COVID-19’s Impact on Veterans
By Sue Coyle, MSW
Social Work Today
Vol. 20 No. 5 P. 22

Social Work Today takes a closer look at how the coronavirus has affected VA services.

The coronavirus pandemic has impacted everyone. Having surpassed 33 million cases worldwide, including more than 7 million in the United States, the numbers are staggering.

But it is not just the individuals who become ill who have felt and will feel the effects of COVID-19. The population as a whole has endured a stress on physical and mental health, and it will not be for some time that society truly understands the extent of that experience. However, it is important to begin looking now at the potential impact and the services that have been disrupted during the crisis.

By examining how small subpopulations, such as veterans, have fared, researchers and service providers can identify risks, needs, and successes. For veterans, that means understanding not only how they have responded to the coronavirus but also how the VA is tackling the crisis.

Physical Health
Veterans have not been spared from the coronavirus. As of July 6, the VA reported 24,718 confirmed COVID-19 cases and 1,690 deaths, a mortality rate of approximately 6%, which is slightly higher than the national mortality rate. These figures do not take into account veterans not receiving services through the VA or whose deaths are not being counted by the VA.

One of the reasons veterans may see more fatalities during the pandemic is their age. Nearly 50% of veterans are 65 or older, which puts them at greater risk of severe illness or death due to COVID-19. Additionally, many veterans are at a higher risk of respiratory illness due to the environments and toxins they were exposed to while on active duty, which places them in a higher risk group for coronavirus.

Outside of contracting COVID-19, veterans face concerns about maintaining their health in general, particularly with a lack of in-person services.

“Military life is hard. It’s hard on your body,” says Sara Kintzle, PhD, MSW, a research associate professor and deputy director of military and veterans programs at the University of Southern California’s Suzanne Dworak-Peck School of Social Work.

For example, many veterans struggle with chronic pain, relying on acupuncture, massage, yoga, and other services to cope. “Those are a whole group of services they probably haven’t had access to [throughout the pandemic],” Kintzle says.

Mental Health
As many have noted, the abrupt change to society and the disappearance of everyday normal has been not just challenging but also traumatizing and grief-inducing for most everyone.

Kintzle says community is often an important aspect of a veteran’s transition to civilian life. “When you leave the military, one of the things you’re leaving behind is a community and a job. Those are both losses,” she says. “How do you [then] figure out what comes next and how do you build what comes next?”

Kintzle says it’s important for veterans to reestablish themselves within a community. For those who have not had the opportunity to do so or who have and rely heavily on their community’s support, the move to social isolation will have been particularly challenging.

Elizabeth Marshall, MD, MBA, associate director of clinical analytics at Linguamatics, an IQVIA company, says, “Social isolation, although necessary to an extent during a pandemic, is a possible trigger for worsening mental health symptoms and habits. I, too, am a veteran, and I have a strong history in mental health research. I have seen how social determinants of health, such as issues with substance abuse, food insecurities, social support, living situations, employment, etc., make a huge difference to the welfare of an individual patient.”

Marshall notes that while veterans are not the only ones to struggle with mental health, they, as a population, experience it more prevalently.

“Veterans have always had unique mental health needs because of their military service,” notes Julie Irwin, LCSW, chief of social work at the VA New York Harbor System, adding that it’s difficult to know exactly how the pandemic will affect these needs. However, by examining the mental illnesses more prevalent in the veteran population and how social isolation may impact them, social workers can surmise some of the challenges veterans face.

“For example, PTSD and suicide aren’t unique to veterans but, statistically speaking, are much more common,” Marshall says. “If an individual who might have PTSD is forced to socially isolate, they are much more likely to self-isolate to the extreme and perhaps completely shut themselves off from others. They may be less likely to reach out for help when they are trying to cope, perhaps due to military-instilled pride. Instead, they may be more likely to turn to substance abuse, which generally worsens mental health problems.”

Laura Taylor, LSCSW, national director of social work at the VA, notes that there is also a greater likelihood that events such as intimate partner violence will occur during the statewide lockdowns. In fact, the Substance Abuse and Mental Health Services Administration (SAMHSA) warns, “The home may not be safe for many families who experience domestic violence, which may include both intimate partners and children. COVID-19 has caused major economic devastation, disconnected many from community resources and supports systems, and created widespread uncertainty and panic. Such conditions may stimulate violence in families where it didn’t exist before and worsen situations in homes where mistreatment and violence have been a problem.”

Although SAMHSA speaks of the general population, this is of particular importance to veteran families. The estimated rate of past-year perpetration of intimate partner violence is between 13.5% and 42% for male veterans.

Services
To address the challenges—in regards to both physical and mental health—that veterans face during the pandemic, the VA, like so many other providers, moved every service possible to an online setting.

“The VA had always been moving toward robust telehealth programs across the board,” Irwin says. “Once the pandemic hit the New York City area and the governor issued his pause on New York, everybody had to pivot quickly to full telehealth capabilities—the same level of social work service but in a more virtual capacity. We needed to rely on technology much more.”

As expected, this created an array of challenges, particularly in regard to access. While the use of technology may seem universal, many lack the equipment and/or the connection to internet service to maintain effective, ongoing treatment.

“The technology is great as long as it works, but not all patients have access to reliable internet or the right technology, especially anyone with financial issues or living in a rural location,” Marshall says. “Some individuals, such as the elderly, may feel uncomfortable with devices such as smartphones or iPads. Most people are staying at home due to the pandemic, which is creating internet connectivity problems in many areas.”

Marshall also notes that video and phone calls can lead to more late cancellations, with patients making last-minute decisions on whether or not to answer or log in.

While various locations addressed the issue of access differently, Irwin recounts a partnership with a community resource in New York. A number of veterans connected with the VA in New York are homeless and do not have regular access to computers, tablets, or smartphones. With the community partner, the VA was able to obtain and distribute smartphones to the veterans who needed them.

“It’s been really terrific that we have had these kinds of resources,” Irwin says. “They’ve gone into homeless shelters, into people’s homes.”

The teamwork needed during this crisis was not just relegated to community partners. On a more intimate level, the professionals within the VA needed to rely on each other to keep services running smoothly.

Louisa Daratsos, PhD, LCSW, psychosocial coordinator for oncology/palliative care at the VA New York Harbor Healthcare System, remembers being asked to step in on a particular case. “I was asked by my colleague to give a call to one of the wives who is widowed because of COVID-19,” she says. “She was having a hard time filling out forms. She understands that you can’t see people, [and] we came to an agreement that she’s going to try to fill them out. If she gets stuck, she’ll call me.”    

In-Person Services
Of course, not all services could be moved to telehealth. “All of a sudden, we kind of woke up collectively in the middle of what looked like this big tidal wave of illness,” Daratsos says. “[But] people didn’t stop needing real, practical things as well. People on dialysis still needed to be on dialysis. I cover oncology, and people were on radiation treatment. They needed to get through the radiation treatment. The day-to-day work didn’t stop.”

In those instances, every precaution available was taken and technology was still employed where possible. Taylor describes an ICU unit in Ohio where an early surge of COVID-19 patients occurred: “They actually were a pilot for tele-ICU. As opposed to discharge planners going bedside, social workers were able to meet with the patients through the technology. They (the patient) would have a monitor in their room that the social worker could use. To my knowledge, we were not using [monitors] in the space of discharge planning previously.”

Where technology such as this was not available, social workers were expected to meet face to face, just like all essential health employees were required. “Certainly, if it’s necessary, social workers will go in the rooms provided they are wearing the full PPE [personal protective equipment] required for the situation,” Irwin says.

Lessons Learned
While veterans and the VA are still in the midst of the pandemic, some takeaways can be garnered from what has already occurred and been observed. For one, technology is likely to be more widely employed when providing health services—and not just during the pandemic.

 “The real interesting aspect of the way we have had to change what we do is to see how effective the use of technology can be in getting our jobs done,” Irwin says. “It’s not the same as sitting down face to face in the way it might have been even six months ago. But social workers really know how to be flexible and really know how to call on those engagement skills that we have to make the technology work.”

Taylor agrees. “I truly believe that this is going to transform the way that we deliver care,” she says. “That is the silver lining in this pandemic. It’s going to be transformative with the possibilities that it opens up for access.”

In fact, according to a press release, the VA “has now seen more than a 1,000% increase—totaling more telehealth visits in March 2020 than in all of 2019.”

Outside of what has been learned about available services, the coronavirus has shown that veterans face certain risks. “We don’t always recognize veterans as a vulnerable group, but they are,” Kintzle says. “We forget about that.”

By recognizing instead of forgetting, social workers can be better prepared to assess and intervene in a crisis. But they aren’t the only ones who need to pay attention.

Marshall encourages veterans to be in tune with themselves. “It takes strength to know when you need help. Know your mental health triggers and do your best to provide healthy outlets for relieving stress,” she says. “Remember we all have limitations. Reach out to someone that can assist—the sooner the better. Don’t suffer alone in silence—even during a pandemic. It’s possible to be solitary without being lonely. There are good people out there that understand what you are going through. There are plenty of available resources. If you need help, reach out to your clinician or seek other helpful avenues [including social workers],”

“Why are we here?” Daratsos asks. “We are to help people; we are here to help each other.”

— Sue Coyle, MSW, is a freelance writer and social worker in the Philadelphia suburbs.