembers about the full range of VA benefits, including 
disability compensation claims and healthcare.
    They coordinate the transfer of care to VA Medical Centers 
near their homes, maintain follow-up with patients to verify 
success of the discharge plan, and ensure continuity of therapy 
and medications. These VA case managers also refer patients to 
VA benefits and vocational rehabilitation counselors. As of 
August 2005, more than 3,900 patients have received VA 
referrals at the participating military hospitals.
    In order to enhance the important value of the Seamless 
Transition program, the Marine Corps recently assigned two 
field grade officers to the VA Seamless Transition Office. This 
has facilitated better integration of Marine Corps and VA 
handling of servicemembers cases, involving both VA healthcare 
and benefits delivery. These liaisons, with the help of other 
Marine for Life--Injured Support counselors and VA liaisons, 
also help ensure that all documents needed by VA are gathered 
to begin VA processing.
    Many of the seriously injured Marines will already be under 
the VA umbrella for care and treatment by the time their case 
is finalized at the physical evaluation board. With the Marine 
liaisons officers at the VA Seamless Transition Office, injured 
servicemembers are now provided better case management 
oversight through the transition process to VA.
    In many instances, the Marine Corps has expedited a 
Marine's separation, making his or her eligible to receive 
compensation from VA in 30 days instead of the 60-plus days 
that was previously experienced. This Marine Corps effort has 
assisted not only Marines, but members of the other services, 
too.
    Transition Assistance Management Program: In addition to 
healthcare transition, the Marine Corps also focuses on 
assisting servicemembers in their transition from DoD's to VA's 
benefits system. Our Transition Assistance Management Program 
(TAMP) provides resources and assistance to enable separating 
Marines and their families to make a successful and seamless 
transition from military to civilian life.
    TAMP provides information and assistance on various 
transition topics, including: employment, education and 
training benefits, determining health and life insurance 
requirements, financial planning, the benefits of affiliating 
with the Marine Corps Reserves, and veterans benefits and 
entitlements.
    For our injured Marines, we provide TAMP services at a time 
and location to best suit their needs, whether at bedside at a 
military treatment facility or their home. In cases where the 
Marine is not in a condition to receive transition information 
but the family members are, assistance and services are 
provided to the family members. We have five full-time TAMP 
representatives at Marine Corps Base Hawaii who are prepared to 
help Marines at Tripler Army Medical Center one-on-one at their 
bedside.
    Transition services are available to all Marines and their 
family members who are within 12 months of separation or within 
24 months of retirement. On a space-available basis, separated 
Marines can attend workshops up to 180 days after their date of 
separation. Pre-separation counseling and the Transition 
Assistance Program workshops are mandatory for all separating 
Marines.
    Other services include: career coaching employment and 
training assistance; individual transition plan career 
assessment; financial planning instruction in resume 
preparation, cover letter, and job applications; job analysis, 
search techniques, preparation, and interview techniques; 
Federal employment application information; information on 
Federal, State, and local programs providing assistance; 
veterans benefits; and the Disabled Transition Assistance 
Program.
    In conclusion, severe injury has a traumatic impact on our 
Marines and their families. Not only are life and death at 
stake, but there are also significant disruptions to family 
systems for months and years to come. The Marine and his or her 
family will find themselves navigating new territory and facing 
possibly some of the greatest challenges of their lives.
    Without a doubt, taking care of our wounded servicemembers 
and their families is one of the Marine Corps' top priorities. 
It is why we tackle mental and physical health issues before, 
during, and after deployments. The goal is for our Marines to 
get the information, services, resources, and assistance they 
need to be self-sufficient, contributing members of their 
communities.
    On behalf of all the selfless, dedicated men and women who 
serve in our Armed Forces, I thank this Committee for your 
continued support during these demanding times. I want to 
specifically thank you for the recent Traumatic SGLI program. 
The idea began with this Committee and, without your efforts, 
would not be law today.
    The Department of Defense, Department of Veterans Affairs, 
and all of the individual services are committed to keeping the 
treatment, recovery, and transition of our injured as their 
highest priority. As challenges arise, they will be addressed 
and resolved, and best practices will be instituted as they are 
developed. We must continue to partner and communicate to 
ensure the transition process is a positive one, helping our 
veterans to face this next phase of their lives with optimism 
and confidence.
    Again, I thank the Committee for its unwavering support.
    [The prepared statement of Lieutenant General Osman 
follows:]

Prepared Statement of Lieutenant General H.P. (Pete) Osman, U.S. Marine 
           Corps, Deputy Commandant for Manpower and Reserve

    Mr. Chairman, Senator Akaka, and distinguished Members of the 
Committee, I am grateful for this opportunity to appear before you 
today to discuss the interaction between the Marine Corps, DOD and the 
Department of Veterans Affairs (VA) to care and support for our 
returning servicemembers, including those from the State of Hawaii.
     The State of Hawaii has been the source of great help to the 
Marine Corps in the Global War on Terrorism (GWOT). Marine Corps Base 
Hawaii, including the Kaneohe Bay and Camp H.M. Smith installations, is 
home to over 16,000 Marines, Sailors, family members, and Marine Corps 
civilian employees. Tripler Army Medical Center in Honolulu is also an 
important facility for the Marine Corps, currently providing medical 
care to several injured Marines. The Spark M. Matsunaga VA Medical 
Center and Oahu VA health care clinic are also resources for our 
injured servicemembers. The State of Hawaii has also witnessed its 
share of casualties and injuries during GWOT, with 2 Marines with 
Hawaii homes of record killed in combat and 9 others injured. The 
Marine Corps is highly focused on caring for these and all injured 
Marines, ensuring that their family members are provided for and 
comforted in the wake of their injury, and, when necessary, assisting 
with their transition to civilian life.
     Supporting injured Marines and their families is a complex task. 
We do our best to tailor our support to fit their individual needs. 
This support comes from numerous Marine Corps initiatives designed to 
promote and provide treatment for the mental and physical well being of 
all servicemembers and their families. These include community-based 
services, buddy care, non-medical support resources, chaplains, morale, 
recreation, and welfare programs, and the full spectrum of clinical 
care and patient movement of the Military Health System. There are also 
many joint VA-DOD programs whose goal is to help injured servicemembers 
transition from DoD to VA health care, convert from DoD to VA benefits 
systems, improve VA-DoD sharing of personnel and health care 
information, and to otherwise assist servicemembers who, for whatever 
reason, are transitioning to civilian life.
     Today, I'd like to touch upon several programs, many of which are 
the result of lessons learned from the Marine Corps' central role in 
Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF). 
Many of these programs involve close communication and joint effort 
with VA. All of these programs are available to all Marines, including 
those stationed here in Hawaii; many have program liaisons based at 
Marine Corps Base Hawaii.

                COMBAT/OPERATIONAL STRESS CONTROL (COSC)

    Military leaders and medical professionals realize that many 
deployed servicemembers experience combat stress and that it affects 
some individuals more than others. The stress of current operations has 
affected not only those Marines deployed to a war zone, but also those 
remaining in garrison and their family members. To maintain the 
readiness of the Marine Corps as a war fighting force, we remain 
vigilant in watching our young, expeditionary, and vigorous members for 
signs of distress and effectively manage operational stress at every 
level. The goal of this effort is to provide pre-deployment training, 
assistance when the stress is occurring, and post-combat monitoring and 
assistance to identify mental health problems early so they will have 
the best chance of healing completely.
    Since the Marine Corps crossed the line of departure into Iraq in 
March 2003, we have continuously developed and improved our operational 
stress control programs based upon lessons learned. For example, in 
January 2004, we launched the Operational Stress Control and Readiness 
(OSCAR) program, which embeds mental health professionals with ground 
units. OSCAR has been successful in helping Marines deal with the acute 
stress of combat. It also keeps Marines with low-level problems at 
their assigned duties and allows those with more severe conditions to 
immediately receive appropriate treatment. In addition, we learned that 
as we redeployed from OEF and OIF, that returning home from an 
operational deployment can be a stressor, not only for Marines, but for 
their family members. In response, in May 2003, we launched the Warrior 
Transition and Return and Reunion Programs. These programs help Marines 
and their families cope with the stress of homecoming.
    Though we provide many prevention and treatment programs, we know 
that their success is dependent upon Marines confidently availing 
themselves of the support offered. As such, we consistently reassure 
Marines that the combat/operational stress they are experiencing is not 
uncommon, and we urge use of available resources. We also emphasize 
that stress heals more quickly and completely if it is identified early 
and managed properly. With this in mind, over the past 2 years we have 
greatly expanded our efforts to educate Marines and their family 
members about combat/operational stress control.
    To coordinate our efforts, we have established a Combat and 
Operational Stress Control (COSC) section in our Manpower and Reserve 
Affairs Department. The objectives of the Marine Corps' COSC program 
are to provide the tools to prevent, identify, and treat combat/
operational stress injuries in war fighters and their family members 
before, during, and after deployment.
    To assist during the pre-deployment phase, Marine Officers and 
staff NCOs are trained to prevent, identify, and manage stress 
injuries. Moreover, Marines are trained on the stressors to be expected 
and how to monitor and manage personal stress levels. During 
deployment, in addition to OSCAR, there are mentorship programs and 
treatment services by Chaplains. For our dedicated families who await 
the return of their Marine, we have counseling and referral services 
available through various venues. For example, the Key Volunteer 
Network supports the spouses of the unit Marines by providing official 
communication from the Command about the welfare of the unit and other 
key status or information. We also have Marine Corps Community Services 
programs, and Military/MCCS One Source. Military/MCCS One Source is a 
24/7/365 information and referral tool for Marines and their families 
that provides counseling on virtually any issue they may face, from 
childcare to deployment stress, to financial counseling.
    Additionally, in the case of mass casualties experienced by a 
command/unit, the Marine Corps' Critical Incident Stress management 
trained teams provide crisis management briefings to family members and 
friends of the command/unit. During crisis management briefings, Marine 
Corps personnel, Chaplains, and Managed Health Network (MHN) counselors 
are available to provide information and answer questions concerning 
the casualties. MHN is an OSD-contracted support surge operation 
mechanism that allows us to provide augmentation counselors for our 
base counseling centers and primary support at sites around the country 
to address catastrophic requirements.
    After deployment, we help with readjustment by providing briefs for 
Marines and families on how to recognize problems and seek help, and by 
screening redeployed Marines for mental health problems. Marine 
officers and NCOs receive training close to the time of redeployment on 
the normal stress of readjusting to life in garrison and of reuniting 
with family members. They also are taught how to identify their Marines 
who are having problems, and how to get them help. We have begun 
screening all returned Marines and sailors for a wide variety of health 
problems after they have been back home for 90-180 days, and those who 
screen positive are evaluated and treated. Family members also receive 
redeployment stress briefs, including information about how to take 
care of their own stress as they reunite with their Marine spouses, and 
how to know whether their spouse is experiencing a stress problem that 
requires attention.
     To ensure COSC training participation, we have a system using the 
Marine Corps Total Force System for unit-level tracking by individual 
Marines during pre-deployment, re-deployment, and post-deployment. We 
have also implemented the Department of Defense pre-deployment and 
post-deployment health assessments, which facilitates early 
identification and treatment of persistent stress problems.
    Another important component of COSC is our web-based information 
and referral tool, the ``Leaders Guide to Managing Marines in 
Distress.'' The guide gives leaders the ability to help Marines at the 
point of greatest positive impact: Marine-to-Marine. It offers leaders 
at all levels information to resolve high-risk problems faced by 
Marines that could be detrimental to personal and unit readiness. The 
faster and more effectively these problems are solved, the more time 
the individual and unit will have to focus on the mission. The guide is 
separated into six major categories: deployment, family, personal, 
harassment, substance use, and emotional. Within these categories, 
there are 16 main problem areas that include an overview of the 
problem, risk factors, why Marines may not seek help, prevention 
strategies, resources, and Marine Corps guidance. The guide can be 
accessed at http://www.usmc-mccs.org/leadersguide.
    The Marine Corps appreciates the Committee's attention to this 
important issue, and I commend your steadfastness in ensuring that 
servicemembers receive appropriate care, in terms of both prevention of 
combat stress and treatment. I can assure you the Marine Corps' 
commitment to the mental and emotional well-being of our force remains 
strong. We will continue to seek validation of our COSC program and 
closely interact with Commands to capture lessons learned and best 
practices for future improvements and adjustments.

                        CARE FOR INJURED MARINES

    The Marine Corps has a long history of caring for its fallen and 
injured Marines. Many of the Marines and Sailors who have suffered 
extremely serious combat injuries would not have survived in previous 
wars. Due to improved combat equipment, forward-deployed trauma 
stations, and post-injury medical care, they are fortunately still with 
us. Nevertheless, their trauma still has a potentially devastating 
impact on them, their families and their future. Therefore, the Marine 
Corps places top priority on the health care of our returning, injured 
Marines.
     Marine Casualty Services. Marines who are seriously wounded in 
Iraq or Afghanistan, once stabilized, are ordinarily transported first 
to National Naval Medical Center (NNMC) in Bethesda, MD. Based on 
lessons learned from the treatment and processing of servicemembers 
injured during OIF/OEF, we established a Marine Casualty Services (MCS) 
patient administration team at that facility under the leadership of a 
Marine officer. MCS at Bethesda is a team of 27 professionals dedicated 
to assisting every admitted Marine. The team is composed of surgeons, 
mental health specialists, nurses, case management specialists, and a 
VA benefits coordinator. The team helps with all facets of the 
servicemembers's care--from assisting with family members' travel and 
lodging, to filing all appropriate claims for entitlements, to ensuring 
medical records are transferred in a timely fashion. They collaborate 
with the hospital staff, family members and VA Medical Center staff on 
a daily basis in order to ensure a seamless transition of care and 
services. Intensive case management is a key component for post 
discharge and follow-up care. Continued communication and coordination 
between the Marine Corps Medical Treatment Facility Case Manager, 
Veterans Health Administration-DoD Liaison, VA Medical Center OEF/OIF 
Case Manager, and the Marine for Life--Injured Support representative, 
is absolutely crucial as our injured proceed through their recovery. To 
enhance continuity, clinical outcomes, and improve family support, the 
trauma team doctors at NNMC conduct weekly teleconferences with primary 
VA transfer sites. Because of the importance of the MCS, the Marine 
Corps has established teams at Andrews Air Force Base to meet all 
incoming medevac flights, a team at Walter Reed to provide onsite 
support for Marines receiving amputee rehabilitation, and personnel 
augmentation to the Joint Personal Effects Division at Aberdeen. These 
teams remain actively involved with the day to day care of our injured 
Marines and do their best to support and advocate for our Marines and 
families even after they transfer to a VA Medical Center or other 
facility.
    Marine for Life--Injured Support. Marine for Life--Injured Support 
is a formal program instituted by our Commandant to assist injured 
servicemembers and their families. The concept of Injured Support gives 
renewed meaning to ``Once a Marine, Always a Marine'' and assures all 
Marines that they never truly leave the Corps. The goal of this program 
is to bridge the difficult gap between military medical care and 
transition to VA. The key is to ensure continuity of support through 
transition and, in combination with Office of the Secretary of Defense 
Military Severely Injured Center, to provide case management tracking 
for several years forward. As our injured Marines continue with their 
recovery, potentially transfer from active to veteran status, and 
assimilate back into their communities, Marine for Life--Injured 
Support will be their greatest supporter and advocate. This program has 
been in operation since last January with features that include 
advocacy within both DoD and external agencies, assistance with 
military disability processing and physical evaluation boards, 
assistance with employment, and improved VA handling of health care and 
benefit cases. On average, 30 percent of our discharged injured Marines 
who have been contacted request and receive assistance. Injured Support 
representatives interact with Marine Casualty Services on a weekly 
basis to provide program information and contact numbers to 
hospitalized Marines and family members. Marine for Life--Injured 
Support is living proof of our motto--``Semper Fidelis.''
    Health Insurance Portability and Accountability Act (HIPAA). While 
the Marine Corps is not a keeper of servicemembers medical records, it 
wants to make sure that MCS and Marine For Life--Injured Support 
follows the law's mandates. As such, these personnel have received 
training from the NNMC HIPAA Compliance Specialist, as well as online 
follow-up training. Moreover, all injured Marines receiving health care 
at DoD and VA installations are counseled on their HIPAA rights and 
provided the necessary disclosure forms. In June 2005, DoD and VA 
signed MOU on the sharing of medical information, called the ``HIPAA 
MOU.''

                         TRANSITION ASSISTANCE

    Our hope is that many of our injured Marines will be able to return 
to duty. Clearly, in many cases, this is not possible. Consequently, 
the Marine Corps and DoD, along with the help of VA, has developed 
several initiatives to assist servicemembers who, for whatever reason, 
transition back to civilian life.
    Seamless Transition Program. The Marine Corps is an active 
participant in the DoD-VA Joint Seamless Transition program. VA 
established the program in coordination with the services to facilitate 
and coordinate a more timely receipt of benefits for injured 
servicemembers while they are still on active duty. There are VA social 
workers and benefit counselors assigned at eight Military Treatment 
Facilities (MTFs) that serve the highest volumes of severely injured 
servicemembers, including Walter Reed Army Medical Center and National 
Naval Medical Center in Bethesda. VA staff stationed at these MTFs 
brief servicemembers about the full range of VA benefits including 
disability compensation claims and health care. They coordinate the 
transfer of care to VA Medical Centers near their homes, maintain 
follow-up with patients to verify success of the discharge plan and 
ensure continuity of therapy and medications. These VA case managers 
also refer patients to VA benefits and vocational rehabilitation 
counselors. As of August 2005, more than 3,900 patients have received 
VA referrals at the participating military hospitals.
     In order to enhance the important value of the Seamless Transition 
program, the Marine Corps recently assigned two field grade officers to 
the VA Seamless Transition Office. This has facilitated better 
integration of Marine Corps and VA handling of servicemembers cases, 
involving both VA health care and benefits delivery. These liaisons, 
with the help of other Marine for Life--Injured Support counselors and 
VA liaisons, also help ensure that all documents needed by VA are 
gathered to begin VA processing.
    Many of the seriously injured Marines will already be under the VA 
umbrella for care and treatment by the time their case is finalized at 
the physical evaluation board. With the Marine Liaison Officers at the 
VA Seamless Transition Office, injured servicemembers are now provided 
better case management oversight throughout the transition process to 
VA. In many instances, the Marine Corps has expedited a Marine's 
separation, making them eligible to receive compensation from VA in 30 
days instead of the 60+ days that was previously experienced. This 
Marine Corps effort has assisted not only Marines, but members of the 
other services too.
    Transition Assistance Management Program. In addition to health 
care transition, the Marine Corps also focuses on assisting 
servicemembers in their transition from DoD's to VA's benefits system. 
Our Transition Assistance Management Program (TAMP) provides resources 
and assistance to enable separating Marines and their families to make 
a successful and seamless transition from military to civilian life. 
TAMP provides information and assistance on various transition topics, 
including: employment, education and training benefits, determining 
health and life insurance requirements, financial planning, the 
benefits of affiliating with the Marine Corps Reserves, and veteran's 
benefits and entitlements. For our injured Marines, we provide TAMP 
services at a time and location to best suit their needs, whether at 
bedside at a military treatment facility or their home. In cases where 
the Marine is not in a condition to receive transition information, but 
the family members are, assistance and services are provided to the 
family member. We have 5 full-time TAMP representatives at Marine Corps 
Base Hawaii, who are prepared to help Marines at Tripler Army Medical 
Center one-on-one at their beside.
     Transition services are available to all Marines and their family 
members who are within 12 months of separation or within 24 months of 
retirement. On a space-available basis, separated Marines can attend 
workshops up to 180 days after their date of separation. Pre-separation 
counseling and the Transition Assistance Program workshops are 
mandatory for all separating Marines. Other services include:
     Career Coaching Employment and training assistance
     Individual Transition Plan Career assessment
     Financial planning Instruction in resume preparation, 
cover letter, and job applications
     Job analysis, search techniques, preparation and interview 
techniques
     Federal employment application information
     Information on Federal, State, and local programs 
providing assistance
     Veteran's benefits
     Disabled Transition Assistance Program

                               CONCLUSION

    Severe injury has a traumatic impact on our Marines and their 
families. Not only are life and death at stake, but there are also 
significant disruptions to family systems for months and years to come. 
The Marine and his or her family will find themselves navigating new 
territory and facing possibly some of the greatest challenges of their 
lives. Without a doubt, taking care of our wounded servicemembers and 
their families is one of the Marine Corps' top priorities. It is why we 
tackle mental and physical health issues before, during, and after 
deployments. The goal is for our Marines to get the information, 
services, resources and assistance they need to be self-sufficient, 
contributing members of their communities.
     On behalf of all the selfless, dedicated men and women who serve 
in our Armed Forces, I thank this Committee for your continued support 
during these demanding times. I want to specifically thank you for the 
recent Traumatic SGLI program. The idea began with this Committee and, 
without your efforts, would not be law today.
     The Department of Defense, Department of Veterans Affairs, and all 
of the individual services are committed to keeping the treatment, 
recovery and transition of our injured as their highest priority. As 
challenges arise, they will be addressed and resolved, and best 
practices will be instituted as they are developed. We must continue to 
partner and communicate to ensure the transition process is a positive 
one, helping our veterans to face this next phase of their lives with 
optimism and confidence.
    Again, I thank the Committee for its unwavering support.

    Senator Akaka. Thank you, General Osman.
    General Mixon.

   STATEMENT OF MAJOR GENERAL BENJAMIN R. MIXON, U.S. ARMY, 
 COMMANDING GENERAL, 25TH INFANTRY DIVISION (LIGHT), SCHOFIELD 
                        BARRACKS, HAWAII

    General Mixon. Mr. Chairman, Senator Akaka, and 
distinguished Members of the Committee, thank you for inviting 
me to testify. We at the 25th Infantry Division appreciate the 
opportunity to discuss the transition of our soldiers from 
active, Reserve, and National Guard duty to veterans status, an 
issue that is very important to us.
    The 25th Infantry Division has had over 1,700 leave the 
military honorably over the past 6 months. We have found that 
these departed soldiers have had various degrees of interaction 
with VA, with most of the interaction being extremely helpful 
to both the soldier and the family members of the veterans. The 
most influential programs we've seen working are for soldiers 
who return early from deployment due to injury or illness, and 
soldiers who are medically discharged from the Army.
    There are programs such as the Deployment Cycle Support 
process where the soldiers returning from deployment with their 
unit receive information about VA, and programs to inform 
separating soldiers and retirees within 180 days of discharge 
of their VA benefits and disability claim abilities through the 
Army Career and Alumni Program (ACAP) and the VA Benefits 
Delivery at Discharge (BDD) program. The ACAP and BDD programs 
inform all separating or retiring soldiers of their VA benefits 
due to their honorable service, including medical disability 
claims.
    The VA Pacific Islands has a very thorough system in place 
for Army veterans who separate or retire from the 25th. 
Separating soldiers participate in the ACAP and BDD processes, 
where they are briefed by a representative from the VA on all 
VA programs available to them.
    Following the briefing, every separating or retiring 
soldier is linked up with both a VA disability and a healthcare 
representative, who sit down with the soldier and his or her 
medical records to discuss all the available options. The VA 
representative goes page by page through the servicemembers's 
records to inform the soldier of any possible benefits that he 
or she can apply for from the VA.
    Servicemembers can file their claims while still on active 
duty as long as they are within 180 days of separating or 
retiring. If they are not able to file a claim within that 
window, they can file their claim after they retire at the VA 
Regional Office closest to their residence. The VA immediately 
processes claims of service men and women who are still on 
active duty through the BDD program, so the VA encourages 
soldiers to file their claims as close as possible to within 
180 days of discharge, with the goal to complete their claim 
prior to discharge.
    Servicemembers are finding a majority of the portions of 
the VA BDD process efficient while other segments, such as 
final electronic cycle input of VA disabilities following a 
decision with award of compensation benefits, are slowing the 
process of receiving a disability check in conjunction with a 
retirement check.
    One upcoming retiree said initiating his claim was very 
efficient; someone called him within a week of putting in his 
paperwork. This is considerably faster than it would have been 
had he not submitted his claim for benefits until after he had 
been discharged. It then took a month for him to see a VA 
doctor to assess his injuries which he received while still on 
active duty. He presently is still on active duty and waiting 
for VA to certify his claim so he can receive disability after 
retirement.
    The overwhelming significance of the 25th Infantry Division 
working with the VA to assist in the transition of the soldiers 
and their families into civilian life and VA care and benefits 
is twofold. First, the claims are processed much faster while 
the soldier is on active duty, with decisions of benefits made 
in almost two-thirds less time than it takes for claims 
processed after departure from service. Second, the up-front 
knowledge of available VA programs and benefits can be a key 
decisionmaker for the soldier and his or her family of how to 
use these benefits immediately following discharge, and how to 
program their transition into a new lifestyle, based on 
available VA benefits.
    Twenty-fifth Infantry Division soldiers who return early 
from deployment due to illness or injury receive assistance 
from the Tripler Managed Care Division and the recently formed 
Patient Family Assistance Team. These services provide the 
servicemembers with everything from medical care to financial 
services. The Patient Family Assistance Team was organized in 
2004 by Tripler Army Medical Center and has been very 
successful thus far in aiding our troops.
    The team has social workers, a physician, a VA benefits 
representative, liaisons with other military care facilities 
across the world, and a presiding officer who is the Chief of 
Patient Administration. The team also helps coordinate travel 
for dependents, personal and specialized care, housing, and 
financial services for each soldier.
    The VA benefits representative became a great liaison 
between the VA Vet Center and Department of Army, helping 
facilitate direct counseling referrals for dependents of those 
killed and service men and women suffering with symptoms of 
post-traumatic stress disorder.
    This VA team member also plays a crucial role in 
facilitating a seamless transition of care between the military 
behavioral health staff and the VHA mental health professionals 
who are helping provide care to the numerous soldiers suffering 
from emotional trauma caused by combat. The VA social work 
staff has trained military personnel, and at times provided 
direct care for soldiers dealing with drug and alcohol abuse.
    The Tripler Managed Care Division provides a case manager 
to each soldier. The case manager is an activated National 
Guard registered nurse who has successfully completed the case 
manager course and is on orders to Tripler Army Medical Center 
for this purpose. There are about 250 medical cases the Managed 
Care Division handles, with a ratio of approximately 1 case 
manager for 50 active duty soldiers.
    The ratio is approximately 1 to 35 for Hawaii National 
Guard and Reservists who return to the island due to the fact 
that their care will most likely be longer term on the island, 
as opposed to active component soldiers moving back to the 
mainland for various reasons.
    The case managers have daily interaction with soldiers and 
meet twice a month with the Patient Family Assistance Team to 
discuss any changes to or new benefits for soldiers to pass 
along information. The case managers direct the soldiers to the 
VA office in the hospital to make sure they get registered. 
They explain to the soldiers individually, based on their 
specific circumstances, the programs and benefits that apply to 
them and for which they are eligible.
    One of the most important actions case managers take is 
ensuring no soldier leaves the hospital without the proper line 
of duty paperwork that is critical for future care and 
disability payments for which they may want to apply. The 
Managed Care Division also has a contracted social worker who 
is accustomed to working with soldiers who do not want to seek 
mental health or post-traumatic health treatment from military 
physicians.
    Soldiers returning from deployment on schedule with their 
unit all must go through a reverse soldier readiness process in 
which they complete paperwork documenting their return from 
deployment, undergo a mental health screening, financial and 
housing processing, and other readiness items. One of the 
booths they must stop at has a health benefits advisor who 
gives them informational pamphlets on veterans assistance and 
TRICARE.
    In order for soldiers to complete their reverse soldier 
readiness process, they must have the health benefits advisor's 
signature on their paperwork signifying they received the 
information. We have realized that many soldiers do not take 
the time to read this valuable information; their focus is 
solely on completing all re-deployment tasks and enjoying being 
home.
    To better inform soldiers of their VA benefits, they attend 
various briefings and appointments on the third day of this 
process, after their 72-hour pass, to help them adjust to being 
back in Hawaii and in a garrison environment, and to help them 
get appointments for housing, finance, and vehicle pickup. On 
this day of briefings, one of them is given by a VA 
representative. The briefing is extremely informative and gives 
the soldiers all the information and points of contact 
necessary to use the VA.
    Soldiers who may be medically discharged undergo a 
different process. They will first receive a permanent profile, 
documenting their permanent injury and/or illness. As soon as 
they receive this profile, they are required to attend a 
division and medical briefing to begin the medical board 
process, which ultimately will determine fitness for duty.
    At the medical brief, they are informed about the VA 
programs and benefits they are entitled to and are referred to 
VA employees for benefit counseling and to complete benefit 
applications. This is especially significant for those who are 
eligible and need disability compensation. Some soldiers are 
referred to the VA's Vocational Rehabilitation Division where 
they receive contact vocational educational counseling.
    The VA in Hawaii is doing tremendous things for the 25th 
Infantry Division and U.S. Army Hawaii soldiers. They provide 
extremely knowledgeable counselors and case managers to help 
every individual who returns from war and those who are 
retiring after a lifetime of service to the Nation. The 
soldiers in the 25th Infantry Division and U.S. Army Hawaii are 
fortunate to have such a dedicated staff at the Hawaii VA who 
are continually developing and improving their programs to 
better support our servicemembers.
    [The prepared statement of Major General Mixon follows:]

   Prepared Statement of Major General Benjamin R. Mixon, U.S. Army, 
           Commanding General, 25th Infantry Division (Light)

    Mr. Chairman and distinguished Members of the Committee:
    Thank you for inviting me to testify. We at the 25th Infantry 
Division appreciate the opportunity to discuss the transition of our 
Soldiers from Active, Reserve, and National Guard duty to veterans' 
status, an issue that is very important to us.
    The 25th Infantry Division has had over 1700 Soldiers leave the 
military honorably over the past 6 months. We have found that these 
departed Soldiers have had various degrees of interaction with Veterans 
Affairs (VA), with most of the interaction being extremely helpful to 
both the Soldier and the family members of the veterans. The most 
influential programs we've seen working are for Soldiers who return 
early from deployment due to injury or illness, and Soldiers who are 
medically discharged from the Army. There are programs such as the 
Deployment Cycle Support process where the Soldiers returning from 
deployment with their unit receive information about VA, and programs 
to inform separating soldiers and retirees within 180 days of discharge 
of their VA benefits and disability claim abilities through the Army 
Career and Alumni Program (ACAP), and the VA Benefits Delivery at 
Discharge (BDD) program. The ACAP and BDD programs inform all 
separating/ retiring soldiers of their VA benefits due to their 
honorable service, including medical disability claims.
    The VA Pacific Islands has a very thorough system in place for Army 
veterans who separate or retire from the 25th. Separating soldiers 
participate in the ACAP and BDD processes, where they are briefed by a 
representative from the VA on all VA programs available to them. 
Following the briefing, every separating/ retiring solder is linked up 
with both a VA disability and healthcare representative, who sit down 
with the Soldier and his or her medical records to discuss all the 
available options. The VA representative goes page by page through the 
servicemembers' records to inform the Soldier of any possible benefits 
that he/she can apply for from the VA. Servicemembers can file their 
claims while still on active duty, as long as they are within 180 days 
of separating or retiring. If they are not able to file a claim within 
that window, they can file their claim after they retire at the VA 
Regional Office closest to their residence. The VA immediately 
processes claims of servicemen and women who are still on active duty 
through the BDD program, so the VA encourages Soldiers to file their 
claims as close as possible to within 180 days of discharge, with the 
goal to complete their claim prior to discharge.
    Servicemembers are finding a majority of the portions of the VA BDD 
process efficient while other segments, such as final electronic cycle 
input of VA disabilities following a decision with award of 
compensation benefits, are slowing the process of receiving a 
disability check in conjunction with a retirement check. One upcoming 
retiree said initiating his claim was very efficient; someone called 
him within a week of putting in his paperwork. This is considerably 
faster than it would have been had he not submitted his claim for 
benefits until after he had been discharged. It then took a month for 
him to see a VA doctor to assess his injuries which he received while 
still on active duty. He presently is still on active duty and waiting 
for VA to certify his claim so he can receive disability after 
retirement.
    The overwhelming significance of the 25th Infantry Division working 
with the VA to assist in the transition of the Soldiers and their 
families into civilian life, and VA care and benefits is twofold: 
First, the claims are processed much faster while the Soldier is on 
active duty, with decisions of benefits made in almost two thirds less 
time than it takes for claims processed after departure from service. 
Second, the upfront knowledge of available VA programs and benefits can 
be a key decisionmaker for the Soldier and his/her family of how to use 
these benefits immediately following discharge, and how to program 
their transition into a new life style, based on available VA benefits.
    25th ID Soldiers who return early from deployment due to illness or 
injury receive assistance from the Tripler Managed Care Division and 
the recently formed Patient Family Assistance Team (PFAT). These 
services provide the servicemembers with everything from medical care 
to financial services. The Patient Family Assistance Team was organized 
in 2004 by Tripler Army Medical Center and has been very successful 
thus far in aiding our troops. The team has social workers, a 
physician, a VA benefits representative, liaisons with other military 
care facilities across the world, and a presiding officer who is the 
Chief of Patient Administration (PAD). The team also helps coordinate 
travel for dependents, personal and specialized care, housing, and 
financial services for each Soldier. The VA benefits representative 
became a great liaison between the VA Vet Center and Department of Army 
(DA) helping facilitate direct counseling referrals for dependents of 
those killed and servicemen and women suffering with symptoms of Post 
Traumatic Stress Disorder (PTSD). This VA team member also plays a 
crucial role in facilitating a seamless transition of care between the 
military behavioral health staff and the VHA Mental Health 
professionals who are helping provide care to the numerous Soldiers 
suffering from emotional trauma caused by combat. The VA Social Work 
staff has trained military personnel, and at times provided direct care 
for Soldiers dealing with drug and alcohol abuse. The Tripler Managed 
Care Division provides a Case Manager to each Soldier.
    The Case Manager is an activated National Guard Registered Nurse 
(RN) who has successfully completed the Case Manager course and is on 
orders to Tripler Army Medical Center for this purpose. There are about 
250 medical cases the Managed Care Division handles, with a ratio of 
approximately 1 Case Manager for 50 active duty Soldiers. The ratio is 
approximately 1 to 35 for Hawaii National Guard and Reservists who 
return to the island due to the fact that their care will most likely 
be longer term on the island as opposed to active component Soldiers 
moving back to the mainland for various reasons. The Case Managers have 
daily interaction with Soldiers and meet twice a month with the Patient 
Family Assistance Team to discuss any changes to or new benefits for 
Soldiers and to pass along information. The Case Managers direct the 
Soldiers to the VA office in the hospital to make sure they get 
registered. They explain to the Soldiers individually, based on their 
specific circumstances, the programs and benefits that apply to them 
and for which they are eligible. One of the most important actions Case 
Managers take is ensuring no Soldier leaves the hospital without the 
proper Line of Duty paperwork that is critical for future care and 
disability payments for which they may want to apply. The Managed Care 
Division also has a contracted social worker who is accustomed to 
working with Soldiers who do not want to seek mental health or post 
traumatic health treatment from military physicians.
    Soldiers returning from deployment on schedule with their unit all 
must go through a reverse Soldier Readiness Process in which they 
complete paperwork documenting their return from deployment, undergo a 
mental health screening, financial and housing processing, and other 
readiness items. One of the booths they must stop at has a Health 
Benefits Advisor who gives them informational pamphlets on Veteran's 
Assistance and TRICARE. In order for Soldiers to complete their reverse 
Soldier Readiness Process, they must have the Health Benefits Advisor's 
signature on their paperwork signifying they received the information. 
We have realized that many Soldiers do not take the time to read this 
valuable information; their focus is solely on completing all 
redeployment tasks and enjoying being home. To better inform Soldiers 
of their VA benefits, they attend various briefings and appointments on 
the third day of this process, after their 72 hour pass, to help them 
adjust to being back in Hawaii and in a garrison environment, and to 
help them get appointments for housing, finance, and vehicle pick-up. 
On this day of briefings, one of them is given by a VA representative. 
The briefing is extremely informative and gives the Soldiers all the 
information and points of contact necessary to use the VA.
    Soldiers who may be medically discharged undergo a different 
process. They will first receive a permanent profile, documenting their 
permanent injury and/or illness. As soon as they receive this profile, 
they are required to attend a Division and medical briefing to begin 
the medical board process, which ultimately will determine fitness for 
duty. At the medical brief, they are informed about the VA programs and 
benefits they are entitled to and are referred to VA employees for 
benefit counseling and to complete benefit applications. This is 
especially significant for those who are eligible and need disability 
compensation. Some Soldiers are referred to the VA's Vocational 
Rehabilitation Division where they receive contact vocational 
educational counseling.
    The VA in Hawaii is doing tremendous things for 25th Infantry 
Division and US Army Hawaii Soldiers. They provide extremely 
knowledgeable counselors and case managers to help every individual who 
returns from war and those who are retiring after a lifetime of service 
to the Nation. The Soldiers in the 25th Infantry Division and US Army 
Hawaii are fortunate to have such a dedicated staff at the Hawaii VA 
who are continually developing and improving their programs to better 
support our servicemembers.

    Senator Akaka. Thank you, General Mixon.
    General Lee.

 STATEMENT OF MAJOR GENERAL ROBERT G.F. LEE, ADJUTANT GENERAL, 
                STATE OF HAWAII, DEPARTMENT OF 
                            DEFENSE

    General Lee. Chairman Craig, Senator Akaka, and Members of 
the Senate Committee on Veterans' Affairs, I am Major General 
Robert G.F. Lee, the Adjutant General for the State of Hawaii. 
Within the State Department of Defense, there are four major 
divisions: the Hawaii Army and Air National Guard, State Civil 
Defense, and the Office of Veterans' Services (OVS). The 
Director of the Office of Veterans' Services is Colonel (Ret.) 
Edward Cruickshank, who previously testified before this 
Committee.
    The Office of Veterans' Services is the single office in 
the State government responsible for the welfare of our 
veterans and their families. OVS serves as the liaison between 
Governor Linda Lingle and the veterans groups and 
organizations. They also act as an intermediary between the 
Department of Veterans Affairs and Hawaii's veterans.
    The Department of Veterans Affairs latest data, as of 
September 2004, shows there are 107,310 veterans in the State 
of Hawaii. Taking another view, this means that more than 10 
percent of our State's populations are veterans. The majority 
of them--about 72 percent--live on the island of Oahu, 13 
percent reside on the island of Hawaii, 10 percent live on one 
of the 3 islands that comprise Maui County, and about 5 percent 
live on the island of Kauai.
    Within this large veteran population, there are many World 
War II veterans, such as members of the famed 100th Battalion 
and the 442nd Regimental Combat Team. Prior to September 11, we 
faced a reduced veteran population due to the passing of many 
World War II veterans. Correspondingly, VA resources were also 
reduced.
    However, as the Global War on Terrorism kicks into high 
gear, we will now see an increased veteran population with the 
call-up of many Guard and Reserve units. Hawaii presents this 
situation on the high end of the spectrum. The reality is that 
90 percent of our Army National Guard in the State of Hawaii 
have been called to active duty for service in Iraq and 
Afghanistan.
    So the Hawaii Army National Guard stands about the highest 
in the Nation for the number of soldiers called up. Sir, the 
only major unit left that hasn't been called up is the band. 
And we have not only from Hawaii, but primarily our Polynesian 
Brigade Combat Team that have served in Iraq, and that's the 
major portion that's coming back right now.
    I'm glad that my colleague General Mixon covered the 
details of what happens to our soldiers. They're treated just 
like Army soldiers, go through the same process on the 
demobilization, and get all the benefits and the tie-ins with 
VA. And it's been a great partnership. We know personally all 
the people in VA that we work with, and I think we really have 
a great advantage in the State of Hawaii.
    But I think now that our partnership is going to be tested 
because earlier on, even in the two rotations in Afghanistan 
earlier on and one in Iraq, it has been mostly our aviation 
units that have gone first. But now we have the big bulk of the 
Brigade Combat Team coming back, and I just want to talk about 
two concerns that I have.
    One is as the soldiers return, and we're very happy to have 
that final physical, the clearance, to establish this baseline 
so we know what the baseline is at, their state of health when 
they leave the service. But what's been happening with a lot of 
Guard combat units nationwide is the report of PTSD 
subsequently.
    And I want to talk about the unit that--units from American 
Samoa and Saipan which we have our VA medical clinics not quite 
up and running with, and I'm not even sure in Saipan that we 
have that--that a lot of these soldiers, from their culture and 
the warrior culture is that to be brave and tough, we kind of--
we can suck it up.
    But I tell you, I've been receiving a lot of reports over 
the 1 year in Iraq where, thankfully, it's been a patrol run 
into another IED, treated for headache, and returned to duty. 
We've got real tough soldiers. But when will it occur that we 
find out that something is wrong with them?
    So we're doing a lot of post--at drills, and getting the 
families together, and keeping family readiness groups intact 
so that we can find out that something is wrong within the 
family and they need help. So primarily the concern is for our 
more remote soldiers, when they go on back, that some of this 
psychological care might not be as quickly administered.
    The second area is kind of an inequity in VA payments to 
the State of Hawaii to the families upon the death of a 
veteran. And in the interests of time, I'm just going to go 
with my written testimony. It's just that now with the 
Punchbowl being full, the State of Hawaii now bears the burden 
for many of the costs for burial of our veterans and the 
maintenance of the cemeteries.
    Thank you again very much for your support, Senator.
    [The prepared statement of Major General Lee follows:]

Prepared Statement of Major General Robert G.F. Lee, Adjutant General, 
                 State of Hawaii, Department of Defense

    Chairman Craig, Senator Akaka and Members of the Senate Committee 
on Veterans' Affairs, I am Major General Robert G. F. Lee, The Adjutant 
General for the State of Hawaii. Within the State Department of 
Defense, there are four major divisions: the Hawaii Army and Air 
National Guard, State Civil Defense and the Office of Veterans' 
Services (OVS). The Director of Office of Veterans' Service is Col 
(Ret) Edward Cruickshank who previously testified before this 
Committee.
    The Office of Veterans' Services (OVS) is the single office in the 
State government responsible for the welfare of our veterans and their 
families. OVS serves as the liaison between Governor Linda Lingle and 
the veterans groups and organizations. They also act as an intermediary 
between the Department of Veterans Affairs and Hawaii's veterans.
    The Department of Veterans Affairs' latest data, as of September 
2004, shows there are 107,310 veterans in the State of Hawaii. Taken 
another view, this means that more than 10 percent of our state's 
population are veterans. The majority of them--about 72 percent--live 
on the island of Oahu, 13 percent reside on the island of Hawaii, 10 
percent live on one of the three islands that comprise Maui County, and 
about 5 percent live on the island of Kauai.
    Within this large veteran population are many World War II 
veterans, such as members of the famed 100th Battalion and the 442nd 
Regimental Combat Team. Prior to Sept. 11 we faced a reduced veteran 
population due to the passing of many WWII veterans. Correspondingly, 
VA resources were also reduced. However, as the Global War on Terrorism 
kicks into high gear, we will now see an increased veteran population 
with the call up of many Guard and Reserve units. Hawaii presents this 
situation on the high end of spectrum. Nine of every ten soldiers in 
the Hawaii Army National Guard have been activated to serve in Iraq and 
Afghanistan. They served honorably and our largest unit, the 29th 
Brigade Combat Team, is returning to Hawaii after their yearlong 
deployments.
    We must insure our soldiers are certified that they are healthy 
before these new veterans return to their civilian lives. The Office of 
Veterans Services partners with the Veterans Administration here during 
the soldiers demobilization process. The major work in this partnership 
is still untested as we care for our new veterans in the follow on 
years.
    The United States government must take care of military members 
from enlistment, through their service years, to veterans' benefits and 
finally, death benefits. I come to you with two concerns.
    My first and most important concern is the Veterans Administration 
services to all of our mobilized soldiers that served in Iraq and 
Afghanistan, especially, our neighbor island veterans and other Pacific 
Islander veterans from Saipan and American Samoa. We must insure that 
all veterans receive the health care necessary to treat Post Traumatic 
Stress Disorder (PTSD), especially in the remote areas. The VA has mini 
clinics in the neighbor islands that can service our veterans. I am 
hopeful that resources will be available should we need to rapidly 
expand these clinics. I have serious concerns for our soldiers 
returning to American Samoa and Saipan where VA clinics do not exist.
    Another important part of VA care goes to the families upon the 
death of a veteran. Their burial shall be honorable with full military 
honors. I would like to point out inequities in this area for the State 
of Hawaii. The National Memorial Cemetery of the Pacific at Punchbowl 
is almost at capacity. There are no remaining burial plots at Punchbowl 
and they only accept inurnments. Inurnments will end in a few years as 
the existing columbarium becomes full. Veteran burials are now 
conducted at the State Veterans Cemetery in Kaneohe.
    Currently the Veterans Administration reimburses the State $300 per 
burial. The $300 stipend has been in existence for many years. The 
actual cost incurred by the State is $1,100. We are asking the Veterans 
Administration to increase the burial reimbursement and recommends an 
amount of $900 per burial. This will allow the State to cover most of 
our expenses.
    The National Cemetery of the Pacific at Punchbowl is a beautiful 
and well-kept facility. Punchbowl receives an annual budget of 
$2,000,000+ and a staff of 19 personnel to maintain its beauty. In 
comparison, the State Veterans Cemetery receives an annual budget of 
$500,000 and has a staff of 6 personnel to maintain the facility. The 
State's veterans cemetery is larger than Punchbowl.
    We believe the cost sharing of annual maintenance is appropriate 
and recommends a 40 percent Federal and 60 percent State split. This 
will allow the State to bring our Kaneohe facility up to the Punchbowl 
standard. We owe it to our deceased veterans and their families to have 
a beautiful, tranquil final resting place.
    I thank you for your time. Are there any questions?

    Senator Akaka. Thank you. Thank you, General Lee.
    [Applause.]
    Senator Akaka. Colonel Horn.

STATEMENT OF COLONEL MATTHEW HORN, DEPUTY COMMANDER, U.S. ARMY 
       RESERVE, COMMANDER, 9TH REGIONAL READINESS COMMAND

    Colonel Horn. Good morning, Senator Akaka, Members of the 
Committee. I'm Colonel Matthew Horn, and I'm the Deputy 
Commander of the 9th Regional Readiness Command, the 9th RRC. 
My commander, Brigadier General Ma, and I both appreciate the 
opportunity to testify before this Committee. General Ma's 
duties unfortunately require him to remain on the Island of 
Oahu this morning, but he sends his warm regards and his mahalo 
for all of the fine support that you've provided our soldiers 
and our veterans over the years.
    As you are probably aware, the 9th Regional Readiness 
Command is responsible for Army Reserve units in American 
Samoa, Guam, Saipan, Alaska, and Hawaii. Additionally, many of 
our members live and work in Japan, Korea, and other Pacific 
Rim countries. We are responsible for 3,400 soldiers serving 
proudly in the Pacific and other parts of the world. We refer 
to ourselves proudly as the Pacific Army Reserves.
    This morning I will limit my comments to the issue of 
returning 9th RRC Army Reserve veterans and the necessity for 
collaboration between the Department of Defense and the 
Veterans Health Administration to prepare for their future 
needs.
    The 9th RRC's Army Reserve soldiers are still early in the 
redeployment cycle. The 411th Engineer Battalion returned last 
summer. The 793rd Engineer Detachment has just returned to 
American Samoa. The 100th Battalion, 442nd Infantry is 
redeploying as we speak. The 322nd Civil Affairs Brigade is 
expected back next summer. The 1101st Garrison Support Unit 
will continue on active duty at Schofield Barracks until later 
this year.
    In addition to these larger units, many smaller units and 
portions of units and individuals have also been deployed. 
Additional units and soldiers of the 9th RRC are expected to be 
deployed some time next year and in future years.
    We have been--there have been approximately 1,030 9th RRC 
soldiers who have returned from active duty, and there are 
approximately 1,180 9th RRC soldiers still mobilized. So within 
a year, two-thirds of the Pacific-based 9th RRC will have 
served on active duty in support of the Global War on 
Terrorism. We are just beginning to learn about our returning 
soldiers' and future veterans' specific needs for veterans 
services.
    There are approximately 26 Army Reserve soldiers currently 
in the medical retention processing unit, the MRPU, on Oahu on 
continued active duty for evaluation and treatment of serious 
medical conditions. While assignment to the MRPU is for 179 
days with a possibility of extensions, we think it may be a 
while before these soldiers will need to assess what their VA 
needs will finally be.
    These 26 individuals possess the most severe medical 
conditions that have appeared among our soldiers to date. There 
are many other soldiers whose conditions may not yet have 
manifested themselves and may not do so for months or years.
    While it may be difficult to predict the exact numbers of 
types of conditions that may appear, we can anticipate seeing 
certain types of problems such as back and leg injuries, 
hearing injuries, perhaps post-traumatic stress disorders, 
based on the nature of the operations we've been involved in.
    Our latest returning group of soldiers, the 100th 
Battalion, has really been in the thick of things with the 29th 
Brigade Combat Team, and we anticipate that we may have more 
needs among this group of soldiers. The bottom line is while it 
may be too early at this point in the redeployment cycle to 
know exactly what our utilization rate of VHA services will be, 
we know that they will be greater.
    We should anticipate that the number of individuals needing 
these services in the Pacific region will very likely be 
greater than in previous years by the mere fact of our soldiers 
joining the ranks of veterans in the 9th RRC's area of 
operations.
    Again, while it may not be possible to predict the specific 
number of Army Reserve soldiers who will need to access VHA's 
services in the future, it is critical that we work with the 
VA, as we are, to ensure that we understand the processes and 
the procedures to enable our returning soldiers to receive care 
through the current VHA systems. Also, we must plan for our 
soldiers' needs throughout our entire area of operations, 
including our remotest locations in American Samoa and Saipan 
where resources are more limited.
    We look forward to working together with the Veterans 
Administration to care for these new veterans. I thank you 
again on behalf of General Ma and myself for all of the care 
that you have shown to our soldiers and our veterans. I'd be 
pleased later to answer any questions you may have.
    [The prepared statement of Colonel Horn follows:]

Prepared Statement of Colonel Matthew Horn, Deputy Commander, U.S. Army 
           Reserve, Commander, 9th Regional Readiness Command

    Good morning. I appreciate being given the opportunity to speak 
before the Senate Committee on Veterans' Affairs. I am COL Matt Horn 
and I am the Deputy Commander with the 9th Regional Readiness Command. 
As you are probably aware, the 9th RRC is responsible for Army Reserve 
units in American Samoa, Guam, Saipan, Alaska and Hawaii. Additionally, 
many of our members live and work in Japan, Korea and other Pacific Rim 
countries. We are responsible for 3400 soldiers serving proudly in the 
Pacific and other parts of the world.
    This morning I will limit my comments to the issue of returning 
Army Reserve servicemembers and the collaboration between the 
Department of Defense and the Veterans Health Administration.
    The Army Reserve is still early in the redeployment cycle. The 
793rd Engineer Detachment just returned. The 411th Engineer Battalion 
returned in Summer, 2005. The 100th Infantry Battalion is expected back 
in early 2006 and the 322nd Civil Affairs Brigade is expected back in 
Summer, 2006. The 1101st Garrison Support Unit is expected to continue 
on Active Duty at Schofield Barracks until early 2006. In addition to 
these larger units, smaller units or portions of units and individuals 
have been deployed. Additional units of the Army Reserve are expected 
to be deployed sometime next year. There have been approximately 1030 
individuals returned from active duty to date and there are 
approximately 1180 personnel still mobilized.
    Other than routine dental care, there has been no significant need 
for Army Reserve personnel to utilize Veterans Health Administration 
services yet. There are approximately 26 Army Reserve personnel in the 
Medical Retention Processing Unit and being continued on Active Duty 
for evaluation and or treatment. The average ``days left'' in MRPU 
status is 130 days. Since assignment to the MRPU is for 179 days with a 
possibility of extensions, it may be a while before these soldiers will 
need to access Veterans Health Administration services. These 26 
individuals represent the most severe conditions which have present 
impact on their performance of duty. Many servicemembers may have 
conditions that have not yet manifested itself and may not do so for 
months or years. While it would be difficult to predict numbers at this 
point, we can anticipate seeing certain types of problems such as back 
and leg injuries and post traumatic stress disorders. The first group 
returning, the 100th Infantry Battalion, has been in the thick of 
things, so we can anticipate more problems with this group.
    The bottom line is that it is too early, at this point in the 
redeployment cycle, to know what the Army Reserve utilization of VHA 
services will be. However, we should anticipate that the number of 
soldiers needing those services will very likely be greater than in 
previous years.
    Anticipating a greater need for VHA services, we need to focus on 
availability and accessibility of services. VHA services are very 
limited on Hawaiian Islands other than Oahu and on Guam. We also know 
that VHA services are non-existent on American Samoa and Saipan. It is 
estimated that 46 percent of presently deployed personnel are from 
locations other than Oahu. Of the 26 personnel in the MRPU, 12 are from 
American Samoa. Of the returning soldiers from the 100th Infantry 
Battalion, 300 are from American Samoa. There has been some discussion 
about establishing a VHA clinic in American Samoa. This idea is worthy 
of consideration. However, it should be noted that this is only a 
partial solution to the problem of access of medical care on American 
Samoa. For example, if the VHA clinic does not have a specific service 
that a soldier needs and there is no TRICARE network (as is the case in 
American Samoa), the soldier will still not have access to services and 
may need to come to Oahu for follow-up care.
    While it may not be possible to predict the specific number of Army 
Reserve personnel who will need to access VHA services in the future, 
we can predict that there will be shortfalls in places such as American 
Samoa. It is critical to plan for, develop and establish VHA services 
in areas other than Oahu.
    Thank you. I would be pleased to answer any questions you may have.

    Senator Akaka. Thank you very much.
    [Applause.]
    Senator Akaka. Secretary Perlin.

   STATEMENT OF HON. JONATHAN B. PERLIN, M.D., Ph.D., UNDER 
     SECRETARY FOR HEALTH, DEPARTMENT OF VETERANS AFFAIRS, 
 ACCOMPANIED BY ROBERT WIEBE, M.D., VA NETWORK DIRECTOR, VISN 
21, SIERRA PACIFIC NETWORK; JAMES HASTINGS, M.D., DIRECTOR, VA 
  PACIFIC ISLANDS HEALTH CARE SYSTEM; AND STEVEN A. MacBRIDE, 
  M.D., CHIEF OF STAFF, VA PACIFIC ISLANDS HEALTH CARE SYSTEM

    Dr. Perlin. Aloha kakahiaka.
    [Applause.]
    Senator Akaka. You heard that.
    Dr. Perlin. And mahalo nui loa, Senator Akaka, for the 
opportunity to appear here before you today to discuss the care 
of veterans here in Hawaii, and also the care of those 
servicemembers upon whom their return become veterans.
    Senator Akaka, I greatly appreciate your holding hearings 
not only here on the Big Island but throughout other islands of 
Hawaii this week. I've learned a great deal about the care 
that's being given, the compassion and excellence that's 
demonstrated throughout the islands. I visited this morning our 
Community-Based Outpatient Clinic here in Hilo, and I'm pleased 
to go back knowing that the quality of care is very, very high 
and the compassion and sense of community is absolutely 
unsurpassed anywhere in VA.
    I thank you and Chairman Larry Craig for your leadership, 
your advocacy, and your passion and commitment to veterans 
throughout our great country, and your passion especially for 
those veterans right here in the State of Hawaii.
    Senator, I can perhaps inform veterans of the Big Island 
two important improvements that we're making to help VA provide 
them with the exceptional healthcare that they've earned. 
First, I'm pleased to note that Hawaii will build its first 
State Veterans Home here in Hilo, providing nursing home and 
domiciliary care to eligible veterans. VA is contributing $20 
million, or approximately two-thirds of the construction cost, 
to partner with the State in constructing a 95-bed facility on 
the site of the former Hilo Hospital.
    I thank you and the State delegation for all of your 
support and leadership in bringing that to fruition. It was 
indeed gratifying to drive by this morning and see construction 
in progress and dirt flying. We hope that that facility will 
open in the spring of 2007, and we look forward to this new 
collaboration.
    Second, VA currently maintains two outpatient clinics on 
the Big Island, at Hilo, as I mentioned, and at Kailua-Kona as 
well. And we have plans to renovate both clinics this year. 
We'll be moving the Kailua-Kona Clinic to a larger facility, 
and we'll spend nearly half a million dollars to outfit the new 
space.
    We also have plans to renovate further the Hilo outpatient 
clinic this year, and we're interested in acquiring the Army 
Reserve Center in Hilo that has been identified for closure so 
that we might relocate both the clinic and the Hilo Vet Center 
there in the future should that become available.
    Our Hilo and Kailua-Kona Vet Centers provide counseling, 
psychological support, and outreach to veterans with 
readjustment issues. And we plan in the near future to begin a 
formal substance abuse treatment program right here in Hilo.
    I should note also the move of our PTSD Residential 
Rehabilitation Program from Hilo to Honolulu. Our PTSD 
residential rehab program was established in Hilo about 10 
years ago to meet the needs of veterans with chronic PTSD who 
would benefit from specialized residential treatment care.
    And over the years, approximately 830 veterans have been 
treated at that center. Many of these patients, nearly 75 
percent, I should note, were not in fact from the Big Island, 
and we expect, of course, to receive some veterans from the 
Global War on Terror with PTSD or acute stress disorder and 
expect them to seek services from VA. And most of these 
veterans reside in Oahu, and locating the inpatient unit there 
allows a number of benefits, including important synergies, 
with other medical services available at Tripler. Consequently, 
we're in the process of moving that program to Honolulu.
    Besides their outpatient clinic and Vet Centers here at 
Hilo and in Kona, VA provides care to Hawaii's 113,000 veterans 
at four additional locations, the absolutely spectacular Spark 
M. Matsunaga Ambulatory Care Center and the Center for Aging on 
the campus of Tripler Army Medical Center in Honolulu, and as 
well at Community-Based Outpatient Clinics on Kauai, on Maui, 
and also in Agana, Guam.
    At all of our centers of care, we provide direct primary 
care, including preventive services and health screenings, and 
of course mental health services. In hearings this week, we 
have discussed improvements, and VA is sending clinicians and 
support staff to provide services, particularly on the islands 
of Molokai and Lanai, and augmenting the services with 
increased outreach through telemedicine and telehealth 
programs. And we're very pleased to announce just this week an 
additional $1 million in funding to support tele-mental health 
services and other services through that outreach program.
    I'd also note that in addition to the Vet Centers here in 
Hilo and in Kona, we have Vet Centers on Oahu, on Kauai, and in 
Maui. And we operate a formal substance abuse treatment program 
in Honolulu as well.
    Inpatient mental health services are provided by VA staff 
on a ward within Tripler, and I had the great pleasure of 
visiting that unit yesterday and seeing again the excellence in 
quality and the commitment that is equally compassionate.
    We rely on Tripler for emergency room care, acute medical 
surgical inpatient care, outpatient specialty care, and 
ancillary services. And all of our sites in Hawaii are 
authorized to provide DoD beneficiaries care as TRICARE 
providers as part of the seamless transition initiative between 
VA and DoD.
    I'd just note that I want to thank General Osman and the 
Commandant of the Marine Corps, as well for your great 
commitment to the seamless transition program, and the 
commitment of the other services at similarly high levels as 
well.
    Veterans who have particularly grievous injuries are also 
treated at our polytrauma unit in Palo Alto, California, part 
of VISN 21 or the network that Dr. Wiebe is the director of 
that also includes the VA Pacific Islands Health Care System.
    In conclusion, with the great support and leadership of 
Senator Akaka, who I would be remiss if I didn't acknowledge 
his role in bringing to fruition the new State Veterans Home 
and also the $83 million in funding that were really the basis 
for building the Spark M. Matsunaga Ambulatory Care Center and 
Center for Aging.
    I want to thank you for your leadership and that of other 
Members of Congress, our Chairman of the Senate Veterans' 
Affairs Committee, Senator Larry Craig, to help us provide 
services to veterans of Hawaii at unprecedented levels, and 
services that are equally excellent throughout this great State 
and throughout the country.
    Thank you very much.
    [The prepared statement of Dr. Perlin follows:]

   Prepared Statement of Hon. Jonathan A. Perlin, M.D., Ph.D., Under 
          Secretary for Health, Department of Veterans Affairs

    Mr. Chairman and Members of the Committee, mahalo nui loa for the 
opportunity to appear before you today to discuss the state of VA care 
in the Hawaii. It is a privilege to be here on the Island of Hawaii--
The Big Island--to speak and answer questions about issues important to 
veterans residing in Hawaii.
    First, Mr. Chairman, I would like to thank you for your outstanding 
leadership and advocacy on behalf of our Nation's veterans. During your 
tenure as Chairman of this Committee, you have clearly demonstrated 
your commitment to veterans by acting decisively to ensure the needs of 
veterans are met. In addition, I appreciate your interest in and 
support of the Department of Veterans Affairs (VA).
    I also would like to express my appreciation and respect for 
Senator Akaka, Ranking Member of this Committee. Along with his 
colleague, Senator Inouye, Senator Akaka has done so much for the 
veterans residing in Hawaii and other islands in the Pacific region. As 
I will highlight later, his vision, guidance and assistance have 
directly led to an unprecedented level of health care services for 
veterans, construction of state-of-the-art facilities in Honolulu and 
remarkable improvements in access to health care services for veterans 
residing on neighbor islands, including the Big Island.
    Today, I will briefly review the VA Sierra Pacific Network that 
includes Hawaii and the Pacific region; provide an overview of the VA 
Pacific Islands Health Care System (VAPIHCS) and the VA facilities here 
in the Big Island; highlight issues of particular interest to veterans 
residing in Hawaii, including the relocation of the Post-traumatic 
stress disorder Residential Rehabilitation Program (PRRP) from Hilo to 
Honolulu on the campus of the Tripler Army Medical Center (AMC), 
veterans returning from Iraq and Afghanistan, substance abuse treatment 
programs and the future State Veterans Home; and address any questions 
posed by Members of the Committee.

                  VA SIERRA PACIFIC NETWORK (VISN 21)

    The VA Sierra Pacific Network (Veterans Integrated Service Network 
[VISN 21]) is one of 21 integrated health care networks in the Veterans 
Health Administration (VHA). The VA Sierra Pacific Network provides 
services to veterans residing in Hawaii and the Pacific Basin 
(including the Philippines, Guam, American Samoa and Commonwealth of 
the Northern Marianas Islands), northern Nevada and central/northern 
California. There are an estimated 1.25 million veterans living within 
the boundaries of the VA Sierra Pacific Network.
    The VA Sierra Pacific Network includes six major health care 
systems based in Honolulu, HI; Palo Alto, CA; San Francisco, CA; 
Sacramento, CA; Fresno, CA and Reno, NV. Dr. Robert Wiebe serves as 
director and oversees clinical and administrative operations throughout 
the Network. In Fiscal Year 2005 (FY05), the Network provided services 
to 227,000 veterans. There were about 2.8 million clinic stops and 
24,000 inpatient admissions. The cumulative full-time employment 
equivalents (FTEE) level was 8,200 and the operating budget was about 
$1.3 billion, which is an increase of $378 million since 2001.
    The VA Sierra Pacific Network is remarkable in several ways. In 
fiscal year 2005, the Network was the only VISN in VHA to meet the 
performance targets for all six Clinical Interventions that directly 
address adherence to evidence-based clinical practice. The Network 
hosts 11 (out of 65) VHA Centers of Excellence--the most in VHA. The VA 
Sierra Pacific Network also has the highest funded research programs in 
VHA. Finally, VISN 21 operates one of four Polytrauma units that are 
dedicated to addressing the clinical needs of the most severely wounded 
Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) veterans.

            VA PACIFIC ISLANDS HEALTH CARE SYSTEM (VAPIHCS)

    As noted above, VAPIHCS is one of six major health care systems in 
VISN 21. VAPIHCS is unique in several important aspects: its vast 
catchment area covering 2.6 million square-miles (including Hawaii, 
Guam, American Samoa and Commonwealth of the Northern Marianas); island 
topography and the challenges to access it creates; richness of the 
culture of Pacific Islanders; and the ethnic diversity of patients and 
staff. In fiscal year 2005, there were an estimated 113,000 veterans 
living in Hawaii (9 percent of Network total).
    VAPIHCS provides care in six locations: Ambulatory Care Center 
(ACC) and Center for Aging (CFA) on the Tripler AMC campus in Honolulu; 
and community-based outpatient clinics (CBOCs) in Lihue (Kauai), 
Kahului (Maui), Kailua-Kona (Hawaii), Hilo (Hawaii) and Agana (Guam). 
VAPIHCS also sends clinicians and support staff from these locations to 
provide services on Lanai, Molokai and American Samoa. The inpatient 
post-traumatic stress disorder (PTSD) unit formerly in Hilo is in the 
process of relocating to Honolulu. In addition to VAPIHCS, VHA operates 
five Readjustment Counseling Centers (Vet Centers) in Honolulu, Lihue, 
Wailuku, Kailua-Kona and Hilo that provide counseling, psychosocial 
support and outreach.
    Dr. James Hastings was recently appointed Director, VAPIHCS. Dr. 
Hastings has impressive credentials, including tenure as Chair, 
Department of Medicine, John A. Burns School of Medicine, University of 
Hawaii, and Commanding General at Walter Reed AMC and Tripler AMC. I am 
excited about the possibilities that his tenure as Director at VAPIHCS 
brings.
    In fiscal year 2005, VAPIHCS provided services to 18,300 veterans 
in Hawaii (8 percent of Network total). There were 194,000 clinic stops 
in Hawaii during fiscal year 2005 (7 percent of Network total), an 
increase of 36 percent since fiscal year 2000. The cumulative FTEE for 
the health care system was 478 employees. The budget for VAPIHCS 
(including General Purpose, Specific Purpose and Medical Care Cost 
Funds [MCCF]) has increased from $53 million in fiscal year 1999 to 
$102 million in fiscal year 2005 (about 8 percent of Network total). In 
addition, VISN 21 provided over $20 million in supplemental funds to 
VAPIHCS over the past two Fiscal Years to ensure VAPIHCS met its 
financial obligations.
    VAPIHCS provides or contracts for a comprehensive array of health 
care services. VAPIHCS directly provides primary care, including 
preventive services and health screenings, and mental health services 
at all locations. Selected specialty services are also currently 
provided at the Honolulu campus and to a lesser extent, at CBOCs. 
VAPIHCS recently hired specialists in gero-psychiatry, 
gastroenterology, ophthalmology and radiology. VAPIHCS is actively 
recruiting additional specialists in cardiology, orthopedic surgery and 
urology. Inpatient long-term care is available at the Center for Aging. 
Inpatient mental health services are provided by VA staff on a ward 
within Tripler AMC and at the PTSD Residential Rehabilitation Program 
(PRRP) that was formerly here in Hilo (now relocating to Honolulu). 
VAPIHCS contracts for care with Department of Defense (DoD) (at Tripler 
AMC and Guam Naval Hospital) and community facilities for inpatient 
medical-surgical care.
    The current constellation of VA facilities and services represents 
a remarkable transformation over the past several years. Previously, 
the VAPIHCS (formerly known as the VA Medical and Regional Office 
Center [VAMROC] Honolulu) operated primary care and mental health 
clinics based in the Prince Kuhio Federal Building in downtown Honolulu 
and CBOCs on the neighbor islands that were staffed primarily with 
nurse practitioners. Senator Akaka and his colleagues in Congress 
approved $83 million in Major Construction funds to build a state-of-
the-art ambulatory care center and nursing home care unit on the 
Tripler AMC campus and these facilities were activated in 2000 and 
1997, respectively. VISN 21 allocated nearly $17 million from FY98-
FY2000 to activate these projects. VISN 21 also provided dedicated 
funds (e.g., $2 million in FY01) to enhance care on the neighbor 
islands by expanding/renovating clinic space and adding additional 
staff to ensure there are primary care physicians and psychiatrists at 
all CBOCs.

                            BIG ISLAND CBOCS

    VA operates CBOCs in both Hilo (1285 Waianuenue Avenue, Suite 211, 
Hilo, HI, 96720) and Kailua-Kona (75-5995 Kuakini Highway, Suite 413, 
Kailua-Kona, HI, 96740). VHA also operates Readjustment Counseling 
Centers (``Vet Centers'') in Hilo (120 Keawe Street, Suite 201, Hilo, 
HI, 96720) and Kailua-Kona (co-located with the Hilo CBOC).
    The Big Island's CBOCs serve an estimated island veteran population 
of 15,309. In fiscal year 2005, 3,980 veterans were enrolled for care 
on the island and 2,929 received care (``users'') at Big Island VA 
facilities. The market penetrations for enrollees and ``users'' are 26 
percent and 19 percent, respectively, and compare favorably with rates 
within VISN 21 and VHA.
    Hilo CBOC. Many veterans view this clinic like an old-fashioned 
doctor's office. In a recent letter, a retired Marine veteran wrote, 
``I am a 100 percent disabled veteran of the Vietnam War and suffer 
from several war-related illnesses. This letter is not about me, but 
about the care that the people at our Hilo primary care unit dispense. 
I do not know all the staff, but the ones I do know have helped me 
enjoy a healthier life and are some of the most caring, friendly and 
knowledgeable individuals I have ever met in VA. You can be proud of 
them and the jobs they do.''
    VAPIHCS spent about $100 thousand in fiscal year 2001 to remodel 
the Hilo CBOC and plans to spend additional funds in fiscal year 2006 
to further renovate the clinic. VA has also expressed interest in 
acquiring an Army Reserve Center in Hilo from the 2005 Base Realignment 
and Closure (BRAC) process and potentially relocating the clinic and 
Vet Center to this location in the future.
    The current authorized full-time employment equivalents (FTEE) 
level at the Hilo CBOC is 11.0, including two full-time primary care 
physicians and a psychiatrist. With this staff, the Hilo CBOC provides 
a broad range of primary care and mental health services. The Hilo CBOC 
also has a formal home-based primary care (HBPC) program that provides 
clinical services in the homes of veterans. Additional staff will be 
added from the former PRRP to increase mental health services (see 
discussion below).
    VAPIHCS provides specialty care services at the clinic by sending 
VA staff from Honolulu and other VA facilities in California. Services 
provided by clinicians traveling to Hilo include cardiology, 
geriatrics, nephrology, neurology, optometry, orthopedics, rheumatology 
and urology. If veterans need services not available at the clinic, 
VAPIHCS arranges and pays for care in the local community (e.g., Hilo 
Medical Center), Honolulu (including Tripler AMC) or VA facilities in 
California. In fiscal year 2005, VA spent more than $7.5 million in 
non-VA care in the private sector (i.e., not including costs at other 
VA or DoD facilities) for residents of the Big Island.
    In fiscal year 2005, the Hilo CBOC recorded 8,843 clinic stops, 
representing a 10 percent increase from fiscal year 2000 (i.e., 8,072 
stops). The clinic has short waiting times for new patients with very 
few veterans waiting more than 30 days for their first primary care 
appointment. The Hilo HBPC program recorded 678 clinic stops for 
providing home care to veterans residing on the east side of the 
island.
    Kailua-Kona CBOC. Veterans at the Kailua-Kona CBOC are also very 
satisfied with the care they receive. For example, a veteran recently 
wrote, ``I couldn't be more pleased with the way Kona VA handled my 
care. All of the staff are very helpful, and will take that extra step 
to make me feel comfortable, and answer all of my concerns and 
questions. The feeling I get when I go to my veteran's center or even 
to Tripler hospital is like I'm going home to my family.''
    In part because of high patient satisfaction, the workload at the 
Kailua-Kona CBOC has grown over the years and staff needs additional 
space to meet increasing demand for VA services. In fiscal year 2006, 
VAPIHCS will relocate the Kailua-Kona CBOC to a larger facility and 
spend nearly $500 thousand to renovate the new space.
    The current authorized full-time employment equivalents (FTEE) 
level at the Kailua-Kona CBOC is 10.0, including a full-time primary 
care physician, psychiatrist and nurse practitioner. With this staff, 
the Kailua-Kona CBOC provides a wide array of primary care and mental 
health services. The Kailua-Kona CBOC also has a formal home-based 
primary care (HBPC) program that provides clinical services in the 
homes of veterans.
    VAPIHCS provides specialty care services at the clinic by sending 
VA staff from Honolulu and other VA facilities in California. Services 
provided by clinicians traveling to Kailua-Kona include cardiology, 
geriatrics, nephrology, neurology, optometry, orthopedics, rheumatology 
and urology. If veterans need services not available at the clinic, 
VAPIHCS arranges and pays for care in the local community (e.g., Kona 
Community Hospital) and Honolulu (including Tripler AMC). As noted 
before, in fiscal year 2005, VA spent more than $7.5 million in non-VA 
care in the private sector (i.e., not including costs at other VA or 
DoD facilities) for residents of the Big Island.
    Clinic staff also occasionally refers patients to VA facilities in 
California. Access to other VA facilities was especially important to a 
veteran who wrote, ``The veteran's health center in Kona has not only 
helped me get my prescription drugs at a lower cost, but last year they 
helped me go to the Western Blind Rehabilitation Center in Palo Alto to 
learn how to cope with my blindness. For the first time in many years, 
I have confidence to do things I never thought I could do without 
sight.''
    In fiscal year 2005, the Kailua-Kona CBOC recorded 6,888 clinic 
stops, representing a 26 percent increase from fiscal year 2000 (i.e., 
5,456 stops). The clinic has short waiting times for new patients with 
very few veterans waiting more than 30 days for their first primary 
care appointment. The Hilo HBPC program recorded 609 clinic stops for 
providing home care to veterans residing on the west side of the 
island.

                             SPECIAL ISSUES

    PTSD Residential Rehabilitation Program (PRRP). The PRRP was 
established in Hilo about 10 years ago to meet the needs of veterans 
with chronic PTSD who would benefit from a specialized inpatient 
program. Over the years, approximately 830 veterans, mostly Vietnam era 
veterans, have been treated at the center. The vast majority of these 
patients--nearly 75 percent--did not originate from the Big Island. 
Although the PRRP in Hilo fulfilled its original goals, the 
demographics and epidemiology associated with PTSD is changing as 
result of the war in southwest Asia. VA expects an increasing number of 
OIF/OEF veterans with PTSD or Acute Stress Disorder (ASD) to seek 
services from VA. Most of these veterans reside in Oahu and the best 
treatment for them is outpatient care that integrates treatment with 
their families and community.
    Consequently, VA is moving the PRRP from Hilo to Honolulu to 
provide enhanced mental health services to veterans with both acute and 
chronic PTSD. The 16-bed unit will be maintained and initially 
relocated to the 5th floor of Tripler AMC. VAPIHCS expects to activate 
the unit in early 2006, once minor renovations have been completed and 
staff has been relocated from Hilo and/or hired. VAPIHCS has submitted 
a $6.9 million Minor Construction project for fiscal year 2007 to 
construct a combined inpatient and outpatient PTSD facility on the 
Tripler AMC campus. VA will also augment outpatient PTSD services, both 
in Honolulu at the new PRRP location and in Hilo at the local CBOC. 
VAPIHCS will add four or five new staff to the Hilo CBOC, including a 
clinical nurse specialist, addiction therapist and psychiatric social 
worker. As a result of this redesign, VA will provide a higher level of 
service and greater accessibility for existing and new patients with 
PTSD. The relocation will also facilitate greater collaboration with 
DoD.
    OIF/OEF outreach. At the groundbreaking ceremony for the State 
Veterans Home here in Hilo, Senator Inouye referenced the three-word 
motto of the U.S. Military Academy and noted, `` `Duty, honor, country' 
is not a one-way proposition.'' VA fully understands this and its 
commitment to our newest veterans--those who bravely served in 
Operation Iraqi Freedom and Operation Enduring Freedom (OIF/OEF). We 
stand ready to meet their needs.
    VA estimates up to 15,000 residents of Hawaii have been deployed to 
Afghanistan and Iraq as active duty personnel, Reservists or Hawaii 
National Guard personnel. Major General Lee, Adjutant General, State of 
Hawaii, Department of Defense (DoD), reports there are 2,200 Reservists 
and National Guard serving in Iraq and Afghanistan.
    All VAPIHCS sites of care, including CBOCs, are authorized to 
provide care to DoD beneficiaries as Tricare providers. This allows 
OIF/OEF veterans living in Oahu or neighbor islands to utilize VA 
services, including mental health care. In fiscal year 2005, VAPIHCS 
provided care to 393 OIF/OEF veterans, with the facilities in Honolulu 
treating 345 of these veterans. Veterans residing in Hawaii also have 
access to the Polytrauma Unit at the VA Palo Alto Health Care System. 
This is one of four specialized units designed to meet the needs of the 
most severely injured OIE/OEF veterans and active duty personnel.
    VAPIHCS is preparing for additional OIF/OEF veterans. The facility 
has appointed an OIF/OEF outreach coordinator. As noted earlier, 
VAPIHCS is revamping its PTSD program to meet the special needs of OIF/
OEF veterans. Additionally, VAPIHCS has requested additional funds 
through the national VHA mental health funding initiative in fiscal 
year 2006 to hire dedicated staff for OIF/OEF outreach and enhanced 
services at CBOCs, including Hilo. Although VAPIHCS cannot forecast the 
exact number of OIF/OEF veterans who will seek care from VA, I am 
confident VAPICHS will be able to meet the needs of our newest veterans 
and provide them safe, effective and accessible care.
    Substance abuse. VAPIHCS operates a formal Substance Abuse 
Treatment Program (SATP) at the ACC in Honolulu. SATP staff includes a 
board-certified addiction psychiatrist, two clinical nurse specialists, 
social worker and two addiction therapists. Staff treats patients with 
substance abuse issues related methamphetamine, opioids, alcohol and 
other substances. In fiscal year 2005, VAPIHCS recorded 4,841 clinic 
stops in SATP. In addition, VAPIHCS collaborates with the Veterans in 
Progress (VIP) program operated by U.S. VETS at Barbers Point on Oahu.
    Currently, VAPIHCS does not have specialized substance abuse 
treatment programs at the CBOCs on neighbor islands. Services are 
provided by VA psychiatrists at the CBOCs and through referrals to 
community providers or VA SATP in Honolulu. VAPIHCS recognizes that in 
some locations, this may not be sufficient. As an example, in the Big 
Island, the use of crystal methamphetamine (or ``ice'') is a 
significant problem. As noted earlier, as part of the restructuring of 
the PRRP, VA will begin a formal substance abuse treatment program in 
Hilo this year. At other locations, VAPIHCS will utilize telehealth 
technology and add staff as demand dictates and the availability of 
resources allow.
    State Veterans Home. The State of Hawaii is planning to build its 
first State Home in Hilo. This will be the first State of Hawaii 
facility to provide nursing home and domiciliary care to eligible 
veterans. Plans call for the construction of a 95-bed facility on the 
site of the former Hilo Hospital on the Hilo Medical Center campus. The 
cost estimate for the project is $31 million and VA is contributing 65 
percent (i.e., $20 million) to compliment state funding. VA is excited 
about this project and looks forward to our continuing collaboration 
with Hawaii.

                               CONCLUSION

    In summary, with the support of Senator Akaka and other Members of 
Congress, VA is providing an unprecedented level of health care 
services to veterans residing in Hawaii and the Pacific Region. VA now 
has state-of-the-art facilities and enhanced services in Honolulu, as 
well as robust staffing on the neighbor islands and has expanded or 
renovated clinics in many locations. VA is bringing more specialists on 
board and preparing for the newest generation of veterans--those who 
bravely served in southwest Asia.
    VAPIHCS still faces several challenges, in part due to the 
topography of its catchment area. VAPIHCS will meet these challenges by 
utilizing telehealth technologies, sharing specialists, developing new 
delivery models and opening new clinics as demographics suggest and 
resources allow. I am proud of the improvements in VA services in 
Hawaii, but recognize that our job is not done.
    Again, Mr. Chairman and other Members of the Committee, mahalo nui 
loa for the opportunity to testify at this hearing. I would be 
delighted to address any questions you may have for me or other members 
of the panel.

    Senator Akaka. Thank you very much.
    [Applause.]
    Senator Akaka. I have some questions for our witnesses. 
This first question is for each of our witnesses.
    Based upon the feedback from post-deployment health 
assessment questionnaires and from what you have seen and 
heard, what kind of health trends are you beginning to see in 
the soldiers coming back from Iraq and Afghanistan? Some of 
these have been mentioned already by our witnesses. We're 
looking for all information we can get.
    Another part of the question is: Are you seeing any 
indication of undiagnosed illnesses similar to the Gulf War 
Syndrome in servicemembers returning from Iraq and Afghanistan? 
And we'll take your responses in the order you were introduced.
    General Osman.
    General Osman. Senator Akaka, to answer the undiagnosed 
illnesses that we had seen come out of the first Iraq war, the 
Army Medical Surveillance Activity, which is headquartered in 
Fort Detrick, Maryland, is the agency that tracks that. At this 
point, they've seen no indication of undiagnosed illnesses 
coming out of Afghanistan or Iraq.
    When we look at what we see in the Marines who are 
returning at this point, we have seen some indications, as we 
would expect, of combat stress. That is part of combat. It's a 
very natural part of combat. Probably some of the challenges 
we've had in the past is accepting that.
    There's a tendency, of course, for military members kind of 
in a macho manner to try to look past that or ignore it and not 
accept the fact that combat stress is just another combat 
injury, much as would be a wound from a weapon that produces 
shrapnel. Accepting that, understanding that, allows us to 
address those combat stress issues early on.
    We do that through our redeployment and post-deployment 
efforts. Because of those efforts, I really do believe we have 
seen probably a lesser number of combat stress-related 
incidents than we would have expected otherwise. Thank you, 
sir.
    Senator Akaka. Thank you.
    General Mixon. Yes, sir. I would echo what General Osman 
has said in reference to the undiagnosed illnesses. We have not 
seen any. And the tracking system is very effective.
    I can say just from my own experience--I'm a Gulf War 
veteran as well as a veteran of having served in Afghanistan, 
and I am registered in the Gulf War illness data base, if you 
will. I routinely get updates on what is going on in that 
system, and I am sure that as we document and provide updates 
on the current Global War on Terrorism, those that are 
registered will be provided accurate updates. I'm comfortable 
to tell you that no, we have not seen anything like the Gulf 
War illness syndrome.
    As far as health trends are concerned, other than those 
soldiers that we know are wounded and what their specific 
injuries are, we see common things such as orthopedic and what 
we might refer to as sports medicine type of injuries. The 
stress of combat, particularly on those soldiers that are 
involved in deliberate combat operations, we see similar 
injuries with them--knees, joints, backs, and so forth. And 
those are treated in a similar manner that you would treat a 
sports injury type of injury.
    But the trend that we have to watch is exactly what General 
Osman said, is that of mental health problems. And these come 
in varying degrees. And we must be sensitive to those issues 
and provide the treatment. And at the present time, I believe 
we are taking the appropriate steps to do that.
    We do so in two ways. First of all, the immediate screening 
that is done by the soldiers that re-deploy helps to try to 
identify those that may have been immediately affected. But I 
will tell you the soldiers, as they return, there is a euphoria 
of having returned. They're reunited with families. And a lot 
of times, the stress that they have undergone might be masked. 
It may be months later before it reappears.
    The services have instituted a program of rescreening those 
soldiers about 3 to 6 months after they return to identify that 
period where they might be experiencing some stress, things 
such as sleep disorders, possible abuse of alcohol, drugs, and 
those kinds of activities.
    So my point, Senator, is that it has to be a continual 
process. Combat is stressful no matter what you are doing. So 
we are sensitive to the issue of treating our soldiers for 
potential combat stress, both short-term and long-term effects 
that it might have.
    General Lee. Senator, for the Hawaii Army National Guard, 
we've had aviation units come on back. And so far, we have not 
noticed anything similar, you know, unknown like the Gulf War 
Syndrome. We're keeping close tabs with our soldiers, with our 
family readiness, family support groups to keeping those intact 
such that sometimes they may be a little reluctant to maybe 
come forward, and we'll find out about that through the family 
support groups.
    As General Mixon mentioned, the screening some time 
afterwards that we'll do during the drills. But now, with the 
larger Brigade Combat Team returning and certainly the units 
that have been in the thick of the action, we're going to look 
very closely at the results of the screening and perhaps, based 
on that, even recommend another rescreening maybe another 2 to 
6 months down the line just to make sure we get a good trend.
    Senator Akaka. Thank you.
    Colonel Horn.
    Colonel Horn. Sir, we among our population have not seen 
any indication of any undiagnosed illness similar to Gulf War 
Syndrome. Among the soldiers that have returned so far, we've 
had more engineers come back than anything else. And I think, 
in addition to the sports type injuries that General Mixon 
referred to, I think we have some occupational workplace type 
injuries among those soldiers that you would expect in the 
construction trades--some back injuries, legs, hands, that type 
of thing.
    We also as the National Guard have a rigorous program of 
revisiting our soldiers with professionals, teams of 
professionals, periodically after their return and 
demobilization so that we provide the opportunity to make 
referrals and follow up on the self-assessments that come from 
the soldiers, input from our family readiness groups, and also, 
most importantly, input from the chain of command.
    I think that a strong chain of command that knows their 
soldiers and is concerned for their welfare is our front line 
in dealing with emerging problems that may come up later. And 
so that's a major point of leadership within our organization.
    Senator Akaka. Let me say that Chairman Craig and I have 
been very concerned with the National Guard and Reservists 
because they are considered working people who were deployed, 
and concerned about when they return home and go back to work.
    We ask active forces to go back to a base, and they go 
through some of these programs that are there for them. And we 
are very interested in seeing what can be done with the 
Reservists and National Guardsmen who come back to their 
families and go back to work.
    And as all of you said, our military folks are macho. Many 
times they don't want to tell you they have a problem.
    But some do, in fact, have a problem. As was mentioned 
here, it takes time before they finally admit it. But we need 
to help them as early as possible so that the problem doesn't 
get worse for each one of them. So I'm so glad to hear from you 
on this subject.
    Dr. Perlin. Thank you, Senator Akaka. Since the beginning 
of operations and the Global War on Terror, we've seen 119,247 
servicemembers separated from all components, regular as well 
as all Reserve components. In fact, the electronic health 
record that we have really means that we can follow the health 
issues of each and every one of them and understand what are 
the top issues.
    It's a generally younger population, and just as General 
Mixon said, the issues are not dissimilar from a younger 
population. Many of the musculoskeletal orthopedic issues are 
best characterized as sort of sports medicine type issues.
    The other big category of issues are some dental health 
issues that we've been working with Department of Defense on. 
There is some difference between readiness for deployment and 
ultimate dental health, and we're working together on those 
issues.
    We share the commitment that we screen, and are aware of 
any mental health issues as well, and are really appreciative 
to note that in the Department of Defense, this starts at the 
very front lines. There are combat stress teams forward 
deployed that include psychologists, and they don't wait for 
people to self-identify. If something happens on that day, 
bring the whole unit together and say, you know, what we saw 
today or what we experienced is very difficult, and we will 
talk about it. It's not--one doesn't have to self-identify.
    We have much better information coming from the front. 
There are a number of programs that bring that health 
information forward. And of course, upon return, there's not 
only the separation examination, but as these gentlemen 
mentioned, the post-deployment health reassessment, a 
systematic reevaluation of return servicemembers' health 90 to 
180 days following deactivation or demobilization.
    We have not seen anything akin to the undiagnosed illnesses 
as occurred after the Gulf War, and we feel very confident 
about these data, because as General Mixon indicated, he 
participated in a registry, which is something people had to 
actively sign up for.
    In fact, for the veterans who receive care in VA, having 
all of their electronic health records means that we can follow 
each and every diagnosis and really look at what issues stand 
out--again, the sports medicine, the dental health, and being 
aware for mental health issues, including some totally normal 
symptoms after abnormal circumstances. And those are combat 
stress reactions that we neither want to overly medicalize, but 
we do, with shared outreach on support, want to be able to 
provide assistance for. Thanks.
    General Osman. Senator Akaka, if I could have a follow-up?
    Senator Akaka. Please, General.
    General Osman. Please, sir. I have two points I think would 
be important.
    First, you raised an important issue, Senator, about the 
Reservists who come back from deployment, maybe a small bit of 
time with a unit and then they're back to their civilian job. 
How do we take care of those folks, particularly when we're 
looking at combat stress.
    OSD has a managed health network that they've created. 
These are individuals who are experts in mental health 
addressing those problems. These are civilians. We're going to 
try to tie that network with our Reserve establishment.
    Dr. Nash, who's the psychiatrist that heads up our combat 
operational stress program, is with our Marine Reserves right 
now trying to come up with a program that will allow these 
practitioners to actually call the Reservists at home after 
they've been demobilized, talk with them on the phone, things 
like sleepless problems, as General Mixon mentioned, problems 
with alcohol, relationships with their families, with friends, 
how things are going on the job.
    An expert over the phone can begin to tell if maybe that 
individual could use some more help. So we're trying to address 
that issue that you raised because it is a very, very 
challenging one indeed.
    I would like to add one other point, and that is there is a 
trend that we are seeing in this war that we haven't seen in 
previous ones, and it's probably not in line with what we would 
have thought. Today's battlefield is very mobile. It's 
incredibly lethal, and fortunately we have our doctors as 
forward deployed as possible.
    We see soldiers and Marines that are sustaining combat 
injuries that in previous wars they would not have survived. 
But because we get them to medical care, to trauma centers 
very, very quickly, they survive. But they survive with some 
horrific injuries, ones that, again, you would not have 
survived in previous wars.
    This is a challenge from several perspectives: one, to heal 
the broken body, but obviously, the mental health aspect in the 
future. And I know that our partners in the Veterans 
Administration, as we hand off these very seriously injured and 
disabled individuals to the Veterans Affairs, are going to have 
a challenge that is really different from ones they've faced in 
the past. It's something we're going to have to pay very, very 
close attention to.
    The great thing is the spirit of these wounded individuals 
is something to behold. Senator, I brought with me a picture of 
a young Marine who lost both of his legs above the knee. It's a 
picture of the young Marine back home in Colorado running 
around a track with a prosthetic device that we were able to 
provide.
    Fortunately, the young Marine has the right kind of spirit 
you're looking for. He had a wonderful girlfriend. They've 
gotten married, and they're now going on with life. It's the 
ability to do that that's going to make a difference, 
particularly when it comes to the combat stress and the mental 
health aspect.
    And I provide this picture of the young Marine running and 
he with his new bride because it tells an awfully, awfully good 
story, sir.
    Senator Akaka. Thank you very much, General. Thank you for 
your additional words on that. And you are correct, you know. 
This war is a little different. And our medical science is so 
good that they can keep people alive, but there are other kinds 
of problems that we've never faced before. And we need to 
certainly look at this.
    And here's another problem I'm going to ask again for each 
of your responses. And this came about, too, 1 day after a 
hearing. Dr. Perlin, usually when we have high level hearings 
on veterans, Secretary Nicholson is there and so is Secretary 
Perlin. And after one of those hearings, we talked about PTSD.
    And one thing he mentioned that stuck in my mind was that 
we need to be very careful about the records of these military 
people in terms of mental health issues and how they are 
reported. I understand that there are safety issues involved in 
the combat zones.
    But if a servicemember did come forward with mental 
illness, for instance, issues, what kind of impact would this 
have on his or her career? So I'd like all of the witnesses to 
share whether or not you believe that there is a stigma 
attached to mental health problems.
    General.
    General Osman. Senator Akaka again has hit on a very 
important issue, and that is if you're going to address combat 
stress and mental health issues, you have to get past the 
stigma that we have unfortunately had to deal with for so many 
years.
    Through our training efforts in pre-deployment, we really 
have tried to reach our leaders, our families, and each 
individual Marine that combat stress is going to be part of 
what they're going to experience, and that it's OK. Now, in a 
combat situation, if an individual should exhibit combat 
stress, again, treating it like any other kind of injury a 
Marine may encounter, we'll address it.
    It may be something that is not serious at that time, and 
sometimes the buddy aid, talking things out, will allow the 
individual essentially to get past that and be able to continue 
to cope and perform, and it would have no impact at that time. 
It's possible that the individual may have more acute combat 
stress problems, in which case, much like if you had a more 
serious physical combat injury, you may have to be taken out of 
the game in order to address it. And that's OK also.
    I think the message is getting particularly to our leaders 
that combat stress is part of combat. The idea is to get them 
better so that we can get them back with their unit and get 
them back performing again. That's the goal. We have had many 
success stories, I'm proud to say, Senator Akaka, of 
individuals that did exhibit combat stress that got past it and 
have continued very successfully in their careers. Thank you, 
sir.
    General Mixon. Senator Akaka, I think we all know, and I 
can testify without any doubt in my mind whatsoever, that there 
is no stigma attached to their career development once an 
individual receives assistance.
    However, perception may be reality. And there is a 
perception down at the lower levels that if I go seek 
counseling and my chain of command learns about it, there may 
be some impact. And that's the challenge that we have. We have 
to remove that stigma.
    Ladies and gentlemen, Senator Akaka, isn't it interesting 
that a person that's having trouble hitting a baseball can seek 
out a sports psychologist, and it can be all over the national 
media, and there's no stigma whatsoever. So we have to get to 
that level. And that's what we try to do through many of the 
programs that we run up at Schofield Barracks. And I'll just 
give you just a few examples.
    First of all, we have, through a Government contract, 
contracted counselors that are down at the unit level. These 
are non-DoD personnel. They are male and female. And they work 
through the unit in a very informal manner. They're very low 
threat, if you will. And they get to know members of the unit, 
and they talk to members of the unit in the dining halls and 
the unit areas.
    And if they identify problems like General Osman just 
mentioned, they encourage the soldier to go to the professional 
counseling. But these particular people keep no records. They 
do not report these things unless they see some serious threat 
to that individual's life. This is a program we're trying at 
Schofield, and we think it's being very successful. That's one 
program.
    The other program is the education of those soldiers' 
families prior to deployment. The wives will attend what we 
call, you know, re-engagement sessions: How are you going to 
re-engage with your husband, your spouse, when they return from 
the combat zone? And what are some of the signs that you may 
look for that there are stress problems? And what are the 
agencies on Schofield Barracks and other places where you can 
seek help for your spouse? So educating the full family team is 
important.
    In addition to that, we continue to run marriage enrichment 
programs at Schofield Barracks so that 3 and 6 months 
afterwards, those families that are deployed go to marriage 
enrichment programs, weekend retreats, if you will, so they can 
reconnect and possibly identify problems. We have identified 
cases where the servicemember has held back until they go to 
these particular sessions in an offsite, in a very low threat 
environment.
    And I would mention one last thing. The experience that our 
Vietnam veterans had and are experiencing now years after the 
end of the Vietnam conflict is important. We have connected 
many of today's veterans with the Vietnam veterans that are in 
the local veterans organizations in and around Schofield 
Barracks. Specifically, we brought an individual to the 
Schofield Barracks area named Mr. Dave Riever [ph].
    Mr Dave Riever was a Navy person who operated on the rivers 
of the Mekong Delta who was seriously burned and disfigured in 
a combat accident. He is a motivational speaker that shares his 
experiences of how he recovered and how that process--and how 
he went through that, and the mental anguish that he 
experienced over the years.
    We brought Mr. Riever to Schofield Barracks. He spoke to 
many of our combat veterans and almost to every soldier on 
Schofield Barracks about his experience. The outcome of that 
was some soldiers seeking assistance because they now 
identified with another veteran who over a period of years has 
dealt with the challenges of the injuries that he sustained.
    So we take a multi-faceted approach, is my point, Senator. 
We'll stay tuned in to what's going on and do the best we can. 
But once again, my up-front statement: No stigma to their 
career development. The challenge is getting them to seek 
assistance when they need it. Thank you, sir.
    Senator Akaka. General Lee.
    General Lee. Senator, in the Reserve components, I guess 
the division between the Guard and the Reserve, you have most 
of the combat units being in the Guard, and with the one 
exception that we're real happy to have the 100th Battalion, 
442nd Infantry, as part of the 29th Brigade.
    And as such, you know, we are very concerned about the 
mental health side. And like General Mixon says, we have this 
ingrained perception to overcome where if you have a physical 
wound and the bandages are gone, you know, it is equal to 
recovery. But from the mental state, it's difficult to really 
determine the start and the end.
    And I think we've just got to set by example so that the 
soldiers know that, you know, by example, by actions, they're 
still eligible for promotions. It's not going to encumber their 
career. And it's just going to take some time for the word to 
get on out that says, hey, this is OK. We really need to help 
you. Come and talk to us, even in a discreet manner.
    So sir, for the 29th Brigade Combat Team, as an extra, we 
mobilized our trained mental health counselor. She was head of 
our family readiness program, but I said, hey, this is even 
more important. You go ahead and mobilize with the brigade, 
that as a trained mental health counselor, her discussions with 
me before the unit departed for Iraq is, hey, I know how to 
talk to the local guys, you know? I can connect with them.
    And so what I'm trying to do right now is to continue her 
service in active duty because she has her list of clients that 
she has seen in country, from California to the brigade, the 
rest of the units in the brigade, American Samoa and Saipan, 
that she has spoken with me that she would really--she kind of 
knows who needs the extra help and are reluctant to come 
forward.
    And I'm trying to keep her on active duty to provide this 
continuity of service for however long it takes, months or 
years down the line to--because they've earned her trust in the 
combat zone, talking to her. And in many cases, it's just 
talking to someone that understands. She's certainly been there 
with them, and I think we'll be successful in keeping her on 
active duty to continue this engagement with our soldiers of 
the brigade.
    Senator Akaka. Thank you.
    Colonel.
    Colonel Horn.  Sir, our organization spans many different 
cultures, from small Indian villages in Alaska all the way out 
to the Manu'a Islands in American Samoa. Unfortunately, I think 
across all of those cultures, there is still a stigma 
associated with mental health issues.
    Our challenge is, again, as with all of our organizations, 
to break through that stigma and make sure that our soldiers 
understand that there will be no repercussions, no harm to 
their careers, from coming forward or seeking assistance.
    Again, I think, as for all of us, the challenge is in 
educating our soldiers that there is no stigma. We've 
incorporated that effort into our institutional training in the 
Army, into our specific training in preparations for 
deployments. As with the active component, we incorporate our 
families in that training.
    There's pre-deployment training for the families. Shortly 
before our soldiers return, there's reintegration training. And 
part of that is, as with the active component, using many of 
the same resources here in the Pacific to educate the families 
to be on the looking to be helpful, to bring issues forward.
    It's a multi-disciplinary effort. Again, our chaplains have 
been a tremendous help in this process. Substance abuse 
counselors. Legal people. Often these problems manifest 
themselves in other dimensions--domestic abuse, substance 
abuse, legal problems.
    We have had a few cases--just yesterday I was speaking to 
our command chaplain about a soldier from Samoa that's here on 
Oahu now receiving help at Tripler. So we have a support 
network in place to help these soldiers. The problem is getting 
out there identifying them and getting the appropriate help at 
the earliest possible time, and helping them with their career, 
and retaining them as soldiers.
    Senator Akaka. There's no question that the cultural values 
and aspects are really becoming noticeable, and particularly in 
Hawaii. We're such a diverse State and we have many ethnic 
groups here. This is also true throughout the country. I'm so 
glad to hear that we're focusing on this as well to help our 
military people heal well.
    Dr. Perlin, do you have any comments to make on this?
    Dr. Perlin. Thank you, Senator Akaka. Regrettably, I do 
think we have to acknowledge that in the world, there still are 
stigmas associated with mental health issues. I think, though, 
behind your question, there are really two issues. One, how do 
we get people the care they need? At the same time, how do we 
avoid overly labeling individuals in ways that may be limiting, 
not only in terms of--and even if not especially outside of the 
military, in their own career development, but in terms of 
their own definitions.
    Yesterday, we were honored to have you lead off the stress, 
violence, and trauma conference on Oahu. Thank you very, very 
much for that. So much of the theme there was, how do we change 
to make sure that we build on the person's strengths and build 
on their inner resilience so that they can be as functional as 
possible and recover as much as possible, and define their 
lives not in terms of illness but in terms of recovery, not in 
terms of disability but in terms of possibility. I think that's 
so important.
    Yet at the same time, I think we acknowledge that there are 
history where it's been difficult to identify, and from the 
forward deployment of combat stress teams to the very novel and 
proactive and absolutely contemporary approaches that 
Department of Defense is using today, to when an individual 
separates, the post-deployment health reassessments, to VA's 
outreach.
    Secretary Nicholson has sent 433,398 letters to separating 
servicemembers from the Global War on Terror identifying that 
there are resources there, and again, emphasizing recovery and 
function without overly medicalizing or putting labels on, 
pathologizing. It's really something that we hope to effect 
through our Global War on Terror outreach counselors, 
coordinators at our Vet Centers.
    We met on Wednesday at Oahu, at the hearing on Oahu, 
Matthew Handel [ph], himself a veteran of OIF, who was there to 
provide that sort of non-medicalizing support for stress 
reactions that may be in fact a very normal part of the 
experience. Again, not PTSD. When symptoms are severe or 
intrusive, then we get into a more intensive sort of treatment.
    Again, the ability to outreach by people who have been 
there. And it's my pleasure, if I might be somewhat unorthodox, 
and introduce Mr. J.L. Sisto [ph], Army Reserve, who is in fact 
part of the VA Pacific Islands Health Care System. Jay, would 
you--in the purple lei there--and provides that sort of 
outreach without medicalizing, helping people to identify 
issues and anxieties, deal with them, and where more intensive 
issues exist, to refer those for appropriate and greater depth 
of therapy.
    Senator Akaka. Dr. Perlin, the VA clinic in Kona on this 
island is bursting at its seams. This is widely known. My 
question to you is: Are there plans to do anything to expand 
their space?
    Dr. Perlin. Yes. I've been--thank you, Senator Akaka, for 
that question. Let me ask Dr. Steve MacBride, our chief of 
staff for the VA Pacific Islands Health Care System, to 
describe some of the plans to augment services there at Kona.
    Dr. MacBride. Thank you, Dr. Perlin.
    Welina, Senator Akaka.
    Senator Akaka. Welina.
    Dr. MacBride. I'd like to just take the opportunity very 
quickly before I answer the question to bring you greetings 
from the clinical staff of VA here in Hawaii. We all have been 
working to prepare for the hearings, but we wanted to let you 
know how much we appreciate you, Sir. And it's always a delight 
when you come to visit us. We salute your caring for veterans, 
and we very, very much appreciate your personal caring for us 
as individuals. And it seems very appropriate that the fourth 
hearing here is on the Big Island, the home of the greatest 
Hawaiian warrior, Kamehameha the Great.
    We are very pleased to announce that we will be relocating 
the Kona CBOC. We have found new space, and a brand-new 
building is being constructed. VA is going to be relocating in 
order to provide that additional space, and with that we're 
able to bring new telemedicine equipment that we did not have 
at the former CBOC in the amount that we will be able to have.
    As well, all of our CBOCs have the automatic drug 
dispensing MCS, which allow veterans to receive their 
prescriptions right there in the clinic, dispensed remotely 
from our pharmacy in Honolulu. We weren't able to do that in 
Kona because of space considerations, and now that will be 
possible.
    We expect to be opening the new clinic by mid-year of 2006.
    Senator Akaka. Good news. Thank you very much.
    Dr. Perlin, I know we discussed this a bit at the hearing 
in Maui. But I'd like to again address the relocation of the 
clinic. It is my understanding that there will be outpatient 
services put in place on the Big Island to ensure that veterans 
can get mental health treatment if the need it.
    But how will inpatient psychiatric needs be met here in 
Hilo? And of course, we're interested in when will the new Hilo 
mental health clinic be up and running?
    Dr. Perlin. Well, thank you, Senator, for that very 
important question. I was very much assured this morning when I 
visited the Hilo CBOC to find and meet Dr. Andrew Bissett [ph], 
who is the psychiatrist, and Gordon Schrader [ph], who's 
actually sitting here in the second row, one of the very few 
certified addiction specialists here in Hawaii. And they are in 
location in the Hilo CBOC.
    In fact, the PTSD Residential Rehabilitation Program has 
always been just that, a residential rehabilitation program, 
not inpatient psychiatry. Our Hilo CBOC is located across the 
street from the Hilo Medical Center, which has attached to it 
an inpatient psychiatric unit. Of course, that unit is 
available in emergencies, and that will not be dissimilar from 
what's existed in the past, the emergency use of that.
    We of course have our inpatient psychiatry at Tripler. I 
was absolutely pleased to see that the new venue for the PTSD 
Residential Rehabilitation Program on the Tripler campus is in 
an area that actually exists above the office of the commanding 
general's--well, actually, the commanding general's lanai. 
Anyone who might have been on that lanai knows that it's 
absolutely panoramic.
    This is one floor, one or two floors up. It's 5C1. And in 
fact, if you look out to the right, you see Pearl Harbor. To 
the left is Diamond Head. So, there is suitable space for this 
unit to relocate, and they're in the process of relocating that 
there.
    So increased mental health support at the CBOC, with the 
new substance abuse program based here with certified addiction 
specialists, a continuing relationship with Hilo Medical 
Center's inpatient unit, and of course, our inpatient unit at 
Tripler. And a really very nice venue over at 5C1 in Tripler.
    Senator Akaka. Thank you very much, Dr. Perlin. Let me 
further ask, are efforts being made to find employment for the 
PRRP employees who were displaced in Hilo?
    Dr. Perlin. Well, as I mentioned, I'm pleased that Dr. 
Bissett and Mr. Schrader are going continuing to be part of the 
staff. I'm going to ask Dr. Wiebe to elaborate on where people 
are relocating.
    Dr. Wiebe. Thank you, Dr. Perlin.
    As Dr. Perlin noted a moment ago, we are relocating the 
center from Hilo to Honolulu. And there were several reasons 
why we made that decision. One of them has been the difficulty 
of recruiting staff here in Hilo at the PRRP, and that's 
resulted in some lower class sizes over the years.
    But the major reason for relocating the PRRP is to better 
serve our veterans. As we have talked about it today, there 
will be a large number of our newer veterans coming into the VA 
system, and our way of approaching their needs, whether it be 
an acute adjustment disorder or full-fledged PTSD needs, to 
change as well.
    The 16-bed unit will be, in its entirety, relocated to 
Tripler, as Dr. Perlin noted. But in addition, at that 
location, we will also institute an intensive outpatient 
program to serve our newer veterans, who often come with 
families, with jobs, and are not able or willing to spent the 6 
to 10 weeks in the PRRP, and would instead benefit from an 
outpatient program that would be similar to a PTSD day 
treatment program.
    For the employees that were employed here at the PRRP, we 
have offered every employee the opportunity to transition with 
the center to Honolulu, and VA would pay for the relocation 
expenses. It's my understanding that several employees have 
accepted that and are choosing to do just that.
    In addition, as Dr. Perlin noted, we are enhancing our 
outpatient mental health services here in Hilo, and several 
employees--again, including Dr. Bissett and Mr. Schrader--are 
working now already at the CBOC. For the remainder of the 
employees, we will need to continue to talk with them and with 
their union representatives.
    My first position in the VA system was as an emergency room 
physician at the Martinez VA Medical Center, and approximately 
5 years into my VA career, a decision was made to close that 
facility in Martinez, California because of concerns about 
damage to the building from a major earthquake.
    So I personally know some of the concerns and some of the 
disruption that such a change can occur. And I can assure all 
the employees and all of their families and all of their 
friends that we are very aware of that, and we will work very 
closely with each individual employee to come up with the best 
possible solution.
    Again, some of them hopefully will continue to relocate to 
Honolulu. Some will remain here in Hilo. And again, on an 
individual basis, we'll work with each employees to hopefully 
come up with a solution. Thank you.
    Senator Akaka. Thank you very much. We're talking about 
families and the importance families have in what we're trying 
to do. Programs such as the New Hampshire National Guard's 
Reunion and Re-entry Program place importance on the inclusion 
of family members of returning soldiers and military folks, and 
the transition process.
    Dr. Perlin, how can this type of transition program be 
duplicated in Hawaii, and how could VA collaborate with the 
Department of Defense to ensure that this program can be 
established?
    Dr. Perlin. Thank you, Senator, for this important 
question. The transition program is inadequate if it doesn't 
really accommodate spouses and other family members in assuring 
that there is a continuity of information.
    I want to thank our colleagues from Department of Defense 
for participation at every level, from the unit commands to 
Adjutant General's office and to National leadership who have 
helped really create unprecedented partnerships.
    Let me just note what has happened in New Hampshire as an 
example of the sort of collaboration. It may be a little 
forward of the rest of the country, but something that we would 
hope to do here in Hawaii and throughout. It's absolutely a 
model.
    The program, these programs, the Reunion and Re-entry or 
similar programs, involve really a collaboration between all 
elements of VA, not just our Veterans Health Administration, 
but our sister agency, the Veterans Benefits Administration, 
and colleagues from Department of Defense and representatives 
of State Departments of Veterans Affairs, in meeting and 
greeting returning servicemembers.
    Basically, in the past, what's happened is that people who 
were demobilizing have been greeted with an onslaught of 
information. And if one line says, you know, sign up for 
additional screenings, additional conferences, et cetera, et 
cetera, et cetera, and you've been on a tour for 6, 12, 18 
months, and the other line says, go home, you're going home. 
You're not going to go to line A, as much as we would hope that 
people would get that information.
    So this program really involves all of these elements 
coming together from Veterans Health, Veterans Benefits, DoD, 
State, et cetera. But when the servicemember returns home, 
they're given 24 to 72 hours of leave to decompress and 
reacquaint with family, and then come back with family members, 
family members who also can hear some of the information that's 
provided.
    That information extends from outreach coordinators, such 
as J.L. Sisto and his colleague in the Vet Centers; Matthew 
Handel here in Hawaii, greeting those returning troops and 
first identifying that it's OK, it is not improper, to identify 
that you might have a need.
    It's providing information such as the more than a million 
and a half of these brochures that provide a summary of 
benefits--this one for Reserve; there's a similar one for 
separating active duty servicemembers. CDs and little pocket 
CDs and wallet cards and all sorts of information that really 
helps to make a very positive approach. Information from 
Veterans Benefits about loans for housing, about the G.I. Bill 
benefits for education. Things that the individual may not have 
themselves thought about in terms of next steps. Things perhaps 
that their spouse may have thought about in a great deal of 
detail, or wants to attend to in terms of thinking about 
relocations or further educational opportunities.
    And so it really is very much a family activity. It's very 
much an interdepartmental activity. It involves the highest 
levels of our departments, at our Secretary's level--the 
Commandant of the Marine Corps has--I've met with, with 
Secretary Nicholson, and appreciate, as an example, that degree 
of relationship and the seamless transition there--to the very 
front line, the garrison commands who support these programs 
with all elements involving spouse and family members.
    And we will continue to push forward in these sorts of 
activities to make sure that the transition back to civilian 
life is as effective and well-supported as possible. We look 
forward to working in particular with General Lee and the State 
of Hawaii, and General Mixon and Colonel Horn and colleagues in 
terms of anything we might do here in collaboration with our 
Vet Centers and with our health system.
    Senator Akaka. Thank you very much, Dr. Perlin. I am so 
grateful for the responses we've heard this morning here. And I 
want to say mahalo nui loa, to our military leaders in our 
country. I'm Ranking on Readiness Subcommittee and on Armed 
Services. We have the best military leaders around. I've been 
with the Department of Defense.
    So when I say this, I really mean it, that we have the best 
military leaders in the world, and some of them are here today. 
We are so fortunate in our country because they've ensured our 
liberty and freedom that we enjoy today.
    Also, I'm so delighted to have the leaders of our VA, both 
nationally and locally, who are here to witness and give their 
testimony. And we've heard from them. So you've heard the best 
advice you can get, the best information, and I'm really 
grateful. And I want to say mahalo nui loa to all of you for 
being here this morning and for making these four sessions, 
hearings, on Veterans' Affairs the best. No ka oi ichiban.
    So thank you very much, all of you. And I'll call up the 
second panel in a moment. Thank you very much.
    [Recess.]
    Senator Akaka. The hearing will come to order.
    At this time I'd like to introduce our second panel. Jon 
Harlan, M.S.W., Team Leader, Hilo Veterans Center; Kevin Kunz, 
M.D., President, American Society of Addiction Medicine; 
Sergeant Greg Lum Ho, Army National Guard; and a veteran, 
Katherine King.
    So we're glad to have all of you this morning. We look 
forward to your testimony. And we will give our testimony in 
the order in which I introduced you.
    John Harlan.

         STATEMENT OF JON HARLAN, M.S.W., TEAM LEADER, 
                        HILO VET CENTER

    Mr. Harlan. Aloha, Senator Akaka. It is an honor to appear 
before you today, especially due to your long and continued 
support for Vet Centers in our Nation, and knowing that you are 
the father of the Vet Centers in Hawaii. Over the years, your 
continued support for our Vet Centers and our existence has 
been noted and appreciated. So I thank you for that, first of 
all.
    Today I want to outline the role the Hilo Vet Center has in 
providing care and services to veterans of all eras, with 
special emphasis on newly returning veterans from Operation 
Enduring Freedom and Operation Iraqi Freedom. Although I will 
focus on the Vet Center's involvement, our efforts are typical 
of the 207 Vet Centers across our Nation.
    Under the leadership of Dr. Alfonso Batres, Chief of the 
RCS, and Mr. Richard Talbott, the Western Pacific Regional 
Manager, the Hilo Vet Center, located in old downtown Hilo, 
strives to provide the highest quality of care and services to 
veterans who walk through our doors and those we meet through 
our outreach efforts. It is a privilege and honor to serve 
them.
    The Hilo Vet Center is responsible for providing services 
to veterans from the southern end of the Big Island, Naalehu, 
to the far west side town of Waimea. Services provided by our 
Vet Center include individual, family, and group counseling, 
with a special emphasis and expertise in counseling for combat-
related post-traumatic stress disorder.
    We also emphasize community outreach and assistance in 
gaining access and working with our brethren in the VA medical 
community, CBOC. We also provide onsite assistance with the VBA 
staff, who come to our Vet Center once a month to assist 
veterans with their claims. We also work closely with the State 
of Hawaii Veterans Service Officer, Mr. Keith Rivencho [ph], 
who helps us with veterans in filing of their claims. And we 
conduct joint outreach services with him. He is a partner of 
our Vet Center in every way.
    Concerning specifically the returning veterans and our 
concern there is in the Hilo area, we have many Guard and 
Reserve units. One is Army National Guard 2nd Battalion, 299th 
Infantry, which, as was described to you earlier, is currently 
returning to Hawaii and was definitely in the thick of combat.
    We also have the Army Aviation, Army National Guard 193rd 
Aviation Regiment, and the Army Reserves 411th Combat 
Engineers. In addition, there is a section of the Reserves' 
storied 100th Battalion, 442, that's co-located with the 411th 
Combat Engineers.
    The Kona Vet Center covers the remainder of the Big Island, 
providing services to all eligible veterans, which includes one 
company of the Hawaii Army National Guard 2nd Battalion, 299th 
Infantry, which is located in Kealakekua, Kona. As a member of 
the Hawaii National Guard, as well as being the Hilo Vet Center 
Team Leader, I have personally made frequent contact with 
members of these units and their families to provide them with 
information about Vet Centers and VA services, and to support 
family members during the time of deployment.
    The staff of the Hilo Vet Center was prepared and given the 
additional mission of providing bereavement counseling for 
family members of military personnel killed on active duty in 
Iraq or Afghanistan. Sadly, we have on this island suffered the 
loss of one fine young American from the Volcano area, and I 
made contact and offered support to his family.
    We hope and pray that all of our service men and women will 
return home safely soon, as most of them, their deployments are 
more than halfway over. Most of them are on their way home. But 
guarantee you for that family in Volcano who lost their son, 
their life will never be the same again.
    The Hilo Vet Center tries to maintain nontraditional hours 
to ensure services are available to all veterans, both those 
that work and those who don't. We are currently open Mondays 
and Tuesdays from 8 till 6:30 p.m., and Thursdays from 8 in the 
morning to 8 in the evening. We expect to increase 
substantially evening hours as more soldiers, especially the 
Guard soldiers, return home and return to work, and their need 
for services will be in the evenings and possibly on weekends, 
as they will not want to interfere with their work schedules 
because that issue we talked about of stigma.
    Although we want to say maybe it's not there, it is still 
there. And many soldiers I've talked to don't want their 
employers yet to know that they are, you know, coming to a 
place like the Vet Center.
    We strive to support these units and these veterans' 
organizations by providing outreach and informational 
presentations whenever they are requested. We believe by doing 
this and always being available, veterans who otherwise may 
never come to the VA will come and get the care and help they 
have earned.
    During the time the units have been deployed, we have 
worked numerous times with family support groups to inform them 
about the Vet Centers and the type of services we offer, and 
urging them to be ready for their husbands or wives when they 
return, and kind of what kind of things to expect.
    I believe this has paid dividends in the fact that on 
Monday, we received a call from a soldier in Kuwait, who was 
calling before he even left Kuwait to set up an appointment to 
come see us upon his return because, somehow, he's already been 
given the information about a Vet Center and he is going to be 
seen very soon upon his return home.
    The Vet Center has a core staff of three people: a Team 
Leader--myself, one counselor, and an office manager. Currently 
we are happily in the process of hiring a full-time Global War 
on Terrorism outreach worker that is currently in the Honolulu 
VA personal office. We hope to have that person on board. It's 
a female soldier who is a recent veteran of OIF herself.
    Her responsibility will be stationed at the Hilo Vet 
Center, but she will be responsible to cover the entire island, 
to include the Kona side. And the Kona and Hilo Vet Center work 
very closely together. Felipe Salas [ph] is my fellow Team 
Leader. He was back here somewhere.
    The other thing about the Vet Center is all of our staff 
are veterans. One member holds licensure. Two of them are 
Vietnam veterans. The other two of us are Gulf War veterans. We 
have--due to our small permanent staff--we augment ourself for 
clerical support with the VA Work Study Program, which helps 
young veterans attend college, earn a salary while helping 
other veterans, and provides for a smooth operation of our 
small Vet Center.
    Having them has been a godsend, not only for the additional 
work they do, but more importantly, because usually they are 
veterans themselves of OIF/OEF operations and have been able to 
give us, who haven't been there, key insights into 
understanding the unique experiences and needs of their peers 
in the current conflict.
    All of our Work Studies have been outstanding and show a 
great deal of compassion for their fellow veterans who come in 
or are contacted as they assist us with outreach. I believe 
this program could be very valuable in recruiting future 
professional staff for our Vet Centers, as most of us in Vet 
Centers are reaching very near retirement age.
    The Hilo Vet Center continues to provide readjustment 
counseling and supportive services also to a large number of 
Vietnam veterans, as well as veterans of World War II, Korea, 
and other conflicts such as Somalia. During fiscal year 2005, 
the Hilo Vet Center provided services to 731 individual 
veterans in 5,800 sessions, and to family members.
    During this same period, we began to see an increasing 
number of OEF/OIF veterans and their families. In fiscal year 
2005, we saw 51 veterans of these new conflicts for 118 visits, 
compared with only 4 for the year 2004. Our expectation and 
concern is that when the largest deployed unit from this 
island, the 2nd Battalion, 299th Infantry, returns to Hilo, we 
will be seeing far more OEF/OIF veterans because they were in 
heavy combat situations. We would naturally expect their degree 
of acute stress, stress reactions, would be higher than the 
units that have already returned.
    Our Vet Center strives to provide intense and complete 
counseling for veterans on the east side of the Hawaii island. 
Our goal is to assist veterans in leading productive--sorry, 
Senator, this is nerve-wracking, in an way--and satisfying 
lives. As stated earlier, we do this by providing individual, 
family, and group counseling. And again, as mentioned earlier, 
involvement of the family is key.
    The families are already concerned, even before their 
soldiers have returned, about what the soldier is going to be 
like, whether male or female spouse. And they want to know what 
services are going to be available for them and their families. 
In the past, family services were lacking. So I am hoping that 
it is an area that we will be able to increase in order to 
achieve the goals of preventing post-traumatic stress disorder 
and keeping it as a readjustment issue.
    Our intent is to extensive outreach to these units. In 
other words, the National Guard units that have returned, we 
have attended all of their welcoming ceremonies and set up a 
table with numbers and mainly that they see the face, that, you 
know, here we are. We want to help you. Come see us. I think 
that when you're there, you know, in the welcoming ceremonies, 
it pays great dividends later on because you've established a 
comfort level with them. That is one way I met Sergeant Lum Ho, 
was when his unit had a welcoming ceremony and I spoke to him 
and decided he would be a great witness for his fellow vets.
    Our challenges as we do this is to continue to provide high 
quality care to our core constituency of World War II, Korean, 
and Vietnam veterans. I consider it a great honor to provide 
services to multiple generations of America's finest. I believe 
it's the greatest job in the world, and I want to thank Senator 
Akaka and your Committee for providing the support for allowing 
our Vet Centers to exist.
    Senator Akaka, this concludes my statement. I thank you for 
your time and your efforts on behalf of our State's veterans 
and our Nation's veterans, and look forward to answering 
anything questions you or your Committee may have. Thank you, 
sir.
    [The prepared statement of Mr. Harlan follows:]

 Prepared Statement of Jon Harlan, M.S.W., Team Leader, Hilo Vet Center

    Aloha, Senator Akaka. It is an honor to appear before you today to 
outline the role of the Hilo Vet Center in providing care and services 
to veterans of all eras, with special emphasis on newly returning 
veterans from Operation Enduring Freedom (OEF) and Operation Iraqi 
Freedom (OIF). Although I will focus on the Hilo Vet Center's 
involvement, our efforts are typical of the services provided by the 
207 Vet Centers nationwide.
    Under the leadership of Dr. Alfonso Batres, Chief of the Office of 
Readjustment Counseling Service, and Mr. Richard Talbott, the Pacific 
Western Regional Manager; the Hilo Vet Center, located in old downtown 
Hilo, strives to provide the highest quality of services to all 
Veterans who walk through our doors and those we meet through our 
outreach efforts. It is a privilege and honor to serve them.
    The Hilo Vet Center is responsible for providing services for 
veterans from the southern end of the Big Island, (Naalehu) to the far 
west side town of Waimea. Services provided by the Hilo Vet Center 
include individual, family and group counseling, with special expertise 
in counseling for combat-related Post Traumatic Stress Disorder; 
community outreach; assistance in gaining access to medical care 
through the Hilo VA Community Based Outpatient Clinic (CBOC); and 
onsite assistance for veterans with VA disability claim issues by a VA 
Benefits Counselor once a month. We work closely with the State of 
Veterans Service Officer, referring veterans to the VSO for in-depth 
service on claims issues; we also conduct joint outreach efforts with 
the VSO in the Hilo Vet Center's catchment areas.
    In the Hilo area we have one National Guard Unit: the 2nd BN, 299th 
Infantry BN, Army Aviation Units (193rd AVN RGT), and the Army Reserves 
411th Combat Engineers, in addition to a section of the Reserves' 
storied 100th, 442nd Infantry. The Kona Vet Center covers the remainder 
of the Big Island, providing services to all eligible veterans, which 
includes a company of the Hawaii Army National Guard 2nd BN, 299th 
Infantry BN located in Kealekekua, Kona. As a member of the Hawaii Army 
National Guard as well as being the Hilo Vet Center Team Leader, I have 
personally made frequent contact with the members of these units and 
their families to provide them with information about Vet Center and VA 
services, and to support family members during the time of deployment.
    The staff of the Hilo Vet Center is prepared to provide bereavement 
counseling for family members of military personnel killed on active 
duty in Iraq or Afghanistan. Sadly we have suffered the loss of a fine 
young American from the Volcano area, and the Vet Center offered 
support to his family. We hope and pray that all our servicemen and 
women will return safely very soon, as their deployments are more than 
half-way over.
    The Hilo Vet Center maintains non-traditional hours to ensure that 
all services are available to veterans, both those that work and those 
who don't. Currently we are open Monday and Tuesday from 8 am to 6:30 
pm and Thursdays 8 am to 8 pm. We expect to provide additional evening 
hours as more soldiers return home and to work and need or want more 
services. We strive always to support military units and veterans' 
service organizations by providing outreach and informational 
presentations whenever they are requested. We believe by doing this and 
always ``being available,'' veterans who otherwise may never come to 
the VA will get all the care and help that they have earned.
    The Hilo Vet Center has a core staff of three: Team Leader, one 
counselor and an Office Manager. Currently we are in the process of 
hiring a full time Global War on Terrorism (GWOT) Outreach Worker. This 
person will be stationed at the Hilo Vet Center, but will cover the 
entire Island, to include the Kona side. The Kona Vet Center and Hilo 
Vet Center staff work together closely on outreach each week, so this 
arrangement will work well. All Team Members are veterans. One member 
holds mental health licensure (Social Work); and the others have many 
years of experience working with Veterans, especially in the area of 
combat-related trauma. The Hilo Vet Center, due to its small permanent 
staff, has augmented clerical support staff for several years through 
the VA Work Study Program, which helps young veterans attending college 
earn a salary while assisting other veterans and helps provide for the 
smooth operation of the Hilo Vet Center. Having them has been a 
Godsend, not only for the additional work they do, but more 
importantly, because they are usually veterans of the OEF/OIF 
operations and give staff key insights into understanding what the 
unique experiences and needs of their peers in current conflicts. All 
of our Work Study students have been outstanding and show a great deal 
of compassion for their fellow Veterans who come in or are contacted 
during outreach. I believe this program could prove to be valuable in 
recruiting future professional staff for our Vet Centers.
    The Hilo Vet Center continues to provide Readjustment Counseling 
and supportive services to a large number of Vietnam Veterans, as well 
as veterans of World War II, Korea, the current conflicts and others. 
During fiscal years 2004 and 2005, the Hilo Vet Center provided 
services to 731 individual veterans in 5,894 readjustment counseling 
visits for veterans and their family members. During the same time 
period we began to see increasing numbers of OEF/OIF Veterans and their 
families. In fiscal year 2005, we saw 51 individual OIF/OEF veterans 
for 118 visits, compared to just 4 OIF/OEF veterans for 17 visits in 
fiscal year 2004. Our expectation is that when the largest deployed 
unit (2nd BN, 299th Inf.) returns to Hilo, we will be seeing far more 
OEF/OIF veterans. Our Vet Center provides intense and complete 
counseling for veterans of the east side of Hawaii Island. Our goal is 
to assist veterans in leading productive and satisfying lives. As 
stated earlier, we do this by offering veterans individual, family, and 
group counseling. To achieve our goals and meet the full range of needs 
for the veteran and family members, many of our veterans are involved 
in all three modes of counseling. In regards to OEF/OIF Veterans, our 
intent in offering extensive outreach to them is to let them know of 
our presence, to introduce them to the services that we provide, and to 
give them a sampling of the range of readjustment counseling services 
available to help them make a positive return to civilian life, as well 
as to assist their families. At the same time, we continue to provide 
the same high quality readjustment assistance to our core constituency 
of World War II, Korean War, and Vietnam veterans. It is a great honor 
to provide services to multiple generations of ``America's Finest''. I 
believe I have the greatest job in the world, and I thank you and your 
colleagues for providing the support to allow our Vet Centers to exist.
    Senator Akaka, this concludes my statement. I thank you for your 
time and look forward to answering any questions you or other Members 
of the Committee might have.

    Senator Akaka. Thank you for your testimony.
    [Applause.]
    Senator Akaka. Dr. Kunz.

 STATEMENT OF KEVIN KUNZ, M.D., M.P.H., FASAM, PAST PRESIDENT, 
              HAWAII SOCIETY OF ADDICTION MEDICINE

    Dr. Kunz. Senator, thank you for the opportunity to come 
before you today to offer these comments regarding the 
treatment of Hawaii's veterans who have PTSD and drug-related 
problems. Also mahalo for all of you, aloha to our veterans in 
Hawaii and for your activity in the treatment of drug addiction 
both in Hawaii and across the country.
    The Hawaii Society of Addiction Medicine is an organization 
of 26 physicians, a chapter of the American Society of 
Addiction Medicine with 3,000 physicians. Our organization is 
dedicated to improving the treatment of alcoholism and other 
addictions, educating physicians, promoting research and 
prevention, and enlightening and informing the medical 
community and the public about these issues. Our members 
practice in all aspects of medical care in this community and 
nationally, from research to positions in clinics and in the 
VA.
    We wish to immediately acknowledge our military men and 
women from both past and present wars and all veterans. Their 
volunteerism and gallantry is a source of pride for all 
Americans, and we sincerely thank them for their service. And 
particularly, we wish our men and women in the current 
battlefields a speedy and safe return home.
    My comments today will be influenced by my own 25 years of 
family practice medicine in Kona--where many veterans are my 
patients, and where I have a working relationship with the 
superb staff of the VA's Community-Based Outpatient Clinic and 
the Vet Center. I have been sub-specializing in addiction 
medicine for 11 years, and in this capacity have cared for many 
more Big Island veterans. I am also a Vietnam veteran and have 
personally received services from Hawaii's VA programs.
    The association of combat service, post-traumatic stress 
disorder, and substance abuse is well-known. Perhaps the most 
poignant lessons from our old wars has been these: (1) PTSD and 
its co-morbidities are predictable, preventable, and treatable; 
(2) The co-occurrence of PTSD and substance abuse is the norm, 
not the exception. As we know in all aspects of civilian and 
military life in any setting, violence is the superhighway to 
addiction; and (3) PTSD can be successfully treated only to the 
extent that co-existing substance abuse is treated.
    The problems of PTSD, addiction, and dysfunctional lives 
will only grow as more vets return. We should never use the 
term ``normal'' in explaining PTSD. That is denial and 
perpetuates the stigma of the disease. And with PTSD and 
addiction--unique in medicine--the worse someone gets, the less 
likely they are to ask for help.
    Our final lesson: Whether or not we honor the war, we must 
always honor and care for the warrior. We must have adequate 
addiction care resources within the VA system to treat our 
veterans in need.
    I will now summarize seven specific problems and make 
recommendations for Hawaii's programs, with particular 
attention to the outer islands, where resources for the 
treatment of substance abusing veterans are woefully 
inadequate.
    (1) Substance Abuse Counselors: On the outer islands, the 
VA Community-Based Clinics are all lacking a certified 
substance abuse counselor. If the vet has a significant alcohol 
or drug problem, he will need to obtain specialized services, 
perhaps medical detoxification or intensive outpatient 
treatment. It's not enough to suggest they go to AA or NA. Many 
vets are too sick for that. Ten years ago, there was a CSAC 
rotating between Hilo and Kona. Now we have none. We recommend 
that what's been spoken of here today be put in place, where we 
have certified substance abuse counselors at each clinic.
    (2) The Modern Treatment for Opiate Addiction: Many 
veterans, from previous wars and from Afghanistan and Iraq, 
have come home with or subsequently acquired opiate problems. 
Opium, heroin, and pain pills are all readily available in many 
battlefield and civilian settings. In addition to the war-
addicted, America now has currently an epidemic of prescription 
opiate abuse and dependence: pain pills. And non-opium, non-
heroin opiate prescription drugs are readily available.
    It is notable that Afghanistan produced more opium last 
year than any country in recorded world history. Our military 
men and women there are at an increased risk. There are now 
reports of Americans returning home addicted to Afghanistan's 
opium.
    Opiates can be a tonic for the pain and dysfunction of war 
and of PTSD, and then they often become an insurmountable 
addiction. Five years ago, Congress passed the Drug Abuse 
Treatment Act of 2000, which made available the medication 
buprinorphine for the treatment of opiate dependence.
    Unlike methadone, buprinorphine can be prescribed by 
physicians outside of the classic methadone clinics. It has 
less risk of diversion and abuse, and a much better safety 
profile. Methadone is currently associated with emergency room 
deaths from overdose.
    Although thousands of physicians are successfully 
prescribing this medication across the country, the VA has been 
slow to integrate its use. It needs to be an option within the 
VA system. It is available in Los Angeles and about 10 other 
States, but not Hawaii. We recommend that this proven, safe, 
and accepted therapy become available within Hawaii's VA 
programs for the treatment of opiate withdrawal and opiate 
maintenance therapy in properly selected patients.
    (3) Residential and Other Treatment Opportunities: The 
outer islands do not have residential or ``clean and sober'' 
houses available for vets who require these levels of substance 
abuse care. This may be due to the complicated and restrictive 
Federal requirements for such facilities.
    We recommend that some accommodation be made to permit 
matriculation of vets in local residential programs and ``clean 
and sober'' houses, as well as outpatient substance abuse 
treatment programs. Perhaps until the VA itself can establish 
these facilities, it can contract with existing programs that 
meet every other State and National certification.
    (4) A brief comment on the Hilo PRRP: The benefit of that 
program on the Big Island was not limited to the vets who 
participated there. The staff was available to other healthcare 
providers on the Big Island for consultation, and the 
recovering vets themselves were very effective outreach workers 
and therapeutic guides for other vets with PTSD and/or alcohol 
and drug co-morbidities.
    Your announcement, Senator, 2 days ago of additional 
funding for PTSD treatment, including the much-needed 
additional staffing for the Hilo CBOC, provides the opportunity 
for this proposal to become reality. Expanded mental health 
services beyond what is currently provided by neighbor island 
CBOCs and Vet Centers are needed. It is to be hoped that Hilo 
will lead the way in establishing a model of comprehensive 
treatment that can be instituted on the neighbor islands, on 
other neighbor islands.
    (5) Prevention Services: Although some veterans from the 
current war are trickling in, as Mr. Harlan said, we expect 
that it will be 5, 10 years or longer before most vets with 
PTSD and related substance abuse problems ask for help. Yes, 
some of them will be seen at emergency rooms, jails, 
institutions, divorce courts, and unemployment lines before 
then.
    Often now it is the family of the vet who says that 
something is wrong, but they can't get the vet to seek help. 
Our military services, as has been spoken of here today, are 
trying pre-emptively to deal with this by educating personnel, 
et cetera. But history has shown that most vets don't see the 
problem or resist help.
    Therefore, there needs to be more outreach early on, both 
to the newly discharged vet and to family members. PTSD and 
addictions are family and community disease, as well, diseases 
of the individual who has it. When we consider the 3 to 400 
National Guard soldiers who are expected to return to the Big 
Island this year, we know that we need to gear up new types of 
services. We recommend a new set of outreach services.
    Two final things. First--
    (6) Training for VA Addiction Physicians: The education and 
availability of physicians who treat addictive disease is an 
important issue. Specialists in addiction medicine have several 
routes to certification. Residency programs are the best. There 
is a combined addiction medicine/ psychiatry residency 
available in Hawaii. We are lucky to have it. It's a good 
program, well run. It is run through the University of Hawaii's 
School of Medicine.
    The Spark Matsunaga VA Medical Center is currently lacking 
a postgraduate, year-5 position in addiction medicine/
psychiatry. Such a physician could rotate inter-island and 
educate and support physicians in the VA and in private 
practice in the care of vets. This position would support and 
compliment the expansion of services that have been talked 
about.
    (7) Finally, Community Cooperation: VA physicians, 
including psychiatrists, often do not participate as equal 
members of the medical community. At least on the outer 
islands, they do not routinely share hospital work, including 
on-call, with other physicians.
    There are two down sides to this. First, it sets up the 
veterans and the VA physicians as being apart from, rather than 
a part of, the community healthcare resource network. Second, 
when a vet who is receiving care from the VA needs hospital 
admission, he or she can be perceived as being ``dumped'' on 
the community physician who is on call.
    This alienates the on-call physicians and speaks poorly to 
the continuity of care that all patients deserve. We recommend, 
at a minimum, that VA physicians maintain membership in local 
medical societies, and that they maintain at least a courtesy 
staff status at hospitals.
    I will now talk about the statistics of how we've seen 
people increase in the VA system for PTSD, a 42 percent 
increase and other details over 5 years, most of whom have been 
Vietnam vets, not vets of the current war.
    We are now funding wars in two countries, increasing the 
probability that there will be more men and women with war 
injuries, including PTSD, alcoholism, drug addiction. There is 
a perception that services aren't being matched and that we are 
cutting services. Will we wait a few decades, then fight the 
war at home again--the war on drugs, the war on PTSD, the war 
on broken lives of gallant veterans and their blameless 
children?
    We recommend, Senator, that you continue your efforts, that 
America match its commitment to the war with the resources for 
our warriors when they return home. Thank you for allowing me 
to offer these comments.
    [The prepared statement of Dr. Kunz follows:]

Prepared Statement of Kevin Kunz, M.D., M.P.H., FASAM, Past President, 
                  Hawaii Society of Addiction Medicine

    Mr. Chairman and distinguished Members of the Committee, thank you 
for the opportunity to come before you today to offer these comments 
regarding the treatment of Hawaii's veterans who have drug related 
problems.
    I am Dr. Kevin Kunz, from the Hawaii Society of Addiction Medicine. 
We are an organization of 26 Hawaii physicians, and a chapter of the 
American Society of Addiction Medicine. Our organization is dedicated 
to improving the treatment of alcoholism and other addictions, 
educating physicians and medical students, promoting research and 
prevention, and enlightening and informing the medical community and 
the public about these issues.
    Our member physicians work in research, administration and the 
direct clinical care of persons with addictive disease. We can be found 
in many practice settings, including solo practices, hospitals, 
community clinics, rehabilitation programs, and within government 
agencies, including the VA.
    We wish immediately to acknowledge our military men and women from 
both past and present wars, and all veterans. Their volunteerism and 
gallantry is a source of pride for all Americans, and we sincerely 
thank them for their service. And particularly, we wish our men and 
women in the current battlefields a speedy and safe return home.
    My comments today will be influenced by my own 25 years of family 
practice medicine in Kona--where many veterans are my patients, and 
where I have a working relationship with the superb staff of the VA's 
Community Based Outpatient Clinic and the Vet Center. I have been sub-
specializing in addiction medicine for 11 years, and in this capacity, 
have cared for many more Big Island veterans. I am also a Viet Nam 
veteran and have personally received care in Hawaii's VA programs.
    The association of combat service, post-traumatic stress disorder 
and substance abuse is well know. Perhaps the most poignant lessons 
from that old war, Viet Nam, have been these: (1) PTSD and its' co-
morbidities are predictable, preventable and treatable. (2) The co-
occurrence of PTSD and substance abuse problems is the norm, not the 
exception. (3) PTSD can be successfully treated only to the extent that 
co-existing substance abuse is treated. Senators, the problems of PTSD, 
addiction and dysfunctional lives will only grow as more Vets return.
    And the final lesson: whether or not we honor the war, we must 
always honor and care for the Warrior. We must have adequate addiction 
care resources within the VA system to treat our veterans in need.
    I will now list 8 specific problems and make recommendations for 
areas within Hawaii's VA programs, with particular attention to the 
outer islands, where resources for the treatment of substance abusing 
veterans are woefully inadequate.

                 1. SUBSTANCE ABUSE COUNSELORS IN CBOCS

    On the outer islands, the VA Community Based Outpatient Clinics 
(CBOC) are all lacking Certified Substance Abuse Counselors (CSACs). A 
VA counselor or therapist caring for a Vet with PTSD will of course ask 
about and advise (often with a referral to AA or NA) about substance 
use, but if the Vet has a significant alcohol of drug problem, he or 
she will also need to obtain specialized services, perhaps medical 
detoxification or counseling, often delivered in a group setting with 
educational and cognitive-behavioral therapies. Ten years ago, there 
was a CSAC rotating between Hilo and Kona. Now we have none, and the 
need is as great, if not greater. We recommend that the CBOCs on Maui, 
Kauai and the Big Island (Kona and Hilo) all receive a CSAC position. 
And of course, the staff person would also need the physical space to 
carry out their job.

                2. MODERN TREATMENT FOR OPIATE ADDICTION

    Many veterans, from previous wars and from Afghanistan and Iraq, 
have come home with, or subsequently acquired, opiate problems. Opium, 
heroin and pain pills are all readily available in many battlefield and 
civilian settings. In addition to the war addicted, America now has, 
currently, an epidemic of prescription opiate abuse and dependence, and 
non-opium, non-heroin opiate prescription drugs are readily available. 
And it is notable that Afghanistan produced more opium last year than 
any country in recorded world history. Our military men and women there 
are at an increased risk, and there are now reports of Americans 
returning home addicted to Afghanistan's opium. Opiates can be a tonic 
for the pain and dysfunction of war, and of PTSD, and then they often 
become an insurmountable addiction. When the problem of heroin 
addiction in returning Viet Nam Vets was recognized, President Nixon 
appointed America's first Drug Czar, who quickly stimulated the 
research that located the brain's own heroin, the endorphins and 
enkephalins, and the brain's opiate receptors. Next were the treatment 
initiatives, which included residential and outpatient programs, and 
the medication methadone. The VA system played a large role in these 
treatment initiatives.
    If medication is used for the detoxification or maintenance therapy 
of opiate addiction, methadone is no longer the only option, and 
probably is not the best option.
    Five years ago Congress passed the Drug Abuse Treatment Act of 
2000, which made available the medication buprenorphine for the 
treatment of opiate dependence. Unlike methadone, buprenorphine can be 
prescribed by physicians outside of federally regulated, often 
dysfunctional, methadone clinics. It has less risk of diversion and 
abuse, and has a much better safety profile than methadone. Recently, 
methadone has become a leading ingredient in overdose deaths--in part 
because of increased availability for the treatment of pain, and 
diversion to illicit use. Although thousands of physicians are 
successfully prescribing buprenorphine for opiate dependent patients, 
the VA has been slow to integrate this medication. Our colleagues from 
across the country say that Vets are not being offered this option with 
the VA system. In Hawaii, it is not available from the VA. We recommend 
that this proven, safe and accepted therapy become available within 
Hawaii's VA programs for the treatment of opiate withdrawal, and opiate 
maintenance therapy in properly selected opiate dependent veterans.

           3. RESIDENTIAL, AND OTHER TREATMENT OPPORTUNITIES

    The outer islands do not have residential or ``clean and sober'' 
houses available for Vets who require these levels of substance abuse 
care, and do not contract with existing residential or programs. This 
may be due to the complicated and restrictive Federal requirements for 
such facilities. We recommend that some accommodation be made to permit 
matriculation of Vets in local residential programs and ``clean and 
sober'' houses, as well as outpatient substance abuse treatment 
programs. Perhaps the VA can establish contract services with existing 
programs and practitioners until they have their own outer-island 
operations in place. We believe that there are counselors, 
psychiatrists and addictionists who have had experience in veterans' 
care who could fill some of the gaps. This also would address the 
``community cooperative'' aspects of the VA's care of Vets, which I 
will comment on again.

    4. HILO PTSD REHABILITATION PROGRAM/HILO VETERANS MENTAL HEALTH 
                                SERVICES

    The relocation of the PTSD Rehabilitation Program (PRP) from Hilo 
to Oahu has left a gap in services here. The benefit of this program on 
the Big Island was not limited to the Vets that matriculated there. The 
staff was available to other health care providers on the Big Island 
for consultation, and the recovering Vets themselves were very 
effective outreach workers and therapeutic guides for other Vets with 
PTSD and/or alcohol or drug co-morbidities. While there is an 
anticipated development of new services in Hilo, this is presently more 
of a wish than a reality. Expanded services beyond the Hilo CBOC and 
Vet Center are needed, and since the PRP positions were relocated to 
Oahu, at least 5 new positions are needed now in Hilo: a Social Worker, 
a psychiatric registered nurse, a licensed practical nurse, a clerk, 
and a Certified Substance Abuse Counselor. A psychiatrist position 
already exists, but needs to be permanently filled.

                         5. PREVENTION SERVICES

    Although some veterans from the current war are trickling into the 
CBOCs and Vet Centers, we expect that it will be 5-10 years, or longer, 
before most Vets with PTSD and related substance use problems ask for 
help. Yes, some of them will be seen in Emergency Rooms, jails and 
institutions, divorce courts and unemployment lines before then. Often 
now, it is the family of the Vet who says that something is wrong, but 
they can't get the Vet to seek help. Our military services are pre-
emptively dealing with this--by educating personnel about the risk of 
PTSD, and the availability of counseling. But history has shown that 
most Vets don't see the problem, or resist help. Therefore, there needs 
to be more outreach early on, both to the newly discharged Vet, and to 
family members. Just consider the 3-400 National Guard soldiers who are 
expected to return to the Big Island this year. We recommend that a new 
set of outreach activities for Vets and families of Vets be instituted.

                  6. TRAINING VA ADDICTION PHYSICIANS

    The education and availability of physicians who treat addictive 
disease is an important issue. Specialists in addiction medicine have 
several routes to certification. Residency programs that train doctors 
are one of the best. There is a combined addiction medicine/psychiatry 
residency available in Hawaii. We are lucky to have it--it is an 
invaluable resource, well run with a positive impact on Hawaii's 
physicians-in-training and for all of our medical community. This 
residency is run through the University of Hawaii's School of Medicine. 
The Spark Matsunaga VA Medical Center is lacking a Post-Graduate Year--
5 position for an addiction medicine/psychiatry resident. Such a 
physician could rotate interisland and educate and support physicians--
VA and private practice--in the care of Vets. This position would 
support and compliment any other expansion of needed services 
statewide, and allow better integration of chemical dependency care for 
Hawaii's veterans. We recommend that this physician training position 
be funded.

                        7. COMMUNITY COOPERATION

    VA physicians, including psychiatrists, often do not participate as 
equal members of the local medical community. At least on the outer 
islands, they do not routinely share hospital work, including call, 
with other physicians. There are two downsides to this. First, it sets 
up the veterans and VA physicians as being apart from, rather than a 
part of, the community health care resource network.
    Second, when a Vet who is receiving care from the VA needs hospital 
admission, he or she is ``dumped'' on the community physician who is on 
call. This alienates the on-call physicians, and speaks poorly to the 
continuity of care that all patients deserve. We recommend, at a 
minimum, that VA physicians maintain membership in the local medical 
societies, and that they maintain at least ``courtesy staff'' status at 
local hospitals.

                   8. CRISIS IN VETERANS HEALTH CARE

    Is it not a crisis, and is it not shameful that for many of the 
services that I have listed, a veteran must become so ill and 
dysfunctional, that finally their care is provided by our welfare 
system, and our jails and other institutions rather than the VA? And 
what does the future look like?
    The number of VA patients with PTSD increased 42 percent from 1998 
to 2003. The number of veterans receiving compensation for PTSD has 
grown almost 7 times as fast as the number receiving non-PTSD 
disability. These increases reflect mostly Viet Nam veterans seeking 
help decades after their service. Even with adequate outreach, it may 
be, as mentioned, 5, 10 or more years before Vets from the current wars 
actually show up at treatment centers. We know that 26 percent of 
veterans returning from Iraq and Afghanistan who were treated at VA 
medical centers in 2004 were diagnosed with mental health disorders. 
And that up to 20 percent of all Operation Iraqi Freedom and Operation 
Enduring Freedom veterans are believed to meet criteria for PTSD.
    Despite a welcome 8 percent increase that Congress mandated for VA 
Mental Health Care in 2006, there remains a general perception among 
Vets, and many VA staff, that the VA is trying to cut back services. 
There is perceived erosion, of lack of care. If this is true, it is 
certainly sad.
    Here we are funding wars in two countries, increasing the 
probability that there will be more men and women with war injuries, 
including PTSD, alcoholism and drug addiction, and we are cutting 
services? Will we wait a few decades, then fight the war at home--
again--the war on drugs, the war on PTSD, the war on the broken lives 
of gallant veterans and their blameless children? We recommend that 
America's commitment to our present wars abroad be matched with 
resources to care for our Warriors when they come home. Now, and in the 
future.
    Thank you for the opportunity to have offered these comments.

    Senator Akaka. Thank you very much.
    [Applause.]
    Senator Akaka. Sergeant Lum Ho.

 STATEMENT OF SERGEANT GREG LUM HO, HAWAII ARMY NATIONAL GUARD

    Sergeant Lum Ho. Aloha, Senator Akaka and distinguished 
Members of the Committee on Veterans' Affairs. I am truly 
honored to come before you today to speak as a returning 
soldier who served in Operation Enduring Freedom in this Global 
War on Terror. I served with Bravo Company 193rd Aviation, of 
the Hawaii Army National Guard. Our unit has the distinction of 
being the first Hawaii Army National Guard unit to deploy to a 
war zone since the war in Vietnam, a distinction I am very 
proud of. Bravo Company 193rd was attached to the 10th Mountain 
Division while in Kandahar, Afghanistan, and we provided Army 
aviation intermediate maintenance support for all Army aircraft 
on Kandahar Airfield.
    While I have nothing but positive things to say about my 
time in the sandbox, it is the support back home that I'd like 
to address to you today.
    While our unit was mobilizing prior to our deployment, 
there were a lot of programs that would be provided to the 
families while we were on this deployment. But when I would 
inquire if these services would be provided to our families 
back on the Big Island, the same answer I got every time was, 
``Sorry, only on Oahu.''
    Now, I don't blame the Army. They were not prepared for the 
unique situation that arises here in the State of Hawaii. When 
they deploy troops stationed at Schofield Barracks, every 
soldier lives on Oahu and has access to these programs and 
services on Oahu. Being that we were National Guard members, 
they were not prepared to deal with these programs--to deal 
with the soldiers' programs and services, like storage 
facilities and child care, to more important things like 
medical care, here on the Big Island.
    So our families were literally on an island having to take 
care of themselves. My wife Imelda, who headed the Hilo Family 
Support Group, would make frequent phone calls to check on the 
well-being of other families on the Big Island. She would later 
tell me that she did it more for herself. Knowing that other 
families were going through the same situation she was going 
through, while the families she was contacting thought she was 
supporting them, it was actually them supporting her.
    After returning home, the way I found out about the Vet 
Center was through Lieutenant Colonel Harlan, who is also 
currently with the Army National Guard. He is also the team 
leader at the Department of Veterans Affairs Hilo Vet Center. 
He provided outreach services to our families and mentioned 
that he worked at the Vet Center and would like to discuss, on 
behalf of the Vet Center, provided outreach programs to 
veterans and their families.
    I mentioned to him that I had a few soldiers that could use 
some assistance, and if he wouldn't mind speaking to my 
soldiers from Hilo. We were all in for a surprise, as I'm sure 
Lieutenant Colonel Harlan was, to find out that many of these 
programs were not mentioned to us in any out-briefing since 
returning home.
    Needless to say, we learned a lot that day, and wish that 
more time could be set aside for people like Lieutenant Colonel 
Harlan and his staff to speak to returning Guardsmen. I have 
seen my men and women literally grow up to become soldiers 
proud to wear the uniform. I just want them to get a fair shake 
as veterans.
    Of course, not all was negative with our families while we 
were deployed. Lieutenant Colonel Laura Wheeler, who was in 
charge of the Hawaii National Guard Family Support Program, 
kept my wife informed on any updated information. She called my 
wife Imelda numerous times, and even flew out to Hilo 
occasionally to meet with the Hilo families. She even set up 
question-and-answer sessions with Governor Linda Lingle and the 
Adjutant General, Major General Robert Lee. These meetings 
provided a comfort to the families we left behind in Hilo, 
knowing that just because we are from the neighbor island, our 
families were not forgotten.
    In closing, I would like to say that I am proud to be an 
American soldier, and I wear my combat patch proudly. But for 
all the awards and decorations I have received, it is the loved 
ones we leave behind who hold the family together who are the 
true heroes. I commend them all.
    I thank you, Mr. Chairman, Senator Akaka, and your 
Committee for allowing me to speak before you today. It was 
truly an honor I will never forget. Thank you.
    [Applause.]
    [The prepared statement of Sergeant Lum Ho follows:]

 Prepared Statement of Sergeant Greg Lum Ho, Hawaii Army National Guard

    Aloha Mr. Chairman and distinguished Members of the Committee on 
Veterans' Affairs: I am truly honored to come before you today to speak 
as a returning soldier who served in Operation Enduring Freedom in this 
Global War on Terror. I served with Bravo Company 193th Aviation of the 
Hawaii Army National Guard. Our Unit has distinction of being the first 
Hawaii Army National Guard Unit to deploy to a war zone since the War 
in Vietnam. A distinction I am very proud of. Bravo Company 193 was 
attached to the 10th Mountain Division while in Kandahar, Afghanistan 
and we provided Army Aviation Intermediate Maintenance support of all 
Army Aircraft on Kandahar Airfield.
    While I have nothing but positive things to say about my time in 
the sandbox, it is the support back home that I'd like to address to 
you today.
    When our unit was mobilizing prior to our deployment there was a 
lot of programs that would be provided to the families during this 
deployment. But when I would inquire if these same services would be 
provided to our families back on the Big Island, the answer I got was 
always the same, ``Sorry, only on Oahu.'' Now I don't blame the Army, 
they were not prepared for the unique situation that arises here in the 
State of Hawaii.
    When they deploy troops stationed at Schofield Barracks. Every 
soldier lives on Oahu and has access to the programs and services the 
Army provides. Being that we were National Guard Members they were not 
prepared to deal with soldiers programs and services like storage 
facilities and child care to more important things like Medical Care. 
If a family needed to see a medical professional they would have to 
travel to Tripler Army Medical Center on Oahu, I'm sure at their own 
expense. So the families were literally on an island having to take 
care of themselves. My wife Imelda, who headed the Hilo Family Support 
Group, would make frequent call to check on the well being of the other 
families. She would later tell me that she did it more for herself. 
Know that other families were going through the same situation she was 
going through. While the families she was contracting though she was 
supporting them, it was actually they supporting her.
    After returning home, the way I found out about the Vet center was 
through Lt. Col. Harlan who is also currently with the Army National 
Guard. He is also the Team Leader at the Department of Veterans Affairs 
Hilo Vet Center. He provided outreach services to our families and 
mentioned that he worked at the Vet Center and would like to discuss on 
behalf of the Vet Center provided outreach programs to Veterans and 
their families. I mentioned to him that I had a few soldiers who could 
use some assistance and if he wouldn't mind speaking to my soldiers 
from Hilo. We were all in for a surprise, as I am sure Lt. Col. Harlan 
was, to find out that many of these programs were not mentioned to us 
in any out-briefing since returning home. Needless to say we learned a 
lot that day, and wish that more time could be set aside for people 
like Lt. Col. Harlan and his staff to speak to returning guardsmen I 
have seen men and women who literally grew up to become soldiers proud 
to wear the uniform. I just want them to get a fair shake as Veterans.
    Of course not all was negative with our families while we were 
deployed. Lt. Col. Laura Wheeler, who was in charge of the Hawaii Army 
National Guard Family Support Program kept my wife informed on any 
updated information. She called my wife, Imelda, numerous times even 
flew out to Hilo occasionally to meet with the Hilo families. She even 
set up question and answer sessions with Governor Linda Lingle and The 
Adjutant General Major General Robert Lee. These meetings provided a 
comfort to the families we left behind in Hilo knowing that just 
because we are from the Neighbor Islands, our families were not 
forgotten. In closing, I would like to say I am proud to be American 
Soldier and I wear my combat patch proudly.
    But for all the awards and decorations I have received it is the 
live ones we leave behind, who hold the family together, who are the 
true heroes, I commend them all!!
    I thank you Mr. Chairman and your Committee for allowing me to 
speak before you today. It was truly an honor I will never forget.

    Senator Akaka. Thank you very much.
    Katherine King.

              STATEMENT OF KATHERINE KING, VETERAN

    Ms. King. I would like to first introduce myself. My name 
is Katherine King, and I am a 100 percent service-connected 
disabled veteran. I suffer from PTSD rated at 100 percent, 
bladder injury rated at 60 percent, loss of reproductive organs 
rated at 50 percent, bowel resection rated at 10 percent, and 
hypothyroid rated at 10 percent. I bring these issues to light 
as to why proper medical attention is so vital here.
    Before I start, I would like to take this opportunity to 
thank you, Senator Akaka, and all of your staff, with special 
thanks to Dahlia Melendrez and Robert Mann, for taking the 
effort to come to Hawaii and personally addressing veterans' 
health issues. I also want to thank you for the honor of 
allowing me to testify before you.
    Before becoming a resident to Hilo 2 years ago, I had been 
living on Oahu for many years. The care on Oahu was 
considerably more professional than what I have experienced 
here in Hilo. I find this quite distressing, since it would 
seem that all veterans should receive equal quality care 
because we were all willing to give our very lives for this 
country when we were needed.
    The workload and lack of resources on the understaffed at 
CBOC Hilo is so overwhelming by the constant needs of veterans 
that they have become desensitized. It is so bad, in fact, that 
they had to hire a security guard. Because of these 
circumstances, it is the veterans that bears the brunt of the 
extreme stressed-out environment that exists here.
    If better quality care could be given via more doctors and 
nurses hired, waiting time reduced, and a more pleasant 
environment augmented, a security guard would not be necessary 
because they already have bullet-proof glass windows installed.
    There are no doctors designated for walk-ins, nor any on-
call psychiatrists. As a matter of fact, psychiatrists and 
other staff members leave CBOC in shorts periods of time, like 
a drive-through hamburger joint.
    PTSD victims do not schedule when they're going to have an 
episode. It is not an 8 a.m. to 4 p.m. disorder. Because there 
are no 24-hour services available, and because of the recent 
removal of the PRRP program, veterans like myself with PTSD and 
other mental health issues tend to self-medicate because the 
pain inside becomes so great, it is either self-medicate or 
suicide.
    I cannot bring myself to a civilian psych ward that does 
not have much knowledge or experience with military veterans. 
It is too frightening of a thought. I have endured, by the 
grace of God, many nights of hanging on by my nails. But just 
how long does a veteran have to endure before they cannot hang 
on any longer?
    CBOC hired a female psychiatrist, and then fired her a few 
weeks later. She was helping me. Female veterans need female 
therapists. I am not comfortable with male psychiatrists, and 
please, do not get me wrong, I am not saying that they're not 
any good. I am just not comfortable discussing sexual assaults 
with men therapists at this time.
    If you need care after hours, we have been told to call 1-
800-214-1306 and get authorization for the ER. It is nearly 
impossible to reach a live person with this number. You are 
kept on hold until you just cannot take another hour of hold 
time. It is very difficult to hold a phone to your ear when you 
are very ill and in need of acute care. Can you just imagine a 
veteran having a heart attack or stroke stopping to call a 
useless 1-800 number prior to going to the ER? Well, that is 
exactly what this system expects.
    Another 100 percent service-connected veteran told me that 
they called this number the other day and they actually got a 
live person, but was told that it was not an authorization 
number. The veteran was told that you just go to the ER, and 
maybe Fee Basis will pay for it and maybe they won't. I have 
several large doctor bills that I had to pay since moving to 
this island because Fee Basis has denied every claim that I 
have submitted.
    This creates another issue. Because I live on a fixed 
income, I have been going without after hours urgent care 
because I cannot afford the bills. I am not one to abuse the 
ER--please check my records--neither have I gone without care 
since becoming 100 service-connected in 1995 until I moved 
here. I invite you to call this 1-800 number that CBOC or Fee 
Basis has demanded veterans to call for authorized ER care. 
Please, just see how it is for us.
    If you go to CBOC as a walk-in, this is the time-consuming 
steps it takes for the sick, frail, and fragile veterans to 
complete in order to receive care.
    You check in to CBOC, and you wait no less than 2 to 3 
hours. You will not be called until all the appointment vets 
have been seen unless the staff gets it, that you are acutely 
ill and/or begging for help.
    Once seen by a CBOC doctor, you are authorized to go to the 
ER across the street. Have you ever been so sick, sir, that you 
could hardly walk 10 feet, but yet you are expected to cross a 
busy highway and then walk up 25 flights of steps to sit in the 
ER another 2-plus hours being called in by a doctor, then 
another 2-plus hours before all your test results come back. 
While waiting for the tests, the ER could heavily medicate you.
    Once discharged back to CBOC, you are then expected to 
walk, heavily medicated, back across the busy highway to sit in 
CBOC for up to an hour waiting for a piece of paper authorizing 
you to pick up your medications from a civilian drugstore.
    Once you have that paper in hand, then you go to the 
drugstore and you sit there for up to 2-plus hours waiting for 
your medications.
    This process is way too long and too much to ask for 
veterans that are sick, frail, and fragile. A suggestion that 
may help is to have the ER dispense the medications right 
there, or the ER fax over to CBOC the prescription, and then 
CBOC fax the authorization to the local drugstores.
    The ER at Hilo Medical Center makes good money off of 
veterans. They could also provide transportation back to CBOC 
if the veteran is heavily medicated by the ER staff because you 
do not want to move your car once you find parking because 
parking can be difficult at times.
    I challenge you to come here and go through a day in the 
life of any veteran of your choice. Come and see the ridiculous 
red tape and bad attitudes that the veterans face daily here 
with their care, or lack of.
    Why is it that in many States, CBOCs do not exist? The VA 
regulations in those States are: If a veteran lives outside of 
a 40-mile radius of the nearest VA, then Fee Basis pays for the 
care. No hoops, loops, or bureaucratic red tape. The veterans 
in those States see the same doctors, and do not have to keep 
repeating their medical and mental health history to a new 
staff member every other month.
    As a veteran, I am not asking for anything impossible. I am 
asking for a little consideration, respect, and proper medical 
care. Instead, people on welfare receive better quality care 
than our veterans on this island.
    Although there could be more issues to address, I will sum 
this up with one final point, and that being, my dear Senator, 
I want you to know personally and it be made part of permanent 
records that the fear of losing my benefits has been put to me 
by several people. People have advised me that if I rock the 
boat or make too many waves, the system will come gunning for 
me. It is my sincere prayer that this is false and you truly 
want to know the truth.
    It has taken a lot out of me to set aside my fears and 
testify before you today. I sincerely appreciate your extensive 
workload, but I please ask you to see it from our eyes. Thank 
you.
    [The prepared statement of Ms. King follows:]

             Prepared Statement of Katherine King, Veteran

    I would like to first introduce myself, my name is Katherine King 
and I am a 100 percent SC Disabled Veteran. I suffer from PTSD rated at 
100 percent, Bladder Injury rated at 60 percent, Loss of reproductive 
organs rated at 50 percent, Bowel resection rated at 10 percent, and 
Hypo-thyroid rated at 10 percent.
    I bring these issues to light as to why proper medical attention is 
so vital here.
    Before I start, I would like to take this opportunity to Thank you 
Senator Akaka, and all of your staff, with special thanks to Dahlia 
Melendrez, and Robert Mann for taking the effort to come to Hawaii and 
personally addressing Veteran's Health issues. I also want to Thank you 
for the Honor of allowing me to testify before you.
    Before becoming a resident to Hilo 2 years ago, I had been living 
on Oahu for many years. The care on Oahu was considerably more 
professional, than what I have experienced here in Hilo.
    I find this quite distressing since it would seem that all veterans 
should receive equal quality care, because we were all willing to give 
our very lives for this country when we were needed.
    The work load and lack of resources on the under-staffed at CBOC-
Hilo is so overwhelming, by the constant needs of veterans, that they 
have become desensitized. It is so bad in fact that they had to hire a 
security guard. Because of these circumstances, it is the veteran's 
that bares the brunt of the extreme stressed out environment that exist 
here.
    If better quality care could be given via more doctors and nurses 
hired, waiting time reduced, and a more pleasant environment augmented, 
a security guard would not be necessary, because they already have 
bullet proof glass windows installed.
    There are no doctors designated for walk-ins, nor any on call 
psychiatrists. Matter of fact psychiatrists and other staff members 
leave CBOC in short periods of time like a drive though hamburger 
joint.
    PTSD victims do not schedule when they are going to have an 
episode, it is not an 8AM to 4PM disorder. Because there are no 24 
hours services available because of the recent removal of the PRRP 
program, veterans like myself with PTSD and other MH issues, tend to 
self medicate because the pain inside becomes so great, it is either 
self medicate, or suicide.
    I cannot bring myself to a civilian psych ward that does not have 
much knowledge or experience with military veterans. It is too 
frightening of a thought. I have endured by the grace of God, many 
nights of hanging on by my nails, but just how long does a veteran have 
to endure before they cannot hang on any longer?
    CBOC hired a female psychiatrist, and then fired her a few weeks 
later. She was helping me. Female veterans need female therapists. I am 
not comfortable with male psychiatrists and please do not get me wrong, 
I am not saying that they are not any good, I am just not comfortable 
discussing sexual assaults with men therapist at this time.
    If you need care after hours, we have been told to call 1-800-214-
1306 and get authorization for the ER. It is nearly impossible to reach 
a live person with this number. You are kept on hold until you just 
cannot take another hour of hold time. It is very difficult to hold a 
phone to your ear when you are very ill and in need of acute care. Can 
you imagine a veteran having a heart attack or stroke stopping to call 
a useless 1800 number prior to going to the ER? Well, that is exactly 
what this system expects.
    Another 100 percent SC veteran told me they called this number the 
other day and they actually got a live a person, but was told that it 
is not an authorization number. The veteran was told that you just go 
on to the ER, and maybe Fee basis will pay for it and maybe they won't. 
I have several large doctor bills that I had to pay since moving to 
this Island, because Fee Basis has denied every claim that I have 
submitted.
    This creates another issue, because I live on a fixed income I have 
been going without after hour's urgent care, because I cannot afford 
the bills. I am not one to abuse the ER, please check my records, 
neither have I gone without care since becoming 100 percent SC in 1995 
until I moved here. I invite you to call this 800 number that CBOC or 
Fee Basis has demanded veterans to call for authorize ER care. Please 
just see how it is for us.
    If you go to CBOC as a walk in, this is the time consuming steps it 
takes for sick, frail, and fragile veterans to complete in order to 
receive care.
    1. You check into CBOC, and wait no less than 2-3 hours. You will 
not be called until all the appointment Vets have been seen. Unless the 
staff ``gets it,'' that you are acutely ill, and or begging for help.
    2. Once seen by a CBOC doctor, you are authorized to go to the ER 
across the street. Have you ever been so sick that you could hardly 
walk 10 feet, but yet you are expected to cross a busy highway, then 
walk up 25 flights of steps to sit in the ER another 2+ hours before 
being called in by a doctor. Then another 2+ hours before all of your 
test results come back. While waiting for the tests, the ER could 
heavily medicate you.
    3. Once discharged back to CBOC, you are then expected to walk 
heavily medicated back across the busy highway to sit in CBOC for up to 
an hour waiting for a piece of paper authorizing you to pick up your 
medications from a civilian drug store.
    4. Once you have that paper in hand, you then go to the drug store, 
and sit there for up to 2+ hours waiting for your medications.
    This process is way too long and too much to ask for veterans that 
are sick, frail, and fragile.
    A suggestion that may help is to have the ER dispense medications 
right there. Or the ER fax over to CBOC the prescriptions, and then 
CBOC fax the authorization to the local drug stores.
    The ER at Hilo Medical Center makes good money off of veterans. 
They could also provide transportation back to CBOC if the veteran is 
heavily medicated by the ER staff. Because you do not want to move your 
car once you find parking, because parking can be difficult at times.
    I challenge you to come here and go through a day and a life of any 
veteran of your choice. Come and see the ridiculous red tape and bad 
attitudes that the veterans face daily here with their care or lack of.
    Why is it that in many states CBOC's do not exist? The VA 
regulations in those states are; if a veteran lives outside of a 40 
mile radius then Fee Basis pays for the care. No hoops, loops and 
bureaucratic red tape. The veterans in those states, see the same 
doctors, and do not have to keep repeating their medical and mental 
health history to a new staff member every other month.
    As a veteran, I am not asking for anything impossible. I am asking 
for a little consideration, respect, and proper medical care. Instead 
people on Welfare receive better quality care than our veterans on this 
Island.
    Although there could be more issues to address; I will sum this up 
with one final point, and that being my dear Senator, I want you to 
know personally and it be made part of permanent records that the fear 
of losing my benefits has been put to me by several people. People have 
advised me that if I rock the boat or make too many waves, the system 
will come gunning for me. It is my sincere prayer that this is false 
and you truly want the truth. It has taken a lot out of me to set aside 
my fears and testify before you today.
    I sincerely appreciate your extensive work load, but I plead with 
you to see it from our eyes.
    Thank you.

    Senator Akaka. Thank you very much, Katherine. I know it 
has been difficult for you to come this far with it. But first, 
let me thank you for your service to our country. We really 
appreciate that. And I also appreciated your comments. This is 
exactly the type of information we need to try to make things 
better. And so I thank you for that.
    My question to you, Katherine, is, what does the closure of 
the PTSD unit in Hilo mean to you?
    Ms. King. I have no place to go to keep me safe from me at 
times. At night--the nights are the worst for me. Daytime I do 
fairly good. But the nighttimes are the worst, and I have 
nowhere to go.
    When I would get attached to--they would bring in a female 
therapist. Beth was one of them. Then they brought in Dr. 
Klein. I started developing a relationship with them and they 
were actually helping me. But then I don't know what happened. 
They're not there.
    Senator Akaka. Thank you.
    Sergeant Lum Ho, I too want you to know that I appreciate 
your service to our country. I also appreciate your comments 
here, and especially the insight that you provided us in your 
testimony.
    Let me assure you that I will work with my staff to ensure 
that our Guardsmen and Reservists on the neighbor islands 
receive the services and attention they deserve. We will 
certainly be working on this, and I thank you for letting us 
know. Because you can tell from the testimonies today, the 
questions, that families are very, very important to us, too.
    Sergeant Lum Ho. Yes, sir.
    Senator Akaka. And if we cannot take care of the families, 
then it affects the troops.
    Sergeant Lum Ho. Right. If I could add something, sir?
    Senator Akaka. Yes.
    Sergeant Lum Ho. We were the first unit from Hawaii 
National Guard, like I stated. But I see vast improvement with 
the returning troops, with the out-briefings. When we came 
home, it was like, OK, here's your checklist. Get this done, 
and your deployment is over.
    Now you see more--I was sitting in Colonel Harlan's office 
preparing my statement, and you see young veterans coming back 
from Iraq signing up with the Vet Center. And so I know the 
word is getting out. It's just I don't want my unit to be 
forgotten just because we were the first one there.
    But I do see the generals are speaking about the outreach 
programs of the 25th. I was with 10th Mountain, and it seems 
like we got forgotten. But I do see improvements, and that's a 
testament to everybody that's--90 percent of the Hawaii 
National Guard has deployed. People like Lieutenant Colonel 
Harlan getting the word out, I really appreciate that. Thanks.
    Senator Akaka. Thank you, Sergeant.
    Dr. Kunz, in your testimony, you recommend a new set of 
outreach efforts to be implemented for veterans and their 
families. What do you think is the most effective way to 
conduct outreach to veterans and their families?
    Dr. Kunz. Senator, I don't think that having a table at a 
welcome home ceremony or a reunion is enough. The veteran that 
truly needs care is going to end up accessing it through family 
members or other community resources. The vet themselves, as 
one of the gentlemen said this morning, is going to take line A 
that's ``Go home'' and not line B that's ``Sign up for 
services.'' It may be 20 years before they're ready to sign up 
for services.
    So we must reach the family and we must reach the 
community. And so it needs to be at community events. It needs 
to be public service announcements. There needs to be a new 
visibility to the Veterans Affairs and DoD workers across the 
country that integrates those conditions that veterans have 
coming home with the general thought of what is health in 
America. We are ignoring and denying the existence of this 
disease if we just go to where we expect the veterans to come 
and have some ice cream and cake.
    So I would say, and I don't have any specific ideas, but we 
have to break out of the mold that really isn't working or 
we'll find ourselves in 5, 10, 15 years with the onslaught we 
now have of Vietnam veterans that are still coming forward.
    So to beat that, the table with the brochure and the vet is 
great, but it's not reaching the guys who need it the most. We 
need community education and family education.
    Senator Akaka. Yes. I thank you for mentioning that, too, 
in your testimony about the community and its importance. And I 
thank you again for this about reaching the family. I did 
mention this at one time--last year--where I went to a meeting 
and I noticed a person who was sort of hanging around.
    Finally, when I went to the parking lot, there he was. So 
he wanted to see me, only to tell me about his son. He said, 
``My son was one who liked to surf. He would go out with his 
friends. He always had a good time. He was never home.''
    He went to Iraq at the beginning of the war and now he is 
home. And so he went to his son and said, ``The surf is up. Why 
don't you go surfing?'' He didn't want to. ``Why don't you go 
to--call your friends up?'' He stays at home and just sits at 
home.
    And he said, ``I'm worried about him.'' You know, now, this 
is coming from a father to me. We really need to get to the 
fathers and mothers and wives and husbands to try to get their 
help to let us know really what is wrong.
    Also, I mentioned about culture in Hawaii. We're very 
diversified. And, you know, we have types of folks here who 
don't want to admit they need help. They'll never admit it. But 
the families see it and the families can tell us. And as I 
mentioned earlier, you know, after you talk to them and ask 
them, what's wrong? Oh, I'm OK, and just let it go at that, and 
on.
    But we need to try to reach them. And that's why I asked 
that question because you had ideas. Thank you for mentioning 
the family, instead of the table with all the information. 
Maybe this is part of the problem facing Sergeant Lum Ho. We 
need to go beyond the troops and go to their families to see 
what kind of help they need. Well, thank you for that.
    Mr. Harlan, how can we--and when I say ``we,'' I mean VA--
better utilize Vet Centers and its services to reach out to the 
veterans in Hawaii?
    Mr. Harlan. Well, Senator, I think the first step has 
already been taken with the funding that you've provided for 
the outreach workers. I would like to see that expanded so that 
maybe more of them, like Dr. Kunz is saying--I mean, our goal 
for our outreach worker is that they're going to be going to 
actually visiting people in their homes, not just at, you know, 
some table event.
    But their job is full-time outreach, where they'll be out 
at every kind of event and making--contacting--like one of our 
goals is to contact every single soldier and their family who 
came back, every single one, and to make sure that every one 
has been contacted by us; and then to follow up in a couple 
months and years, and to--when I mean contact, it's not only 
with the soldier, but with the family.
    And so the family can feel free to call us and tell us if 
they think that--like the father said to you. Because we're 
already having that also. I've had an exact story like that 
just in the past couple of weeks, where the soldier has 
returned to Hilo but he won't return home. He has yet to visit 
his family because of what's going on in his head. Luckily, 
he's visiting us, but not frequently enough.
    So, you know, the outreach. And Vet Center staffs, in my 
opinion, we need--you know, the workload and to provide quality 
care is we need more staffing, you know, so that we frequently 
can meet with people, not the limited number of sessions that 
we can offer.
    And for another concern I have is, as Ms. King mentions, 
there's many female veterans returning. We need more female 
therapists to be around. We did have, and now we don't. And I 
have had a number of female soldiers who have returned who 
stated they had suffered various events in Iraq and they felt, 
you know, rather uncomfortable discussing it with me as a male. 
But I'm their only choice right now.
    And so, you know, I try to be as empathetic as possible. 
But, you know, with no females available or even under 
contract, you know, it's a great concern because approximately 
40 percent of the soldiers are female now. And the numbers of 
them who suffered sexual harassment at the very least, I was 
kind of shocked by some of the things I've heard by the 
returning females.
    Senator Akaka. Thank you so much for your remarks.
    I want to tell you that our whole effort here as a Member 
of Congress, the U.S. Senate, as Members of our Veterans' 
Affairs, as members of our armed services, as folks and 
citizens of Hawaii, that we are getting the message from you. 
We're trying to provide the best we can, but we know we must do 
better. This is what we're trying to do.
    Now, what we've heard from you will help us do that. And 
this is why we're happy to have you, you know, say what you 
really feel about your situation. And Congress, for instance, 
you mentioned funding. Funding is limited. Funding has been 
difficult. The Veterans' Affairs Committee is not viewed as a 
top Committee. As a result there is limited funding.
    Chairman Craig and I have been working on a bipartisan 
basis and working well to turn things around. And we're looking 
for ways of increasing that funding. And what we're saying now 
is we cannot take what we get in funding. We want to ask for 
what we need.
    You're telling us what you need. So that means that we're 
going to have to increase that funding. So we're looking for 
ways of doing that.
    Secretary Nicholson, Dr. Perlin and his associates are the 
ones who will be working on this. And what they've heard will 
help them.
    Of course, there are limits. But I want to tell you Dr. 
Perlin did mention in one of the hearings that in the future, 
the services will be different because of technology. Senator 
Craig also mentioned this, that the delivery of services will 
not necessarily be institutional. It's going to have to change, 
using technology, so that services will be different. It has to 
be different.
    So on their level, they're trying to do better as well. Of 
course, from our side, we have the inside duty and 
responsibility. So we keep an eye on VA and try to help them 
out to do the best job they can, too.
    And of course, our military and delivery of security is 
very, very important to them, and the attitudes, the feelings, 
of the troops and their families are very important to them. 
Otherwise, you know, they're not as capable as they can be. So 
you see all of these levels are affected. And we're all trying 
to improve this.
    Now, on the military level, too, I think all of you know 
that we've been building quarters for troops. Now, this is part 
of raising the quality of life for our troops and their 
families. So all of this together is the effort of trying to 
improve whatever we've been doing.
    But I want all of you to know that this is not finished. In 
Hawaii, we use the word ``pau.'' It's not pau. It's still going 
on. And we are looking for ideas and better ways of doing 
something better. And with the use of technology, we expect to 
see this kind of changes coming about. This is why I'm so happy 
we've had these hearings. This is the last hearing of a series 
here in Hawaii. It will really help our Committee do our job in 
Congress.
    I'd like to take the time to express a warm mahalo nui loa 
to Blaine Hanagami [ph] and Charlie Kunz [ph] for helping us 
set up this hearing. It was set up nicely, and we've conducted 
a good hearing.
    I'd like to recognize Barbara Fujimoto [ph] and Beverly 
Chang [ph] from the Hilo CBOC. I'd like to thank Sergeant Alan 
Kellogg [ph] from VBA and all of the VBA staff who have come to 
all of our hearings. Thank you so much.
    I'd also like to recognize Janice Nielson [ph] on the front 
row, who has been with us through our hearings, and for all 
that she does just by her presence. And Major Rick Starz [ph] 
and all DoD personnel who have joined us as well. I really 
appreciate all of that.
    I'd like to again recognize my staff who have been working 
for many months to coordinate these hearings: Blaine Saito, who 
has transcribed every hearing. Michelle Moreno, Alex Sardegna, 
Dahlia Melendrez, Rob Mann, Pat Driscoll, Ted Pusey [ph], 
Donalyn Dela Cruz, and John Yoshimura. This is my staff.
    Again, I want to mention the chief of staff of Senator 
Craig, Lupe Wissel [ph], who's here, and her staff, too, who's 
here and helping out. I'd like to especially thank Kim Lipsky 
[ph] from my staff for all of her hard work in setting up these 
hearings.
    Finally, I'd like to thank all of you, Hawaii's veterans, 
for your dedication and sacrifice in making our State and 
Nation so great. Really, we do have a great Nation, and I can 
tell you that because I travel in Congress, and we go to other 
countries as well.
    When you look back at our country when you're there or when 
we're at home, you can feel the difference. And we're so 
fortunate. We have a lot to be grateful and thankful for, and I 
thank the Lord and thank God.
    But, you know, we have lots of work to do.
    I will take back your mana'o or your thoughts as I've heard 
them these days, including all of your written testimony and 
comments that we received, and work to see how we can improve 
the care and services which are already, I should say, stellar, 
and what I mean by stellar is you know that--and it's a fact--
that our Veterans Administration is rated as the highest kind 
of service of healthcare that we have in our country. Thanks to 
them.
    And also, for our Hawaii veterans, because they have served 
our country so well and we're proud of all of them.
    So together and united, we will continue to work to make 
things better for all of us. Mahalo nui loa. A hui ho, which 
means we'll meet again, and I want to wish you well in 2006 and 
the years ahead. And let us be grateful and thankful for all 
that we have.
    Thank God. God bless America. God bless all of you. Aloha.
    [Applause.]
    Senator Akaka. The hearing stands adjourned.
    [Whereupon, at 12:40 p.m., the Committee was adjourned.]

                            A P P E N D I X

                              ----------                              

                 Prepared Statement of Floyd D. Eaglin

    I am a Disabled American Veteran rated at 100 percent and 
housebound because of PTSD and physical injuries I received while 
serving in Viet Nam. I am also a life time member of DAV organization 
and belong to Chapter 6 located on the Big Island. There are several 
issues that I would like to bring to your attention regarding the 
Department of Veterans Affairs medical services to veterans in the 
county of Hawaii:
    1. The county of Hawaii has approximately 15,000 veterans residing 
on the Big Island.
    2. There are approximately 8,000 veterans living in east Hawaii. 
Presently there is only one (1) social worker to provide both medical 
and social advice to all 8,000 veterans which makes her task 
impossible.
    3. Because of the limited number of Social Work positions on the 
Big Island, Veterans have to wait a long time to get help. A simple 
call to the Social Worker, takes a week or more for a reply. There are 
no outreach programs that provide social services to all Big Island 
Veterans. Some of these veterans are unaware of the services the 
Department of Veterans Affairs has to offer, such as medical, housing, 
financial, social, and etc.
    4. Many veterans and my-self included, believe that the Department 
of Veterans Affairs' Officials are not listening to our advice or 
recommendations as to how ``the Veterans'' could be better served. 
Example: Veterans wrote numerous letters recommending that the PRRP 
remain in Hilo. The serene and low-keyed environment that Hilo 
provided, along with the integration of the community activities that 
were program requirements helped with the overall therapeutic well 
being of veterans in the program. We were informed by VA Officials, 
that no one wanted to work in Hilo. When we pointed out that this was 
not the case, we were ignored. (As a matter of fact two of the 
employees, who are veterans, went back to school and attained their 
Master of Social Workers degree and State of Hawaii licenses. To my 
knowledge these veteran employees were not promoted to the entry level 
GS-9 positions and therefore never given their year of supervised 
training in order to meet the qualification required by the VA to fill 
the GS-11 vacant positions).
    On several occasions I requested and challenged the Department of 
Veterans Affairs managers in Honolulu and Hilo to put into place the 
Minority Veteran Outreach Program as set forth in the VA Hand Book 0801 
that is supported by ``38 U.S.C., Part 1, Chapter 3, Section 317, 
Center for Minority Veterans.''
    I informed these managers that this would insure that the needs of 
all Minority Veterans would be addressed in every aspect of the 
Veterans Affairs' nationwide delivery of services and benefits. The 
mission of the Minority Veterans Outreach Program as defined in VA Hand 
Book 0801 states that adequate representation for all veterans in every 
phase of treatment will be provided.
    In other words, more emphasis should be placed on ``representation 
of the veteran population served'' in the Therapeutic Setting. This 
would insure that all veterans would be afforded equal access to all VA 
healthcare and benefits.
    In closing, I would like to thank you for this wonderful 
opportunity to be a part of the Senate Committee on Veterans' Affairs 
hearing, entitled ``THE STATE OF VA CARE IN HAWAII.''

                               __________

            Prepared Statement of Bud Pomaika'i Cook, Ph.D.

    Aloha Senator Akaka and Members of the Committee on Veterans 
Affairs:
    This testimony is presented to inform the Committee on vital work 
being done in Hawaii to address the cultural needs of military 
veterans; especially those veterans of Hawaiian ancestry. Starting in 
1990 with the Department of Veterans Affairs Vietnam Veterans Project 
and their report, ``The Legacy of Psychological Trauma of the Vietnam 
War for Native Hawaiian and Americans of Japanese Ancestry Military 
Personnel'' and then again in 1998 when the Readjustment Counseling 
Service--Vet Center Asian Pacific Islander Veterans Working Group 
released ``Asian Pacific Islander Veterans''--it has been consistently 
recognized that culture plays a critical part in the appearance of 
Post-Traumatic Stress Disorder symptoms. In 2005 Ka Maluhia Learning 
Center was contracted by Papa Ola Lokahi to work with a consortium of 
representatives from the John A. Burns School of Medicine, Native 
Hawaiian civic organizations, and Hawaiian veterans from the community 
to form a working group to launch the Hawaii Veterans Pu'uhonua 
Project.
    The Hawaii Veteran's Pu'uhonua Project's primary purpose is to set 
up culturally-centered methods to assist Hawaiian military veterans lay 
to rest the affects of trauma experienced during their time of service. 
A secondary objective for the project is to use cultural education to 
resolve the impacts of cultural trauma also experienced by Hawaiian 
veterans. Healing this combination of war and cultural trauma will lead 
to improvements in veteran's health and well-being. The project is in 
the first year of an initial 7-year cycle of work. During this time 
emphasis will be given to community led research and intervention 
activities to determine the efficacy of cultural interventions for 
improving Hawaiian health. As the project advances its understanding of 
cultural trauma and cultural healing, it will share this knowledge with 
other Hawaiian and community cultural groups.
    Attached to these introductory comments are two documents. The 
first, ``Healing the Warrior Self--Changes in Kanaka Maoli Men's 
Health'' is an article that appeared in the 2005 edition of The 
International Journal of Men's Health. The second, ``Kanaka Maoli Men: 
Changes in Station, Changes in Health'' is a draft of a chapter from a 
forthcoming book on Hawaiian culture and health. These are presented to 
inform the Committee as to recent research findings that affirm the 
causal link between the mental and physical health of Hawaiians with 
the social and historical trauma they are heirs to by birth.
    The Hawaii Veteran's Pu'uhonua Project is in the first year of a 7-
year program design to aid Hawaiian veterans and their families. The 
first phase of this project will gather the most current information 
from health care professionals working in similar populations in other 
parts of the United States, Canada, and the Pacific to determine the 
best ways for providing cultural services to remediate the impacts of 
war trauma. It is hoped that the Committee on Veterans Affairs will 
support this project and similar projects in Native populations.
    Thank you for hearing this testimony on behalf of our Hawaiian 
veterans.

Healing the Warrior Self--Changes in Kanaka Maoli Men's Roles and 
    Health
Bud Pomaika'i Cook, Ph.D., Ka Maluhia Learning Center, Hilo, HI
Kelley Withy, M.D., John A. Burns School of Medicine, Honolulu, HI
Lucia Tarallo-Jensen, Hale Naua III, Kea'au, HI
Shaun P. Berry, M.D., John A. Burns School of Medicine, Honolulu, HI

           HEALING THE WARRIOR SELF--CHANGES IN KANAKA MAOLI

Abstract
    In the 225 years of contact with the Western colonial powers, the 
health and well-being of Kanaka Maoli (Hawaiian) men has declined 
dramatically. Studies seeking the causes for these adverse changes in 
morbidity and mortality do not demonstrate specific physiological or 
environmental sources for these declines in vitality. This paper 
describes pre-contact cultural structures that shaped and guided the 
lives of these men toward constructive and healthy ends. The authors 
pose an argument for socio-cultural factors that may be noteworthy in 
understanding lifestyle choices taken by pre-contact Maoli males. Some 
of these practices are considered for possible revival as they may 
produce positive changes in current negative health realities for 
modern Kanaka Maoli men.

Keywords: cultural trauma, men's health, Hawaiian health.

                         MEN'S ROLES AND HEALTH

    The survival of a culture depends as much, if not more, on the 
continued existence, recognition, and celebration of a coherent self-
perception--on the preservation of a cultural identity--as it does on 
the continued existence of a sustained population or physical 
boundaries . . . a culture can be destroyed or supplanted by other 
means than genocide or territorial conquest. A culture's identity is 
defined by its deepest values: the values its citizens believe are 
worth defending, worth dying for . . . And it is that ``way of life'' 
that warriors fight to maintain.

                              INTRODUCTION

    Early European explorers arriving in what today is called Hawai'i, 
remarked on the amazing health and vigor of the indigenous Kanaka Maoli 
population, (Beckwith, 1932, p.74). In the 250 years since contact with 
Western colonial powers the resident culture of the Hawaiian 
archipelago has undergone a series of traumatic changes; some initiated 
by the indigenous population, but most forced upon them by contact with 
the modern world. The loss of an indigenous sense of self, one with a 
clear sense of traditional roles and responsibilities for native men 
has removed Kanaka Maoli males from connection to values and practices 
that once sustained their vitality and well-being at the highest level.
    One marker of these changes is that presently modern Hawaiian men 
are consistently categorized in the most grievous of health status 
indicators. Studies in environmental factors and genetics have not 
fully answered questions as to why these declines have occurred, and 
why increases in morbidity and mortality are so virulent in this 
specific population demographic.
    In this paper an explanatory model for understanding how social 
history impacts group health and well-being--Cultural Trauma Syndrome--
is presented. Special attention is given to pre-contact Kanaka Maoli 
men's roles as the physical and spiritual protectors of their society. 
Through examination of changes in these roles, with special attention 
to indigenous warrior values and practices, the reader is introduced to 
a plausible cause for the decline in health and well-being of Kanaka 
Maoli men in the colonial period (1778 to present). Also, the way back 
to health through a process of healing education and cultural renewal 
is examined.
    While focused on the warrior archetype and role, this paper is not 
a call for a revival of the ways of war-making by modern Hawaiian men, 
for they already swim in an ocean of anger and grief. This paper is 
instead a call for restoring the fullness of the values underpinning 
pre-contact Kanaka Maoli warrior traditions. These traditions encompass 
education, moral development, physical health, and social 
responsibility; all within the borders of a structure of life giving 
values. Amplification of these practices and values will allow present-
day Hawaiian men to re-establish a state of personal and collective 
wholeness; allow them to once more be Maoli, spiritually true. As was 
done in the past, following these traditions is likely the most 
efficacious path for modern Hawaiian men to realize their journey out 
of dire circumstances to a fullness of health and vitality.

                     I. MODERN HAWAIIAN MALE HEALTH

    These Indians, in general, are above the middle size, strong, and 
well made, and of dark copper color, and are, on the whole, a fine 
handsome set of people. (Beaglehole, 1967, p. 1178.)
    Prior to contact with Western civilization, there was an indigenous 
population somewhere between 250,000 and 1,000,000 individuals (Jurvik 
and Jurvik, 1989, p.164) in the lands now known as the Hawaiian 
Islands. Current population statistics describe a completely different 
picture of the native population. In the year 2000 census, Hawaiians 
made up only 19 percent of the population or 239,655 individuals, of 
which less than 5,000 self-identified as full-blood quantum Hawaiian. 
From the start of contact with colonial powers in 1778, Native 
Hawaiian's have faced significant challenges to their health. They have 
the highest rate of infant mortality in the state at 8.9/1,000 live 
births, compared to 7.6/1,000 live births statewide (Office of Hawaiian 
Affairs, 2002). Although Hawaiians make up only 19 percent of the 
population, 45.7 percent of the live births are to an unmarried mother 
of Hawaiian descent. Hawaiians are almost twice as likely to have 
asthma as all other races in the state, (Office of Hawaiian Affairs, 
2002). On average, Hawaiians children are physically hurt by an adult 
at twice the level of all other populations, and male children are 
abused more frequently than females (13.9 percent compared to between 
3.2 and 9.3 percent of other ethnic groups in Hawaii), (Hawaii State 
Department of Health, 2002).
    The disproportionate burden of illness only increases after 
childhood. Diabetes rates in Hawaiians are 2.5 times those of the 
general population of Hawaii, (CDC, 2004). Hawaiians also have higher 
rates of hypertension and death or disability from stroke than all 
other ethnic groups in Hawaii, (Hawaii Primary Care Association, 2002). 
In a study that indicates a possible genetic factor in these 
statistics, full-blooded Hawaiians have a heart disease mortality rate 
of 375.9/100,000 population, part-Hawaiians have a mortality rate of 
146.8/100,000 population, and non-Hawaiians living in Hawaii have a 
rate of 68.2/100,000, (National Heart, Lung, and Blood Institute, 
2004). In other words, full-blooded Hawaiians have a mortality rate 
from stroke 382 percent higher than non-Hawaiians, (National Heart, 
Lung, and Blood Institute, 2004). A question for future research is how 
the blood quantum issue is tied to lifestyle choices affected by 
factors of historical and social disenfranchisement.
    In addition, Hawaiians have the highest rates of age-adjusted 
cancer mortality in Hawaii when compared to other ethnic groups, and 
the second highest mortality rate from all cancers combined for all 
racial/ethnic groups in the United States (Hawaiians 207.2/100,000 are 
second and African Americans are first at 209.8/100,000), 
(Intercultural Cancer Council, 2001). Despite advances in diagnosis and 
treatment of cancer, mortality rates for Hawaiians have increased not 
decreased (by 62 percent for men and 123 percent for women between 1967 
and 1990), (Intercultural Cancer Council, 2001). Cancer outcomes are 
also worse for Hawaiians, as their 5-year relative survival rate is 18 
percent lower than Caucasians and 15 percent lower than the U.S. 
population for all cancers combined, (Intercultural Cancer Council, 
2001). It has been hypothesized that this is due to late detection, 
lack of seeking care, lower rates of being medically insured, and lack 
of trust in Western medicine.
    Hawaiians also have the highest rates of many risky behaviors, 
demonstrating a probable lack of value placed upon health and life. 
Statewide surveys demonstrate that 75.6 percent of Hawaiians are 
overweight or obese based on Body Mass Index, a number 50 percent 
higher than the other population groups in the state, (Hawaii State 
Department of Health, 2002). Hawaiians smoke cigarettes at an average 
rate of almost 60 percent higher than all other population groups (33.8 
percent compared to 15-21 percent), (Hawaii State Department of Health, 
2002). Hawaiian children from 12-18 years of age far outstrip their 
peers of all other races in use of tobacco, marijuana, cocaine, 
inhalants, methamphetamines, ecstasy, and steroids, (Office of Hawaiian 
Affairs, 2002). In the last 30 days 6.4 percent of Hawaiians drove 
after drinking, compared to between 1.3 and 2.6 percent of other ethnic 
groups, (Hawaii State Department of Health, 2002). Hawaiians have the 
lowest seatbelt usage, with 6.8 percent seldom or never utilizing seat 
belts compared to between 0.9 percent and 2.8 percent for other groups 
in the state, (Hawaii State Department of Health, 2002). Hawaiians, who 
make up 19 percent of the population of Hawaii, make up 39 percent of 
the male prison population, 44 percent of the female prison population, 
(Hawaii State Department of Health, 2002). Hawaiians comprise 29 
percent of the homeless population, (Hawaii State Department of Health, 
2002).
    When examining overall health status, Hawaiians have the highest 
rate in reporting that their general health status is fair or poor 
(15.7 percent compared to 8.8 percent for Caucasians, 10.5 percent for 
Filipinos, 13.9 percent for Japanese, and 11.5 percent for all others) 
, (Hawaii State Department of Health, 2002). Hawaiians report the 
highest number of unhealthy days per month, citing a rate of 5.3 days 
in the prior thirty days at the time of the survey, (Hawaii State 
Department of Health, 2002), (Pobutsky, 2003, pp. 65-82). They also 
have the highest rates of disability for working age individuals, and 
they experience the most severe levels of disability in the state, 
(Pobutsky, 2003, pp. 65-82).
    Feelings of helplessness, hopelessness, and powerlessness prevent 
people from taking proactive steps to improve their lives. The data 
listed above demonstrated that these feelings dispose them to choose 
the option of the more negative lifestyle choices more frequently than 
other populations. While there is little research demonstrating a 
causal relationship between a person's reported level of self-worth and 
impact on health, there is adequate evidence to support a subjective 
impression that frailty in one's self-esteem is tied to deteriorations 
in vitality, leading to early mortality, (Aboriginal Corrections Policy 
Unit, 2002, pp. 7-8, 23-24). It is the authors' hypothesis that 
political and cultural repressions faced by indigenous and other 
disenfranchised populations are probable contributing factors disposing 
portions of communities to increased levels of disease and earlier 
onset of mortality. With the loss of indigenous cultural mechanisms to 
support the formation of a positive self-image through expression of 
traditional men's roles, modern Hawaiian men are lacking critical 
guidance in their pursuit of personal vitality. Self-image, self-
esteem, these and similar terms have emerged in the psycho-social 
lexicon to describe a person's self-perception, descriptors of 
structures by which one judges their worth in the world.

                   II. HISTORICAL AND CULTURAL TRAUMA

    In order to understand how indigenous populations may have sunk to 
the bottom of most health status indicators, it is necessary to 
demonstrate a causal link between cultural health and physical health. 
For indigenous peoples who have been displaced, either physically or 
politically, in or from their traditional homelands, specific forms of 
psycho-physical trauma can now be described. Studies by the Canadian 
Aboriginal Corrections Policy Unit in cooperation with First Nations 
communities and private agencies indicate that aggression against a 
person's ethnic identity and community culture forms the basis for a 
recognizable trauma condition, producing discernable impacts on health 
and social development, (Aboriginal Corrections Policy Unit, 2002, pp. 
7-8, 23-24). Brave Heart (1999), coined the term Historical Trauma 
Response to describe the way violation of selfhood a classified group 
feels in relation to their being identified, by self or others as a 
part of a historically disenfranchised population. These violations are 
perpetrated when the individual and their group are described as 
different in race, culture, and/or creed, from the peoples of the 
incoming colonial power.
    Cultural Trauma Syndrome (CTS) is a structure for describing the 
dynamic link between cultural identity and personal well-being. The 
entwined formations of CTS bring to light distinguishing social traits 
that may authenticate a causal relationship between ethnic identity and 
long-term health. Significantly, CTS is designed to account for 
individuals who may not have lineal origins in a targeted culture, but 
are people whose sense of personal identity is rooted in specified, 
disenfranchised culture. CTS specifically addresses the trauma of 
individuals whose familial lineage is genetically linked to the 
communal history of a subjugated culture. Cultural Trauma Syndrome can 
be seen in a series of defining formations:
    1. This injury is a process of cultural genocide.
    Targets cosmology, epistemology, pedagogy, and social structures as 
objects for repression It is not necessarily linked to declines in 
population. However, rapid declines in cultural population numbers 
usually correspond with actions of cultural assault.
    2. Attacks on indigenous social norms bring breakdowns in many 
normative cultural social structures. Breakdowns occur in traditional 
religious and spiritual boundaries, forms of community leadership, 
family configurations, and gender specific social roles Lack of 
continuity and understanding of traditional social structures slows 
cultural renewal.
    3. Trauma related events and perceptions of their intensity do not, 
by necessity, have temporal continuity. What may not have been felt as 
injurious by one generation of a population may be experienced as an 
offense by later generations.
    Cycles of severity may correspond to modifications in political 
efficacy.
    4. Sources for injury may come from within, as well as from outside 
a defined cultural group. Disenfranchised individuals and sub-groups 
take on the role of perpetrator of cultural wounds as an adjunct to 
violations originating from outside the cultural group.
    Internal divisiveness reduces advocacy for healthy relationships 
with other cultural groups
    5. Incidents of traumatization have inter-generational 
transference. The mechanisms of Cultural Wounding keep the insult of a 
trauma event activated across time.
    Insults may remain dormant for long periods of time, only to be 
rejuvenated by recent events. Cultural Wounding is a term 
distinguishing specific incidents of violation to a person's sense of 
culturally centered self. These insults are tied to some form of 
cultural, ethnic, or racial artifact. These artifacts might include one 
or more of the following:

a. physical characteristics;
b. family genealogy;
c. indigenous intellectual or aesthetic property;
d. geographical place of origin;
e. traditional religious practices;
f. forms of indigenous government or commerce;
g. traditional social practices, gender roles, family pattern, etc.; 
    and
h. distortions of the historical record.

     Cultural Wounding is a confrontation, an incident of 
psychological, spiritual, and/or cultural injury. It is the mechanism 
by which the historical cycle of trauma is revisited upon an individual 
or community. It is the means by which the wound of a previous 
generation is made fresh in the minds and spirits of those living in 
the present. Cultural Wounding is the mechanism that accounts for the 
power of social and cultural trauma to last for several generations of 
time. Cultural Wounding is the way contemporary persons are linked into 
the continuum of Cultural Trauma Syndrome suffered by their people.

               III. THE WAY IS LOST--THE COLONIAL PERIOD

The Veil of Isolation is Pierced
    Now it is possible to more fully understand the dynamics of change 
that caused the once healthy and vital Kanaka Maoli male population to 
descend to the unfortunate state they are found in modern society. In 
the late 18th Century, the indigenous Hawaiian society was in an 
advanced stage of development, rapidly changing from a multi-island 
tribal society to a proto-state. The people of this land, the Kanaka 
Maoli, lived their lives in accord with a philosophy founded in an 
intrinsic balance of opposites--in all things, for all cultural 
functions. Men and women had corresponding, and sometimes contrasting 
responsibilities in many areas of community development and function. 
Kanaka Maoli men were responsible for not only their gender-based 
tasks, but also for preserving the integrity of Loina Kane, the Male 
Aspect of the Kanaka Maoli Sacred Law, the `lhi Kapu. In the last 250 
years Kanaka Maoli men have lost essentially all of their traditional 
social and religious responsibilities; thereby losing a functional 
source point for much of their native sense of self. This loss of 
selfhood is a point for examination in determining its impacts and ties 
to significant health disparities present in modern Hawaiian men.
    When the ships of European explorers arrived in the Hawaiian 
archipelago in the late 18th Century, an all too familiar set of social 
and cultural transformations, changes common for many colonized 
indigenous peoples, were set into motion. Arrival of these strangers 
was, from the perspective of cultural sustainability, unfortunately 
coincidental with local events that had been unfolding for almost 100 
years. A long-standing internal war between several powerful tribal 
groups in the archipelago was coming to a decisive moment in time. The 
balance of local political power had been contested in a series of 
regional conflicts with the center of preeminent power shifting from 
one island to another, cycling back and forth across the island chain. 
Warfare had progressed from isolated, low intensity inter-tribal 
conflicts to inter-island rivalries of armies numbering thousands of 
combatants.

New Ways of War Making
    Contrary to popular images of surprised natives, even at Cook's 
arrival in the islands in 1778, local chiefs were not intimidated by 
displays of Western war technology. In truth, these leaders were quick 
to grasp the potential benefits to their cause, quickly seeking to 
harness these weapons for their own needs. Alliances with Western ship 
captains were quickly sought, with several chiefs adapting their war 
making potential by integrating the new weapons. New weapons 
necessitated new tactics. Western advisors and allies were sought to 
adapt Kanaka Maoli military tactics to deploy the new weapons systems 
to maximum effect. These alliances were not relationships built on a 
shared sense of political idealism; they were largely predatory in 
nature. Each side sought to gain ascendancy for their personal 
political and commercial interests.
    The new weapons brought with them the advantage of distance in 
making war. Except for the Ka ma'a, the sling, the Kanaka Maoli 
traditional technique for making war upon others was an intimate 
affair; hand to hand combat supported by slashing, piercing and impact 
weapons, plus sophisticated systems of grappling arts. Because of their 
increased killing range, the new weapon's technology allowed for 
depersonalizing the violence of war. These new methods also increased 
the numbers of dead and wounded in battle. And, most importantly, this 
increase, depersonalized violence was accomplished without the 
traditional and spiritual warrior's bond existing between perpetrator 
and victim.
    The new weapons and tactics allowed a common foot soldier to take 
the life of the most sacred chief; highborn men that were the most 
highly trained and skilled in the warrior arts. This killing could 
occur anonymously and outside the credence of honor-centered values 
seen in the previous period of more intimate forms of combat. In the 
traditional Kanaka Maoli approach to war, significant import was given 
to the spiritual ties binding combatants to one another through the 
relationship of combat. Combatants became bonded to one another through 
the hazards of falling at each other's hand. The Kanaka Maoli believed 
that a life taken in battle belonged to the victor forever; that the 
soul of the vanquished would remain the relic of the victor's until his 
own death. With the new weapons no one might ever know who had killed 
any one person lying dead upon the field. No one was then held 
responsible for the release of the fallen warrior's spirit into the 
nether world of PO, the Kanaka Maoli source of origin. No one could 
then properly usher the released spirit through its proper transition 
from this plane of existence on to the next.
    In a battle where weapons allow violence to be conducted at great 
distances, it is almost impossible to know in any specific way, who 
perpetrated violence on whom. In traditional Maoli warfare it was vital 
to know who had killed whom. For the Kanaka Maoli there was a tie 
between combatants, a relationship that demanded proper social 
observation, for example: after the battle, who could claim the chief's 
Mana, his spiritual strength? And then, who should assist his spirit to 
transition from this plane of existence to the next? And most 
importantly, when confronting the issue of war trauma, with the new 
distance-oriented weapons, how would any individual account for his 
specific actions in the post-battle rituals for washing away of 
spiritual profanity taken on by the commission of violence?
    The release of violence and the spiritual malaise that accompanied 
war was a psycho-spiritual matter the Kanaka Maoli addressed in pre- 
and post battle rituals. The violent release of a person's spiritual 
power in battle brought significant psychic burdens to bear. The 
psychic stain upon the soul of the survivor was expiated through post-
battle rituals lasting for several days, culminating with the ritual 
rebirth of the warriors in a temple site specific to the female 
principle. Through rituals common to many Maoli tribal groups 
throughout the Pacific, warriors were cleansed of the stain of war 
violence, reborn into the world through ritual protocol, through 
ceremonies initiated at the women's shrine, the Hale `0 Papa. 
(Fornander, 1974, pp. 26-29) provides one illustration for the Kanana 
Maoli vision of life/death/rebirth in a translation of a prayer that 
was recited at the Hale `0 Papa:

    E ua maika'i ae ne'i keia po o ko Akua Wahine.
    A'ole e ola na wahine waha hewa mai is `oe
    E make `ia i ko Akua Wahine.

    This night has been favorable because of your female Ancestors, 
Life is not granted to those before you by the Female Ancestors with 
satiated mouths.
    They (the warriors) will die at the hands of the Female Ancestors.
    After the abrogation of the native religious system in 1819, a 
change perpetrated by a narrow segment of the conquering elite, ritual 
renewal was no longer available to provide relief from the psycho-
spiritual stains acquired in life. The removal of this potent structure 
for reconciliation of violence, one that renewed health and order in 
Kanaka Maoli, post-battle society was not replaced by a correspondingly 
powerful Western system. Without these rituals and their supporting 
moral structures, post-modern Kanaka Maoli men lost an important social 
and spiritual support for self-identity and a vital way of release from 
the afflictions of violence.

                ADDITIONAL CHANGES IN SOCIAL STRUCTURES

Authority and Governance
    With the completion of Kamehameha Pai'ea's campaign of conquest and 
consolidation of the islands into a single administrative entity in 
1805, the region entered a new period of social control. Until this 
time the islands were largely ruled by individuals born to chiefly 
families from regional tribes, `Oiwi. Pre-1780, a single island might 
have dozens of people fulfilling a variety of community leadership 
roles. Under the political regime of Kamehameha Pai'ea, a smaller group 
of people, largely from Hawaii and Maui islands ascended to rule the 
archipelago. With the death of Kamehameha Pai'ea, his son and heir 
Liholiho (also known as Kamehameha II), instituted the beginning of a 
monarchical government in the style of the European courts. Under his 
rule the government of the island chain evolved from chiefdom to modern 
kingdom. The form and shape of governance continued to evolve in form 
and structure throughout the 18th century. The native government 
eventually became a modern constitutional monarchy with treaty 
relations with all of the major colonial powers. This government 
continued until 1893 when it was conquered by immigrant and military 
forces of the United States, eventually becoming a Western-styled 
democracy under the flag of the United States.

               LOSS OF WARRIOR/SPIRITUAL RESPONSIBILITIES

    Kanaka Maoli tradition held that men of the Ali'i, ruling, class 
would have concurrent religious and military responsibilities. 
Following conquest of the island chain by Kamehameha Pai'ea, primarily 
to prevent their being used to overthrow the conquering government, all 
established military groups, except for a small force loyal to the 
King, were disarmed and disbanded. Therefore, from 1805 onward, Kanaka 
Maoli warriors as a distinct social class ceased to exist in any 
functional manner; either as war fighters or as protectors of the 
spiritual life of the community. Traditionally Kanaka Maoli males were 
the warrior/protectors of their physical society, but, more 
importantly, they were also the protectors of the spiritual well being 
of the society. Kanaka Maoli warriors maintained the subliminal will 
that sustained the mystical glamour of ritual, protected rites that 
would forever shield Maoli-kind.
     In 1819 the state religion of the Kanaka Maoli was dismantled by 
the ruling elite, bringing further decline in men's social and 
spiritual responsibilities. On the death of Kamehameha Pai'ea, his 
primary wife Ka'ahumanu, declared herself Kuhinanui, regent, to the 
heir. She then ordered the new chief Liholiho to join her and his 
mother, the sacred chiefness Kapi'olani, in disbanding the existent 
Maoli religious system. Her motivation for this radical decision 
appears to be solely concerned with the preservation of war booty, 
primarily in the form of land holdings for her family. With this 
pronouncement, all of the spiritual foundations that balanced the 
violence of the warrior with efforts of moral rectitude and all of the 
ceremonies providing for reconciliation and redemption from violence 
were removed from society-at-large. This edict effectively ended the 
uniquely Kanaka Maoli tradition linking spiritual and warrior practice. 
Coincidentally, less than one year after the abrogation of the 
indigenous religion, Calvinist Christian missionaries landed in the 
islands to begin a campaign of spiritual conquest on behalf of their 
religious ideals.
    Removing men's function as the warrior/protectors of the society, 
while also removing their ritual and cosmological basis for developing 
meaning, is a case in point example of a powerful process of cultural 
wounding. This twofold loss for indigenous men has been seen in other 
populations.
    Warriors are supposed to repel the enemy and insure the safety of 
the community; when this is not possible, defeat has deep psychological 
ramifications. Add to this the destruction of men's roles in the 
traditional economy, and you have men divested of meaningful cultural 
roles. (Duran and Duran, 1995, p. 35).

                   DEPOPULATION AND THE NEW RELIGIONS

    Beginning with the arrival of the first European ship in 1778, with 
its cargo of new diseases and continuing through to the end of the 19th 
century, the native population in the islands was reduced to 10-20 
percent of its pre-contact size, (Stannard, 1989, p.51). This traumatic 
decrease in aboriginal census led to striking changes in communal 
patterns and lead to an increase in Western values arriving with 
immigrants into the kingdom. In large part due to this massive loss in 
population, norms for social relations and family structures were set 
aside. For example, in pre-contact times when seeking a mate, a Kanaka 
Maoli individual would have been quite conscious of class distinctions 
based on genealogical implications. With the loss of so many, and the 
loss of the defining philosophical structure of the state religion, 
families intermarried in patterns not usually existing before the loss 
of so much life.
    Ancillary to the devastation from disease was a corresponding loss 
of confidence in royal control over the physical world, (Kame'eleihiwa, 
1992, p. 82). Even though the Kanaka Maoli religion, whose cosmology 
confirmed the ideology of spiritual rectitude affirmed by physical 
presents, had long been put aside, long-standing core beliefs did not 
die off so readily in the minds of the populace.
    Without the support of the indigenous religion, those of the 
pivotal Ali'i class were no longer able to confirm for the populace 
their spiritual efficacy through ritual or manifestation. No longer 
could the masses turn to their leaders, assured that they stood in good 
stead with the Divine. The rampant spread of diseases and the massive 
die-off of the Kanaka Maori was a powerful message, a spiritual 
affirmation telling the indigenous people of the islands that their 
time on this plane of existence was in decline. Calvinist missionaries 
brought the religious concept of ``original sin'' to the islands. The 
presence of so much death and disease in their population could only 
confirm for the Kanaka Maoli that they had somehow offered offense to 
the Divine, were guilty of some great offense--a belief affirmed by the 
immigrant religion. As the royal leadership moved to embrace the new 
religion, the people could only follow suit in order to regain some 
measure of religious rectitude. This conversion to Christianity would 
in effect move many of the people closer to the new religious leaders 
and farther from their traditional chiefs as their temporal and 
spiritual loyalties were realigned.

                              LAND TENURE

    Another social change factor unfolding during this period of time 
was introduction of the notion of land as a commodity, as something 
that could be owned by an individual. Like other high-context, 
aboriginal societies, individual Hawaiians drew upon their local 
environment for certain aspects of identity. Place names were actually 
clues or markers that were often about the ancestral antecedents of 
those living in the locality. For the ruling classes, limited-term 
stewardship of locations was a direct way to acknowledge their 
community responsibilities and social import. In the 19th Century, the 
island kingdom experienced dramatic changes in local practices 
concerning land tenure and ownership. Some of these changes came from 
within the native culture and others were motivated by colonial 
political and commercial pressures. The first of these changes came 
from the way some Ali'i families violated traditional protocols in the 
distribution of land stewardship at the death of Kamehameha Pai'ea. 
Eventually these concerns were intertwined with the imperialist 
interests of immigrant and foreign entities. In 1848 Kamehameha III 
decreed The Great Mahele, an edict enacted to resolve questions of land 
title being pressed by foreign interests. While the decree was authored 
to provide property and economic stability for the indigenous 
population, in actuality the edict allowed the ownership of land among 
immigrants to increase so rapidly as to leave most of the indigenous 
population effectively landless. Unfamiliar with Western land title 
laws and procedures, many Maka'ainana class persons lost their 
opportunity to gain ownership of traditional lands. The Mahele allowed 
immigrant business interests to acquire and consolidate large tracts of 
plantation lands for agricultural markets in foreign ports. For the 
Ali'i leaders, many of whom were not allowed to assume tenure over 
lands at the death of a great chief, these changes meant they were 
unable to grow and develop in their responsibilities as community 
leaders. For the land-based Maka'ainana class, they became a displaced 
people, shifting from a largely agrarian lifestyle to an urban life, 
regardless of their needs or desires.
    For a high-context oriented society, like that of pre-contact 
Hawaii, these changes in land tenure had significant and detrimental 
impacts on the self-identity of the Kanaka Maoli people, the echoes of 
which may still reverberate through the psyche of the modern Hawaiian 
community.

                     THE WAY IS WELL AND TRULY LOST

    By the middle of the 18th Century most of the native population who 
had survived the initial onslaught of colonial diseases, found 
themselves in poor health and landless. By royal decree, conversion to 
Christianity and inundation by Western educational practices, the 
Kanaka Maoli population had been almost entirely stripped of the means 
for teaching and reinforcing traditional cultural values and practices; 
cultural norms and values used to establish a healthy indigenous 
self identity. Within the span of one generation, they were 
dispossessed of their spiritual foundation and the ways for 
understanding of the intrinsic meaning of cultural norms that had 
sustained them for millennia. The Kanaka Maoli had even lost their 
traditional self-identifying name. By this time they were being called 
``Hawaiians'' to fit with Westerns notions of geo-political naming for 
populations. Due to lack of an indigenous spiritual structure for 
guiding their maturation as Kanaka Maoli men or women in a modern 
world, this alteration of native identity remains in place to this day. 
At this point in history Hawaiian men, as warriors, as leaders, as 
beings, are almost entirely estranged from traditional sources that 
might guide them through the storm of cultural change that was the 
colonial movement of the last 225 years.

                 IV. IMPLICATIONS--HEALING THE WARRIOR

Cultural Healing--An Educational Process
    For modern Kanaka Maoli men to make headway against the negative 
health status profile they currently epitomize, they must begin to feel 
worthy of basic goodness. In order that they avoid any comparison to 
earlier colonialist attempts to ``civilize the savage'', cultural 
healing interventions must not take on the methods or philosophy of a 
social rescue initiative--either for individuals or communities. A 
disenfranchised person does not benefit from a remedial approach that 
first requires them to accept an image of themselves as a victim of 
some larger power before allowing them to find their sense of personal 
power.
     Healing through education is a use approach for improving the 
health of populations that have suffered the rigors of colonial 
oppression. Different than conventional health education initiatives, 
healing through education, especially for disenfranchised populations, 
brings into account cultural factors not found in curricula produced by 
government health agencies. Most health education efforts do not 
acknowledge the specific pedagogical or epistemological basis used in 
the construction of their approach to knowledge and human change. 
Molded by Western concepts of health and learning, the approach of such 
unexamined curricula can be posited as a direct form of cultural 
wounding, making them counter-productive in the effort to improve the 
self-image of indigenous populations seeking greater health and well-
being.
    Education for purposes of healing is a pedagogical construct 
largely missing from the traditions of Western education. Contemporary 
societies are more apt to separate the concerns of education and 
healing into discrete fields of discipline. In modern capitalist 
societies, the role of teacher is to pass along knowledge and 
information, largely bounded by the values of commercialism. In 
contrast, the role of healer is tasked with addressing the traumas of 
mind and body. The modern priest is the one most usually called upon to 
treat wounds of the soul. Separation of these roles and 
responsibilities is not as distinct in many indigenous populations--
especially those who still live in a high-context orientation with 
regards to human and community development (Meyer, 2003, pp. 4-6). 
Division of an individual's life into discrete, isolated compartments 
is in direct opposition to models of reality used by many 
environmentally centered, indigenous populations. Observation of the 
natural environment has led them to a philosophical structure that is 
inherently interdisciplinary.
    Education for healing is a pedagogical approach which accepts a 
philosophical position that the processes and goals of education are to 
move the individual and the collective learning community beyond 
knowledge and information, entering the province of wisdom, in both 
intention and practice. For many people education is the acquisition of 
knowledge. In contrast the pedagogy of healing education targets wisdom 
and is therefore concerned with the production of meaning in the lives 
of learners. In the development of wisdom it is necessary to learn to 
constructively embrace the wounds of life. Traumas are examined to 
reveal process. Pain is uncovered to show the interconnected 
contributions each party may have furnished to the pain felt, and each 
person's responsibilities to the collective journey of healing. This 
process of examination is undertaken to allow the dynamics of 
relationship to be revealed. Being thus informed, armed with insight 
and wisdom, a person can grow to move more confidently into an 
uncertain future.

                     KANAKA MAOLI HEALING PROCESSES

    The process of educational healing for Kanaka Maoli men is of 
necessity an initiative that must acknowledge the importance of 
cultural renewal. Present-day Hawaiian men are learning to recognize 
and reclaim the value of the Maoli philosophy--an indigenous 
epistemology based in a meticulous cosmology common to native people 
throughout the Pacific. It will be through the Ano, moral integrity of 
their Kupuna, wise Ancestors, that these men will once more reclaim 
their right to the ways of healthy living. The `lhi Kapu, the Sacred 
Law was what kept countless generations of Kanaka Maoli whole and 
healthy during their great migrations across the Pacific. Far from 
being a pre-colonial anachronism, the Kapu retains capacities which may 
be used to assist modern Hawaiian men in regaining their selfhood in 
the world.
    The ultimate aim of educational healing is to free people from 
fear, shame, and doubt. As Hawaiian men come to understand the 
circumstances and forces influencing their lives, they will be afforded 
access to knowledge about cultural dynamics that have led them to a 
negative sense of self-worth. Awareness of these multi-generational 
influences holds the potential to free them from the cycles of 
suffering that have constrained their power. In the pedagogy of 
education for healing, forgiveness is a key quality--forgiveness for 
self and for others. Eventually, through engaging in many cycles of 
insight, forgiveness and wisdom, a person or community can develop 
options for living a healthy and powerful life. Options are freedom. 
Freedom allows for graciousness and peace to emerge.

                    WARRIOR CULTURE AS HEALING AGENT

    Almost paradoxically, the way to healing for Kanaka Maoli males as 
warriors lies in the world of warriorship. Traditionally, for Asian and 
Pacific peoples, war-making skills were counterbalanced by strict and 
demanding social and spiritual obligations. Recognizing the trauma for 
all parties due to the expression of their vocation, indigenous warrior 
societies integrated healing traditions and cleansing rituals into 
their human and warrior development practices.
    In most instances, cultural definitions of the warrior self are 
constrained to associations with violence and death. In Asia and 
Polynesia, where native philosophical constructs require the harmonious 
balance of opposites, the warrior archetype is as much a figure for the 
generation of life as it is for death. In the Japanese warrior 
traditions of Budo, two images are contrasted: Satsujinto, the sword 
that gives death, and Katsujinken, the sword that gives life. For the 
Kanaka Maoli there were corresponding structures allowing for 
differentiation between warrior intentions leading to death, and those 
that were associated with healing and life-giving: Lawe Ola, death 
without conscience, and, Malu Ola, a tradition that safeguards life. 
Also, in the Kanaka Maoli pantheon of deities, the male entity Ku is 
most often associated with war. Among his more than seventy named 
aspects includes Kuka'ilimoku, the Island Snatcher. He also encompasses 
Kukapono, the Beneficent; Kukaloa'a, the life giver; Kukaha'awi, the 
Bestower; and Kukepa'a, the Steadfast. The Kanaka Maoli a warrior could 
only be true accord with his warrior self if his vocation balanced the 
war making with the generating of life.
     An inherent obligation for the pre-contact Kanaka Maoli warrior 
was to enter the ways of ritual practice to balance the pain of 
violence with the relief of healing practices. Unfortunately, many of 
these skills and obligations were largely set aside as colonial powers 
swept into the region. Warrior-healing values, and their associated 
ritual/educational systems, represent native forms of healing 
education. If properly revived, these values and practices may once 
again be useful in serving Hawaiian men who wish to orient their lives 
to traditional Maoli ways.

                 SANCTUARIES FOR MOURNING AND RE-ENTRY

    In pre-contact Kanaka Maoli's society specific locations were 
designated for rituals to expiate the stains of war. These sites 
allowed returning fighters to be cleansed of the emotional and 
spiritual profanity taken on in battle before reentering the society at 
large. Setting aside a period between the battle and reentry into 
common society is a critical interval for initiation of a warrior's 
healing. Some form of considered re-entry into civil society is common 
to many indigenous warrior societies. Before the age of modern air 
travel, armies were allowed a period of transitional grace on the long 
walks home, and then on ships. This allowed soldiers to adjust from the 
rigors of war before again entering the measured pace of civilian life. 
During periods of reentry it is possible for the psychological and 
spiritual processes of cleansing to proceed with a rhythm of 
graciousness. Storytelling, bouts of celebration, times to laugh and 
cry, all are ways veterans use to begin the cleansing needed to assist 
their return to normative society.
    In pre-contact Hawaii, Pu'uhonua, places of refuge, and Heiau, the 
temples, were locations where such reentry work would originate. In 
part, these sanctified places were used to affirmation of a person's 
sense of responsibility for their contribution to social decency. These 
locations allowed the Kanaka Maoli warrior to proceed into normal life 
cleansed and free from guilt--reborn to a settled conscience. The 
places of refuge and temples were in essence the Eternal Womb, a 
symbolic location from which warriors could reemerge cleansed of the 
taint of death, sacrifice, and metaphysical trauma. They were places 
for spiritually rebirthing Kanaka Maoli warriors to normalcy. Such 
places of healing and wisdom are echoed in the halls of educational 
institutions and in the treatment rooms of healers. Unfortunately, 
nowhere in present-day Hawaii is there a consistent place for modern 
Kanaka Maoli men to gather to integrate healing lessons in the manner 
of their ancestors.

                      V. WALKING THE HEALING PATH

    For substantial change in the health status of the present 
population of Hawaiian males, it will be necessary to understand the 
nature of the violation of self embodied in the hearts of modern 
Hawaiian men over the last 225 years. Only when the scope and scale of 
the malaise filling their hearts and minds is understood and accepted 
will Western health care professionals and policymakers be able to 
support a culturally appropriate return to health and well-being. Using 
the structure of Cultural Trauma Syndrome, research into the processes 
of pain and injury felt by Hawaiian men is already opening the way to a 
greater understanding of the scope and scale of their cultural 
wounding. Ultimately the task of healing must be motivated, controlled, 
and activated by these men themselves--no one can fully heal another 
without leadership from those to be healed.
    Modern Hawaiian men need to regain a sense of cultural wholeness 
missing since the abrogation of the sacred laws in 1819; a loss of 
selfhood exacerbated by many forces in the colonial period. Their 
healing must be supported by the psychological, social, and spiritual 
elements of ritual cleansing and rebirth. The progress of cultural 
healing and renewal will set a healthy social and spiritual precedence 
for modern Hawaiian men to adhere to in their lives. The presence of a 
viable structure of moral regulations and guiding values is necessary 
to support the indigenous men of Hawaii on a journey of self-healing.
    The road to recover may take many generations to complete, but what 
great task is ever easy? The reason for undertaking such an arduous 
task is simple; to not do it means to die--as men, as a people.
    `` `A mama,' Ua noa.''
    ``It is complete. It is free.''

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Kame'eleihiwa, L. (1992). ``Native Lands and Foreign Desires--Pehea a E 
    Pono Ai?'' Honolulu, HI. Bishop Museum Press.
Meyer, M. (2003). ``Ho'oulu: Our Time of Beginning''. Honolulu, HI. 'Ai 
    Pohaku Press.
National Heart, Lung and Blood Institute, Bethesda, MD., The Impact of 
    Heart Disease on Asian Americans and Pacific Islanders, Retrieved 
    April 9, 2004 from the World Wide Web: http://hp2010.nhlbihin.net/
    aapi slds/download/aapislds.pdf.
Office of Hawaiian Affairs (2002). Native Hawaiian Data Book, Retrieved 
    March 26, 2004 from the World Wide Web: www.oha.org/pdf/
    databook602.pdf.
Potutsky, A., Hirokawa, R., & Reyes-SIvail, F. Estimates of disability 
    among ethnic groups in Hawaii. ``California Journal of Health 
    Promotion''. 2003 v.1, 65-82.
Stannard, D.E. (1989). ``Before the Horror: The Population of Hawaii on 
    the Eve of Western Contact.'' Honolulu, HI, University of Hawaii 
    Press.
        kanaka maoli men: changes in station, changes in health
Draft Chapter for ``Hawaiian Culture and Health'' Ben Young, M.D., 
    Editor
Bud Pomaika'i Cook, Ph.D., and Lucia Tarallo-Jensen

    This was a great people at the beginning. It filled the Hawaiian 
group. A people with clean body, large-limbed and strong, a little less 
than the lion in strength, long-lived on the earth. A lovable people, 
amiable kindhearted, hospitable to strangers . . . Such is the 
character of the Hawaiian people. Kepelino \1\

                       INTRODUCTION--THE CONTRAST

    When European explorers first arrived on the shores of Ka Pae Aina, 
modern Hawaii, they found a vigorous society and a healthy indigenous 
population. In their physical well-being the Kanaka Maoli \2\ living in 
the islands embodied almost an Aristotelian ideal of physiological 
health and beauty. The vibrancy of their physical condition was echoed 
by the elevated state of development of their intellectual and material 
property. Drawings from these first expeditions show a vibrant people, 
living in beautiful communities, bounded by agricultural and fishing 
industries supporting a large population.
    In the next one hundred years, changes more devastating than could 
be imagined were to take an immeasurable toll on the Kanaka Maoli. 
Imagine living in a cultural group where: ninety percent of the 
population die; the religious structure that has sustained the 
community for hundreds of generations is erased by a local elite and 
replaced by a foreign system of beliefs; the approach to government 
used for thousands of years is replaced by an imported government put 
in place at the point of a gun; and, the indigenous forms of economy 
that have brought sustainable but equitable prosperity to the community 
are wiped away, all within the span of a single century. Is it hard to 
imagine that the survivors of a trauma event of this magnitude would be 
rocked to their core and would show effects from this insult for 
generations to come?

                       KANAKA MAOLI MEN'S HEALTH

    These Indians, in general, are above the middle size, strong, and 
well made, and of dark copper colour, and are, on the whole, a fine 
handsome set of people. Beaglehole \3\
    The descendants of the Kanaka Maoli, modern day Native Hawaiians, 
cannot make claims to health status like that described by Beaglehole 
and his peers. The health status indicators for Native Hawaiian men are 
a dire recitation of poor health statistics. Native Hawaiian men are 
disproportionately represented in almost all areas of risk for 
increased morbidity and early mortality. Although census data indicates 
that Native Hawaiians are a growing segment of the population, what is 
not shown is just how those people suffer from the aftermath of 
cultural trauma events that echo from the arrival of Cook in 1778 to 
the present time. For Native Hawaiian males this burden of trauma has 
been especially exacting. The statistical bottom line for health may be 
found in how long a person is expected to live, and in this instance 
Native Hawaiian males are the clear losers. On average, a Native 
Hawaiian male will die 6 years earlier than the average for all other 
male populations, and almost 16 years younger than the average for all 
women. Hawaii State Department of Health \4\

                        CULTURAL TRAUMA SYNDROME

    No matter their racial origins or places of residence, the health 
statistics for disenfranchised cultural populations is distressingly 
similar across the United States. Similarities in negative health 
status support the assumption that neither environment nor genetics are 
the likely factors driving these declines in well-being. Searching for 
additional perspectives to explain these circumstances, in 2004, Cook, 
Withy, and Tarallo-Jensen proposed a culturally driven model for 
describing the development of poor health in these populations--
Cultural Trauma Syndrome, (CTS). This condition is recognized by an 
interdependent set of social and cultural patterns. As an operant 
social change theory it accounts for people born into particular 
cultural groupings and to those persons who, though they may not share 
a genetic link to the history of a cultural faction, are people whose 
personal identity is inextricably tied to the specified group.
    1. This injury is a process of cultural genocide. Targets 
cosmology, epistemology, pedagogy, and social structures as objects for 
repression.
    It is not necessarily linked to declines in population. Rapid 
declines in cultural population numbers, however, usually correspond 
with actions of cultural assault.
    2. Attacks on indigenous social norms bring breakdowns in many 
normative cultural social structures.
    Breakdowns occur in traditional religious and spiritual boundaries, 
forms of community leadership, family configurations, and gender 
specific social roles.
    Lack of continuity and understanding of traditional social 
structures slows cultural renewal.
    3. Trauma related events and perceptions of their intensity do not, 
by necessity, have temporal continuity.
    What may not have been felt as injurious by one generation of a 
population may be experienced as an offense by later generations.
    Cycles of severity may correspond to modifications in political 
efficacy.
    4. Sources for injury may come from within, as well as from outside 
a defined cultural group.
    Disenfranchised individuals and sub-groups take on the role of 
perpetrator of cultural wounds as an adjunct to violations originating 
from outside the cultural group.
    Internal divisiveness reduces advocacy for healthy relationships 
with other cultural groups.
    5. Incidents of traumatization have inter-generational 
transference.
    The mechanisms of Cultural Wounding keep the insult of a trauma 
event activated across time.
    Insults may remain dormant for long periods of time, only to be 
rejuvenated by recent events.
    Cultural Trauma Syndrome can be recognized by a pattern of 
circumstances in the cultural group. Because this is a cultural 
disorder, individual, family, and community patterns of dysfunction 
must be shown for this condition to be identified as a causal factor.
Individual
    1. Cannot maintain intimate, mutually constructive relationships
    2. Cannot trust or be trusted
    3. Cannot persevere when difficulties arise
    4. Cannot function as a constructive parental role model
    5. Cannot hold a steady job
    6. Cannot leave behind harmful habits leading to Suicide-by-
Lifestyle
Families
    7. The family serves as a generator of dysfunction
    8. Patterns of addiction and abuse are passed on
    9. The family is no longer able to provide the foundation for 
healthy community life
    10. The family perpetuates connections to traumas of the past
Communities
    11. Rampant backbiting and internal strife
    12. Internal separation of cultural identity, ``traditionals'' vs. 
``moderns''
    13. A tendency to pull down the good work of anyone who rises to 
serve the community
    14. Political corruption
    15. Lack of accountability and transparency in government
    16. Chronic inability to unite and work together to solve shared, 
critical human problems
    17. Widespread suspicion and mistrust between people
    18. Competition and ``turf wars'' between programs
    19. A general disengagement from community affairs by most people
    20. A climate of fear and intimidation surrounding those who hold 
power
    21. A general lack of progress and success in community initiatives
    Cultural Trauma Syndrome manifests itself in a variety of ways. 
Small but distinct differences are evident for cultures showing 
variations in social history. The ways people are removed from their 
cultural identity, practices, and values has implications for how their 
course of recovery needs to proceed. While not an all inclusive 
description for how all people from any one cultural group are tied to 
their cultural history in the United States, the five key cultural 
trauma variation
    Categories under study are:
    a. Populations that were brought to the United States as slaves, 
and were stripped of all association with their root culture (i.e., 
African American);
    b. High-context cultural populations that were conquered and 
removed from their ancestral lands (i.e., Native Americans);
    c. High-context cultural populations that were conquered but 
allowed to remain on or near ancestral lands, but with no traditional 
rights to access, ownership, or control (i.e., Native Hawaiians, Native 
Alaskans);
    d. Populations that immigrated to another country, voluntarily or 
not, and were pressured to assimilate with the new dominate culture 
(i.e. European Americans);
    e. Populations that immigrated to another country but were allowed 
to maintain enclaves of cultural associations with others from their 
home culture, even in the face of other disenfranchising forces from 
the dominate host culture (i.e., Chinese Americans, Japanese 
Americans).
    Addressing the challenge of cultural trauma is a complex matter. 
Any person or group of people identifying with the social and cultural 
history of a disenfranchised culture is at risk for being impacted by 
the abuse offered to the generations of that culture. Even more poorly 
understood is how people of mixed cultural origins are influenced by 
the complex of social histories they bring together in their diverse 
heritage. What is understood is that the resolution for this problem 
requires the involvement of the whole community, and calls for the 
combined efforts of experts from outside under the leadership of 
members of the effected community.

               KULEANA--THE REALM OF MEN'S RESPONSIBILITY

    In order to more fully comprehend the challenges facing Native 
Hawaiian men in this modern age, it is necessary to have an 
understanding of their pre-contact realm of responsibility. The primary 
issue for any pre-contact Kanaka Maoli male seeking to be an upright 
person would have been the cultivation and protection of his Ano--the 
seed of moral integrity. This essence was the spark of divinity 
residing within any Maoli--true, person. A celestial characteristic is 
inherent to the indigenous self-identity held by all Maoli people of 
the Pacific region. The Ano was a quality that pre-contact Kanaka Maoli 
fostered through carefully planned marriages, religious rituals, and, 
proper and fitting behavior at all times.
    The way to realization for one's Ano was through strict observance 
of the `lhi Kapu--the system of sacred statues. This system of 
consecrated laws enabled a people to live in harmony with one another, 
with nature, and with the spiritual realm of their ancestors. Living in 
accord with this system of laws was what defined a person as Maoli--as 
true and genuine. The Kanaka Maoli male's held a position of social and 
religious leadership for specific responsibilities of the `lhi Kapu. 
From conducting major state rituals to small daily observances for 
deities under his care, the Kanaka Maoli male social role was central 
to maintenance of the kapu--protected, aspects of the society. The kapu 
was a central control over hygiene, environmental policy, land tenure, 
family concerns; almost every aspect of healthy social and personal 
functioning. Both genders carried special responsibilities. It was the 
male's kuleana--honored responsibility, to serve as a shield between 
the community and harm--temporal and spiritual. Almost every area of 
exclusive social responsibility tied to Kanaka Maoli men was lost in 
the colonial period.\5\ The loss of social responsibility has 
contributed to a loss of personal identity for many Native Hawaiian men 
and has left them adrift from the healthy ways that would foster well-
being in their minds, bodies, and spirits.

                        RELIGION AND GOVERNMENT

    Until 1819 and the abrogation of the tradition system of religion 
by a small ruling elite, men carried the bulk of the responsibility for 
religious leadership. Religious leadership was intertwined with other 
social responsibilities involved with economic, diplomacy, and the rule 
of government. Kanaka Maoli society did not fit with the strict 
definition of a theocracy; the rule of government was not held by' an 
elite group of priests. It was, however, clearly a religion-centered 
system of government whereby the Ali`i Nui, principal leaders, mediated 
the interchange between the celestial and terrestrial realms, the 
mundane and the divine worlds, all orchestrated by the Kahuna Nui, 
primary priest. The Kahuna Nui was set in place to make sure that 
thousands of years of sacred laws were upheld, made sure the Ali`i 
under their charge followed the code of behavior required by the `lhi 
Kapu. Proper observation of an annual schedule of religious ritual and 
responsibilities was integral to the functioning of the society. Some 
observations were less grand; each day in the Hale Mua, the men's 
eating house, a small image of Lono with a gourd attached was kept 
where an offering of food was deposited by the men. The elemental 
aspect of Lono shared in the men's daily meal; by being given the first 
bite of food he was made manifest. The annual progress of social and 
community events was bounded by a series of local and state rituals 
designed to keep the society on a proper course of development. 
Temporal and spiritual authority worked in cooperation to bring about 
healthy and prosperous conditions in this and the metaphysical worlds.
    The political mandate of the colonial European and American 
movement was accompanied by a corresponding command for religious 
dominance in the newly claimed territories. The competition between 
Protestant and Catholic religiopolitical forces was played out in 
Hawaii as it was in other parts of the Pacific region. In spite of the 
fact that the first recorded baptism of a Native Hawaiian was in 1819 
by a Catholic priest, it was the Protestant sects that were the most 
influential in early efforts to convert the island population to 
Christianity. In 1820, several months after orders declaring the heiau, 
temples, be torn down, Calvinist Missionaries landed on the island of 
Hawaii and were granted permission to preach and proselytize. 
Acceptance of the religious message of these first missionaries was 
assured wide acceptance when key Ali`i took up their cause. The need 
for a religious base in a culture that had always paired religious and 
secular power was a critical gap left by the abrogation of the native 
religion. The coincidental arrival of Protestant missionaries filled 
this critical gap for the ruling elite and their agenda for 
consolidating rule. Unfortunately, certain aspects of Protestant 
philosophy and dogma led Native Hawaiian men further from their 
traditional place of personal power, one grounded in observing proper 
relationships with their ancestors.
    The first Protestant wave breaking on the shores of Hawaii was led 
by members of New England Calvinist missionary sects. Calvinism is set 
up on three basic principles Bowker,\6\ the first two of which 
resonated with the Kanaka Maoli vision of creation. The third of these 
provided a crashing blow to the emerging Native Hawaiian image of self:
    1. Supremacy of scripture as the sole rule of faith and practice.
    The Kanaka Maoli held to their religious traditions as passed down 
through a rigid and precise tradition of oral transmission. These oral 
traditions were watched over by Hale Naua, a social institution founded 
by the Maui Island chief Haho in the eleventh century to contain the 
genealogies and protocols of the nation.
    2. An authority confirmed by the inward witness of the Holy Spirit.
    The Kanaka Maoli affirmed the authenticity of this inward witness 
by noting its correspondence with their Wailua--the Soul Cluster: the 
`Uhane--the conscious soul that speaks; the `Unihipili--the 
subconscious soul that clings; and, the Aumakua--the super conscious 
parent that hovers. The Wailua was seen in pragmatic effects, was 
affirmed by the outcomes it brought into the world.
    3. Men and women were inherently sinful, lost in iniquity, and 
could only be delivered by the Bible's message.
    Kanaka Maoli cosmology has no concept paralleling to the Christian 
idea of ``original sin.'' The proposal that a child was born hewa--
profaned by sin, from birth was a new and sad reality to accept. 
Because the Kanaka Maoli did however believe in redemption through 
acts, the presence of the Bible as a means for release from sin was a 
powerful tool wielded by the Missionaries for controlling the behavior 
of the locals, keeping the savage natives in line with social ideals 
they endorsed.

                                  WAR

    Men were not the sole purveyors of war activity; Kanaka Maoli women 
did sometimes accompany their men into battle, sometimes in a combat 
support role, and at times as combatants with their own traditions of 
war-fighting. As is true for most societies, however, Kanaka Maoli men 
carried the lion's share of responsibility for entering the profaning 
realm of shedding blood. Until the era of final conquest by Kamehameha 
Pai'ea in the late-eighteenth century, war making in Hawaii was a 
highly ritualized affair. Great care was taken to contain the horrid 
stain of violence unleashed by battle. Non-combatants, food growing 
areas, and religious sites were noted and cared for in pre-battle 
negotiations. It was not only important to be victorious in battle, but 
also be pono--principled and moral, as well. Because all Kanaka Maoli 
activities took on both temporal and spiritual responsibilities, it 
would be possible to win the earthly battle and lose the moral war. For 
example at the end of his massive campaign of inter-island war, 
Kamehameha Pai'ea took up a series of civil engineering projects, 
building temples, fishponds, and taro fields. These projects and the 
rituals that accompanied them were designed, in part, to expiate the 
burden of spiritual contamination built up during his campaign of 
conquest.
    Kanaka Maoli men engaged in considered practices to safeguard 
themselves from spiritual pollution in war through specific ceremonial 
practices. In these rituals the elemental portion of the Wai Lua, the 
Uhane, was placed in safekeeping in the complex of heiau used to 
consecrate the war effort. After battle, in the Hale 0 Papa, the 
women's heiau dedicated to the Divine Female through her representation 
as Haumea or Papa, the male Mo`o Ku, would conduct a ceremony by which 
the warriors would be ritually reborn through the women of the `Oiwi, 
clan. This ceremony returned the warrior's Uhane from its respite, 
safeguarded from the stain of conflict. While the male priests of the 
Mo`o Ku would orchestrate this elegant ceremony, it was through the 
female space that Kanaka Maoli warriors would be reborn to their civil 
earthly self. The `Unihipili as reborn with a fresh start reunited with 
the `Uhane, repeating the warrior's first birth into the physical 
world.
    Once the indigenous religion was removed in 1819, all supports 
allowing men to redeem themselves from transgressions of `lhi Kapu 
vanished. No longer did the warriors have a place to go to make 
themselves safe in the conduct of their vocation. The Pu`uhonua--
sanctuaries and places of refuge, that allowed the Kanaka Maoli to 
expiate the transgressions of the kapu were left without the requisite 
spiritual foundation to be effective for the people. Kanaka Maoli men 
now had no foundation of support to deal with the emotions of anger and 
violence that might well up in them. The loss of constraint provided by 
the `lhi Kapu meant that all forms of public and domestic violence now 
could only be resolved through punishment. Gone forever were the 
systems of healing education that required violent men to grow and 
develop to show they could be trusted to once again enter civil 
society. All that was left to address male violence was jails and even 
more death--a legacy of judgment that continues today with Native 
Hawaiian men being overrepresented in prison populations.

                          OTHER SOCIAL LOSSES

    In addition to the loss of the supporting structure of the `lhi 
Kapu, almost every other formation required for healthy identity was 
also changed in traumatic ways for the Kanaka Maoli community. In less 
than one hundred years an estimated ninety percent of the pre-contact 
Native Hawaiian population died. The Kanaka Maoli approach to education 
based on oral transmission between a master of knowledge and a selected 
disciple was supplanted by Royal decree with Western text-based 
knowledge. The customs of Kanaka Maoli marriage were careful alignments 
of genealogical relations became marriages of economic convenience, 
with Western traders marrying Hawaiian women for the social benefits 
they might provide. These benefits included the opportunity to become 
citizens of the kingdom, which then allowed these immigrants to 
purchase and sell lands. The collaborations of families arising from 
shared social and genetic histories were replaced by arrangements of 
economic advantage. Once the Federal Hawaiian Homes Commission Act was 
made into law in the 1920's many of the descendents of these unions 
were legally disenfranchised from their identity as Native Hawaiians, 
all because they did not meet the regulatory requirement that they be 
of fifty percent Native blood quantum. Marriages that at one time were 
sought because they provided distinct economic advantages now served to 
distance people of insufficient blood quantum from their island-based 
cultural heritage. The Kanaka Maoli approach to communal wealth, a 
system that tied religious and social development to the production of 
shared prosperity, was supplanted by Western capitalism, a system that 
reduced economic benefit primarily to the shareholders of the corporate 
entity. Finally, in this same short span of history Native Hawaiians 
were asked to adapt their sense of community leadership from a ruling 
Ali`i born with a divine mandate to care for the lands and people, to a 
constitutional republic founded on democratic principles that ``all men 
were created equal.'' Unfortunately, as the historical record clearly 
demonstrates, once American and European interests forcible took over 
the government of the islands in 1893, Native Hawaiians and their 
indigenous culture were consistently treated as less-then-equal in 
almost every social arena.
    Few modern societies have experienced shifts in social structure as 
dramatic as those forced upon the Hawaiian society starting with the 
arrival of European explorers in 1778. The list of tortuous changes to 
local social support structures cast many Native Hawaiian men adrift, 
left them with no clear social role to fulfill in sustaining their 
families through the change required by Western colonialism as it 
spread through their island's cultural milieu. The elaborate complex of 
psychology and spiritual supports required to afford a person the 
skills needed to form a clear and coherent expression of social culture 
were unavailable to many Native Hawaiian men, and remained unavailable 
for several generations. Accommodating for losses and changes due to 
the influx of colonial power was not something Native Hawaiian 
community leaders took into account when taking on new technologies and 
cultural values. These leaders were not alone in their naivet; the 
process of community grieving for changes to long-held social and 
cultural traditions is not well understood in even in today's world. 
How people come to some level of accommodation to new forms of social 
standards and practices was not a concern for Native Hawaiian or 
Western leaders as they instituted massive changes in the social norms 
in the nineteenth and twentieth centuries. The many ways these changes 
influenced the society could not have been foreseen. Perspective on how 
the Kanaka Maoli world view was changed and the demands these 
alterations made on the resident population is something modern 
community activists can take into account in their cultural restoration 
endeavors.

                                HEALING

    The last two hundred and thirty years have been some of the darkest 
times in recorded history for the Kanaka Maoli. This has been a period 
of darkness and death. Another way to look upon this period of social 
change, however, is that it has also been a time for the true strength 
of the Kanaka Maoli character to show its usefulness in the context of 
the world cultural setting. The Kanaka Maoli have always adapted to 
bring about changes in their worldly circumstance. Skills that served 
their ancestors to bring environmental prosperity to barren island 
ecosystems may now be brought to bear to bring this time of great death 
to a close. In essence the Native Hawaiian people have moved from a 
time of Lawe Ola, death without conscience, to one of Malu Ola, the 
traditions that safeguard life.
    In the last quarter of the twentieth century a new sense of 
Hawaiian culture began to emerge. Moving away from culture as a support 
for the tourist industry, Native Hawaiians began to explore the 
knowledge and wisdom of their ancestors as a way to address a need for 
cultural identity. One of the first successful efforts came in 1975 
when the Hokule`a, the first contemporary double hulled canoe built for 
long distant ocean voyages using traditional navigation methods was 
built. At present the building of canoes and revival of traditional 
star navigation techniques has become a Pan-Pacific phenomena; bringing 
hope for continued recovery of culture to indigenous peoples throughout 
the region. Following on from the massive amounts of information 
generated by the voyaging canoes, a companion effort to place Native 
Hawaiian knowledge and values at the center of education gained 
momentum. Another group emerged simultaneously with the Polynesian 
Voyaging Society. Hale Naua Ill, Society of Hawaiian Arts under the 
directorship of Rocky K. Jensen had their first fine arts exhibition on 
the very day the Hokule`a landed in Tahiti. Bringing to the forefront 
an esoteric awareness of the indigenous culture, the Native Hawaiian 
artists sought to create from a spiritual place, allowing for the 
energy to flow through a Piko, the spiritual and physical umbilicus, 
that was still connected to the cosmogonic Ancestors. Building schools 
and institutions of higher learning centered in the Hawaiian language 
and culture found renewed vigor in the mid-1980's. These schools have 
now become the vanguard of a massive social change movement. These 
efforts show that political awareness paired with considered education 
and training can bring about substantive social reform. The path of 
healing from cultural trauma for Native Hawaiian men lies in education; 
a path of knowledge that leads to the redevelopment of the Loina Kane, 
the song of male origins, values and ideals found in the ancestral ways 
of the 'Ihi Kapu.
    The aim of any effort of cultural healing is to afford an 
individual or a community the opportunity to recapture their Ano, their 
seed of moral integrity. These reconciliation and restoration efforts 
must provide verifiable and culturally centered means for increasing 
the substance of person's honor and respectability.
    For all the efforts made in the last few decades in cultural 
recovery by the Hawaiian community, the one element missing is revival 
of an indigenous approach to the Kanaka Maoli esoteric life. The Kanaka 
Maoli visualization of human reality included interplay of corporeal 
and spiritual elements. The physical needs of the body were paralleled 
with the psychic and spiritual needs. Native forms of rehabilitation 
included skills attuned to the needs of the body, mind, spirit, and the 
collective of the community. The Kanaka Maoli knew the importance of 
punishment and redemption as attendant means for addressing 
transgressions of community norms. In many cases there was a concerted 
effort made to allow the individual an opportunity to make things 
right. Prayers, sacrifices, and rituals of redemption could bring the 
transgressing individual back to a place of spiritual and temporal 
wholeness. Places for these activities were the Pu`uhonua, permanent 
sanctuaries that dotted the islands. The dedication to safety and 
redemption was evident in the way the Kanaka Maoli made places of 
refuge available. For example, during battle a specified location or a 
prominent person could be designated as Pu`uhonua, providing a warriors 
and non-combatants a place of refuge from the chaos of violence for 
those who could reach these precincts.
    Native Hawaiian men have been traditionally overrepresented in the 
jails and prisons. While Native Hawaiians comprise about twenty percent 
of the general population, they represent forty-four percent of the in-
state prison population. Office of Hawaiian Affairs.\7\ Loss of rituals 
for redemption, loss of locations where a person can redeem their 
sacred honor makes jails all the more needful. Loss of sacred spaces 
where a Native Hawaiian man can be trained in the Ano of his ancestors, 
in the character and workings of a healthy human being, makes it 
unlikely that a person's behavior will rise any higher than that needed 
to avoid punishment. Since the arrival of Western religious and 
political ideals the primary seat for this authority has been removed 
from the prevue of the individual and their closely held community, and 
given to the judgment of an externally-located authority--judges and 
ministers.
    For Native Hawaiian men to come to a satisfactory cultural vision 
of a healthy male role, they will first have to come to an 
accommodation with the confusing range of voices that tug at their 
heart, mind, and spirit for attention. From the failure of the Colonial 
effort to reshape the Native Hawaiian consciousness into some echo of 
itself it is possible to say that this method is not the means the 
community should use to change the negative health and social 
indicators now describing the population of Native Hawaiian males. The 
effort of cultural recovery cannot be an adversarial undertaking. The 
solution to the Native Hawaiian males circumstance cannot be an 
``either/or'' enterprise. There is no need for these men to try to be 
either a pre-contact Kanaka Maoli, or a fully assimilated Westerner. 
For thousands of years the Kanaka Maoli adapted their knowledge to suit 
the needs of their community. The resolution of the present 
circumstance of cultural trauma cannot subscribe to a rigid plan. 
Remediation of this trauma will pair insight with fortitude. The way to 
health for Native Hawaiian men lies in molding the best of education 
and healing to suit the needs of individuals and their communities. 
Echoing this call for remaining adaptable when charting a course for 
cultural healing, after twenty 5 years of study, the Canadian Federal 
Government came to the conclusion:

          . . . healing means moving beyond hurt, pain, disease, and 
        dysfunction to establishing new patterns of living that produce 
        sustainable well-being.
        Aboriginal Corrections Policy Unit \8\

    The community of Native Hawaiian men will need to embark on a 
voyage of discovery; this time seeking the horizons for a place of 
wholeness, rather than of new lands. For this place to be sustainable 
it will have to find a way to assist them in bridging pre-contact 
values, beliefs and practices over to the present era. This will not be 
a project of assimilation into the Western culture, nor will it be a 
return to the pure ways of their forefathers, but will be something 
drawing from the best each has to offer. Because the Kanaka Maoli 
culture is one of entwined powers, for this journey to be at last 
healthy it will have to include the needs of the women of this 
community.
    Sustainable well-being is the goal. The time for the unending loss 
of life and vitality from the last 228 years--losses to the land, 
people, and culture--must now come to an end. Replacing the systems of 
conflict and indoctrination inherent to the colonial mind set must be 
Maoli systems, structures that honor the deep truth that arises from 
respect between cultures. Native Hawaiian men must once more be allowed 
the respect to renew their alignment with Loina Kane--their song of 
origin.
    ----------------------------
    \1\Kepelino, (1974). Traditions of Hawaii, Bulletin Bishop Museum 
Press, Honolulu, HI, p. 74.
    \2\The designation ``Kanaka Maoli'' will be used to identify 
members of the indigenous population in what is known today as Hawaii 
from pre-contact to 1819 when the aboriginal religion was dismantled. 
The designation ``Native Hawaiian'' will be used to designate all 
persons of this group from 1819 to the present.
    \3\Beaglehole, JH. (1967). ``Samwell's Journal--The Journals of 
Captain James Cook.'' New York, NY., p. 178.
    \4\Hawaii State Department of Health, Honolulu, HI, Behavioral Risk 
Factor Surveillance System, Retrieved June 10, 2005 from the World Wide 
Web: www.hawaii.gov/health/statistics/brfss2002/bffssO2.html.
    \5\The term ``Colonial Period'' will designate the period starting 
at the arrival of the English explorer Capt. James Cook in 1778 to the 
present.
    \6\Bowker, J. ed. (1997). ``The Oxford Dictionary of World 
Religions. New York, NY. Oxford University Press, p. 190.
    \7\Office of Hawaiian Affairs (2002). Native Hawaiian Data Book, 
Retrieved May 26, 2005 from the World Wide Web: www.oha.org/pdf/
databook602.pdf.
    \8\Aboriginal Corrections Policy Unit. (2002). Mapping the Healing 
Journey: Final Report of a First Nation Research Project on Healing 
Aboriginal Communities, Solicitor General of Canada and the Aboriginal 
Healing Foundation, p. 12.

                               __________

                    Prepared Statement of Guy Poulin

    I am submitting the following written comments to the Senate 
Committee on Veterans Affairs which is meeting in Hilo on January 13, 
2006. Since the public will not be able to make oral statements, I am 
submitting the following comments.
    I recently wrote to Senator Akaka to complain of some of the 
problems I have been experiencing at the Hilo PC Clinic. You forwarded 
my complaints to the VA and the VA's response to your inquiry, which 
you forwarded to me, was not accurate, but, filled with numerous 
inconsistencies and errors. My previous complaints were given in a 
brief form which the V.A. has used to spin into fiction to make 
themselves look good. This leaves me to explain in detail, the correct 
facts. These explanations of the facts are stated later in this letter. 
I will begin with several problems (and their brief detail) which I 
hope the Senate Committee will be able to address and solve.
    First of all, here is my brief history with the Hilo PCC clinic. I 
received my full 100 percent Service Connected Disability in March of 
2005, with this 100 percent disability being retroactive: from February 
1999. All my disabilities are Physical Disabilities. I began going to 
the VA Clinic in Hilo, on a regular bases, around 1995. At the time, 
all the doctors at the clinic were either in private practice and only 
at the clinic part-time or, the doctors would come to Hilo from 
Tripler. I can't recall any major problems with these doctors. The only 
problem at the clinic was that patients would have to usually wait 
about 1 hour to see the doctor, but, this was because the doctors would 
not ``shove us out the door''. They would take their time to discuss 
any problems we were having. Oh, and the doctors had to hand write all 
their reports.
    But with this ``new'' VA PCC, and its 2 full-time doctors, there 
are a number of problems. A few of the Chief Complaints are:
    1. The doctors at the Hilo PC Clinic refuse to treat or listen to 
patients. I was Dr. Reviera's patient when he first came to the clinic. 
I was at 50 percent SC at the time. (However, Social Security had 
determined that I was 100 percent, totally disabled in 1995.) Dr. 
Reviera refused to treat me for any condition that I was not receiving 
``monetary compensation for''. For example, at the time, one of my 
disabilities was rated as: ``2nd Degree Burns--0 percent.'' Dr. Reviera 
insisted that this meant that I did not have 2nd Degree Burns and he 
refused to treat me for the severe sensitivity I was experiencing. He 
would not listen when I explained that the rating meant the VA 
recognized my 2nd Degree Burns but would not give me any monetary 
compensation for it. Another time, my right arm (which had broken while 
I was in the service) was extremely painful and my arm and my right 
hand had swelled up. Dr. Reviera refused to do anything because my arm 
and hand were not listed as being service connected. I tried to explain 
to him that because I was at 50 percent SC, he could treat me for 
anything, whether they were recognized as being service connected or 
not. After refusing to treat me for months, (all my conditions were 
getting worse but he would do nothing new to treat me), he offered to 
refer me to a Pain Specialist, Dr. Park. Well, I went to Dr. Park who 
changed my medication and tried new treatments, such as acupuncture and 
nerve blocks. Dr. Park's treatments were welcomed and I finally felt 
some relief. I also switched from Dr. Reviera to Dr. Garrigan. About a 
year later, Dr. Garrigan referred me to an Arthritis Specialist, Dr. 
Uramoto who began treating me. Whenever I saw Dr. Garrigan, she was 
always forgetting about things that had been discussed at our previous 
visit. Many times she would deny something, but, luckily for me, she 
had previously put them in my records. When I went for my January 2005 
appointment, I showed her the bulge near my naval. It was very 
noticeable and painful. She just looked at it and didn't do anything 
other than hurry me out the door. She kept saying she was late, but, I 
had only been with her for about 5 minutes and midway through this 
visit, she had sent me outside while she used the phone for about 20 
minutes. I had to go to a private doctor who referred me to a surgeon 
who did the surgery on me.
    2. Dr. Garrigan has no compassion for patients. Dr. Garrigan 
stopped me suddenly, with no regards to any withdrawal of medications 
which I had been on for years. (Note: A compete explanation of this 
situation is described later in this letter when I respond to the VA 
letter you forwarded to me.). There was also another time when Dr. 
Garrigan ``messed up'' my medication. For about 10 years, the VA has 
prescribed me a medication which contains ``acetaminophen''. In July 
2004, I received my medication but it was different--it did not contain 
``acetaminophen''. I called the Hilo VA clinic and talked to Dr. 
Garrigan's nurse. She said that I should just go to the drug store and 
buy my own Tylenol. I told her, ``I thought I was suppose to have free 
medical.'' The nurse just laughed. When I called to renew my meds in 
August, I reminded the nurse of the previous month's error. She said 
she would get it corrected. Well, the wrong medication came again. When 
I saw Dr. Garrigan on September 1, 2004 and brought it up to her. She 
said she didn't know why the mistake had happened, but, Dr. Garrigan 
said that she was correcting it and the next prescription should be 
correct. Meanwhile, Dr. Garrigan said that I could just pickup the 
acetaminophen ``over the counter''. Well, Dr. Garrigan did not make the 
correction as she claimed. The September and October prescriptions were 
still wrong. I was finally able to have it corrected in November of 
2004.
    3. Dr. Garrigan does not know her patients. In the last 2\1/2\ 
years, Dr. Garrigan has called me at my home, at least 4 times, 
claiming that I had called and asked her to prescribe me with certain 
medications. I never called her nor had I even heard of the 
medications. At the time that she claimed I had made 3 of the calls, I 
was being treated by Dr. Park and whenever Dr. Park changed medication, 
Dr. Park did it right on the computer while I was in her office. And, 
the last time Dr. Garrigan called me, I had just walked into my house, 
returning from Kona where I had spent the last 7 days and, I hadn't 
used a phone the entire time. She must have confused me with other 
Veterans. Also, whenever I go to an appointment with her, it seems she 
has forgotten most of what was discussed at the previous appointment.
    4. Hilo PCC entering wrong information in my medical records. I 
have found numerous, wrong information entered in my VA Hilo PCC 
medical records. Earlier today, I had an appointment with a Specialist 
from Honolulu regarding having a colon screening. (Since I made 50 
years of age in March on this year, I had asked Dr. Garrigan in August, 
about having a colon test because I had received a notice from my 
personal Medical Insurance, HMSA, recommending that this test be run 
when a person reaches 50 years old.) The nurse who was interviewing me 
for the colon exam, said my VA records stated that I had a ``history of 
problems with my colon''. I told her, ``No. I have no history of any 
colon problems.'' The only ``history'' I had was about 25 years ago 
when a colon test was done. This test showed everything was clear. 
(This test had only been performed because I was having problems with 
my appendix.) Last year during one of my appointments with Dr. Park, 
she went through my list of medications, as usual and asked me ``What 
happened with the Celebrex?'' I asked her what she meant and she told 
me that my VA records stated I was allergic to Celebrex. I told her I 
had never had an allergic reaction to Celebrex and didn't know how the 
information got in my records. A few months before this, Virginia, who 
is Dr. Garrigan's nurse, read me the list of my allergies and she said 
that it was listed that I was allergic to Advil. I told Virginia I had 
never, ever taken Advil so how could I be allergic to it.
    5. The Doctor's at the Hilo PCC are Not Available and Too 
Frequently ``Leaving Early''. We Veterans are told that the doctors are 
available at the 'Hilo clinic, on Monday thru Friday, from 8 am-4 pm. 
If we come in without an appointment, we are told that we will have to 
wait for an available opening. I am a member of the DAV Chapter 9, and 
most members have complaints about coming into the clinic at the above 
listed times and been told that the doctor had already left for the 
day. The last time this happened to me was in July, 2005. It was 3 pm 
and I was told that the doctor had already left for the day. Then the 
Hilo clinic tells us, ``if its an emergency, you can go to the 
Emergency Room at the Hilo Hospital''. Well, the last time I did go to 
the hospital was because of an emergency was about 2 years ago. I had 
returned from a CMP exam in Honolulu, and was feeling extremely ill. My 
wife called the Hilo PCC, around 3 pm and was told the doctor had 
already left for the day and my wife should take me to the Emergency 
Room. Well, I was taken to the Emergency Room and I had to pay for my 
treatment. The VA in Honolulu has refused to reimburse me, claiming 
that I should have gone to the Hilo PCC instead and are claiming that I 
did not have ``official'' permission from the clinic to go to the 
Emergency Room. There was another earlier time, on a weekend, when I 
went to the Emergency Room and again the VA has refused to reimburse 
me, claiming I should have gone to the Hilo PCC. Well, here in Hilo, we 
don't have the advantage available to Oahu Vets--24 hour Emergency 
treatment from Tripler.
    This next complaints are against the VA in Honolulu.
    1. Dental Treatment for 100 percent SC. As I previously stated I 
received my 100 percent SC Disability this year but it was retroactive 
to February, 1999. Around 2001, I began having problems with my teeth. 
I could not afford to have all the work done at this time and was 
waiting for my 100 percent SC to come through so the VA could take care 
of my teeth. Almost immediately after receiving my 100 percent, I made 
my appointments with the dentist. The VA has since refused to complete 
all the necessary work which the dentist has repeatedly told the VA I 
need. I have lost a number of teeth. According to the dentist, if the 
VA had began treatment back in 1999, I would probably still have all my 
teeth. I cannot chew. On my right side, I have teeth on top, and none 
on the bottom. On the left side, I have all my teeth on the bottom, but 
only 1 tooth on top that is being stressed and I could lose this tooth 
if the VA doesn't act fast.
    2. Performing Unnecessary CMP Exams. In my last disability claim, I 
complained that my hearing was getting worse. When the VA sent me to 
Honolulu, I thought it was to test my hearing. But this was not the 
case. I was sent for, what the doctor said was a ``preliminary 
interview & exam to determine if I had any hearing problems''. He would 
than decide if I needed a full hearing test by a specialist. I can 
still remember his total shock and misbelieve when he found out that I 
was wearing hearing aids and that the VA had been providing me with 
hearing aids for years. He asked me 3 times: ``Who gave you the hearing 
aids?'' He was furious that the VA was wasting his time. Well, not only 
was the VA wasting time, but also wasting money on me and my wife's 
plane fare. (My disabilities make it necessary that I have someone 
accompany me on flights, especially with all the delays and 
inconveniences at the airport since 9/11.)
    3. Coordinating CMPs and other Exams. There are many other veterans 
on the Big Island who like me, have a multitude of disabilities. The 
flight to Honolulu is in itself very difficult and strenuous for us. 
There have been times when we have had to travel every month or, even 
twice a month to Tripler for an exam. Why can't the VA schedule us for 
multiple exams during the same trip? We have been told that veterans 
from Guam and other localities in the Pacific have their exams 
scheduled together. The VA would save money on plane fare and we 
veterans would not suffer as much.
    4. The VA has Refused to Pay for Veterans Who Go To the Emergency 
Room when Hilo PCC Hours is closed. My fellow vets and I on the Big 
Island are having to pay for our treatments when we go to the Hospital 
Emergency Room when Hilo PCC is closed. This is why I and many other 
vets are paying for personal medical insurances (usually both HMSA and 
Medicare). And, we are repeatedly told by the VA that we are entitled 
to ``full, free medical care from the VA''.
    The following information is to rebut the statements of November 
21, which the VA submitted to you regarding my complaint of October 18, 
2005. I know the following is very long and time consuming, but, I hope 
you will take the time and read this. The Senate Committee may find it 
enlightening.
    I am enclosing a copy of the VA's November 21 letter to your office 
since my information follows their letter's format.
    First, regarding my canceled appointments. In 2004, I canceled only 
one appointment--my September appointment with Dr. Park, because I 
would be out of the state. This canceled appointment was one which I 
was never informed of and learned of only by accident. Please let me 
explain. On July 22, 2004, I made an appointment to see Dr. Garrigan 
because I was going to the Mainland and I needed to see her about 
receiving my medication while I was gone. I was leaving on the first 
flight out on September 13, 2004 and returning on October 18. I saw Dr. 
Garrigan so she could order my medication (in 3 month supplies) and get 
them to me before I left on my trip. Two of my medications could only 
be ordered monthly, so we determined when I would be receiving them at 
my home and where I would be in the Mainland, at that time, so my 
daughter would know where to forward them to me. Dr. Garrigan said she 
would order the rest of my medication in a 3 month supply. As always on 
the way out of her office, she handed me a paper which I have to turn 
in at the front office upon leaving. So, after meeting with Dr. 
Garrigan, I turned in a paper at the front desk and I made another 
appointment for September 1, 2004 for a checkup before I left on my 
trip. At this time, I also told the girl at the desk that I would be 
out of the state from September 13 through October 18, and to please 
note it in my records so no appointments would be scheduled while I was 
gone. (When I returned home, I called the VA in Honolulu. Since I had 
an ongoing CMP claim. I wanted to make sure that no CMPs would be 
scheduled while I was gone. Honolulu said I only had a CMP scheduled 
for August 17.)
    At my September 1st appointment, Dr. Garrigan told me that she had 
personally checked on my prescriptions and I would be receiving my 
medication before I left for my trip, except for 2 medications which 
could not be ordered ahead of time. When I left Dr Garrigarin's office, 
I reported to the front desk, turned in the paper Dr. Garrigan had 
given me and I told the girl at the desk that I would make my next 
appointment with Dr. Garrigan when I returned from my trip. At this 
time, she told me I had an appointment scheduled with Dr. Park for 
later in the month. I told her that I would be out of the state on the 
scheduled date and reminded her that I had notified the VA Clinic back 
in July that I would be out of town so that no appointments would be 
scheduled. THIS WAS THE ONE AND ONLY APPOINTMENT THAT I CANCELLED IN 
2004. I rescheduled my appointment with Dr. Park for November 15, 2004.
    I am a member of the DAV, Chapter 9, and my wife and I regularly 
attend their monthly meeting. At the November 12th meeting I spoke with 
a fellow Disabled Vet. He mentioned that he also had an ongoing claim 
and was very upset about some information he had recently found in his 
VA medical records. One of his complaints was that he received a copy 
of his VA medical records and in the records were a list of his 
scheduled VA medical appointments. He claimed to have found numerous 
cancellations of appointments he never knew he had and several of them 
were listed that he had personally canceled them. At this time, I had 
an ongoing claim with the VA and also had an updated copy of my VA 
medical records at home. When I looked through my records I found that 
I also had a number of canceled appointment which I knew nothing about 
and some of them had also supposedly been canceled by me.
    There is one appointment cancellation in particular that has caused 
me the most problem and for which Dr. Garrigan has shown ``no 
compassion''. I had been on one particular medication for over 10 
years. A couple of years ago, the VA referred me to the VA Pain 
Specialist, Dr. Park. Because of the severity of my condition Dr. Park 
suggested that I switch from oxycodone cr to methadone. I was very 
hesitant about switching mediation because not only had I been on 
oxycodone a for years. (It had been prescribed to me first in the 
1990's by VA doctors.) Dr. Park promised that if the methadone did not 
work out, there would be no problem with the VA reissuing, me oxycodone 
a. Also, if she (Dr. Park who came to Hilo once a month) was not 
available to switch me back, Dr. Garrigan would be able to switch me 
immediately because she (Dr. Garrigan) had previously been prescribing 
me the oxycodone a. I was told that in my situation, because the VA had 
been prescribing oxycodone a to me for years, the fact the oxycodone a 
had since become a non-formulary drug would have no bearing on me. 
(This fact was also verified by the VA Administration office in 
Honolulu.) So, both Dr. Park and the VA concurred that I would be able 
to get back on oxycodone a without delay or complication. However, I 
also hesitated because Dr. Park said that methadone was a ``last 
resort'' pain medication and all her other patients who were taking 
methadone to control pain were much older than me. (I was in my 40's).
    After a couple of visits with Dr. Park, I did agree to give the 
methadone a try. Almost immediately, I started getting unusual side 
effects. In particular, I began feeling extra tired; the hair on my 
head, chest and legs began thinning; I had great difficulty getting an 
erection and, my testicles were shrinking. After a couple of months, I 
spoke to Dr. Park about switching me back to oxycodone a to see if the 
methadone was the cause of my new conditions. She agreed to change my 
meds to see if my side effects would change. After Dr. Park switched me 
back to oxycodone cr, we found that my hair began thickening and I was 
able to sometime get an erection. Dr. Park said that apparently, the 
methadone was having an ``aging'' effect on me. She didn't know if it 
was the methadone itself or if the methadone was inadvertently 
triggering the side effects of the numerous, other medications I was 
taking.
    After I had been back on the oxycodone a for a couple of months, 
Dr. Park, suggested that I consider going back on the methadone until 
the middle of next year. She explained that she wanted to try and keep 
my body off the oxycodone cr for a year and then hopefully, put me back 
on the oxycodone a at a lower dosage. Dr. Park said that if the 
methadone's side effects got too bad, she would take me off the 
methadone earlier. So, she again changed my meds.
    On November 15, 2004 I saw Dr. Park again. At this time I showed 
Dr. Park that I had lost all the hair on my chest, the hair on my legs 
and arms were almost completely gone, the hair on my head had thinned 
and turned white, and even though I hadn't shaved in 4 days, there was 
very little hair on my face and, I could no longer get an erection. Dr. 
Park suggested that since I had come this far with the methadone, I 
continue with it for another few months and sometime before summer (of 
2005), I would be put back again on oxycodone cr, hopefully, at a lower 
dosage. But then, Dr. Park's entire outlook seemed to change when she 
began reading the medical records on my examinations from other 
doctors. Dr. Park seemed very worried when she read Dr. Uramoto's 
August report that stated how severely disabling my shoulders, arm, and 
hands had become with rheumatoid arthritis. Dr. Park did comment that 
she hadn't realized my arthritis was getting so bad. She also said that 
I may need strong dosages of oxycodone cr after all. We continued to 
talk. Dr. Park said that she would like to try and continue treating me 
with methadone for a couple more months. But now (after having read Dr. 
Uramoto's medical records), she said she would leave it up to me as to 
whether or not I continue with methadone or go back to oxycodone cr 
right away. After much discussion between Dr. Park, my wife and myself, 
I decided to continue with methadone for a couple more months, until I 
saw Dr. Park again. I felt that my side effects from the methadone 
couldn't get any worse and I trusted Dr. Park and was hoping that her 
plan would work. Just before I left Dr. Park, she reiterated that if I 
decided, at any time, to stop the methadone and go back to oxycodone 
cr, I could either contact her in Honolulu, or have Dr. Garrigan re-
prescribe me the oxycodone cr.
    Well, I never got to see Dr. Park again because when I called the 
Hilo Clinic to make an appointment to see her, I was told that she no 
longer works for the V.A.--the V.A. did not renew her contract. So, I 
called Virginia, Dr. Garrigan's nurse and explained the situation to 
her. She said that all she could do was set up an appointment for me to 
come in and see Dr. Garrigan. However, Dr. Garrigan was busy and 
Virginia gave me an appointment for a month and a half later. Well, a 
month later, Dr. Garrigan herself called me to say that she had to 
cancel my appointment and I was to call back later and set up another 
appointment. Because I would have to wait another extra month to see 
Dr. Garrigan, I decided to see my private doctor, Dr. Festerling who 
happens to be a former VA doctor who formerly treated me at the Hilo VA 
Clinic. He is fully aware of all my medical treatments by the VA. He 
noticed himself that I had ``aged'' and after examining me, diagnosed 
that I needed some type of testosterone treatment and that I should go 
back to oxycodone cr immediately. He wrote prescriptions for oxycodone 
cr and androgel and also gave me a testosterone shot. He also explained 
in writing the reasons for these medications. I took all Dr. 
Festerling's paperwork up to the Hilo PCC clinic and asked if I could 
wait to see Dr. Garrigan. This was on July 22, 2005 at 3 pm. I was told 
that the Dr. Garrigan and her nurse, Virginia, had already left for the 
day. (Note: Veterans are repeatedly told that we can ``walk in'' to the 
clinic on Monday-Friday, from 8 am to 4 pm to see the doctor. But if we 
don't have an appointment, we will have to wait. This was not the first 
time that I and other veterans have come to the clinic without an 
appointment and been told that the doctor has left early.) On Monday, I 
called the clinic and was told that the doctor and nurse were not in. 
On Tuesday, I was finally able to talk to the nurse, Virginia, and she 
said that the 2 prescriptions I had dropped off on Friday had 
``expired'' and I would need to go back to Dr. Festerling and have him 
write another set. I explained to the nurse what was going on. I told 
her that Dr. Garrigan could at least, just go ahead and switch me from 
the methadone back to oxycodone a. The nurse said that the oxycodone 
was ``non-formulary'' and special papers needed to be filled out by Dr. 
Festerling. I explained to the nurse that Dr. Park had said that 
because the VA had previously prescribed oxycodone, no special papers 
needed to be filled out. I also told the nurse that if she looked into 
my records she would see that even Dr. Garrigan herself had prescribed 
me oxycodone a in the past. I told the nurses that my records would 
also show that the VA had been giving me oxycodone a since the 1990's. 
She said she would talk to Dr. Garrigan and get back to me. At this 
time, I told the nurse that all my medication needed to be reordered. 
(Every month I have to call the nurse to have my medication ordered.) 
After talking to the nurse, I called the VA in Honolulu and they 
confirmed what Dr. Park had told me--since the VA had been prescribing 
me with oxycodone a for years, no ``special papers'' needed to be 
filled to put me back on oxycodone a. The next day, since I hadn't 
heard from Virginia, I called her and she told me that Dr. Garrigan 
would not issue me oxycodone a until Dr. Festerling filled out some 
papers and his papers were approved by the VA in Honolulu. I again 
tried to explain that both Dr. Park and the VA in Honolulu had said 
that it was not necessary to request special permission to put me back 
on oxycodone a, but she would not listen. When I asked if my 
prescriptions had been processed, I found out that everything but my 
methadone had been renewed. When I asked what had been substituted for 
the methadone, she told me ``nothing''. I was in shock. I said, ``Are 
you telling me that for 10 years the VA has been treating me for pain 
with either oxycodone a or methadone and now you are stopping me ``cold 
turkey''? Virginia said that yes, Dr. Garrigan was not renewing either 
medication.
    I complained to the VA in Honolulu. I was transferred to several 
different people. No one could really help me because it was up to Dr. 
Garrigan. But, several people said that they could not understand why 
Dr. Garrigan needed to process the medication as a ``non-formulary'' if 
I had previously received it from the VA.
    And, they couldn't believe that Dr. Garrigan would suddenly stop my 
pain medication ``cold turkey'' when I had been on it for years, 
especially since my recent exams indicated that my conditions has 
severely worsened. I was advised by the VA in Honolulu, to go back to 
my private doctor and have him prescribe the oxycodone Cr, fill the 
prescription myself and then bill the VA. So, this is what I did. I 
could then submit my receipt to the VA in Honolulu and get reimbursed. 
(I did submit the receipt to your office and have not yet been 
reimbursed.)
    I was finally able to see Dr. Garrigan a couple of weeks later, on 
August 3. She said that she knew I had complained to Honolulu about her 
but claimed that she was in the right because Dr. Festerling had 
prescribed a non-formulary drug. I told her that first of all, if she 
had not canceled our appointment, I would not have had to go to Dr. 
Festerling in the first place. And, second, if she would look in my 
medical records, she would see that VA doctors, including she herself, 
had been prescribing me the oxycodone cr. for years. At first Dr. 
Garrigan denied that she and other VA doctors had prescribed it to me 
but soon found out from my records that she and other VA doctors had 
been giving it to me. She then said, ``Oh, there is no problem. I can 
go ahead and write you a prescription for oxycodone right away''. So, I 
asked her, ``Doctor, why did you give me such a hard time?'' I never 
got an answer. When she went to take my heart beat, I unbuttoned my 
shirt and showed her that when I had seen her in January, I had 
complained to her about a bulge near my navel. I told her that because 
she had not done anything about it, I had gone to Dr. Festerling and he 
had referred me to a surgeon who had operated on me. I told her that I 
would use her as my primary care physician only if she would start 
treating me. Then when I asked her about the testosterone medication, 
she seemed surprise that I was having a problem. I told her to look in 
my medical records and she would see that my problem was well 
documented. Since Dr. Park was no longer around, it was up to her to do 
something. And since she hadn't done anything, Dr. Festerling had run 
tests on me and was treating me with shots and Androgel. Dr. Garrigan 
said that several treatments were available, however, the VA did not 
provide Androgel. I told her that I would try anything that was 
available. She said that she was running out of time and had already 
spent too much time on me. She said she would check my records and get 
back to me about my testosterone. When I didn't hear from Dr. Garrigan 
after a week, I called the VA office and was told that I would have to 
make another appointment and come in to see her again. The earliest 
appointment was about 2 month later, on September 29. I had been told 
several years ago by the VA Patient Advocate that I could bring a tape 
recorder to my appointments and I have done so a few times. I decided 
to go to this appointment with a tape recorder. When I saw Dr. Garrigan 
on September 29, she acted surprise that I was having problems with my 
testosterone. (Apparently she had totally forgotten about our August 3, 
2005 discussion.) Again, my wife and I had to explain everything that 
was going on. Dr. Garrigan denied knowing that I was having any 
problem, even though my problem was repeatedly noted in my VA medical 
records. I told Dr. Garrigan that I had been waiting to hear from her 
since the last time I had seen her and she had said she would be 
treating me. I had not gone back to Dr. Festerling for treatment and 
had been waiting to hear from her. Dr. Garrigan said she had the past 
lab records from Dr. Festerling, which showed a low count, but said she 
wanted a current testosterone count before starting her treatment. I 
told her that I had just come into the clinic for a blood test 2 days 
ago. Dr. Garrigan picked up her phone, called the lab and said she 
wanted to ``add a lab'' and she ``needed it now''. The lab results 
would be available within a day or two and Dr. Garrigan said she would 
start me on the medication immediately after receiving the lab results 
and the results would tell her how much medication I needed. Then she 
told us about the various treatments which were available: weekly or 
monthly shots, and 2 types of patches. She recommended I use the 
patches and she explained how to use the patches. She also said that 
she would need another testosterone count taken about 3 weeks after I 
go on the patches. Before I left her office she repeated that she would 
have the testosterone lab results within a day or two and would call us 
right away so that she could start my treatment. She also said to make 
an appointment for another lab test in 4 weeks so she could see how the 
new testosterone patches were working. (Note: I have this entire visit 
on record. Dr. Garrigan did look directly at the tape recorder which 
was in my pocket.) So, I made a lab appointment for October 31st. On 
October 7, 2005, I still had still not heard from Dr. Garrigan 
regarding the testosterone lab results and the medication she was to be 
put on. I called the Hilo PCC and was told that neither Dr. Garrigan 
nor her nurse, Virginia, was in. The woman who answered offered to take 
a message and I told her to write the following message for Dr. 
Garrigan: ``This is Guy Poulin--when I saw you on September 29, you 
told me you would get back to me within a day or two and let me know 
about the medication I would be taking. You wanted me to take new labs 
within 3 weeks of using this new medication. My lab appointment is on 
October 31. However, since you have yet to start me on my new 
medication, you need to reschedule my labs for 3 weeks after you 
finally start me on this new medication. Please call me and let me know 
what is going on. My number is . . .'' Well, neither Dr. Garrigan 
called me, nor did she start me on medication for my testosterone. So, 
regarding my October 31, 2005 lab appointment, I canceled it because 
the lab test was to see how the new medication was working--THERE WAS 
NO NEW MEDICATION BECAUSE DR. GARIGAN DID NOT GIVE ME ANY NEW 
MEDICATION.
    Shortly after my October 7 phone call, I complained to the 
Honorable Daniel Akaka and the Honorable Ed Case.
    On November 9th, Dr. Garrigan called me to tell me she was sending 
me to a colon doctor. She never mentioned about my testosterone. I 
GUESSED THAT, AS USUAL, SHE HAD FORGOTTEN ABOUT YOU. And, I did not 
bring it up to her because I had already gone back to Dr. Festerling 
and had decided that he would regulate any and all of my testosterone 
treatments. The VA has been inept in treating me for this condition--
they had more than a year to do something and after finally promising 
to treat me, they ``forgot'' or was it that ``they neglected'' to treat 
me.
    Another major problem occurred in January of this year. On January 
4, 2005. I had my regular appointment to see Dr. Garrigan. I had a 
bulge on my stomach, near my navel that I had noticed and had planned 
to have her check it out. She took me in late for my appointment. As 
soon as I got into her office, she said that she was running late. I 
began showing her my stomach, when the nurse came and told the doctor 
there was a phone call. Dr. Garrigan told me to put my shirt back on 
and wait outside. I went outside. After 15-20 minutes, she called me 
back into her office. Again, she said she had to rush my appointment 
because she was running late. She just looked at my stomach, and 
listened to my heart. She asked about my medication, and I mentioned 
the problems I was having with my methadone. It seemed that she was not 
listening to me at all. She hurried me out of the office. As soon as I 
got home, I made an appointment to see Dr. Festerling about the bulge 
near my navel. On January 6, 2005, I saw Dr. Festerling who said I had 
a naval hernia. He referred me to a specialist/surgeon and a couple of 
weeks later I was operated on.
    I am sorry to be so lengthy in my explanation but this is the only 
way to explain what truly happened. So, briefly, these are the accurate 
facts which correct the erroneous information which the VA gave to the 
Honorable Ed Case and the Honorable Daniel Akaka.
    1. I only canceled one appointment in 2004. This appointment was 
made by the Hilo PCC after the office had been told I would be out of 
state.
    2. On November 9, Dr. Garrigan called to tell me she was referring 
me to a colon specialist. She did not talk to me about anything else. 
Dr. Garrigan had already admitted on August 3, that she had made a 
mistake and I could receive the non-formulary medication. In fact she 
had filled out my prescription while I was still in her office on 
August 3. And, yes, on August 3, I was mad, because she had given me 
such a difficult time and had not even had the decency to look in my 
medical files which would have cleared up the problem immediately. And 
what about the fact that after years and years of being treated with 
either oxycodone a or methadone Dr. Garrigan stopped me ``Cold 
Turkey''. (The VA pain specialist, Dr. Park had me on both medication 
for a week as she eased me out of one and into the other) Dr. Garrigan 
showed a total lack of compassion. And, was it laziness that kept her 
from checking my medical records?
    3. When will I receive attention for my medical conditions. In 
January 2005 when I went in with a bulging naval, she just shoved me 
out the door. I had to go elsewhere for my operation. On September 29, 
2005, Dr. Garrigan told me she would call me within a day or two and 
prescribe me a new medication. Well, I gave her over a week, then 
called the VA clinic to remind her and still I did not hear from her. 
So again, I am being treated, at my own expense, by a private doctor 
who I totally respect and who has always shown me great compassion and 
who knows my entire medical history. Oh, and in the past 2 years, I 
have only been treated by 2 specialist from the VA, Dr. Park and Dr. 
Uramoto. However, I have provided the VA with medical records from my 
Private Primary Care Doctor, Dr. Festerling. And these records include 
records from several private specialists whom Dr. Festerling had 
referred me to because of my hernia, (which Dr. Garrigan neglected to 
treat), and for an auto accident. If the VA wants to take credit for me 
going to ``6 Specialists'' then, the VA should pay for the other 4 
specialists.
    I have one question. Why hasn't the VA answered all the questions 
that were addressed to them? And, I had submitted a receipt for the 
Oxycodone CR which I had to pay for because Dr. Garrigan had 
``forgotten'' that she and the VA had previously issued me this 
medication. I have not yet been reimbursed for the Oxycodone CR.
    I am enclosing a brief medication profile which show that I was on 
``OXYCODONE CR'' then put on ``METHADONE'', and later switched back to 
``OXYCODONE CR'' to check on the side effect, then put back on 
``METHADONE'' and finally returned to ``OXYCODONE CR.''
    In closing, I want to notify the VA that because the VA has for 
months, neglected to treat me for my low testosterone, on October 24, 
2005 I asked my Primary Care Physician, Dr. Buddy Festerling, to be the 
physician in charge of overseeing all treatments for my testosterone 
problem. Dr. Festerling immediately took charge and my treatments are 
ongoing. My testosterone problem is finally being handled and I hope 
the VA will respect my decision and not interfere with these 
treatments. I hope that this time you will receive an honest, factual 
response to my complaints.
    I greatly appreciate all your help.

Hon. Daniel K. Akaka,
United States Senator,
 Honolulu, HI.
    Senator Akaka: Thank you for your letter of November 7, 2005, on 
behalf of W. Guy Poulin, and his dissatisfaction with the medical 
treatment he received from the Hilo Community Based Outpatient Clinic 
(CBOC). He expressed concern regarding an excessive number of 
appointment cancellations. In 2004, there were four appointments that 
were canceled by the patient and five that were canceled by the clinic 
due to staff illnesses. Overall, the clinic makes every effort to keep 
scheduled patient appointments and to notify the patient in a timely 
fashion if an appointment has to be canceled unexpectedly. The patient 
is then rescheduled and an appointment notice is mailed to the patient. 
Recently, the Hilo CBOG has implemented a new scheduling process called 
``open access'' to allow more flexibility in the scheduling of 
appointments and to assure that patients are seen in a timely manner.
    Dr. JoAnn Garrigan, who is W. Poulin's primary care provider at the 
Hilo CBOC, called him on November 9, 2005, to discuss the issues that 
were presented in his letter. She related that the patient was angry 
about a medication that he did not receive from the VA. This medication 
could not be ordered for him because any prescription request was not 
served from his outside provider, and the patient did not present for 
his requited laboratory appointment to determine if this particular 
medication was needed.
    Dr. Garrigan also stated that Mr. Poulin has received attention to 
his medical conditions and that no complaints were ever ignored. Over 
the past 2 years, he was referred to six different specialists for a 
total of over 20 visits. The Hilo CBOC staff also noted that W. Poulin 
usually came to the clinic with his wife and did not recall them ever 
leaving the clinic feeling angry or upset. W. Poulin has indicated that 
he would like to continue his medical care with Dr. Garrigan as his 
primary care provider.

                               __________

Prepared Statement of Master Sergeant Keith T. Ribbentrop (Ret.), USAF, 
                                  MBA

    I am pleased that you are here today with expressed concern for 
Hawaii Veterans. It is very timely because this week it is with a great 
deal of pride and joy that we welcome home members of the 29th Infantry 
Brigade returning from deployment in Iraq. With their return, we 
welcome 1000 new combat soldiers to rank and file of Hawaii State 
veterans, more than three hundred of these soldiers are residents of 
Hawaii County their smooth reintegration to their civilian life is of 
utmost concern to us all.
    Hawaii County is the residence of approximately 14 percent of the 
State Veterans population; this population receives about 20 percent of 
the Disability Compensation paid to service connected disabled veterans 
in the State. The numbers demonstrate that while the number of service-
connected veterans in the county is relatively small their health care 
needs are more challenging. A further, affordable and welcoming living 
condition has facilitated significant growth in the number of older 
veterans in the county. Between the 1990 and the 2000 census, Hawaii 
County experienced a 105 percent growth in the age group 55-64; for 
many of these veterans the Veterans Health Administration (VHA) is the 
sole source for health care. As these veterans age, their health care 
needs will increase, creating additional demand on an already heavily 
taxed healthcare system. The rapidly growing number of eligible and new 
beneficiaries to the health care system challenges capacities and 
creates potentially unsafe conditions in care delivery. The Veterans 
Benefits Administration (VBA) has limited presence in Hawaii County 
providing Veteran Service Representative (VSR) Outreach visits twice 
each month, once in Hilo and once in Kailua-Kona. Because of time and 
travel considerations, it can take up to 2 months to file a claim with 
a VSR. I have worked with veterans to resolve issues with the VA. 
Veterans experience a full spectrum of frustrations from receiving 
wrong medication in the mail, to fear of a bad mark on their credit 
report because the VA has not paid a bill in a timely manner and the 
service provider has come to the veteran for payment. The most 
difficult are those that report life-threatening and disabling 
conditions that the VA will not provide care for because the condition 
is not service connected. Further, veterans speak of health care 
providers seemingly more engaged with the tasks related to documenting 
what they are doing versus actually providing care while in the same 
breath give testament to caring people working in a health care system 
that is taxed well beyond its capacity. Likewise, in talking with the 
VHA healthcare providers have similar frustrations with regard to 
facility size, with inadequate space, or no space for the providers to 
do their work. Depending on the complexity, veterans may receive care 
through any number of medical service providers throughout the state. 
Two veterans I have met, both from Hawaii County, have had surgical 
procedures performed on them at Tripler Army Medical Center under the 
contractual sponsorship of VA. For these veterans the care did not 
result in a positive outcome and they were further damaged because of 
the surgeries. The veterans accepted the provided care trusting that 
the VA would provide certain rights and remedies. These cases have been 
addressed by the Board of Veterans Appeals and the claims have been 
denied citing that compensation benefits are not available under 38 
U.S.C. A. 1151 for disability caused by hospital care, medical or 
surgical treatment, or examination furnished at a non-VA government 
facility through which the VA contracts. The Court has held that 
``where the law and not the evidence is positive, the claim should be 
denied or the appeal to the VBA terminated because of absence of legal 
merit or the lack of entitlement under the law.'' Sabonis v. Brown, 6 
Vet. App. 426,430 (1994). These veterans from the County of Hawaii did 
not receive treatment equal to that received by their mainland comrades 
by in large because we do not have a VA Hospital to deliver that level 
of care.
    In their claims preparation there were no statements of Informed 
Consent completed with the nurses or physicians of either VA or the 
Department of the Army; nor can the veterans recall any verbal 
counseling regarding choices. Informed consent is the process by which 
fully informed patients can participate in choices about their health 
care. It originates from the legal and ethical right patients have to 
direct what happens to their body and form and the ethical duty of the 
health care provider to involve patients in their health care. Without 
informed consent, these veterans were not aware of the nature of the 
decision, reasonable alternatives, relevant risks, benefits, rights, or 
remedies. They trusted that the Department of Veterans Affairs was 
acting in their best interest when it referred them to Tripler Army 
Medical Center for surgery. In the State of Hawaii, the VA can only 
provide a small number of medical procedures; the majority is conducted 
under contractual agreement. Compensation benefits are not available 
under 38 U.S.C.A. 1151 for disability caused by hospital care, medical 
or surgical treatment, or examination furnished at a non-VA government 
facility through which the VA contracts, therefore, the veterans in 
Hawaii do not receive care or benefit equal to their mainland comrades.
    General George Washington established the Purple Heart decoration 
in 1782. The Purple Heart is unique in that the individual is not 
recommended, rather entitled to it upon meeting specified criteria; the 
first of which is for wounds suffered in action against an enemy of the 
United States. During the Vietnam Era, the Department of Defense 
established a program called Project 100,000. Individuals selected for 
participation were allowed to enlist the military even though they did 
not meet minimum enlistment criteria. Two Hawaii County veterans who at 
the time of their conscription had less than a ninth grade education 
and enlistment qualification scores that cause serious doubt with 
regard to their ability to reason. They carry a diagnosis of Post 
Traumatic Stress Disorder and have serious physical problems because of 
the wounds and trauma they received in combat; both received discharges 
under Other Than Honorable Conditions. After their separation they re-
entered society and functioned as best they could, given their 
individual mental and physical limitations. They have come to the VA 
seeking medical assistance for their war related injuries, and denied 
that care because of the character of their discharge. Their character 
of discharge prevents the VA from delivering medical care for the 
traumas of combat injuries. It seems morally and ethically corrupt that 
the county would draft a man, send him into combat, then confer upon 
him the Purple Heart for his actions and then turn its back on him for 
medical conditions resulting form his combat experience. In 
determination of their requests for health care that the VHA and the 
VBA become a bureaucratic dynamo in their resolve to say no; applying 
what appears to be a bar from compensation claims to those of health 
care. Compassion would seem to be in order, and if it is not, then it 
would seem that legislation to allow these decorated American Veterans 
access to care for their war related injuries would be.
    Island life is different from life on the mainland; from the 
culture, we live in to the way we get from point A to Point B. A 
veteran on the mainland can, if necessary, hitchhike to a VA regional 
facility; on an Island, hitchhiking will get you to the other side of 
the highway from where you started. Compounding problems in Hawaii 
County is the lack of mass transportation. Disabled American Veteran 
vans supply some relief, but it is necessary to understand that our 
island has the nickname ``Big Island'' for a reason. It is possible for 
a veteran to miss a ride and have to remain overnight in Hilo or Kona. 
Certain VA care and services require veteran travel to Honolulu. Travel 
to the VA Regional Center always involves air travel. When a veteran is 
eligible, the VA provides reasonable travel accommodations and 
consideration in scheduling with understanding that the veteran has to 
move through his schedule quickly to enable them to get home that 
night.
    Employment of technology particularly video conferencing has 
provided great relief for many veterans receiving services from the 
VHA. The technology could be employed equally well within the VBA. For 
example, a veteran who appeals compensation decision from the VBA and 
requests a Regional Hearing or a Video Hearing before the Board of 
Veterans Appeals must always travel to a Regional Office. From neighbor 
Islands in Hawaii, that travel is always by air; some mainland veterans 
must travel tremendous distances. If a veteran is unable to travel 
alone and needs accompanied travel--his costs double. The De Novo 
Review process has helped many veterans who when presented with the 
associated costs, would simply drop their appeals and therefore their 
claims. The Technology is available within the VA--however, it does not 
appear to be fully employed. Another example, changing a Direct 
Deposit: through the Defense Accounting and Finance ``MyPay'' system 
takes roughly 4 minutes. An equivalent change with the VA can take up 
to fifteen minutes after you have made contact with a service 
representative, it can take several hours of telephone busy signals to 
get to that point, not to mention the time zone change considerations. 
Similar examples of lost time and frustration could be made for Life 
Insurance, Debt Management, Educational Benefits, Home loans and 
CHAMPVA. It would seem that broader employment of technology and 
allowing the veteran to perform simple tasks via the internet would 
both reduce the frustration on the veteran and the overhead costs to 
the government.
    In closing, I wish to thank the Veterans Affairs Committee for this 
opportunity to testify on behalf of all of the veterans in the State of 
Hawaii. I hope you will seriously take into consideration all the 
concerns brought to your attention.

                               __________

                  Prepared Statement by George Tamlin

    I am 100 percent disabled veteran, was referred to your Office by 
Barbara Morgan, the Patient Advocate at Spark M. Matsunaga Center. I 
have Osteoarthritis and I have on many occasions over the past 9 months 
requested a consultation with a specialist for the condition. I have 
made these requests through Dr. Rivera at the Community Based 
Outpatient Clinic in Hilo and a visiting VA Rheumatologist, Dr. Inmura 
(I have probably misspelled the name). I initially requested the 
consultation because I was losing strength and loosing my ability to 
grip and hold things. It has progressed to a point now that the loss is 
now affecting my personal hygiene. I continue to loose strength--and I 
still have no referral or relief in sight. I request your help in 
getting me the proper medical attention I need.

                               __________

              Prepared Statement of Carolle Brulee Wilson
                  va health care and benefits concerns

    What's right?
     Appointments are being outsourced here locally so as to 
receive travel stress on the veteran instead of traveling to Honolulu 
for a 20 minute appointment, consuming your Whole day with travel time
     Medications arrive in a likely manner through the mail 
system
    What's wrong?
     The Hilo vet center is not authorized to allow any 
veterans groups to utilize their conference rooms for meetings. 
According to supervisory personnel, ``it's in writing. Why? I hope the 
planned new vet center doesn't operate that way. In addition, I hope 
the planning of the new vet center would include to have All of the 
veterans offices in one building.
     The procedure for obtaining license plates at the county's 
DMV office should be streamlined. An id card and a DAV membership card 
mean nothing as far as obtaining license plates. You are instead asked 
to produce your dd214.
    Again as they do not keep records. Perhaps a standard Letter from 
VA Honolulu retained on file would help.
     When applying for property tax exemption, the Hilo 
property tax office requires you to mail the forms to VA Benefits in 
Honolulu to obtain the signature required. Why Isn't someone here 
authorized to sign this document?
     Hilo Women's Veterans Organization to hold a homeless 
veterans Standown. This effort failed. Honolulu has had several 
successful ones. I would like to have onsite direction and support from 
the person/s who conducted their event so that we may hold One here as 
well. We need to do something for our homeless veterans.
     Veterans here since many don't drive, should be given a 
bus pass to ride at no charge.

                               __________

               Prepared Statement of Wendall E.K. Kekumu

    Aloha Honorable Daniel K Akaka, U.S. Senator, Hawaii and Members of 
the U.S. Senate Veterans Affairs Committee:
    I wish to take this time to introduce myself, my name is Wendall 
E.K. Kekumu, I served in the Army Airborne that I consider apart and 
quite different from the regular Army units. I also served with the 
U.S. Army Reserve unit at Fort De Russey and the U.S. Army National 
Guard.
    I was service connected for malaria and rated at 0 percent and 
chronic back injury rated at 10 percent. Service at the VA was adequate 
but difficult in the beginning since you could only receive service for 
those conditions connected to military service. Today my rating is at 
100 percent permanent and total.
    With that rating you'd think that the service provided by the VA 
would include all medical conditions regarding my health, well the 
truth is ``NO'' I still receive treatment only for service connected 
conditions.
    While employed at the Pearl Harbor Naval Shipyard from 1978 to 1986 
I left my job after a long term injury and left through the Naval 
Dispensary clinic for depression in 1984 and received treatment from 
the Honolulu Vet Center and psychiatric service from the VA. In 1986 I 
was terminated from my employment because I didn't report to work as 
ordered. After negotiating for 1 year I was allowed to retire with 
medical conditions from the Shipyard. I did not receive any service 
from this organization until 1989.
    I maintain this medical plan for use by the dependents and 
continued to utilize the services at the VA. And within the last 5 
years the VA began to solicit reimbursement from this medical plan for 
my treatment of diabetes that I was ``told'' was service connected by 
the CBOC nurses and physicians.
    I had to apply for service connection of diabetes with the VA and 
was service connected for this condition. It seem unfair to me that a 
veteran who is rated at 100 percent and does not have medical insurance 
for his dependents are treated without cost yet for me that have 
insurance that I have never used for myself are penalized for having 
insurance.
    The VA enrollment for veterans seemed like a good plan if you 
didn't have any type of health insurance. I misinterpreted the word 
enrollment as being covered for all medical services provided by the VA 
where in ``fact'' it still only applies to the service connected 
conditions.
    It is therefore my disappointment that this new enactment of policy 
at the VA only takes care of those veterans without health insurance 
and those veterans providing health insurance coverage for his 
dependents are unfairly penalized.
    In October 2003, I kept an appointment at CBOC in Hilo for the 
continued monitoring of blood sugar levels for diabetes and submitted 
an application to renew my permanent disability plagued to the LPN.
    I did not have a cardiac distress or difficulty with breathing when 
I was ask to walk down a hallway and back was the reason given that 
they would not sign off on the application for a Hawaii County 
Disability Plagued. I had to ask my doctor which I did.
    I applied for and was issued a Disability Plagued in Tacoma, 
Washington, Eastport Idaho, Honolulu Hawaii and Hawaii County. Not 
until my plagued expired in 2003 could I ever imagine that CBOC's LPN, 
Medical Doctor and whoever is in charge of this responsibility, 
interpretation of the application would not allow the renewal of my 
application for a disable plagued.
    It seem over reaching one's authority in this situation and unless 
this is corrected, I continue to suffer from there decision for not 
renewing my disability plagued.
    Aloha P mehana.
  

                                  
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