After coming home from war and striving to reintegrate into civilian life, many military veterans feel like they’re alone on an island. For service members returning to Guam and the Northern Mariana Islands, it’s more than just a feeling.

Four thousand miles west of Hawaii, 1,500 miles south of Japan, and 1,600 miles east of the Philippines, United States military veterans live, work, and strive to heal the wounds of war in extreme isolation.

In these island territories, it’s not unusual for nearly half a graduating high school class to join the military. When faced with a choice between the low-paying hospitality industry or military service, the latter offers young people a higher salary, the security of lifetime government benefits, and a chance to get off the islands. Because of these enticing perks, the 2010 Census estimated that 5.6 percent of the population on these islands is active-duty military compared with 0.4 percent of the mainland U.S. population (United States Census Bureau).

These veterans make the same commitments and sacrifices as their mainland counterparts: they undergo intense training, they leave their families, they fight our wars, they risk their lives. When they return from service, they need adequate medical care and relief from post-traumatic stress, but they also need access to mental health care for help with the deeper, darker scars of war: the grief, shame, guilt, and sorrow associated with moral injury.

Moral injury is a wound to the soul and the psyche. It confuses veterans’ place in society by warping their understanding of right and wrong. A returning veteran wonders, “Was I justified in doing the things I did in war? Am I still a good person if I did bad things? Can I be forgiven?”

These are the questions that haunt combat veterans. Their answers can only be found with long-term, consistent, dependable mental health care, community support, and a diverse regime of healing modalities, which can include anything from meditation and yoga to art therapy and nature immersion.

Like veterans on the mainland, the returning service members of Guam, Rota, Tinian, and Saipan must navigate the complex labyrinth of the VA health system in order to partake in the benefits promised to them. Unlike many of their mainland counterparts, island vets often find that mental health care is either geographically inaccessible or only available via telehealth services like video chat.

Some mainland veterans have to drive several hours to reach the nearest VA hospital. But many vets who live on these islands have to take a seven-hour flight — some 4,000 miles — to see a therapist or other specialist at the nearest VA hospital in Hawaii.

Some veterans have to pay for their flight upfront and get reimbursed months later. Those whose flights are paid upfront by the VA report poorly coordinated, mismatched flights. Sometimes, the flight is paid upfront but the veteran has to pay out-of-pocket for ground transportation, meals and lodging, with the hope of getting partially reimbursed later. And with time away from work and family, in-person mental health care can quickly become an investment of $3,000 or more.

According to Rep. Tina Sablan of the Northern Mariana Islands, some veterans make the trip to Hawaii to find they need treatment that hasn’t yet been approved by the VA.

“It is not uncommon to hear of a vet making the 4,000-mile flight to Hawaii for a particular appointment, finding that they need an additional type of care or service that wasn't already approved by the VA, and then flying all the way back to the Marianas to wait for approval for yet another appointment and flight.”

On a recent trip to the islands, I was astounded to learn that the yoga-for-veterans course I was teaching was one of the only accessible healing modalities provided to address veteran mental health — and I was a visiting teacher, temporarily on the islands as part of a private (non-government) program called VEToga.

Tom Voss

Iraq war veteran Tom Voss teaches yoga on Saipan. (Courtesy photo)

On the island of Rota, I met an Army veteran who was separated from his wife and suffering intensely from post-traumatic stress and moral injury.

“I am lost and confused with my life,” he wrote me after the yoga course. “I am close to ending my life.”

He needed help, fast. His options were to purchase a plane ticket and fly to Hawaii to see a therapist or specialist; purchase a plane ticket to Guam and try to see one of the clinical psychologists or psychiatrists who periodically visit the VA outpatient clinic there; purchase a plane ticket to Saipan and try to get an appointment with the one licensed clinical social worker at the VA there; or video chat with someone online.

Sablan says that telehealth mental health services have proven a poor substitute for access to human-to-human healing.

“Telehealth mental health services are available to Marianas veterans, but we have heard many complaints about that,” said Sablan.

“Vets say they don't like the impersonal contact via TV screen or laptop, and there is high turnover of therapists, so they are constantly having to repeat their stories and build rapport anew, which is frustrating and discouraging in any case but especially over a screen.”

Because of the level of care he needed, the veteran I met was thinking of leaving Rota altogether and moving 7,000 miles away to Texas, where he had been stationed during his time in the service. When moving 7,000 miles away from home is the best choice for a suicidal veteran to get the help he needs, it’s clear we have a gap in care.

The government has not invested in mental health services for these islands because it considers these veterans a low-priority population. Their low numbers when compared with the mainland veteran population make them easy to overlook. The VA further evaluates the need for care based on the number of veterans taking advantage of the current care offerings.

Since it takes a superhuman effort to get care in the first place, demand for care remains low. Getting on a plane just to see a therapist in person is a lot to ask of anyone. But for someone with moral injury, for whom just getting out of bed in the morning can feel next to impossible, the monumental nature of seeking help can stop them from seeking help altogether. Demand for care remains low even though the need for care is high. Since demand is low, government resources remain low.

If the government evaluates the need for help by the number of veterans who ask for help, they will continue to draw the wrong conclusions. Signing up to serve in the first place was the moment the service member raised her hand to say, “I need support right now, as I’m learning how to protect and serve this nation, and I will need support later, after I have given myself, body and soul, to this nation.”

The long-term solution to this problem is simple enough: stop making war. Stop sending high school graduates into battle. Stop ending lives before they begin. The short-term solution is to provide accessible, effective mental health care to all returning combat veterans, no matter where they are in the world. We should not ask veterans to make sacrifices that result in moral injury unless we’re willing to help heal that moral injury, however — and wherever — it appears.

The need for mental health care is borne of the actions we ask our service members to take during war. Until we can stop engaging in war altogether, it’s our duty to make that mental health care convenient, accessible, affordable and effective. If we don’t, the wounds of war will continue to negatively impact our service members, families, communities and the strength of our nation for generations to come.

Iraq War veteran Tom Voss and his sister Rebecca Anne Nguyen are co-authors of the new book Where War Ends: A Combat Veteran’s 2,700-Mile Journey to Heal — Recovering from PTSD and Moral Injury through Meditation.

Editor’s note: This is an Op-Ed and as such, the opinions expressed are those of the author. If you would like to respond, or have an editorial of your own you would like to submit, please contact Military Times managing editor Howard Altman, haltman@militarytimes.com.

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