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COMMUNITY IMPACTS OF DEPLOYMENT

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This chapter examines the effects of deployments to Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) on communities. The committee studied the effects in two ways: First, it conducted an extensive review of the literature. Second, it commissioned ethnographic studies to illustrate the effects of the deployments on six communities either located near major military installations (Jacksonville, North Carolina; El Paso, Texas; Watertown, New York; Lakewood and Lacey, Washington) or having relatively large, recently deployed National Guard populations (Georgetown and Andrews, South Carolina; Little Falls, Minnesota).

REVIEW OF THE LITERATURE

The body of literature documenting the effects of OEF and OIF deployment on communities is scant. The committee found no community-wide assessments of the effects of OEF and OIF deployment. In an effort to find related research, the committee expanded its literature search to cover the community effects of any military deployment. The committee broadly defined the term community effect to refer to any impact on local public or private providers of goods and services.

Community-Wide Economic Effects of Deployments

The committee found no studies that examined the community-wide economic effects of OEF and OIF deployments. It did identify one study, published in 1994, that quantified, over a seven-county region, the economic effects of troops deploying from Fort Stewart and Hunter Airfield in Georgia (Kriesel and Gilbreath, 1994). At the time of the study, Fort Stewart held 25,000 Army troops and had had recent deployments—to the First Gulf War, and to Florida in response to Hurricane Andrew. Fort Stewart is a major employer in the surrounding rural communities. For the economic analysis, the investigators focused on the consequences of a 1,000-troop deployment for 1 year. That unit was selected so that study results could be extrapolated to future deployments of varying lengths and sizes. The investigators found that such a deployment is associated with decreased expenditures in sectors of the local economy including food, housing, retail, transportation, health care, and entertainment. In all, the authors estimated that the 1,000-troop deployment for 1 year reduced direct local spending by $10.56



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7 COMMUNITY IMPACTS OF DEPLOYMENT This chapter examines the effects of deployments to Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) on communities. The committee studied the effects in two ways: First, it conducted an extensive review of the literature. Second, it commissioned ethnographic studies to illustrate the effects of the deployments on six communities either located near major military installations (Jacksonville, North Carolina; El Paso, Texas; Watertown, New York; Lakewood and Lacey, Washington) or having relatively large, recently deployed National Guard populations (Georgetown and Andrews, South Carolina; Little Falls, Minnesota). REVIEW OF THE LITERATURE The body of literature documenting the effects of OEF and OIF deployment on communities is scant. The committee found no community-wide assessments of the effects of OEF and OIF deployment. In an effort to find related research, the committee expanded its literature search to cover the community effects of any military deployment. The committee broadly defined the term community effect to refer to any impact on local public or private providers of goods and services. Community-Wide Economic Effects of Deployments The committee found no studies that examined the community-wide economic effects of OEF and OIF deployments. It did identify one study, published in 1994, that quantified, over a seven-county region, the economic effects of troops deploying from Fort Stewart and Hunter Airfield in Georgia (Kriesel and Gilbreath, 1994). At the time of the study, Fort Stewart held 25,000 Army troops and had had recent deployments—to the First Gulf War, and to Florida in response to Hurricane Andrew. Fort Stewart is a major employer in the surrounding rural communities. For the economic analysis, the investigators focused on the consequences of a 1,000-troop deployment for 1 year. That unit was selected so that study results could be extrapolated to future deployments of varying lengths and sizes. The investigators found that such a deployment is associated with decreased expenditures in sectors of the local economy including food, housing, retail, transportation, health care, and entertainment. In all, the authors estimated that the 1,000-troop deployment for 1 year reduced direct local spending by $10.56 331

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332 RETURNING HOME FROM IRAQ AND AFGHANISTAN million (in 1991 dollars) in the seven-county region. Reduced expenditures were made by the Army itself ($2.71 million) and by individual troops ($7.85 million). Kriesel and Gilbreath (1994) applied those estimates to a software model for input-output analysis that contained county-level economic data. With the model, they were able to forecast the economic consequences of the deployment within the seven-county study area. The model showed that 240 economic sectors were affected by troop deployments from Fort Stewart; however, only 101 of the sectors were present in the seven-county study region, meaning that many of the economic effects associated with deployments from Fort Stewart were felt outside the immediate region. The results of the model are summarized in Table 7.1. “Direct impact” as shown in Table 7.1 includes, for example, decreased sales at restaurants as a result of fewer patrons. “Indirect impact” includes the decreased purchases that restaurants in turn would make from wholesalers, as well as the ensuing chain of decreased economic activity (for example, wholesalers purchasing less produce from farmers, who in response might decrease their production the following year). “Induced impact” considers the broader economic fallout from the deployments—for example, reduced overall consumer spending caused by lower wages as a consequence of less revenue at local businesses. “Direct impact plus indirect impact plus induced impact” equals the total economic impact in the region for each of the categories in Table 7.1. The column labeled “Total Gross Output” in Table 7.1 quantifies the impact that deploying 1,000 troops for 1 year has on the output of goods and services in the region. In 1991 dollars, such a deployment from Fort Stewart would reduce the total gross output in the seven counties by $13.87 million. Wages and salaries paid to employees of local vendors would be reduced by $4.15 million over the year, and total income (wages plus interest, profits, rental income) would be reduced by $7.05 million. Value added (employee compensation plus indirect business taxes and property income) would be reduced by $7.77 million, and a total of 266 jobs would be lost. Although this type of analysis is geographically specific, it does shed light on how a deployment might affect local economies with heavy reliance on military installations. The Kriesel and Gilbreath study suggests that there are significant economic losses to communities that deploy a relatively high concentration of service members. TABLE 7.1 Local Economic Impacts from Deploying 1,000 Troops for 1 Year, Fort Stewart and Hunter Army Airfield (in 1991 USD) Total Gross Wages and Total Income Value Added Jobs Output ($ in Salaries ($ in ($ in millions) ($ in millions) millions) millions) Direct Impact –8.3097 –2.5900 –4.1870 –4.5845 –172 Indirect Impact –1.8761 –0.4982 –0.9299 –1.0339 –27 Induced Impact –3.6811 –1.0636 –1.9380 –2.1513 –65 Direct + Indirect + –13.8669 –4.1519 –7.0548 –7.7697 –266 Induced Impact SOURCE: Kriesel and Gilbreath, 1994 (with permission).

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COMMUNITY IMPACTS OF DEPLOYMENT 333 Impact of Deployment on Employers The majority of reservists and National Guard soldiers hold private-sector jobs in the community (CBO, 2005). They are often activated for deployment with little warning, which can be disruptive and costly to employers. The effects of activation vary greatly among businesses that employ reservists, depending on the size of the business and the nature of the position vacated by the deploying employee. The most adverse effects of deployment are borne by small businesses that lose essential employees, businesses that rely on employees with highly specialized skills, and self-employed businesses owned by reservists (CBO, 2005; Hope et al., 2009). Small businesses (fewer than 100 employees) employed about 18% of reservists in 2004 (CBO, 2005). Approximately 8,000–30,000 of 860,000 reservists in the Selected Reserves1 were estimated to hold key positions in small businesses in 2004. About 55,000 reservists (9% of total reservists in 2004) were self-employed or employed by a family business. Self-employed reservists were more likely to be in construction, legal, health care, and building-maintenance fields than were reservists who were not self-employed. Types of Deployment Effects The committee reviewed the limited literature documenting the effects of National Guard and reserve activation on civilian employers. According to the Congressional Budget Office (CBO), only 6% of businesses employ reservists. However, in communities with a higher concentration of National Guard and reservists, the effect of deployments can be more profound. That is particularly true among businesses that employ reservists in key positions or those with specialized skills (CBO, 2005). Allison-Aipa et al. (2005) interviewed 28 private-sector employers of reservists to measure problems following the activation of the reservists. The employers were a convenience sample identified by a unit of the Maryland National Guard. The 28 employers, 39% of which were in law enforcement, reported that reserve activation had a negative impact on work scheduling (61%), product delivery (50%), coworker workload (68%), morale (29%), and the hiring and training of replacements (57%). Many reported that reserve call-ups came with too little notice (72%), at an inconvenient time (50%), and with an unclear length of assignment (61%). Most employers (71%) reassigned the responsibilities of the activated employee to his or her coworkers. Forty-two percent of employers stated that 2 weeks was the maximum that a reservist could be away before the workplace was negatively affected. A CBO survey found that about 15,000 small businesses reported experiencing financial loss or difficulty operating their businesses in 2001–2004 (CBO, 2005). Reservists notified their civilian employers, on average, 13 days ahead of activation. Sixty percent of reservists gave their employers notice of 1 week or less. Unclear length of deployment further complicated employers’ responses to the reservists’ activation. In many cases it was not known how long a reservist would be away, making it difficult for employers to decide how to respond to the temporary vacancy. 1 The Selected Reserve is a subset of reservists who are required to be available for mobilization within 24 hours. They are drawn from all services: the Air National Guard, Air Force Reserve, Army National Guard, Army Reserve, Coast Guard Reserve, Marine Corps Reserve, and Navy Reserve.

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334 RETURNING HOME FROM IRAQ AND AFGHANISTAN Economic Impact on Employers Call-ups of reservists have direct financial impact on their employers largely because the reservists’ jobs and some benefits are guaranteed to them by law when they return. The Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA; PL 103- 353) requires employers to reemploy reservist employees after their service is completed; the act also prohibits employment discrimination based on past, present, or future military service. Returning reservists are entitled to continued pension benefits as if they had not been activated, and they have the right to retain their health coverage. When they return from activation, reservists are also entitled to career advancement and seniority benefits as if they had been continuously employed. USERRA does not require employers to pay salaries for reservists during mobilization, but some employers elect to supplement military pay. The Institute for Defense Analysis attempted to quantify the cost to employers resulting from reserve activation (Doyle et al., 2004). On the basis of published civilian age-group and firm-size data, Doyle et al. estimated that 50–58% of employed reservists participate in an employer-provided retirement plan and that employers’ costs for reservists’ retirement plans average $372 per month. In addition, using published civilian age-group and firm-size data, Doyle et al. estimated that about 65% of reservists participate in employer-provided health- insurance plans and that the monthly employer cost averages $215 for a single individual and $550 for a family. Small businesses are disproportionately affected by the loss of reservists who are ordered to active duty, because an employee at a small firm accounts for a greater share of output than that of an employee at a large firm. Doyle et al. (2004) interviewed a small number of recipients of Small Business Administration Military Reservist Economic Injury Disaster Loans, which are given to companies that are unable to meet their operating expenses after an essential employee has been called to active duty. The findings indicate that the most common effect of activation is lost business and that losses are experienced even after reservists return from active duty. Furthermore, replacing a reservist, even if it is feasible, does not necessarily offset lost business; in some cases the long-term effect of activation might result in permanent harm to the business (Doyle et al., 2004). The CBO study found financial effects similar to those cited above (CBO, 2005). Health care coverage for activated reservists who elect to keep their employer’s health coverage costs about $260 per month for individual coverage and about $600 per month for family coverage, regardless of how long the activation lasts. If the employer offers a matched contribution to the reservist’s retirement plan and the reservist continues to contribute while activated, the employer is required to continue to match the contribution for the duration of the activation. The CBO estimates that paying this benefit costs employers about $175 a month, or $2,100 for a 1-year activation, for each participating reservist. Some employers voluntarily pay benefits that exceed those required by USERRA. For example, CBO reports that 16% of recently activated reservists continued to receive either partial or full salaries for the duration of their activation. Effect on the Workforce A study conducted by the RAND Corporation found that the overall effect of reservist activation on the workforce was minimal (Loughran et al., 2006). The study found that, at most, activated reservists or deployed active-duty service members constituted 0.2% of the workforce

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COMMUNITY IMPACTS OF DEPLOYMENT 335 nationwide in 2001–2004. The study notes, however, that active-duty service members and reservists are geographically concentrated, and thus the effect of their deployment is likely far greater in some communities than in others. For active-duty deployments, the authors found that for every 10 service members deployed, about one civilian is hired and enters the workforce. It is unclear why this occurs, although the authors speculate that it might be due to the entering of the workforce by spouses of deployed service members while their husbands or wives are away (Loughran et al., 2006). For every reservist activated, the authors found a corresponding short-term decline in the workforce; after 4 months, however, employment levels return to preactivation levels, which is likely due to employers simply taking time to hire replacement workers. The authors acknowledge that although in the aggregate, activations and deployment are not likely to have any long-term effect on the US economy, certain communities and businesses with relatively large concentrations of reservist employees might feel the brunt of deployment more significantly. Police departments, for example, are often staffed by reservists and might have difficulty restaffing in the short term following activations. This is especially true in smaller communities where the pool of eligible trained officers looking for work is likely minimal. Hickman (2006) examined the effect of reserve activation expressly on police forces. The analysis, covering a 12-month period, found that about 2% of the police workforce nationwide was activated in 2003. However, the rate of activation varied greatly depending on the size of the force and community. For example, in the 362 law-enforcement agencies supporting larger communities (250,000 or more), 1.6% of the workforce was activated. The 4,178 law- enforcement agencies serving small-to-medium-sized communities (10,000–49,000) lost 3.7% of the workforce to activation. However, the 9,941 agencies serving small communities (10,000 or less) lost 11.4% of the workforce. Costs associated with those losses are mostly attributable to the increased overtime needed to compensate for the lost workforce. Using the Department of Justice’s Law Enforcement Management and Administrative Statistics (LEMAS) survey data, the author calculated that the total cost per activated officer was $650–$2,000 per week. Hickman estimated the total cost per law-enforcement agency was $2,050–$6,020 per week. The Small Business Administration looked at revenue loss in small businesses related to reserve activation (Hope et al., 2009). The authors found that among small firms (100 or fewer employees), for every reservist activated there was a 0.30% decrease in sales. In large firms, a 0.02% decrease in sales was associated with every employee activated. This 15-fold difference in sales impact demonstrates the heavier toll experienced by small businesses. The authors also found that for every 10% increase in activations of 30 days or more, small firms face a 3.7% decrease in sales. Programs to Assist Employers The committee is aware of programs and federal laws designed to lessen the financial burden that employers of reservists or self-employed reservists face when reservists are activated and deployed. The Veterans Entrepreneurship and Small Business Development Act of 1999 (PL 106-50) allows small businesses that lose essential employees or owners to active duty to defer payment of preexisting direct loans from the Small Business Administration. The law also requires the Small Business Administration to lower the borrower’s interest rate. This law helps many activated reservists who are self-employed, considering that they are generally essential employees or owners.

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336 RETURNING HOME FROM IRAQ AND AFGHANISTAN The Servicemembers Civil Relief Act of 2003 (H.R. 100) can also help relieve the effects of activation on self-employed reservists by allowing them to reduce certain business-debt interest costs and, under certain circumstances, to terminate business leases before a call-up. Finally, the Military Reservist Economic Injury Disaster Loan (MREIDL) program under the Small Business Administration provides funds to help an eligible small business meet the ordinary and necessary operating expenses that it is unable to meet because an essential employee was called up for active duty (US Small Business Administration, 2011). Employment of the Returning Veteran in the Community When veterans return to their communities, they need to readjust to the civilian workforce. Recently separated reservists have the opportunity to return to their previous positions because employers are required by law to hold the reservists’ jobs open. But recently separated veterans who enlisted in the military at a young age might be entering the civilian workforce for the first time. As discussed in Chapter 8, among those in the labor force, veterans who served after 2001 have higher rates of unemployment than do their civilian counterparts. One reason might be that approximately 20–25% of returning veterans have psychiatric symptoms or diagnoses (Hoge et al., 2006; Jacobson et al., 2008; Seal et al., 2007; Tanielian and Jaycox, 2008). Burnett-Zeigler et al. looked at employment status among 585 National Guard service members recently separated (45–60 days), returning from OIF and OEF (Burnett-Zeigler et al., 2011). Less than half (41%) of the participants were employed at the time of the survey. Those who reported recent combat exposure were more likely to be employed (46%) compared with those who did not report recent combat (36%). Physical- and mental-health status, posttraumatic stress disorder (PTSD), depression, alcohol use, and anxiety did not affect the participants’ employment status. Among the employed, 79% were employed full time. Service members below age 30 were less likely to be employed than those 31 or older (29% and 57%, respectively). In the adjusted analyses, those with better mental-health status and poorer physical-health status were more likely to be employed full time vs part time. The authors note that more time might be required for the negative effects of mental-health status, alcohol use, recent combat exposure, and PTSD to affect employment rates. Additionally, Burnett-Zeigler et al. suspect that having a psychiatric illness or combat trauma might affect the maintaining of employment more than it affects the obtaining of employment. The authors also note that selection bias should be considered, as only 60% of those approached chose to participate in the study. Erbes et al. (2011) studied 262 National Guard and reserve service members who returned from OIF after a 16-month deployment. The authors conducted structured diagnostic interviews with these individuals on their reentry into civilian life and sent out a questionnaire 1 year later. In total, 5% had PTSD, 6% had subthreshold PTSD, 11% had major depressive disorders, and 11% were experiencing alcohol abuse or dependence. The study found that the rates of employment of the study participants at both time points did not differ from the rates of employment in veterans without a psychiatric diagnosis, but those with psychiatric diagnoses reported functioning, at both time points, at a lower level of work performance. Smith et al. (2005) looked at PTSD-symptom severity and its effect on employment outcomes. Researchers used the Clinician-Administered PTSD Scale (CAPS) to measure PTSD-

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COMMUNITY IMPACTS OF DEPLOYMENT 337 symptom severity in the 325 Vietnam-era veterans participating in the study. All participants had either severe or very severe symptoms. For every 10-point rise in the CAPS score, indicating a meaningful increase in PTSD symptoms, the likelihood of no employment increased 5.9 percentage points (p < 0.01). Correspondingly, the probability of part-time work decreased 2.1 percentage points (p < 0.01), and the probability of full-time work decreased 3.8 percentage points (p < 0.01). CAPS scores did not have any significant association with earnings for full- time workers or all workers (full-time and part-time combined). Taken together, studies of employment show that veterans who have psychiatric illness are at a disadvantage in obtaining or maintaining employment. When they are employed, it might only be part time rather than full time, or they might be functioning at lower levels. PTSD appears to be the strongest risk factor for occupational impairment. Community Interventions to Assist Employment There are many Department of Veterans Affairs (VA) and other public- and private- sector programs and interventions designed to help veterans enter the workforce. The question is: What types of vocational services are most effective for veterans with psychiatric illness? Resnick and Rosenheck looked at the relationship between PTSD and employment among 5,862 veterans in Veterans Health Administration Compensated Work Therapy, a vocational rehabilitation program (Resnick and Rosenheck, 2008). This program, dating back to the 1930s, aids veterans with disabilities in obtaining competitive employment in the community, working in jobs they choose, and receiving compensation. The VA employs them, finds work for them at other federal agencies, or enters into contracts with private providers that employ them. Resnick et al. found that veterans who had received a diagnosis of PTSD were 19% less likely to be employed on completion of the program (odds ratio [OR] = 0.81, 95% confidence interval [CI] = 0.69–0.96, p = 0.02) compared with veterans who had not received a diagnosis of PTSD. Mood disorders and substance-use disorders were unrelated to employment. Compared with unemployed veterans, employed veterans were more likely to be younger, to receive less public financial support, and to have fewer medical conditions. Veterans with severe mental illness were less likely to be employed. Those who had served in a theater of operations had higher rates of employment, a finding that the authors assert was anomalous. In terms of program efficacy, 30% of veterans who had received a diagnosis of PTSD were employed on completion of the program vs 36% of veterans who had not received a diagnosis of PTSD—rates that the authors considered to be low. Rosenheck and Mares (2007) examined the individual placement and support (IPS) approach to job training for veterans who had a diagnosis of mental illness. IPS is an evidence- based practice that stresses rapid job placement, choice of jobs, emphasis on obtaining competitive jobs, ongoing support without a time limit, and integration of vocational support and clinical care (Bond et al., 2001). The Rosenheck and Mares (2007) study compared employment outcomes between two cohorts: the Phase 1 cohort of 308 veterans participated in the VA program before the IPS was established in 2001, and the Phase 2 cohort of 321 veterans received IPS. Both cohorts were followed and interviewed quarterly for 2 years. Because the cohorts were not assigned randomly, the analyses were adjusted for characteristics that were significantly different between the two groups. Veterans were eligible if they were homeless, were not receiving VA health services, sought competitive employment (a non-VA job in the community), had received a diagnosis for a psychiatric or substance-use disorder, and had been unemployed

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338 RETURNING HOME FROM IRAQ AND AFGHANISTAN for the previous 30 days or longer. The Phase 2 group had 15% more days per month of competitive employment (8.4 days compared with 7.3 days; p < 0.001) and 32% fewer days of noncompetitive employment (a job through the compensated work therapy program, for example). Overall, days of combined employment (competitive and noncompetitive) were not significantly different between the groups; however, the difference in the number of competitive work days was significant at eight of the nine study sites. Davis et al. (2012) were the first to perform a randomized controlled clinical trial of IPS in veterans who had received a diagnosis of PTSD. Veterans were randomly assigned to receive IPS (n = 42) vs standard vocational services (n = 43) sponsored by the VA. Over the course of 12 months, 76% of IPS recipients gained competitive work vs 28% of controls—that is, the IPS group was 2.7 times more likely to gain competitive employment. Further, the IPS recipients worked substantially more weeks and earned higher income. Taken as a whole, the evidence supports IPS as a preferred type of vocational rehabilitation service. Communities serving veterans can utilize this model to deliver vocational assistance for veterans who do not qualify for VA services. Homelessness and Community Impacts Among veterans, those who are homeless have the greatest needs for community-based services—not only for shelter but also for identification and amelioration of the risk factors for homelessness, including psychiatric and substance-use disorders. Consequently, the community- based services needed by the homeless are wide ranging. They include housing, employment, health care, social services, education, and outreach, among others. Epidemiology of Homelessness Among Veterans By January 2009, only 916 veterans of OEF and OIF had formally sought VA homeless services (Perl, 2010). However, the VA has classified an additional 2,986 OEF and OIF veterans at risk for homelessness. Those numbers are relatively low at present, but the risk of homelessness can continue for many years after separation, and the current numbers might well not be indicative of lifetime incidence. For example, 76% of homeless Vietnam combat veterans reported that they had not been homeless for at least the first 10 years after separation (Perl, 2010). The committee is not aware of any studies examining the population-based prevalence of homelessness among those deployed to OEF and OIF. There is one study of the prevalence of homelessness in a national sample of 1.1 million recipients of VA mental-health services: it found that of 124,471 OEF and OIF veterans, 4,478, or 3.8%, were homeless in 2009 (Edens et al., 2011). That figure is likely to be an underestimate because it only examined recipients of VA mental-health services. The only other estimate, made by the VA and the Department of Housing and Urban Development (HUD), pertains to all homeless veterans—irrespective of deployment. The most recent estimate by the VA and HUD is that 75,609 veterans were homeless in January 2009. Of those, 57% were in shelters or transitional housing, and 43% were either on the street or in a place not intended for human habitation, such as in an abandoned building (US Department of Housing and Urban Development and VA, 2011). From 2008 to 2009, 1 of every 168 veterans, or 136,334 veterans, spent at least one night in an emergency shelter or in transitional housing. Veterans are about three times more likely

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COMMUNITY IMPACTS OF DEPLOYMENT 339 than are nonveterans to be homeless. Veterans make up less than 8% of the general population, but they comprise about 12% of the overall homeless population and, more specifically, 16% of the homeless adult population (US Department of Housing and Urban Development and VA, 2011). Minorities are overrepresented among homeless veterans. African Americans constitute 34% of homeless veterans but are only 10.5% of the overall veteran population. Similarly, Latinos are 8.3% of homeless veterans but comprise only 3.6% of the overall veteran population. Native Americans make up 3.4% of the homeless veteran population but are only 0.7% of the overall veteran population. Homeless veterans are generally older, with only 7% of homeless veterans being younger than 30 years of age, compared with 26% of homeless nonveterans (US Department of Housing and Urban Development and VA, 2011). Males who are 45–54 years of age and women who are 18–29 years of age are at higher risk of homelessness compared with those of other ages (Fargo et al., 2012). Similar demographic data are contained in a report from the Congressional Research Service (Perl, 2010). Homeless veteran men are generally older and better educated as compared with nonveteran homeless men. Homeless veteran women are also more educated than their nonveteran homeless counterparts, and homeless veteran men have more physical-health problems than those of nonveteran homeless men. Examined separately, female veterans, of all ages, are two to four times more likely to be homeless than their nonveteran counterparts (Perl, 2010). Risk Factors for Homelessness in Veterans Veterans and nonveterans share many of the same risk factors associated with homelessness (Balshem et al., 2011). These include childhood risk factors (absent or negligent parenting), living in foster care, and prolonged episodes away from home (as a runaway). The homeless, regardless of veteran status, tend to have similar rates of substance abuse, but it is unclear whether homeless veterans compared with the nonveteran homeless have comparable rates of mental illness and different overall health status. Certain veteran-specific exposures, including combat injury, intense combat exposure, and military sexual trauma, are associated with future mental illness and unstable income and employment, all of which are risk factors for homelessness in veteran and nonveteran populations. Prolonged or intense combat exposure can negatively affect long-term employment, mental health, and other social outcomes, all of which can increase the risk of homelessness (Jacobson et al., 2008). Substance-use problems and weak social networks often emerge during active-duty service or during readjustment to civilian life. Alcohol abuse, a known risk factor for homelessness, is generally higher among male and female veterans as compared with the general population. Additionally, National Guard and reserve soldiers are at increased risk of new problem drinking in the postdeployment period after combat exposure. Among persons who are homeless, alcohol abuse is more prevalent among veterans than among nonveterans, but veterans and nonveterans had similar rates of other substance abuse. Homeless individuals are more likely to engage in survival criminal behaviors, such as theft and prostitution, which can lead to incarceration (Balshem et al., 2011). Likewise, legal restrictions and other readjustment difficulties following incarceration increase the risk for homelessness. Adjusted for age, about 1,253 of every 100,000 veterans, or 1.3%, are

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340 RETURNING HOME FROM IRAQ AND AFGHANISTAN incarcerated, which is about 10% lower than the rate in the nonveteran population. Among incarcerated veterans in state prisons, 57% committed violent crimes, compared with 47% of incarcerated nonveterans who committed violent crimes. Legal and regulatory restrictions previously limited homeless veterans with criminal records and untreated drug abuse from accessing some public services. Recent policy changes by the VA and HUD under the Obama administration have relaxed these restrictions and established subsidized housing vouchers in an effort intended to end veteran homelessness by 2015 (VA National Center on Homelessness Among Veterans; Vogel, 2011). War-zone stress among Vietnam-era veterans led to difficulties in readjusting to civilian life, to social isolation, and homelessness among white male veterans, according to the landmark National Vietnam Veterans Readjustment Study (NVVRS) (Kulka et al., 1990). In a followup study involving 1,460 male veterans from the NVVRS, Rosenheck and Fontana (1994) found that postmilitary social isolation, psychiatric disorder, and substance abuse were the strongest risk factors for homelessness. Several premilitary factors also increased risk, including childhood physical or sexual abuse, other childhood traumas, and placement in foster care during childhood. The committee identified two studies on homelessness among OEF and OIF veterans. Tsai et al. (2012) characterized the homeless OEF and OIF veteran population, comparing it with the homeless veteran population overall. Investigators identified 994 OEF and OIF veterans among the 44,577 homeless veterans referred to the Housing and Urban Development–Veterans Affairs Supportive Housing (HUD–VASH) program between 2008 and 2011. OEF and OIF veterans were underrepresented in the homeless population in comparison with the overall veteran population (3% vs 12%). Naturally, however, OEF and OIF veterans are younger than veterans having served prior to OEF and OIF, and more time might be needed before the full extent of homelessness among OEF and OIF veterans is realized. The authors also found that OEF and OIF homeless veterans were much more likely to have received a diagnosis of PTSD compared with homeless veterans from prior conflicts (67% vs 8–13%). Among OEF and OIF veterans, 38% had a substance-use disorder. The authors point out that most homelessness services focus on substance-abuse problems, which is appropriate given the number of homeless with substance-abuse issues. However, they point out that among OEF and OIF homeless veterans, it might be more appropriate to focus on treating PTSD, given the very large number of homeless OEF and OIF veterans with the condition. Edens et al. (2011) studied a national sample of veterans (1.1 million) who used mental- health services at the VA in FY 2009. The authors performed a nested case control study of OEF and OIF veterans, who constituted 11% of the national sample. Consistent with the findings involving Vietnam veterans, almost all psychiatric and substance-use disorders increased the risk of homelessness (Table 7.2). The major exception was PTSD, which neither increased the risk of, nor protected against, homelessness. The authors point out that this finding might be explained by increased outreach by the VA to aid OIF and OEF veterans to access services. The following factors protected against homelessness in this sample: receiving a service-connected disability rating, having income greater than $25,000, and living in a rural location. For reasons unclear, having an anxiety disorder was also mildly protective (OR = 0.9, p < 0.001).

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COMMUNITY IMPACTS OF DEPLOYMENT 341 TABLE 7.2 Multivariate Comparison of Recently Homeless vs Nonhomeless Department of Veterans Affairs Mental-Health Service Users, FY 2009 Diagnosis Odds Ratio for Homelessness Schizophrenia 3.3c Bipolar disorder 1.7c Major depression 1.4c Anxiety disorder 0.9b Posttraumatic stress 1.0 disorder Alcohol-use disorder 1.8c Drug-use disorder 4.4c Pathological gambling 2.4a Personality disorder 2.2c a p < 0.01. b p < 0.001. c p < 0.0001. SOURCE: Edens et al., 2011 (with permission). Female veterans, as noted above, are at two- to fourfold increased risk for homelessness (Perl, 2010). Washington et al. (2010) looked at risk factors among female homeless veterans in Los Angeles, California. They matched 33 homeless women veterans with 165 housed women veterans on age, geographic region, and period of service. Significant risk factors for homelessness included unemployment (adjusted odds ratio [AOR] = 13.1; 95% CI = 2.7, 63.0); being disabled (AOR = 12.5; 95% CI = 3.5, 45.0); having a positive PTSD screen (AOR = 4.9; 95% CI = 1.9, 12.7); having been sexually assaulted during military service (AOR = 4.4; 95% CI = 1.4, 14.0); having a positive anxiety disorder screen (AOR = 4.1; 95% CI = 1.3, 13.2); and having overall fair or poor health (AOR = 3.2; 95% CI 1.3, 7.9). Having at least a college degree and being married were protective, lowering the odds of homelessness 5 and 10 times, respectively. Community Services Needed by Homeless Veterans The Congressional Research Service identified three needs that will have to be met to minimize homelessness among OEF and OIF veterans (Perl, 2010): 1. Permanent and supportive housing for homeless and low-income veterans, 2. Adequate transition assistance for recently returned veterans to help identify and mitigate issues that put them at increased risk of homelessness, and 3. Specific services for women veterans, such as treatment for physical and sexual trauma and child care for dependent children (North and Smith, 1993; Wenzel et al., 2000). A more comprehensive range of services was identified by nearly 20,000 consumers and providers of homeless services who were surveyed by the VA (Kuhn and Nakashima, 2010). The consumer sample consisted of three groups of homeless veterans: those who are homeless, those in transitional housing, and those in permanent housing. The top 10 list of needs varies among the three types of homeless veterans and the providers, but there are many overlapping service needs, such as long-term permanent housing, welfare payments, child care, dental care, job training, and legal assistance (Table 7.3).

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376 RETURNING HOME FROM IRAQ AND AFGHANISTAN We consciously 3.5 years ago, as a staff, saw the deployments and what they were doing to the families. So, on a staff planning meeting for the next year we said, We’re going to do everything we can to reach out to our military community and meet them where their need is. A Jacksonville, North Carolina, minister noted that the church can offer immediate supports “without the red tape,” that is, without the bureaucratic overlay that might occur within the military. He also pointed out that for families or service members who are worried about how seeking help might affect the service member’s career, church-based assistance is confidential and lies completely outside of the chain of command. Specific faith-based support services that were reported to study teams include pastoral counseling for individuals and couples, men’s PTSD support groups, spouses’ support groups, military luncheons, support for single service members, care packages for deployed units, and financial respite and household support. Equally important, interviewees said that families and service members benefit from the comfort of both faith and prayer. Family, Friends, and Neighbors At all six study sites, interviewees described an array of supports offered by family, friends, and neighbors. At both National Guard sites, which are small, rural communities, interviewees frequently commented that extended families live in the area and help pick up the children from school, provide child care while the nondeployed spouse is at work, and offer emotional support to the service member, spouse, or children as needed. In Georgetown, South Carolina, in a telephone conversation with a study team member, a National Guard member about to leave on his third deployment was asked where his wife finds support during his extended absences. He described a social geography of support, including his wife’s sister and brother who live on either side of his and his wife’s home, and his relatives who live very close by. “She has plenty of support when I’m gone.” Similar support networks were described in Jacksonville, North Carolina, where the national recession left some family members unemployed and reportedly prompted them to move into the community to help the nondeployed spouse. Families were foremost in people’s minds at the other sites as well, such as in El Paso, where business leaders said that they intentionally sought to create a service-rich environment so that nondeployed spouses might stay in the city rather than “return home to their families.” Friendships were also described by service-member interviewees as providing valuable support. In the four active-duty sites, however, because so many service members and their families live outside of the military installation, interviewees often reported having only one or two close friends in their neighborhoods or apartment buildings. Although these friendships are strong, they also leave individuals vulnerable to the vagaries of military life. In El Paso, for example, a young woman described the kinds of supports that she and her best friend, a neighbor, provided to each other while their husbands were deployed. Recently, however, her friend’s husband had been severely wounded in an IED attack and the woman was spending all of her free time at Beaumont Medical Center. The interviewee said that she was continuing to support her friend, but she also realized that the mutual nature of their relationship had changed. And with no other military-affiliated individuals in her apartment complex, this young woman’s “network” had diminished considerably. Finally, interviewees routinely described different ways in which neighbors and community members take care of each other, including “Welcome Home” parades, community

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COMMUNITY IMPACTS OF DEPLOYMENT 377 fundraisers, neighbors’ shoveling snow or cleaning someone’s gutters, a random patron picking up the restaurant tab for a service member, and a Little League coach who provides rides to and from practices and games. Unfortunately, not all military-affiliated individuals described feeling so supported by their communities. For example, two spouses of service members interviewed in El Paso perceived the community to be “disingenuous” about their support for the military and mentioned various frustrations with the schools, landlords, and business community. For the most part, however, interviewees recognized community members’ good intentions and appreciated the efforts people were making on behalf of the military. Conclusions Related to the Ethnographic Assessment It is clear from a review of the case study reports from the six communities visited that multiple deployments have notable effects—both positive and negative—on the communities visited. Formal Partnerships Between the Community and the Installation In each of the four active-duty sites, community leaders have worked closely with the local installation command to establish formal, named partnerships that promote the timely flow of information between the two entities and facilitate joint planning efforts. The partnerships include the following:  The South Sound Military and Communities Partnership established between the city of Lakewood, Washington, and JBLM. The SSMCP was developed in response to BRAC and the resultant growth of the installation and aims to foster collaboration around community development projects.  The Armed Services Division within the Greater El Paso Chamber of Commerce that integrates directly with Fort Bliss. The Chamber of Commerce has made a concerted effort to reach out to Fort Bliss leaders, service members, and their families to try to discourage military families from leaving the area when the service member deploys. This communication channel also allows local businesses to prepare for upcoming deployments or demobilizations that might affect their business patterns.  In North Carolina, Project CARE, developed by the Onslow County Chamber of Commerce. Project CARE combines the efforts of various local government, military, and community organizations to provide support to families of deployed services members, assist businesses in dealing with the deployments, and increase community spirit toward the military.  In Watertown, New York, two “homegrown” nonprofit organizations formed by the community to identify and address military-civilian challenges. One of these organizations, the Fort Drum Regional Liaison Organization, which grew out of a committee formed in the 1980s, addresses community planning in general and any specific issues as they arise. The other organization, the Fort Drum Regional Health Planning Organization, focuses on meeting physical and behavioral-health needs. The boards of both organizations represent the local civilian and military communities. Those partnerships reinforce the symbiotic relationship between the military installation and the local community and help to ensure that the needs of all local citizens—whether military or civilian—are acknowledged and addressed. The open channels of communication also promote the timely discussion and resolution of any emerging problems.

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378 RETURNING HOME FROM IRAQ AND AFGHANISTAN Liaisons Between the Military and Civilian Schools In Lakewood, Washington, Watertown, New York, and El Paso, Texas, the local public schools have implemented programs to assist school-age children of military parents through School Liaison Officers. In all instances, the SLOs have been trained to address family issues related to multiple deployments confidentially and are available to provide information, support, and guidance to all students, parents, teachers, and school staff, regardless of military affiliation. The SLOs help school staff understand military culture, notify them about upcoming deployments or returns, and help defuse challenges that arise, such as when children transition to a new school or their parents are deployed. Interviewees commented that the liaisons have been instrumental in helping address the challenges of multiple deployments because faculty are apprised of events (such as deployments or combat casualties) that might adversely affect one or more of their students. Training of Law-Enforcement Officers in Posttraumatic Stress Disorder Symptoms and Crisis Management At each of the active-duty sites, representatives of the city police departments described fairly open lines of communication with their military counterparts. But only in El Paso and in Watertown, New York, did the study teams learn that law-enforcement officers are being trained in how to recognize the symptoms of PTSD and how to respond appropriately to a mental-health crisis. Communities with large populations of service members who have experienced multiple deployments might consider the value of training all law-enforcement personnel in crisis prevention and intervention techniques. Social Capital As noted elsewhere in this report, interviewees at all six study sites said that their communities were “military towns” and that they both recognized and valued the sacrifices made by service members and their families. With rare exceptions, military spouses who were interviewed by study team members acknowledged the importance to them of living in a community where they felt they were “understood.” In addition, the Westat study teams discovered a vast array of community-based supports and services in these locations, including faith-based efforts, outreach conducted by traditional veterans’ organizations, and virtual support groups that make use of Facebook and other social networking technologies. The reader will find accounts of numerous other such efforts in Appendix E containing the detailed case study reports. Continued Needs and Challenges Interviewees enumerated a fairly consistent set of challenges that their communities continue to face with respect to the effects of multiple deployments. Many of these challenges are tied to formal service-delivery systems that lack adequate capacity to meet the demand. Community-Based Behavioral-Health Services None of the six study communities reportedly has sufficient behavioral-health service capacity to meet the needs of its civilian clientele, much less the needs of service members and their families. Fiscal challenges at the state level have only added to financial strains on these

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COMMUNITY IMPACTS OF DEPLOYMENT 379 agencies. Yet community provider agencies believe that it is important to maintain a robust community system because they are aware of the issues related to stigma in the military. In the absence of community services, those individuals in need of treatment might forgo counseling altogether. Targeted grants, such as the TRIAD grants in Texas, have provided an important funding bridge for the military population, but interviewees expressed concern that these funding streams will dry up as the US military continues its drawdown in the Middle East. Interviewees pointed out that some service members might need support for years, whereas others might not show symptoms for years after returning from deployment. Community-based services need to be augmented, interviewees said, in order to properly address the continued and potentially growing demand. Supports and Services for Military Youth With the exception of Georgetown, South Carolina, where youth distress was not reported, interviewees at all sites said that they are worried about the well-being of youth from families in which one or both parents have been deployed multiple times. Interviewees described the availability of numerous resources for military youth, but still expressed the belief that not enough is being done to support that vulnerable population. Commonly mentioned was the need to increase the availability of counseling services that are age-appropriate in order to address issues that arise from deployments and that might have a developmental component. Attention to the Needs of Underserved Populations Interviewees described several populations of service members who, they believe, have unique needs, but who are receiving scant attention from both military and community service agencies. Community members often pointed to single service members, whose social networks were deemed to be leaner and thus less supportive than those of their married counterparts. Some worried that single service members might not receive needed services while deployed, but most expressed concern about the level of social safety nets for these single individuals when they return home from deployment. In the absence of strong supports and social activities, interviewees were worried about a rise in behavioral-health symptoms in the young single population. Community members also mentioned concern for single parents who deploy and for families in which both parents are deployed simultaneously; in those two cases, however, the concerns expressed were primarily for the well-being of the children. Finally, a very few interviewees argued for special attention for the needs of women service members returning home from combat. In particular, they believe that those women might have symptoms of PTSD associated with combat as well as potential sexual trauma from fellow service members. A peer- support network for female service members was being initiated by a community provider in El Paso that might serve as a model for other communities. Communication Despite numerous efforts to establish lines of communication between military installations or National Guard leaders and the local community, interviewees continued to note the need for more formal channels of information exchange. Although much information— including deployment dates, details about resources, and recommendations for useful service and supports—was being communicated by word of mouth, interviewees indicated that informal channels are not always timely or accurate. Areas of particular concern include better communication with school administrators and faculty about deployments and which of their

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380 RETURNING HOME FROM IRAQ AND AFGHANISTAN students might be affected, need for the development of a central point of information at which individuals could learn about both formal and informal community-based supports, and better dissemination of information about PTSD to nonmilitary community members. CONCLUSIONS Local communities are affected by OEF and OIF deployments as troops depart from military installations, return to base, and return home after separation. However, the peer- reviewed literature that has systematically assessed the consequences of deployments and reintegration on communities is sparse. The data that were available to the committee did not have sufficient specificity to allow for a rigorous quantitative analysis of the impact of deployments on local communities that have military installations nearby. Although the committee found no sectorwide economic assessments of communities during the OEF and OIF conflicts, the one study available (Kriesel and Gilbreath, 1994) suggests that there are significant economic losses to communities that deploy a relatively high concentration of service members. Another study from the Congressional Budget Office (CBO, 2005) noted that reservists and National Guard members are often activated for deployment with little forewarning—a practice that can be disruptive and costly to employers. The most adverse effects of deployment are borne by small businesses that lose essential employees, businesses that rely on employees with highly specialized skills, and self-employed businesses owned by reservists. Another study reviewed found that for every 10% increase in activations of 30 days or more, small firms face a 3.7% decrease in sales (Hope et al., 2009). Additionally, among those in the labor force, veterans serving after 2001 have higher rates of unemployment than those of their civilian counterparts (see Chapter 8). The findings from the ethnographic analyses that the committee undertook did not necessarily agree with economic findings from national studies; however, in the communities visited, a clear need for communication between local installations and community leaders was highlighted. Additionally, the perceived shortfall of behavioral-health resources available to returning veterans has also been emphasized. With regard to the community impact of veterans returning home after separation from the service, there is good evidence from past conflicts indicating that communities which receive a substantial number of returning veterans contend with homelessness and behavioral disorders. However, interviewees in the five communities with nearby installations noted that the military is an important economic contributor to their regions. In many respects, the local economies have been shielded from the recession as a result of activity associated with war being waged on two fronts and two installations benefiting from the BRAC process. Finally, a persistent theme in the ethnographic assessment was that clear communication between installations and surrounding communities is important for reducing potential adverse effect of deployments on local communities. Open formal channels of information exchange between base commanders and National Guard leaders with local community leaders, including business leaders, school administrators, law enforcement, and local social service agencies, regarding expected deployments and returns from theater appear to be useful in mitigating some adverse effects on communities.

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COMMUNITY IMPACTS OF DEPLOYMENT 381 FUTURE RESEARCH DIRECTIONS As the committee reviewed the sparse literature on community effects of OEF and OIF deployments and examined the range of federally funded research on outcomes for those deployed in OEF and OIF (Appendix D), it identified several areas for future research and direction:  Studies are needed to quantify the effects of deployment and the return of active duty service members and recently separated veterans on military families and civilians living in the affected communities. Such studies should be a priority for a future comprehensive research agenda that aims to understand readjustment after OEF and OIF deployments.  Studies designed to comprehensively address the questions around readjustment after OEF and OIF deployment should include geographic identifiers that indicate where each service member was residing when deployed, the location to which the service member/veteran returned, and where the veteran went after separation. In addition, such studies should include a systematic set of currently collected indicators of community well-being, including measures of economic performance, availability of social and support services, law- enforcement activity, and school and educational functioning. Those data are available, but data linkages are needed to allow for specific analyses that can more clearly illuminate opportunities to mitigate potential adverse community consequences after service members deploy, return, and separate.  Longitudinal studies of veterans returning from overseas deployment are needed to assess the risk factors for homelessness. Future studies of homelessness should focus on the entire population of veterans and not only on those who enroll in VA health care. RECOMMENDATION There has been too little research on community effects of deployments to OEF and OIF. To supplement the published research, the committee completed ethnographic assessments in six communities that are near large military installations or that have recently deployed National Guard populations. Those efforts provided some insight, but the lack of community-wide assessments of the effects of OEF and OIF deployments on communities made it difficult to respond to this aspect of the committee’s charge. The committee recommends that the Department of Defense, the Department of Veterans Affairs, and other relevant federal agencies fund research on the effects of Operation Enduring Freedom and Operation Iraqi Freedom deployments on communities. Such research should include current indicators of community well- being, such as measures of economic performance, availability of social and support services, law-enforcement activity, and school and educational functioning. Relevant data are available, but data linkages are needed to allow specific analyses that can more clearly illuminate opportunities to mitigate potential adverse community consequences after service members deploy, return, and separate.

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