In the six years after Reuben Paul Santos returned to Daly City from a combat tour in Iraq, he battled depression with poetry, violent video games and, finally, psychiatric treatment. His struggle ended last October, when he hung himself from a stairwell. He was 27.
The high suicide rate among veterans has already emerged as a major issue for the military and the families and loved ones of military personnel. But Santos' death is part of a larger trend that has remained hidden: a surge in the number of Afghanistan and Iraq veterans who have died not just as a result of suicide, but also because of vehicle accidents, motorcycle crashes, drug overdoses or other causes after being discharged from the military.
An analysis of official death certificates on file at the State Department of Public Health reveals that more than 1,000 California veterans under 35 died between 2005 and 2008. That figure is three times higher than the number of California service members who were killed in the Iraq and Afghanistan conflicts over the same period. The Pentagon and Department of Veterans Affairs said they do not count the number of veterans who have died after leaving the military.
The figures, according to the federal Department of Veterans Affairs, legislators and experts in post-traumatic stress, underscore how veterans in Bay Area communities and across the state engage in destructive, risky and sometimes lethal behaviors.
The data show that veterans of Iraq and Afghanistan were two and a half times as likely to commit suicide as Californians of the same age with no military service. They were twice as likely to die in a vehicle accident and five and a half times as likely to die in a motorcycle accident.
"These numbers are truly alarming and should wake up the whole country," said United States Representative Bob Filner, Democrat of San Diego, who is the chairman of the House Veterans' Affairs Committee. "They show a failure of our policy."
The coroners' reports do not indicate whether each veteran was deployed to a war zone. But the ages at which they died — 18 to 34 — match the ages of at least two-thirds of veterans who served in Iraq and Afghanistan. Even the veterans in this cohort who did not see combat served in support functions, often at locations like Walter Reed Army Medical Center in Washington or Landstuhl Regional Medical Center in Germany, caring for those who were wounded on the front-lines.
The analysis was conducted by New America Media, a non-partisan news organization, in partnership with The Bay Citizen. It examined the most recent death certificates filed by coroners, medical examiners, physicians and funeral homes from California's 58 counties.
According to the data, veteran fatalities exceeded the number of combat deaths involving service members from almost every county from 2005 through 2008. In the Bay Area, 114 young veterans died after returning home, nearly three times the number of Bay Area service members who died in the Iraq and Afghanistan conflicts over the same period.
Suicides represented approximately one in five deaths of young veterans, the data showed. Many other deaths resulted from risky behaviors that psychologists say are common symptoms of post-traumatic stress.
Jonathan Shay, a clinical psychiatrist who counseled Vietnam veterans for more than 20 years and has taught at the U.S. Army War College, said the high number of deaths shows how the combat experience can create psychological damage that manifests itself in a range of dangerous and nihilistic activities.
Veterans with post-traumatic stress often try to re-create the rush of combat, Dr. Shay said. "There is definitely an inclination of danger seeking," he said, "seeking out fights, living on the edge, fast motorcycle riding, anything to get that adrenaline rush."
The Department of Veterans Affairs only began to track suicides committed by Iraq and Afghanistan veterans in 2008.
Kerri Childress, a V.A. spokeswoman, said the analysis conducted by New America Media and The Bay Citizen was more accurate than figures available from the federal government. She described the figures as "extremely high and extremely devastating."
Paul Sullivan, a Gulf War veteran and executive director of Veterans for Common Sense, said that the V.A. and Department of Defense are not serious about slowing the death rate of returning soldiers.
These government agencies could monitor this information on a regular basis, Sullivan said, adding that many other states in addition to California report a veteran's status on death certificates.
"V.A. and D.O.D. appear to have a policy for veterans called 'Don't look, don't find," Sullivan said.
Childress said the V.A. had begun efforts to monitor stateside casualties. The agency has started numerous outreach campaigns focusing on veterans of Iraq and Afghanistan, she said. But less than half of returning veterans turn up at a V.A. facility for treatment.
On Sept. 24, Berkeley police found Alex Lowenstein, an Iraq veteran who was months from earning his degree in Peace and Conflict studies at the University of California at Berkeley, dead in his room at the Delta Upsilon fraternity house. Lowenstein, a Mill Valley native who was 24, died of a bullet wound to the head from his own gun.
The police initially concluded that his death was a suicide, but now say it may have been accidental. According to the police report, Lowenstein had been drinking and smoking marijuana on the night he died. No suicide note was found.
He was the second Iraq war veteran to die while attending Berkeley over the past two years. In 2008, Elijah Warren, a 26-year-old political science student who served multiple tours in Iraq and Afghanistan, shot himself in the head.
"These deaths are a difficult thing for everybody because of the preventative nature of it," said Trevor Harris, the secretary of the veterans club at the university.
Harris, a former marine who served two tours in Iraq, said he personally knew three veterans who had died from suicide or motor vehicle accidents.
"We all understand that in war people get shot, but this doesn't have to happen," he said.
Neither Lowenstein nor Warren had visited V.A. health centers before their deaths, Childress said.
Stephen Xenakis, a retired brigadier general who formerly served as Commanding General of Southeast Army Regional Medical Command, said he expected the stateside death toll to increase because the psychological wounds associated with combat may not emerge right away.
"What you're seeing is young men and women who saw combat in their early 20s as well as everything else that went on in the theater and then in their late 20s they get symptomatic," he said.
When Santos, the Daly City veteran, first returned from Iraq in October 2003, his family thought he was fine.
"He still had his sense of humor," his mother Paula, a secretary at a local elementary school, said in an interview.
Santos, who was known as Chip, was the son of Native American parents. He left Westmoor High School early with a G.E.D. to join the Army. It was before the Sept. 11 attacks, and Santos never thought he would go to war, according to his parents.
After he returned from Iraq, he slowly began to lose his spark and wit, his friends and family said. He rarely worked, and he could not keep a job. He would take a class at City College of San Francisco, then drop out. Mostly, he stayed home and played violent video games for most of the day and into the night.
His fixation on the video games infuriated his parents, but in a poem published after his death by the Institute of American Indian Arts in Santa Fe, Santos described the games as a way of "holding onto denial that is burning cancer into hope."
Santos met his girlfriend, Waci Lone Hill, at the institute. The two were enrolled in the same creative-writing program. Lone Hill said she was attracted to Santos by his intelligence, his sense of humor and his old-fashioned style of courtship.
But, as early as 2005, Santos would "wake up in the middle of the night hollering" from nightmares, his girlfriend said. Sometimes, Santos would hold her so tight that she felt like she was being strangled. He started to drive erratically, sometimes at more than 120 miles an hour.
"If there was a lot of traffic, I could see the sweat break out on his forehead and hear the shallow breathing," Lone Hill said. "He'd get this completely stone face, and I'd get scared and just be quiet."
Not until five years after his return from Iraq did Santos see a social worker or a psychiatrist from the V.A. At first, his mother said, Santos did not want to admit that he had a problem. Then, after three years passed, he erroneously thought he was no longer eligible for V.A. health care.
When Santos finally applied, Lone Hill said it was difficult for him get regular appointments. He was only able to see a therapist once a month, she said. The therapists were often different, so Santos was forced to tell his story over and over.
Six months before his death, Santos enrolled in a study overseen by Charles Marmar, an expert in post-traumatic stress who recently left the V.A. to become chairman of the department of psychiatry at New York University.
As part of the study, Santos was able to get treatment every week from the same therapist, who administered cognitive behavioral therapy, in which the veteran relives the traumatic experiences in an effort to overcome them. Dr. Marmar described the therapy as "the gold standard" for treating post-traumatic stress.
Nine weeks into the treatment, Santos left the study, Marmar said. His therapist rated him as having "no clinical anxiety at that time." Marmar said the V.A. tried repeatedly to contact Santos after he withdrew from the study, but he did not respond.
Three months after leaving the program, Santos hung himself in his Santa Fe apartment.
In an e-mail to his brother and his girlfriend that he said took him almost a month to complete, Santos wrote: "I'm tired of fighting this. I feel like I've tried everything but electro shock therapy."
By the time his brother opened the e-mail, Santos was dead.