HJPCV Health Survey (2013)

Health Justice for Peace Corps Volunteers is a group of returned Peace Corps Volunteers (RPCVs) who are working to improve the quality of care that sick and injured Peace Corps volunteers and RPCVs receive. This survey is one step in that process. In it, we attempt to gather information about the difficulties that RPCVs face getting care. The preliminary results of this survey are presented here. The raw data from the survey are included at the end.

Summary

Overall, there are many problems brought up by this survey that are beyond the scope of what Health Justice can solve. The increasing reports over the decades by Returned Peace Corps volunteers (RPCVs) of poor health in country, political and financial considerations influencing the quality of their care, decreased expectation of recovery and increases in the amount of debt that RPCVs take on to pay for Peace Corps-related illness is disturbing. These trends have been discussed with the Peace Corps and will be discussed more at length in the near future. Ultimately, solving these problems rests in their hands, and while we can encourage them, we are not medical professionals, so we cannot help.

However, that does not mean that there are no issues about which Health Justice can speak out. The most surprising issue found while reviewing results from this survey is the rate at which RPCVs filed, or rather did not file, for Federal Employees Compensation Act (FECA) coverage. If a RPCV filed a claim, they had a very good chance of having it approved. However, about 63% did not file claims. An even larger percentage never even informed the Peace Corps that they were ill. While the process is difficult, it can be made more manageable with the assistance of the Peace Corps. With assistance, the number of RPCVs who didn't file dropped significantly.

In addition to these problems, there are problems with the Department of Labor, who oversees FECA. Calls are not returned in a timely manner, bills are not paid, and payments can be quite sporadic. For a population that is quite vulnerable, this can make recovery more difficult.

This is not to say that nothing has improved since the founding of the Peace Corps or that all results are bad. The majority of volunteers finish their service. The Peace Corps has gotten better about informing volunteers about FECA and helping them file claims. The majority of RPCVs are able to get health insurance. The Peace Corps has shown that with effort it can improve the health of PCVs and the access of RPCVs to FECA coverage. We hope that by working with them the Peace Corps will continue to improve. Our recommendations can be seen below.

Methodology

Of the more than 210,000 people who have served in the Peace Corps, over 7400 of them responded to this survey. The survey was written by members of Health Justice for Peace Corps Volunteers (Health Justice for PCVs) and conducted entirely on the internet via a web page form, from when it opened at the end of August 2012 until December 4, 2012. This form presented questions to respondents based on their previous answers, so not all respondents were presented with all questions. The questions that all respondents were presented with were questions 1 through 5, 12, and 18. Those questions that they were not presented with weren't applicable. For example, a respondent who reported no health problems either during service or after returning would not be asked if they filed a FECA claim. At the end of the form, the respondent was able to leave a comment. More than 2,600 comments were received. They are still being processed. The very last element of the form was a request by the National Peace Corps Association (NPCA) for the respondent's contact information. Respondents had the option of not leaving contact information, leaving contact information and not having it sent to the NPCA, or leaving contact information and having it sent to the NPCA. The contact information was stored in a separate table so that contact information could in no way be linked to responses from the survey. The request to fill out the survey was sent mainly by the NPCA through email, although Health Justice also sent out requests to fill out the survey to its membership. It went first to the NPCA's "advocacy" email list, then to the list of all RPCVs (not only members) for whom they had addresses, and finally to all members of Peace Corps Connect, a social networking site for RPCVs run by the NPCA.

There were problems during September which resulted in some comments not being accepted by the survey program. However, because the survey recorded answers after nearly every question, only the comments were lost from these surveys rather than all the data. Also, over the weekend following Thanksgiving, an error caused by the web server made the survey unavailable for two days. As it was a holiday weekend and a notice from the NPCA had already been sent out notifying RPCVs that the results would soon be tallied, most likely few people who wanted to fill out the survey were turned away.

A brief note on the subject of gender: for a very long time, gender had been a simple binary question. Someone was born one gender, and they stayed that gender. However, "they stayed that gender" is no longer true. This is why the question asks for gender at the time of service. There are some people who would prefer not to answer this question, thus the "unspecified" option. There are some people who would like to answer but don't feel that "male" or "female" are the correct options, thus the option where more information could be added in a text box. Some respondents were very angry about the way that gender was handled by this survey. One respondent asked if gender was really relevant. We could not know without asking, which is why we asked. In the raw data and graphs, the "unspecified" and "more information" options are added together to create "Other Gender". This choice of wording is not intended to indicate that there is a single gender called "other" that all these respondents fit into. It only indicates that an option other than "male" or "female" was chosen. In the text of this report, that option is represented by "other gender identification". We apologize to those who are offended. Offense was not intended. Also, when any category had very few respondents, often time those results are not mentioned in the analysis. This happens in the later questions when analyzing by gender the results of those of other gender identification. It is not that their thoughts and experiences do not matter. It is just that one cannot draw conclusions from a sample size that small.

Analysis of Results

The first question we have to ask is "how accurate is this information?". The distribution mainly by the NPCA implies that the RPCVs who were informed of the survey were in contact in some way with the NPCA, so volunteers who were very disenchanted with the Peace Corps might not have received the message. On the other hand, some responders commented that those who had some kind of illness because of their service would be more likely to respond. Or, one could guess that volunteers who felt a great deal of loyalty to the Peace Corps would be more likely to answer because they wanted to defend the Peace Corps' honor. Regardless of guesswork about the motivations of those who responded, the percentage of men and women who filled out the survey are very close to the percentages that the Peace Corps gives for the genders of currently serving volunteers. Also, the average age of the survey responder when serving (if one uses 25 years old as the average age of someone who served in their 20s and likewise for the other ages) is very close to the Peace Corps' reported average age. This seems to indicate that the results are fairly representative of the RPCV community.

Reports of illness in country - question 5 - increase by decade, are higher with women than men, and are highest among volunteers who serve multiple times followed by volunteers in their 20s and 30s. While it could be guessed that volunteers who served in the 1960s don't remember all the little illnesses that they had in country, the results go up fairly smoothly over time, so it seems more likely that memory lapse is not the reason for the increase in health issues. Also, the Peace Corps budget (when adjusted for inflation) on a per volunteer basis went down steadly since the Peace Corps founding in 1962. The only decade that saw an increase was the 1990s, and the reports in the survey of illnesses in country stayed the same in the 1990s as in the previous decade, rather than increasing. It should be noted that in the 1960s volunteers had doctors from the United States caring for them in country. In 1991, a General Accounting Office (GAO) study¹ was highly critical of the care that Peace Corps volunteers received. According to the study, the Peace Corps had already begun making reforms at that time, which might account for the rates of reported illness staying constant from the 1980s through the 1990s.

Volunteers in general were very good about seeking help for their medical problems, as shown in question 6, even making a slight improvement over help seeking rates from the 1960s and 1970s. While the majority of volunteers go to Peace Corps medical staff or a local practitioner for help (although less so to local practitioners in recent decades), volunteers are also seeking help from Peace Corps staff in non-medical positions. This appears to be especially true for those who have other gender identification.

Questions 8 and 9 deal with factors influencing the quality of care during Peace Corps service. Question 8 covers gender and other personal considerations influencing the quality of care. While this did increase over the decades, it still only reaches a height of 13% in 2010s. Males report the lowest incidence, while those with other gender identification report the highest. The results differ least by age, although those who served at multiple ages reported it more often. When the question is political and financial considerations and how they influence the quality of volunteer care, the increase in reports of these issues is much more pronounced, growing steadily since the 1960s. One can note that the incidence of these reports increases the least between the 1980s and 1990s, which may be related to the increase in the Peace Corps budget on a per volunteer basis (when adjusted for inflation) during the 1990s. As mentioned previously, efforts by the Peace Corps to improve care and the 1991 GAO study might also be factors in this small change between the 1980s and 1990s. After the 1990s, however, reports of political and financial considerations influencing care have increased significantly. As with question 8 about gender and personal considerations, question 9 also shows males reporting the fewest positive responses, while those with other gender identification report the highest. Differences in the number of positive responses increased only slightly over those in question 8.

Question 10 asks if the health problems reported in question 5 were entirely resolved by the Peace Corps in the country of service. In the 1960s, 69% left country healthy. By the 2010s, that number had steadily decreased over the decades until it reached only 37%. It was lowest for PCVs serving in multiple decades. Both gender and age responses were close to 50%, with men reporting 60% of the time that they recovered in country, women reporting 52% recovery in country, and those with other gender identification reporting only 38%. It is hard to know how representative the other gender identification responses are, though, as there were so few respondents in that category. As for age, the results were fairly closely grouped, with volunteers in their 20s (at the time of service) reporting the highest recovery rate at 53% and those who served in the 40s reporting the lowest at 42%.

Question 11 dealt with whether the respondent was able to complete their service. While the number of early terminations and medical separations has risen since the 1960s, most volunteers were still able to complete their service. Those with other gender identification reported a much lower rate of completing service than other genders, but again the sample size is very small for this group, so the results might not be accurate. Those who served in their 60s were less likely to complete their service, while those who served at multiple ages were more likely to be medically separated and very unlikely to terminate their service early.

Continuing to progress from the end of Peace Corps service, question 12 asks if the respondent developed any physical or mental health problems as a result of their service that did not come up in country. Most of the results are grouped together for this question, with two thirds saying that no problems developed with the rest of the respondents being split between answering "yes" and not being sure. The exceptions to this were those who served in multiple decades, those who served in the 2010s, those with other gender identification and those who served at multiple ages. They were significantly more likely to be unsure. Volunteers with health problems that are difficult to diagnose or who have only recently returned from their service may be unsure if their health problems are a result of their service.

Those who had a problem that came up after their service that was related to their Peace Corps service were asked how long after the end of their service they contacted the Peace Corps. Most RPCVs contacted the Peace Corps about the problem within the first 6 months after the end of their service or not at all. While the number of volunteers who did not contact the Peace Corps has come down from its high in the 1970s of 81%, the lowest it gets is 61% with those who served in multiple decades. The results by gender are pretty closely grouped, as are those by age. The one exception is that those who served in their 40s or 50s responded "did not contact" much more often than volunteers who served at other ages.

If an RPCV had a health problem that had not been resolved in country or that arose after they finished their service that was a result of their service and they informed the Peace Corps, then they were asked if their health issue was resolved by Peace Corps Headquarters. Some, presumably those whose health issues were not resolved in country, did not inform Peace Corps Washington of their ongoing problems. As seen previously, the percentage of those who did not report their problem to the Peace Corps has been declining. Of the rest, from the 1960s through the 1990s, they were divided almost evenly between those whose problem was resolved and those whose problem was not. However, the reporting of recovery decreased in the 2000s and decreased even more sharply the following decade. Those who served multiple decades saw rates of recovery similar to those who served in the 2010s. By age, respondents who served in their 20s were the least likely to contact the Peace Corps about their health problems, and volunteers who served in their 40s and 50s were the least likely to recover. Generally, the rest of the results by age, and all of those by gender were fairly closely grouped.

"The biggest issue I've had with the PC PCU is them losing paperwork that I've sent. It's happened at least 4 times. When things are urgent and I have to call and find out where I am at in my paperwork being accepted and I find out they have lost the paperwork and never called to tell me, its beyond aggravating." - Survey Comment

Question 15 asks if calls to the Peace Corps were returned in a timely manner. Timely responses times peaked in the 1980s and 1990s, falling in recent decades. Volunteers who served in multiple decades reported even worse response times, falling almost to 50% answering "yes" and 50% answering "no". RPCVs with other gender identification report 100% that calls were not returned in a timely manner. However, the number of these volunteers is so low that it is doubtful that this is a representative sample. Volunteers who served in their 20s, 30s and 40s reported slightly more often that calls were returned in a timely manner. When asked if returned calls were helpful and polite, generally respondents said they were, with volunteers with other gender identification and volunteers who served in their 40s and 50s reporting the most problems.

Respondents are asked in question 17 if the Peace Corps ever contacted them to find out if they had made progress in their recovery after they officially left the Peace Corps. While slightly more responded "yes" who served in the 1970s and 1980s and who served at multiple ages, the vast majority responded "no".

"While CorpsCare/AfterCorps was helpful at the most basic level (i.e. having it to rely on when if I was sick), I had awful experiences with the way Peace Corps handled the transition to/from the service providers and the quality of coverage offered to RPCVs at the price paid. The premium rate change and the elimination of premium options in 2011 occurred with nearly NO communication to volunteers. It was an appalling and inexcusable behavior towards those who've served this country and represented its face overseas. When I inquired about the 2011 service change in July 2011, I was initially ignored and then stonewalled by Peace Corps' health desk. I never felt that my concerns were ever addressed let alone followed up with. As a result, this has solidified much of my opinion for the organization at the senior level. I fear this survey will prove to be a waste of time. I've taken the time to voice my opinion again, with little faith that it will ever be addressed." - Survey Comment

Question 18 asks if the respondent was informed that private, post-Peace Corps health insurance (AfterCorps/CorpsCare) was available. While the majority of those who served before the 1990s either did not have this option or were not aware of it, in the 2000s and 2010s, reports of having been informed increased dramatically, with only a small percentage in 2010s reporting that they were not informed. In response to question 19 as to whether the respondent signed up for this insurance, understandably positive responses were very rare before the 1990s. The 2000s and 2010s show rates of about 60% signing up for this insurance. Women were more likely than men to sign up for it, and those of other gender identification even more likely than women. By age, those who served in their 40s and 50s were more likely to sign up for this insurance than other ages. When asked about the insurance's usefulness, clearly those who served before the 1990s generally didn't use it. Of those who did use the insurance, they were fairly evenly divided between those who found it helpful and those who did not. Respondents who served most recently found it slightly less useful than those from previous decades who used it, as did those of other gender identification. Volunteers who served in their 50s and 60s found it more useful than those of other ages.

For those volunteers who were ill after their service, either because they did not recover in country and did not recover with the help of Peace Corps headquarters or because they became ill after their service, question 21 asked if the Peace Corps informed them that they could file a Federal Employees' Compensation Act (FECA) US Department of Labor Workers' Compensation claim. Note that only those who were sure that their illness was related to their service and only those who had notified the Peace Corps of their illness were asked this question, which ended up being about 10% of respondents. Very few from the 1960s were informed of this option, and from there responses of those who were informed increase to more than 75% in the 2010s. Men were informed less often than women, while the small number with other gender identification who responded were all informed. Those who served in their 60s and those who served at multiple ages were informed more often than others.

This number of 10% for those who were ill as a result of their service and who had notified the Peace Corps corresponds well with numbers presented in the 1991 GAO study¹. The study showed that from 10 to 30 percent of former volunteers had medical problems related to their Peace Corps service, and of these, about half had not filed a FECA claim. In this Health Justice study and as noted earlier, 10% of respondents were still ill after their service and had informed Peace Corps of their illnesses. 31% was the percentage of total responders who were still ill after their service, including those who had not notified the Peace Corps. This report will discuss who filed and who didn't in a few paragraphs.

"I need help to navigate how to file a claim for a condition that happened after returning from service. I need to file the federal papers but it is unclear what paperwork to file or how to fill it out. I need help!" - Survey Comment

Question 22 asks if anyone from the Peace Corps helped the respondent file a claim. The number who responded positively, while low, is increasing. The number who did not file has been decreasing, as well. Men and those of other gender identification were less likely to file, while those who served in their 50s and 60s were more likely than average to file. Those who served in their 50s were the least likely to receive assistance filing, while those who were in their 60s were the most likely to receive assistance.

The following question, 23, asked if the respondent was informed that if they were too disabled to work that they could file for lost income. There was a steady increase over the decades of those who were informed, peaking in the 2010s at 19%. The results for men and women were very close, while when sorting by age, those who served in their 40s and at multiple ages were the least likely to be informed.

When asked if the Peace Corps helped them file for lost income, most responses were fairly closely grouped. The exceptions by decade are the those who served in the 2000s were less likely to file for lost income, while those who served in multiple decades more often got help. By gender, the results were fairly close. However, by age, those who served in their 50s were less likely to get help, but much more likely to file a claim.

Respondents were asked in question 25 if they had been informed by Peace Corps that they might be eligible for vocational rehabilitation through the Department of Labor. Almost universally, the answer was no. Only 2% of respondents reported being told.

Question 26 asks if the respondent's FECA claim was accepted. Only respondents who had reported that they had an illness because of their service were asked this question. Almost twice as many respondents reported that their claims were accepted versus those who reported that their claim was not. However, about two thirds of all respondents to this question reported not filing for FECA. Those who served in the 1960s and 1970s were the least likely to file, and filing rates have steadily improved since then. Also, volunteers who served in recent decades were more likely to have their claims accepted. Interestingly, volunteers who served during multiple decades and those who served in the 1970s were the only groups who had more claims rejected than accepted. By gender, the responses were pretty close, with men being only slightly less likely to file a claim. By age, those who served in their 40s were the least likely to file a claim, while those who served in their 60s were both the most likely to file and the most likely to have their claim accepted. Those who served at multiple ages were the most likely to have their claims rejected. This could be because they were more likely to file multiple claims, and therefore had a greater chance of being rejected.

When looking at statistics related to FECA claims, the percentage of total responders whose FECA claims were accepted was two percent, while three percent of all responders filed FECA claims. As previously noted, 31 percent of all respondents were ill as a result of their service. Of all who were eligible to file claims, those who early terminated (quit their service early) were the least likely to have a claim accepted at only 19 percent. Those who were medically separated were almost twice as likely to have a claim accepted. Respondents who received assistance from the Peace Corps when filing were dramatically more likely to have a claim accepted: 73% had their claims accepted. In general, these numbers are low because most volunteers don't file for FECA. When looking at the percentages of those who did not file out of those who were eligible to file for FECA, it was those who completed their service who were least likely to file at 68 percent. Repondents who were medically separated were the most likely to file: 51% did not file. However, the most interesting number here is the number of those who were helped by the Peace Corps who did not file - only 11 percent. Once RPCVs filed claims, their chances of having their FECA claims accepted was fairly high. Of those who early terminated and filed a claim, fifty percent had their claims accepted. This number rises to 75% for those who were medically separated. When a respondent received assistance from the Peace Corps, 82 percent of the time their claim was accepted versus 59 percent for those who did not receive assistance. When looking at who received assistance, those who were medically separated were more likely than other groups, with 19 percent as compared with eleven percent for those who early terminated and those who completed their service. For an injured or sick volunteer, assistance from the Peace Corps filing a FECA claim can clearly increase their chances of having their claim accepted. This survey did not ask why volunteers did not file claims. Honestly, this was in part because we did not know beforehand that so many ill RPCVs did not file for FECA. If the Peace Corps chooses to look into this matter further, they may wish to try to discover why RPCVs don't file. Another question that could have been asked is if respondents would have filed for FECA if they had more than three years to do so.

Questions 27 through 36 were asked only of those who responded that their FECA claim was accepted. This makes, unfortunately, for a much smaller sample size of only about 150 respondents. This means that some groups will not be well represented. However, Health Justice feels that many ill RPCVs suffer under a very difficult system with the Department of Labor (DoL), which is the agency that administrates FECA. We wanted to know if our impression was correct, and these questions explore that issue.

When asked, in question 27, approximately how much time elapsed between when the respondent officially left the Peace Corps and when their benefits from the DoL began, respondents were almost evenly split between less than 6 months and more than 6 months. Those who served in the 1970s, 1980s and in multiple decades reported much longer waits for benefits than those who served other decades. Also, reports of wait times over six months have decreased in recent decades. Men report slightly longer wait times, while those who served in their 40s and at multiple ages reported more often a delay of more than 6 months before benefits began.

Question 28 asks if respondents were under more financial stress during this time due to lack of benefits. The responses from the 1960s and 1970s are nearly opposite, which makes for some confusion. However, beginning in the 1980s, reports of increased financial stress increase steadily by decade. Men and women have very similar responses, with a little less than two thirds indicating increased financial stress while without FECA benefits. By age, those who served in their 40s, 50s, and 60s indicated more financial stress than those who served when they were younger or at multiple ages.

Next, respondents were asked if the DoL provided any assistance for them in finding a doctor or filling out forms (for example, with an occupational nurse). In general, few respondents received assistance from the Department of Labor. A small number from each group reported being helped, but because the numbers for most groups are small, it is hard to tell which numbers are representative. It may be that slightly more assistance has been given in recent years, but the results are not especially clear.

In question 30, the survey asks if respondents are currently receiving or received income for lost wages. In general, the answer is no, with 78% giving this response. The remaining responses are divided almost evenly between those who receive or received income for lost wages and those who did but not reliably, either because the wages ended before the respondent recovered or because the payments were inconsistent. While it is difficult to pick out any trends, one can safely say that unreliable lost wage payments trouble almost every demographic group.

"I found Peace Corps very helpful, and my FECA claim was quickly accepted, but my doctor had a terrible time actually trying to get paid, and I eventually had to shell out several thousand dollars myself. It was very embarrassing, as I had a longstanding relationship with my doctor and every charge was absolutely legitimate, but the DOL was incredibly unresponsive and kept making excuses not to pay. I thought if the claim was accepted that meant they would pay. I was wrong. If I had it to do over I would not have bothered filing a claim. If the problem had been worse and the amount of money I lost had been larger I would have considered suing. It was all extremely disappointing." - Survey Comment

When asked, "Does or did the USDOL pay for your medical and prescription bills?", because of the low number of respondents for some categories, the results are somewhat chaotic. However, when first looking at the overall results, 36% reported that the Department of Labor paid medical and prescription bills. The same number reported that the DoL was supposed to pay but did so inconsistently. If we set aside the categories with few respondents, we see that those who served in the 1990s more often responded that DoL paid their medical and prescription bills. Those who served in the 1980s, 2000s and 2010s all reported results that were fairly similar to those in the overall results. Those who served in the 2010s report more inconsistent payments than those who served in the 1980s through the 2000s. Men reported a lower rate of medical and prescription payments than women. The results by age are somewhat problematic, as most categories have few respondents.

Question 32 asks if respondents had difficulty getting bills covered by the Department of Labor. With the exception of those who served in the 1960s and multiple decades (totaling only 6 respondents), around 70% of respondents reported this difficulty. Only 59% of those who served in the 1990s had this difficulty. This corresponds to the responses for the 1990s in the previous question. By gender, men showed slightly more difficulty getting bills covered by the DoL than women. The results by age generally correspond to the overall percentage of 73% reporting difficulties. While the total number of respondents is small, those who served in their 60s and at multiple ages reported an equal number of repondents who had no difficulty as those who did have difficulty getting their bills covered by the DoL.

When asked if calls to the Department of Labor were returned in a timely manner, the results are fairly closely grouped around the overall average of 70% who did not have calls returned in a timely manner versus 30% who did. Interestingly, while most volunteers who served in the 1960s reported that they did not have trouble getting their bills covered by the Department of Labor in the previous question, 100% of respondents reported that their calls were not returned in a timely manner. Those who served in the 2000s, a much larger number of repondents than those who served in the 1960s, reported the second worst numbers, with only 26% saying that their calls were returned in a timely manner. Men reported having calls returned in a timely manner less frequently than women. This seems to correspond to their responses in previous questions of more difficulty getting bills paid and fewer saying that the Department of Labor was paying their medical and prescription bills. By age, the percentage of respondents who had calls returned in a timely manner is between 20 and 35% for most age groups. The exceptions were those who served in their 50s and at multiple ages, who reported that about 50% of the time their calls were returned in a timely manner.

Question 34 asks if the respondent is currently receiving any type of coverage or compensation under the Federal Employees' Compensation Act (FECA). 70% reported that they were not receiving any type of coverage or compensation, with 30% of those who had their claims accepted reporting that they were currently receiving coverage or compensation. This is 0.6% of all respondents. Only respondents who served in the 1970s had no member who is currently receiving compensation. All other respondents by decade had at least one, with those serving in the 2010s and multiple decades each having about 50% who were currently receiving compensation of some kind. Men and women both reported percentages very close to the overall percentage. By age, only those who served in their 50s and at multiple ages deviated noticably from the overall percentage, with those serving in their 50s reporting that 60% were receiving some form of compensation.

When asked about the Department of Labor's vocational rehabilitation program in question 35, the majority, 86% overall, had not received any training through the Department of Labor. Of all respondents, only 5 received this training. The majority served in the 1990s and were in their 20s. All were female. Of those who have not yet returned to work, they served almost entirely after the 1990s, more were female, and most were in their 20s, although the last two are more likely because the majority of volunteers are female and in their 20s.

Question 36 asks if the respondent's wages were supplemented by the Department of Labor while they worked part time. As with the previous question, few reported receiving wage supplementation. The same number reported that their wages were supplemented as reported that they received supplemental wages but were dropped before they recovered. The reports of receiving supplemental wages are fairly evenly divided across decade of service and by gender. All those who had their wages supplemented were in their 20s when they served. All who had their supplemental wages dropped before they recovered were female, and most served in their 20s with one who served in her 30s. This question is the last that is specific to those who had FECA claims approved.

Question 37 was asked of all respondents who were ill because of their service. This question asks "If you were sick or injured as a result of your service, have you been able to obtain health insurance?". The majority of respondents - 82% overall - were able to obtain health insurance. In much smaller numbers, volunteers were able to obtain insurance through family (7%) and the government (4%). Only 7% overall were unable to obtain health insurance. The results are grouped fairly closely by decade, until the 2000s, when the rate at which respondents were able to obtain insurance began to drop slightly. In the 2010s, respondents relied much more often (17%) on family and were much less able to obtain medical insurance, only 66%. Those who served multiple decades were far more likely to receive medical insurance through the goverment than other groups. Men and women had responses that were very close to the overall percentages. By age, those who served in their 20s were more likely than any other group to get medical insurance. Those who served in their 50s were the least likely, only 61%. Those who served at multiple ages and those who served in their 50s and 60s were very likely to get their insurance through the government. Going back to questions 19 and 20, those who served in their 50s were the most likely to sign up for health insurance through the Peace Corps, the most likely to use it and the most likely to find it useful. It would appear that for a time, at least, the health insurance offered through the Peace Corps helped some respondents who were in the group with the most difficulty getting insurance.

When asked in question 38 if their health issues lasted more than a year after they ended their service, 45% said no, and 55% said yes overall. There was a slightly better rate of recovery in the 1960s. Also, those who served in the 2010s also reported better rates, although because most have not been back for more than a year, it is hard to know how accurate this is. In general, though, by decade and gender, the results were fairly close to the overall results. By age, the percentage who reported that their health issues lasted more than a year increased with age, to 65% for those in their 50s and 60s.

Question 39 asks if the respondent expects to ever be as well as they were prior to serving in the Peace Corps. Overall, 63% said yes. By decade, those who served in the 1970s were most likely to expect to be as well as before they served at 72%, with the percentages decreasing steadily from there until the 2010s, when the percentage was 57%. Those who served over multiple decades were the only group whose responses were more negative than positive, with only 44% expecting to be as well as they were prior to serving. The percentages for men and women were exactly the same. Respondents who served in their 20s, 30s and 40s reported results very close to the overall percentages. Those who served in their 60s and at multiple ages were evenly split between those who expected to be as well as they were before their service and those who didn't. Those who served in their 50s were the least positive about their prospects, with only 47% expecting to be as well as before their service.

When asked in question 40 if the respondent had lost time from work due to health issues, 73% responded that they had not. The results by decade were closely group, with only those who served in the 1980s and during multiple decades more often reporting time lost from work, 36% and 35% respectively. By gender, the results were very close to the overall percentages. By age, most were again very close to the overall percentages. Those who served in their 60s were less likely to report time lost from work, perhaps because they entered the Peace Corps after retirement. Those who served in their 40s reported slightly more often than the other age groups that they had lost time from work due to health issues, 33%.

Question 41 asks, if the respondent lost time from work due to these health issues, how much time was lost? The results differ quite a bit by decade and age. Overall, respondents reported most often that they lost only days (38%). Whether 1-4 weeks or 1-12 months was more common differs by decade and doesn't seem to follow any specific pattern. In general, those who returned recently reported less time lost, as many have not been back 10 years yet. If looking only at the 1960s through the 1990s, the percentage of those who had lost more than 10 years from work was between 6 and 9%. This is especially interesting when looking at those who served in the 1960s, as they reported the highest percentage (9%). Generally, those who served in the 1960s report the best health and fewest problems. By gender, men reported answers that peaked with "1-7 days" (33%) and decreased steadily to their lowest at "more than 10 years" (8%). Women, as with the overall results, have high points at "1-7 days" and "1-12 months". Men report noticeably higher numbers of longer term time loss. By age, the most noticeable point is that 67% of those who served in their 60s lost 1-12 months from work. On the other hand, there are only 9 people in this group, so perhaps these data points are skewed. Also, those who served in their 40s and 50s reported longer term injuries much more often than those who served at younger ages, with 32% of those who served in their 50s being ill for more than 10 years.

Results when respondents were asked in question 42 if they had had out of pocket expenses for their medical issues were most often positive, with 59% reporting "yes". However, when broken down by decade, the results swing from 52% reporting "no" for those who served in the 1960s to only 28% reporting "no" for those who served in the 2010s. Those who served multiple decades reported only 26% "no". The percentages of "no" responses decrease steadily from the 1960s through the 2010s. By gender, the results are fairly closely grouped and very near to the overall results. By age, those who served in their 20s reported the least percentage of out of pocket medical expenses with 58%. Those who served in their 40s reported the highest percentage with 75%.

When asked how much they had spent on out of pocket medical expenses, the majority of respondents overall, by decade, and by gender all reported $101 to $1,000 (49% overall). Those who served in more recent decades generally had spent less than those who served earlier, probably because they have not been back that long. Those who served in the 1980s reported most often that they had spent $5,000 to $10,000 and more than $10,000 on out of pocket medical expenses for their Peace Corps related health issue. Results differed very little by gender. By age, the two most obvious outliers were those who served in their 50s, as their reported expenses were more often $1,001 to $5,000 (52%), and those who served at multiple ages, as they reported very strongly results of $101 to $1,000 (75%). With regards to those who served in their 50s, they were the least likely to have health insurance, so perhaps this is part of the reason.

When asked in question 44, "Have you gone into debt to pay for treatment for your Peace Corps-related health problems?", the majority of respondents (92%) reported that they had not. However, the number who had gone into debt grew from only 2% for those who served in the 1960s to 10% for those who served in the 2010s. The increase is very steady by decade, despite those who served in the 2000s and 2010s reporting less out of pocket medical costs than those who served in other decades. One reason for this could be because of the poor economy in recent years. By gender, the results were nearly identical and close to the overall results. By age, only those who served in their 50s showed any deviation from the overall results, with 14% reporting that they had gone into debt, as opposed to the overall number of 8%.

When asked in the last question, question 45, if the respondent needed immediate help, those who served in the 2010s and multiple decades were more likely to answer "yes", 18% and 12% respectively. By gender, men were more likely to need help. By age, those who served in their 50s, 60s and at multiple ages, were more likely to need help, while those who served in their 40s were the least likely.

The survey had an option to leave a comment at the end. The survey received a total of 2,875 comments. Some were angry about everything from the way the respondent was treated by the Peace Corps to the way the survey was constructed to the financial cost to the Peace Corps imposed by ill volunteers. Some were comments about changes that needed to be made to the survey. Some thanked Health Justice for their work. Some asked for help. By far, though, the majority were the stories of RPCVs about their health. Not all were negative, and many had suggestions on how to improve the system.

The survey had problems processing some of the punctuation marks in the comments, which led to some comments being lost. While the programmer tried to avoid this problem and beta testing indicated that the survey was working correctly, there were still problems. Health Justice apologizes for any inconvenience this caused. However, due to the way the survey was written, only the comment was lost. The rest of the data for the survey remained in the database.

There were common themes regarding volunteer health in many of the comments. Here is a brief summary:

• Many respondents felt that three post-service councelling sessions weren't enough. Many comments requested more mental health support after service. One comment reported a mental health related suicide after a volunteer returned to the US.

• AfterCorps received many negative comments, although there were those who found it helpful. Post-service care was reported to be confused, confusing, and full of conflicting (or no) information and very little support. There were occasional reports of good post-service care, but they were few.

• While in country care was generally described as good, there were a few areas where it seemed more likely to fail. Dental care in country appears to have more complaints than other aspects. Interestingly, many of those who reported good dental care served in Nepal. Reports of bad dental care seem to taper off somewhat in recent decades, although there are still negative reports through the 2000s. Additionally, there are reports of sexism and harassment from in country health care providers. There are often reports of problems that are gender, gynecological, STD or contraceptive-related. Lastly, there are reports of financial problems that led staff to only treat the most serious problems. Some comments talked about PCVs who were disuaded from seeking medical attention, threatened with having their service terminated if they sought care, or told that the Peace Corps could not affort to provide medical care for them.

• There were comments about the lasting or recurring side effects of malaria prophylaxis. There were fewer of these than reports of intestinal, parasitic, or dental problems, though. This seems logical, when one compares the percentage of volunteers who must take malaria prophylaxis, especially Lariam (generic: Mefloquine), which is most known for causing lasting side effects, to the total number of volunteers who serve, since they are all at risk for dental and intestinal problems.

• A number of respondents reported having developed skin cancer. They generally were more often from tropical regions and served in the earlier decades of the Peace Corps.

• Quite a few respondents felt that they had lingering health problems because of diseases or infections that they acquired during service. Many seemed shocked at the possible life-long complications. To quote one comment, "Peace Corps seems to do a good job now with serious ailments or life-threatening situations but it should better define its responsibility to volunteers who leave service with long-term conditions that impose health care burdens. This information should be available and explained during training and at separation."

The final page of the survey offered the respondent the option of leaving their contact information to be passed on to the NPCA, which is trying to gather contact information for all RPCVs. A box asked if the information could be passed on, so to avoid the confusion of implied consent. This information was stored in a table that contained no information that would link the survey responses to the contact information. While Health Justice has seen no interest by the Peace Corps in reprisals against RPCVs for negative comments, we felt that the responsibility of protecting the medical privacy of respondents was not a burden we wished to take on.

Health Justice would like to thank all those who participated in the survey. We understand that its imperfections caused frustration, and we greatly appreciate those who chose to help us anyway. It is our hope that the information we have gathered can be used to help not only those who are ill but can also be used to improve the Peace Corps itself.

Recommendations

Looking at the survey results, it is clear that help through FECA can be difficult to obtain, and that dealing with the Department of Labor can be frustrating at best. The best solution to this problem would be for the Peace Corps to reverse the trend shown in the study of increasingly poor volunteer health. While there is no sure solution to this problem without more research, which is beyond the scope of both this survey and Health Justice's capabilities, based on the survey responses, the survey comments, and our experience as Peace Corps volunteers, we have the following recommendations:

• Ultimately, it should not be the job of a small group of sick RPCVs to monitor how well the Peace Corps' health system works. The Peace Corps is a government agency and has access to not only volunteers, but also to their medical records (not to mention professional programmers and public health professionals). Our number one recommendation is that the Peace Corps should tap this bountiful source of statistical information to improve volunteer care, root out things that aren't working, and eventually predict problems and find solutions. The Peace Corps should also consider doing a more comprehensive review of how much is spent on volunteer health as compared to illness rates. It might be necessary for the Peace Corps to cut back on the number of volunteers serving if they cannot provide adequate health care for them.

• "I was exposed for several months to a chemical spray called Amatraz. It was used for bees. I became very sick and the PC nurse helped me by finding out the chemical was banned in the US and bad for humans to be exposed to. I was determined to be allergic to this chemical-it was making me sick every day-and so I was medically removed from my job and allowed to find another job. I have no idea what long term effects there might be from several months of almost daily exposure to this toxic chemical. Can you tell me!?" - Survey Comment

  Agricultural volunteers face a danger that other volunteers and the Peace Corps management might not have thought about - pesticides. A recent RPCV who served in Senegal writes the following:

  • "I witnessed massive misuse of dangerous pesticides, many of which are illegal in the United States, sometimes at the urging of Peace Corps staff. I personally witnessed these chemicals being haphazardly applied by untrained villagers, to my food sources, within my work environment and even in the childrens' hair to kill lice. I also encountered numerous instances of Peace Corps staff providing dangerously incorrect information on pesticide application procedures and even recommending the use of banned pesticides."

  He worked with the staff at Peace Corps Senegal to try to resolve this problem. However, this is a danger that volunteers face worldwide. We suggest the following: firstly, agriculture volunteers need standardized authoritative training on pesticides and chemical safety along with rules for interaction with these substances in order to better protect them from exposure in their work environments. Secondly, each post needs to take stock of the toxic substances present in their respective countries and put in place procedures to mitigate the risks of volunteer exposure.

  The Peace Corps should also think about the long term health repercussions of pesticide exposure by previous and current generations of Peace Corps volunteers. The Peace Corps should consider commissioning an independent scientific study to determine if service in fact increases an individual's toxic load and if so what the long-term effects of this will be. If they are unwilling or unable to do this, they should provide information on the Peace Corps website to help those exposed to pesticides determine their own level of risk and to make them aware of long term dangers. Future generations of volunteers deserve to have this information before they commit to serve.

• AfterCorps/CorpsCare, the insurance offered after Peace Corps service through the Peace Corps, needs to be reviewed. Many volunteers commented that, as health volunteers, they were encouraging people during their service to get care that they were not offered through this insurance. One respondent wrote, "The AfterCorps insurance is terrible. It's highly bureaucratic, doesn't cover even basics such as a yearly OB-GYN visit. I found the staff to be terribly unhelpful when I called with questions about my coverage, and I got different answers every time. While I appreciate that Peace Corps works to provide us with coverage when we return home - I truly do appreciate it - the coverage needs to be improved, as it was not worth much at all. I wish I had gone back on my parent's insurance instead." Another said, "I felt I had very good health care while in Peace Corps. I did experience problems with processing paperwork for aftercare upon return to the U.S. as I had amoebas at COS and required follow up testing in the U.S. The follow-up tests were supposed to be covered, but it kept getting rejected by the health insurer so I ended up paying for most of it out of pocket. Not a huge deal, but it was inconvenient and not inexpensive given I wasn't yet employed."

  There must be some basic requirements for this insurance, including being through an insurance company that is familiar to doctors and their billing staff and coverage for STD testing for all RPCVs and gynocological exams for women. If it is not financially feasible to offer high quality medical insurance, volunteers should be made aware ahead of time that this insurance covers very little. After two years of fairly comprehensive medical care, volunteers will not be expecting that the Peace Corps will encourage them to spend money on something that is so far from comprehensive. If AfterCorps was actually high quality insurance and was open to all RPCVs, it could be one way of helping those who are on FECA and not getting insurance through the DoL and those RPCVs who have otherwise been unable to find insurance at a reasonable price. This whole situation may change when "Obama-care" goes fully into effect.

• Volunteers - and their energy and enthusiasm - are a very valuable resource. While much of a PCV's time is going to be dedicated to their Peace Corps project, it isn't unreasonable to think that some of their time could be spent improving the Peace Corps. Volunteers are more often in contact with each other than with Peace Corps headquarters, and there are volunteers who are already being trained to work with health issues. If Health Sector volunteers were empowered to spot common local health issues in other volunteers and encourage them to get treatment, it could result in more health problems being treated in a timely manner. If interested volunteers were trained as alcohol and drug counselors, they could provide help for volunteers before a crisis forces them to talk to the PCMO. Lastly, some mental health training - or at least how to spot mental health issues as they arise - could be helpful, as then PCVs who are having difficulty could be referred to someone for help.

• There are a variety of reasons why a volunteer may not wish to talk to someone in country about a problem. It could be, as happened in Benin, that the problem is with a Peace Corps employee who is the relative of someone high ranking within the local Peace Corps office. Volunteers could have issues with a PCMO, or just wants to speak to someone outside their country of service. As many more volunteers have access to cell phones, there could be a number that volunteers can call or text to contact someone at the Peace Corps Headquarters in Washington, a PCV hotline. Likewise, there could be an email address also available to volunteers for this purpose. This could be especially useful for volunteers who are having mental health problems and not receiving enough help in country.

• In the comments, in country dental care was often listed as a problem. Since it is well known that preventative care makes a huge difference when it comes to teeth, it would make sense to improve this and cut down on expensive dental work at Peace Corps expense later. A program like Peace Corps Response could bring dentists into all Peace Corps countries without high quality dental care - no one wants to have their teeth drilled without anesthesia or by an incompetent dentist - to ensure that volunteers are getting appropriate care.

• Volunteers who served in the 1960s had extensive training before they left the US. This is no longer the case. While it might not be financially feasible to train volunteers in the US, some preparations could ease the stress of transition and better prepare volunteers for the challenges that they will face.

  • Often in the comments in the survey, RPCVs wrote that they hadn't taken into consideration that there could be lifelong health implications from serving in the Peace Corps. While this may seem naive, volunteers should be made aware before they begin their service that, despite the Peace Corps' best effort, some people have life-changing health problems because of their service. Often, people think of death as the only negative consequence and forget that there are lesser, but still very serious, negative consequences.

  • Some anti-malarial medications are supposed to be taken for at least a week before the volunteer leaves the US but are not prescribed this way by the Peace Corps. The benefit of this is that the volunteer will be able to assess side effects in a familiar place under familiar conditions, in addition to the protection from malaria.

  • Symptoms of common diseases and side effects from medication they are likely to be prescribed could be given to volunteers in advance of departing for their training. If volunteers are encouraged to discuss these with their family and close friends, then even if they don't remember the symptoms when they are in country, people who they may be talking to might. Also, this will allow volunteers to better assess the risks they will face when in country.

  • Leaving for a new country and a new way of life can be intensely stressful. Volunteers who lack the appropriate language and cultural skills will find the process more stressful. If they Peace Corps cannot afford to provide PCV trainees with language training, like Pimsleur or Rosetta Stone, before they leave, it could at least strongly encourage them to work on their language skills and provide concrete and specific advice as to how to do this. Likewise with cultural skills, female volunteers may not be prepared for the level of sexual harassment they will face in some countries, and programs in the US may not address sexual harassment in a way that will be appropriate or effective for the country they will serve in. Concrete and specific ways of dealing with sexual harassment, wearing a wedding ring doesn't always work, provided before the volunteer leaves will allow the volunteer to prepare herself before she has to face the situation. This may not be required for all countries. Likewise, there may be other cultural issues that it would be helpful for volunteers to know about in advance.

• Health Justice recently received an email from a volunteer who said that if she had only known how difficult it would be to get treatment for her Peace Corps-related health problems in the US, she would have stayed in country for treatment. There are some problems that are best handled in country. There are some that are better handled in the US. We recommend the following in regards to volunteer care at the end of service:

  • Either the system for post-service care should be fixed so that it is less cumbersome (perhaps it could be integrated with a revision of the AfterCorps insurance or utilize some aspect of what is currently known as "Obama-care"), or volunteers should be strenuously warned about potential difficulties in finding doctors and getting care and should be counseled as to how to work around these problems. This comment relates to that idea, "I think in country health care was the best health care I ever had/will ever have. The PCMO was great and really cared about the volunteers. Care back here in the states was not good, but that is more a function of the poor state of US healthcare as a whole rather than a Peace Corps problem."

  • Any volunteer who at their close of service has a lingering health problem should also have a concrete diagnosis for that health problem. This diagnosis should be good enough that the volunteer could use it to file for FECA compensation or bring it to a doctor in the US for treatment. It is expensive and difficult to get a diagnosis in the US for a problem that is not common here. This wastes both the Peace Corps time and money and the returning volunteers.

  • If a volunteer at the close of service has a health problem that is common in country but not common in the US, the volunteer should be presented with the option of staying in country or at a regional medical unit for care. If the volunteer chooses not to remain, they should be given information that can be passed on to a doctor in the US who may not be familiar with the illness. One commenter said, "I thought the medical care I received in country was great. However, the PCMO who was a doctor, and therefore the only one qualified to do COS exams, was on vacation the week that I - and about 10 other people - COS'ed. No one had told us this would be the case until we got there. As a result, it was up to us to get examined when we returned to the U.S., pay out of pocket, and get reimbursed. While I did ultimately do that and get reimbursed, that bureaucracy was the last thing I wanted to be dealing with at the time. Additionally, most people in the region where I served ended up with schistosomiasis, which we had been tested for at COS but not informed about the results till a couple months later, at which point we were in the U.S., where it's hard to find a doctor who knows how to deal with it. I felt there should have been a better way of handling that."

  • If a volunteer is considering terminating their service early because of a health issue, especially a mental health issue, the volunteer should be given the option of remaining in country and getting more rigorous treatment, going to a regional medical center for more rigorous treatment, going to Washington for treatment by the Peace Corps there, or being medically separated. While some problems will resolve themselves when the volunteer leaves country, volunteers who early terminate their service are less likely to receive help from the Peace Corps and less likely to receive FECA compensation. They need to be informed of the difficulties they will face getting treatment or compensation when they leave country. A volunteer who feels that they must leave immediately will most likely still want to do so, but being medically separated could make their treatment easier in the long run.

• Illnesses related to service arise after a volunteer has left the Peace Corps. Again, some of those problems can be handled in the US. Some will be unfamiliar to US doctors. We recommend that for illnesses that are not common the US, the RPCV could be given the option of going to a Peace Corps country for treatment, which might be more cost effective and resolve the problem more quickly than getting treatment in the US. Another option would be to provide detailed information on how the Peace Corps treats this problem for American doctors or to treat the volunteer at Peace Corps headquarters in Washington.

• The Peace Corps has put up a very minimal webpage to answer frequently asked questions about filing a FECA claim. This page contains incomplete information and lacks information to which the book it was copied from refers. More information for each of the forms that an RPCV must fill out, with examples and instructions on how to fill out every field (even the "address where you were injured" field can be difficult when you live in a village with no street names or addresses), would help simplify the process for RPCVs who are trying to apply.

While the best solution would be for fewer RPCVs to have lingering illnesses or other health problems, there will always be former volunteers in the FECA system. Often, their problems will not fit easily into the insurance diagnosis-code-based system that the Department of Labor's Office of Workers' Compensation uses. This comment speaks to this issue, "I suffered injuries from accident while serving in Guatemala (08-10). All in-country care was excellent, including flight evacuation and emergency surgery. Medical leave in the states and medical care there was equally good. However, as a result of the accident I have had continuing health issues related to the accident. I had the care approved, but the reimbursement process with Peace Corps Washington and DOL has been a big headache. Reimbursement is still pending, phone calls are not retuned, and contact person never answers phone. A streamlined process of reimbursement for an RPCV, with case managers attentive to needs of the patient would be a huge step forward." Our recommendations are:

• Having a small number of claims examiners dedicated to Peace Corps volunteers, may improve their familiarity with the health issues unique to RPCVs, and result in better response times from the DoL and fewer problems with receiving compensation and bill payment.

• Assistance from the Peace Corps makes all the difference when it comes to ill RPCVs getting care. For those with mental illnesses, which the most recent GAO report says is the largest category of illness from the Peace Corps, it is especially difficult to deal both with returning from service and doing everything that is necessary to get FECA coverage. The Peace Corps needs to continue to improve their support for volunteers seeking care. The survey shows that they have already made some progress on this issue, but there is still a ways to go.

• There were RPCVs who were unaware of FECA, were unable to cope with the forms and bureaucracy, or otherwise did not file a FECA claim within the three year window of eligibility. We would like to request a relaxation of these rules that would allow RPCVs who are ill because of their service to file for FECA compensation regardless of how long it has been since their service. If they can meet the burden of proof, then we believe they should be eligible.

• When a FECA claim is accepted, no list of rules and rights or policies and procedures is given out. If RPCVs knew what the procedure was for filing an appeal, how much they were allowed to earn without losing their disability, or who to contact if their claims examiner will not return their phone calls, much less time, effort, and money would be wasted by all parties.

The percentage of RPCVs who have illnesses that last decades, who are unable to get medical insurance, who spend thousands on medical care for their Peace Corps illnesses, and who receive compensation from FECA because of time lost from work is fairly small. However, these are RPCVs for whom the illnesses aquired during their service can make the rest of their lives significantly more difficult. Health Justice will continue to work with the Peace Corps to find ways to improve their chances of getting the help they need. One group that has lasting problems, often tinnitus or mental health issues, is those who took Lariam/Mefloquine during their service. Since the Peace Corps is one of the largest users of Lariam in the world, perhaps it would be in their interest to gather information on effective and ineffective Lariam treatment and to disseminate this information to affected volunteers.

Lastly, for volunteers who have been ill and on FECA for an extended period of time, the normal procedure is to return to work at the federal agency that they left, perhaps on a part time basis to see if they are ready to return to full time work. This is not currently an option for Peace Corps volunteers, or if it is, no one is informed of it. The problem with returning to part time work outside of the Peace Corps is that when someone on FECA receives income it often triggers them getting dropped from the FECA system, meaning that they no longer have access to medical care or lost income compensation. If it turns out that they are unable to work, they may have to fight for years to get reinstated into the program. This provides a strong disincentive to returning to work. If the Peace Corps provided options for these RPCVs who wanted to return to work, like a way of completing their service, serving with Peace Corps Response, or working in some other way with Peace Corps, it could give the recovering RPCV a chance to work, potentially complete their service, and test their readiness to return to full time work. Also, the closure provided by working for the Peace Corps may help show future employers that the RPCV has fully recovered.