“I don’t want to live.” Those five simple words stopped her in her tracks. After more than 20 years of marriage and military service, she heard them for the first time—and understood what they really meant.

The next morning, she contacted a few of his Army and civilian friends, then his mental health specialist at the local Veterans Affairs (VA) clinic. She was told that if he was in crisis he could call the hotline, and that an appointment could be scheduled in 3 weeks. His primary care doctor later told him he shouldn’t talk to her because she “overreacts.”

She realized there was no support for her husband unless he was already in crisis. No one treated the struggle as an opportunity for prevention. She began calling this the “gray area.”

The gray area is a real term, common among rural veterans. It describes those whose symptoms fall short of formal crisis criteria yet significantly impair daily functioning and quality of life for veterans and families. This family’s struggle is not unique. It is the lived reality for millions of veterans who occupy the space between “fine” and crisis—the gray area formal systems still largely ignore.

Rural settings that attract many veterans intensify the problems. “Rural” produces persistent systemic gaps: geographic and social isolation, provider shortages, transportation challenges, social and economic barriers, and higher rates of mental health issues. These obstacles often impede efforts to improve mental and physical health care for veterans.1

North Carolina can strengthen its rural communities by meeting veterans where they are—building sustainable systems that close critical gaps, particularly transportation deserts and support shortages—while leveraging policy, funding, demographic, and technological shifts. Our veterans have earned seamless, comprehensive wrap-around care no matter where they call home.

The Gray Area: When Distress Falls Short of Crisis

In the United States, 4.4–4.7 million veterans live in rural areas.2 These veterans are underdiagnosed and stigmatized; they have higher rates of service-connected disabilities and increased mental health symptoms. The VA does not monitor rural-specific use of Veterans Health Administration (VHA) care, limiting understanding of the disparities they experience.3–5

Veteran-specific factors—combat exposure, military sexual trauma, identity loss after separation, shifting social supports, and employment struggles—interact with how veterans interpret care. These experiences contribute to persistent stress, mental health symptoms, and isolation that erode quality of life and negatively affect families and communities. Formal systems frequently miss the challenges until distress escalates to crisis.6

Research has identified five dimensions through which veterans interpret treatment: worry about stigma, finances, confidence in the system, navigation of benefits, and concerns about privacy or misuse of benefits. These raise anxiety, reduce trust, and discourage continued engagement,1 compounding the non-crisis daily challenges veterans already face.

Left unresolved, the challenges appear in ordinary life: difficulty at work or home, rising symptoms, and progressive isolation. Families absorb them through increased conflict, decreased quality of life, greater caregiving and financial strain, and emotional exhaustion. Community impacts include higher crime and unemployment. As veterans and families isolate, local cohesion erodes, contributing to reduced life expectancy and long-term effects.5

The veteran and his wife in the introduction lived this pattern of unresolved challenges. The veteran had not had a mental health appointment in three years because of provider cancellations until rescheduling stopped. The impact manifested quietly: young-adult children grew angry and unmotivated; the spouse drifted into memory lapses, stalled goals, and isolation. No one outside the household offered help.

This is an often-unrecognized cost of war. A veteran’s mental health creates a ripple that reaches family and community. Addressing the gap is critical for intervention and prevention.

Transportation: The Barrier That Turns Struggle into Isolation

Nowhere do gray-area burdens become more concrete—or more preventable—than in getting to care. For rural veterans, transportation is not a peripheral inconvenience; it is the barrier that turns manageable distress into isolation and elevated suicide risk.

Rural veterans face severe barriers due to limited public transit, long distances to medical and mental health care, and unreliable rides for routine care.2,3,7 These gaps disrupt check-ins, medication management, therapy, and social connections. Consequently, rural veterans face a 20%–22% higher suicide risk than urban peers.2 A single veteran suicide sends a powerful ripple through a rural community. Families, “brothers in arms,” and close community members experience profound grief and trauma. For some, grief and stigma lead to self-medication, missed work, damaged relationships, and their own mental health struggles. Collective grief can erode the bonds veterans rely on for recovery.

Mark Kershaw’s December 2023 documentary Tribal humanizes these struggles through the raw testimonials of three combat veterans. Moving beyond generic post-traumatic stress disorder (PTSD) discussions, the film explores identity loss, the gritty reality of reintegration, and the desperate need for brotherhood. Its themes align with rural realities: geographically isolated veterans are frequently cut off from peer groups, VA appointments, and community networks. Transportation deficits worsen this isolation, turning personal struggles into community-wide wounds. Resolving the transportation crisis is a high-leverage intervention. Awareness alone is insufficient; rural veterans need sustainable systems that bring the “tribe” to them. Strengthening transportation infrastructure improves physical health outcomes and fosters community connection.8,9

Transportation failures hit hardest among the largest and fastest-growing segment of rural veterans: those aged 65 and older, whose physical limitations, generational values, and shrinking informal support networks compound every other obstacle.

Elderly Rural Veterans: Compounded Barriers and Shared Solutions

Every community has elderly veterans—gruff, independent, often widowed. Adult children have moved away; neighbors are no longer lifelong acquaintances. Many elderly veterans share experiences like this: a veteran schedules a VA appointment and coordinates a ride. The day of the appointment comes and the ride backs out. The veteran’s resources and other options are nonexistent. The VA Medical Center Transportation Program is already booked, the pickup point is 30 minutes away, and there are no other local options for rides. So, the veteran misses the appointment.

This scenario is routine. Nearly two-thirds (65%) of those enrolled in VA health care are 65 or older.10 Elderly veterans face compounded challenges: declining mobility, multiple chronic conditions, income often below $35,000, and service-connected disabilities that make independent travel difficult. Long distances translate into high time, fuel, and financial costs.10,11 These burdens can be further compounded by employment obligations, as some elderly veterans continue to work full- or part-time and face the risks associated with missing work.

Cultural norms of stoicism and self-reliance run deep, especially in rural communities shaped by generational values that discourage reliance on formal systems. Many older veterans still view mental health care as weakness, fearing stigma or loss of independence.1,10 Some perceive the VA as focused on younger veterans, breeding resentment and distrust. Limited digital literacy further reduces use of telehealth even when available.

Neurobehavioral symptoms and community-reintegration difficulties intensify when transportation and local support are absent.12 Provider shortages, gaps in geriatric and veteran cultural competency, and poor coordination between VA and local resources deepen isolation. The result is fragmented care, missed follow-ups, and unmet needs that quietly accumulate.

These overlaps point to integrated, veteran-informed solutions: mobile clinics, reliable volunteer drivers tailored to older adults, age-appropriate peer support, and deeper partnerships with existing community resources. Building these supports serves both rural aging veterans and civilians. Dedicated research, policy innovation, and community collaboration are essential.

North Carolina’s rural counties already live with these intersecting challenges. The question is not whether the gaps exist but how to build low-burden systems that fit local realities.

Building Sustainable Systems in Rural North Carolina

North Carolina’s rural communities are the backbone of the state—places where veterans and families build lives rooted in self-reliance, service, and neighborly support. Yet they often face significant barriers to care, especially for veterans navigating gray-area mental health challenges. Distances to the nearest VA facility—sometimes 90 minutes or more—compound isolation.13

The solution lies not in distant institutions alone, but in veteran-centered, community-embedded models that weave mental health support, reliable transportation, and peer or faith networks into the existing rural fabric. These approaches prevent escalation, honor independence, and build lasting resilience.

In many isolated rural pockets, resources are especially limited. Demographics across North Carolina illustrate the struggle: roughly 18% of the population is aged 65 or older, 61% are working-age adults with jobs and family responsibilities, and 21% are youth under the age of 18.14 The volunteer pool is aging and shrinking. Veteran support organizations, nonprofits, volunteer driver networks, and faith communities are stretched thin or absent.

Progress requires realistic, low-burden strategies. Rather than relying heavily on already-overloaded volunteers, North Carolina should prioritize modest investments in training a small number of veteran peer navigators drawn from the working-age population. These roles can be flexibly scheduled, with stipends or mileage support to prevent burnout. Cooperative Extension Services, present in every county, offer an ideal platform for this training—equipping locals to deliver informal gray-area support, reduce stigma, and help veterans access distant services.15

Transportation solutions must be pragmatic: efficient, limited volunteer driver pools focused on reliable individuals; partnerships involving younger adults or supervised youth for non-driving tasks; coordinated ridesharing; expanded telehealth with in-person support for those with digital-literacy challenges; and advocacy for mobile outreach clinics. These steps can reduce isolation without overwhelming the shrinking volunteer base.

Sustainable systems will depend on adaptable community hubs featuring flexible hybrid care models and value-based care that rewards outcomes over volume. Keeping veterans connected and contributing—through mentorship of younger residents or part-time community roles—strengthens the social fabric, eases long-term health costs, and honors service through practical resilience.16

Rural North Carolina faces genuine constraints, particularly in communities with aging populations and busy working families. Yet its strength lies in the self-reliant character of its people. With targeted investments in training, flexible peer roles, and smart coordination, the state can build veteran-centered systems that fit local realities, fostering sustainable support that grows with the community rather than draining its limited resources.

Even carefully designed local systems operate inside larger policy, demographic, and technological shifts.

Veteran-supporting communities face policy shifts, aging populations, and incremental technological change. With limited local resources and little access to many VA rural health grants, progress requires focused, incremental strategies grounded in available state options.

Opportunities include state investments in veteran mental health services and certain federal programs that extend beyond strict rural designations.13,17 Statewide priorities open avenues for funding and care coordination. The large number of aging rural veterans heightens urgency and invites community-driven innovation. Broadband expansion, telehealth, and supportive apps can reduce travel demands when paired with human support and transportation solutions that stretch limited volunteers.8,17

Risks remain real. Digital divides risk excluding older veterans. Short-term grant funding without local foundations undermines planning. Workforce and volunteer shortages persist; most willing community members are already aged 65 years or older. Privacy concerns and stigma in smaller communities amplify service gaps. Evaluations of VA mental health services have long called for better coordination and outcome tracking for those outside crisis pathways.18

Hybrid approaches that blend technology with existing human connections, sustain older volunteers, and seek more inclusive resources offer the most viable path. Success depends on pragmatic, low-overhead initiatives that build incremental resilience.

Workable models already exist in comparable rural settings. An example of a current working model is Connected Communities for Healthy Aging launched by the LeadingAge Minnesota Foundation in 2020. By the end of 2025, the program has grown from two to five communities and supported more than 8000 older adults. The positive impact of this program has increased resource navigation and referrals, improved transportation access, expanded mental health and caregiver supports, created greater social connection, reduced isolation, increased volunteer engagement, and expanded access to remote care technologies. The task is to adapt them to North Carolina’s constraints—limited grants, aging volunteer pools, and thin nonprofit infrastructure—through focused partnerships and targeted investments.

Evidence, Partnerships, and High-Impact Investments

When trained veterans and recovery peers are paired with practical support, isolation is notably reduced by 20%,19 appointment adherence improves by 30% (American Hospital Association), and we see a 59%20 reduction in crisis utilization. Coordinated transportation and collaborative-care frameworks that integrate primary care, behavioral health, and community resources further reduce emergency department reliance and improve quality-of-life metrics.2,9,12,16,18

These impacts are rooted in a shared background. Peers and veterans inherently understand each other and military culture. This instinctual connection rapidly builds deep trust, effectively reducing barriers to service engagement. Furthermore, peers leverage their personal experience and knowledge of VA processes to help veterans better navigate the system. As veterans become more engaged and competent in their care, trust deepens. Ultimately, these veterans can transition into peers themselves, creating a positive, self-sustaining cycle of support.

Adaptation is essential to navigate ineligibility for VA Highly Rural Transportation Grants, the absence of formal volunteer driver networks, limited nonprofit infrastructure, and understaffed, aging faith communities and veteran service organizations. Possible partners already present include veterans service offices, cooperative extensions, senior centers, councils of governments and area agencies on aging, and county health departments. Academic partners and University of North Carolina-system rural-health programs—including the UNC THRIVE Program (tbicenter.unc.edu/thrive/); the UNC Military and Veterans Law Clinic (law.unc.edu/experiential-learning/clinics/military-and-veterans-law-clinic/); and the Veterans Advocacy Legal organization (heellife.unc.edu/organizations/valor) working with the North Carolina Department of Health and Human Services (NCDHHS) on initiatives like AskMeNC (askmenc.org) and the Connections Digital Recovery Platform (Connections App), in collaboration with the North Carolina Department of Military and Veterans Affairs—can provide additional assistance and access to other rural health funding streams.

High-impact investments should concentrate on three priorities: building a local peer-support network, coordinating transportation, and establishing a lightweight collaborative care hub. A small standing advisor group—including a Veteran Service Officer, active peers, extension staff, and one or two older veterans—keeps decisions grounded and trusted. These are relationship-based systems that begin with people and institutions that are already present.

Recall the veteran and his spouse in the introduction. The veteran had three years without consistent mental health contact, young-adult children and his spouse absorbing the quiet costs, and no steady local hand until crisis thresholds were crossed. The same gaps still confront aging neighbors whose rides fall through. Closing the gaps does not require reinventing rural life; it requires connecting the capacities that already exist.

Conclusion: From Gray Area to Connected Communities

Rural veterans helped build and defend the communities that now struggle to return the favor in the quiet spaces between formal systems. Closing the gray-area gaps is both a moral obligation and a practical opportunity to strengthen the entire rural fabric.

Policymakers, local and state leadership, and community partners can work together to identify funding streams and develop low-burden, sustainable solutions.

Concrete steps include:

  1. Veteran peer and transportation collaboration that includes partnerships with Veterans Service Offices, EMS and Post-Overdose Response Teams (PORT), NCDHHS technical assistance, Vaya Health care coordination, and academic evaluation partners from the start.

  2. A structured and sustained volunteer driver and peer recruitment campaign through cooperative extensions, senior centers, and other local resources, offering brief training, liability coverage, and modest stipends so participation is realistic for older and working-age residents.

  3. Securing blended funding to pilot the peer-and-ride model for 18–24 months, with clear gray-area metrics and a plan for sustainability after grant funding ends.

These are not abstract programs. They are relationship-based systems that can be started with the people and institutions already present. By deliberately building peer networks and local volunteer transportation capacity where none currently exist and linking them to collaborative care, communities demonstrate that veterans’ service continues to matter. In doing so, we can build stronger, more connected rural communities for every resident.

Acknowledgments

This author thanks the rural veterans, family members, and community partners whose experiences informed this work, as well as colleagues who provided thoughtful feedback on earlier drafts.

Financial support

This work received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Declaration of Interests

The author declares no conflicts of interest.

Correspondence

Address correspondence to Cherry Kilby, 151 W. Main Ave, Ste 11, Taylorsville, NC 28681 (ckilby@alexandercountync.gov).