National Center for Military Deployment Health Research (1999)

Concerns about the health of veterans of recent military conflicts have given rise to broader questions regarding the health consequences of service in any major military engagement. The Veterans Program Enhancement Act of 1998 directed the Secretary of Veterans Affairs to enter into an agreement with the National Academy of Sciences to help develop a plan for establishing' a national center (or centers) for the study of war-related illnesses and postdeployment health issues. In response to this legislation, the Department of Veterans Affairs (VA) asked the Institute of Medicine (IOM) to convene a committee of experts. The charge to the committee was to (1) assist the VA in developing a plan for establishing a national center (or centers) for the study of war-related illnesses and postdeployment health issues, and (2) assess preliminary VA plans and make recommendations regarding such efforts.

The IOM convened the Committee on a National Center on War-Related Illnesses and Postdeployment Health Issues, composed of experts on war-related illnesses, clinical research, military medicine, epidemiology, health services research, operations research, development of interdisciplinary research centers, research ethics, technology transfer, and the integration of clinical and education programs with research. Between January and September 1999, the committee met three times. The first meeting included a workshop that was held to obtain background information on relevant issues. During subsequent meetings, the committee reviewed information on war-related illnesses and relevant research activities, analyzed alternative models for national research centers, and received testimony from veterans about their views for such a center. Additionally, the committee examined the VA's proposal for developing a national center program within the VA.

The committee conducted its deliberations with an understanding that the nature of military engagement has changed. Contemporary military conflicts

depend on the availability of smaller expeditionary forces that maintain a high level of military readiness. This greater reliance on readily deployable forces includes increased participation by guard and reserve members. Both active-duty, guard, and reserve forces experience profound life disruptions connected to all phases of deployment that, despite the relatively rapid and short-term experience, may have long-standing health consequences. Additionally, there is a component of deployed civilian workers who are similarly impacted by military deployment. The committee found that:

• Extensive research exists on the health of veterans of military conflict.

• The definition of deployment-related health issues selected for research has been too narrowly focused and has excluded some health consequences related to deployment.

• There are gaps in the emerging data relevant to the study of war-related illnesses and postdeployment health issues.

• Many investigations of health issues and effects of deployment have been mounted in response to health problems after they occurred, rather than being undertaken proactively.

• Many veterans and some congressional staff are skeptical of the objectivity of both the Department of Defense (DoD) and the VA in the conduct of research into deployment-related health issues.

• None of the locations of existing or proposed centers provides an adequate model for a national center that not only must be responsible for the conduct of a broad range of research but also must provide for synthesis and coordination of research efforts and for proposing policy changes based on research findings.

• Examples exist of centers that cut across agencies and groups to carry out effective research agendas.

One component of the committee's charge was to review the VA's proposal to establish Centers for the Study of War-Related Illnesses and Postdeployment Health Issues by using the model of the Geriatric Research, Education, and Clinical Centers (GRECCs). The GRECC program has been successful in training health professionals, conducting cutting-edge research, and implementing effective treatment programs. Creating centers based on this model for the study of deployment-related health should contribute greatly to the advancement of knowledge in this area. Therefore, the committee recommends that the Department of Veterans Affairs proceed with its proposal to establish centers for the study of war-related illnesses, and that these centers be similar in structure to the Geriatric Research, Education, and Clinical Centers.

The second component of the committee's charge was to make recommendations regarding a national center. The committee concluded that a national center could provide the needed mechanism to coordinate and synthesize the ongoing research efforts. Such a center would be in a position to provide an overarching research agenda that would identify gaps in current research, to coordinate existing and future research, to focus the infusion of new research funding, and to recommend policies related to such research. Therefore, the committee recommends that Congress establish a National Center for Military Deployment Health Research that will focus on the health of active, reserve, and guard forces, and veterans and their families.

Despite the anticipated contributions of the VA centers, location within the VA carries with it limitations for a national center that is responsible for coordinating and synthesizing research across federal agencies and in university-based settings. The committee examined a number of options for the location of the National Center and concluded that it should be independent of governance by any single federal agency in order to foster scientific excellence and assure scientific and public accountability. Therefore, the committee recommends that the National Center be placed under the auspices of and report to the Military and Veterans Health Coordinating Board (MVHCB). Further, the committee recommends that the National Center replace the Research Working Group of the MVHCB.

The MVHCB was established by Presidential Review Directive and is chaired by the secretaries of the Department of Defense, the Department of Veterans Affairs, and the Department of Health and Human Services (HHS). It is charged with providing ''oversight, coordination, and linkages to other related efforts in the Federal Government in the areas of deployment health, health care, research, health-risk communication and education, record keeping, and compensation." The MVHCB has a broader mission than is found in any single federal agency and has been mandated to foster collaborative effort.

The Research Working Group (RWG) of the MVHCB has been charged with providing recommendations and coordinating research activities on deployment health issues affecting active-duty members of the armed forces, veterans, and deployed civilians, as well as the families of these individuals; preventing unnecessary duplication of research and assuring that resources are directed toward high-priority studies; and with acting as a forum for information exchange within the research community at large and for research coordination among the three participating departments. Since the proposed National Center for Military Deployment Health Research will encompass all aspects of the Re-

search Working Group's mission, the committee suggests that the new Center replace the RWG, rather than duplicate its efforts.

The committee envisions three key structural components for the National Center. These components are:

• a Governing Board, composed of members of relevant constituencies, with responsibility for coordination and agenda-setting, as well as for oversight of the work of the Center;

• a Research Network that integrates research efforts in DoD, VA, HHS, universities, and other sites; and

• a core of specific functions, with appropriate staff to implement such functions, under the overall direction of the Center's board and the WHCB director.

To assure the public, Congress, the scientific community, and others that all efforts of the Center are being conducted with the highest scientific integrity and public accountability, oversight of the Center should be by a Governing Board composed of representatives from a broad range of relevant constituencies. Therefore, the committee recommends that the National Center Governing Board be composed of:

• three representatives each from VA, DoD, and HHS;

• six independent representatives from the research community; and

• six representatives from the community at large, including veterans and their families and the general public.

Additionally, the committee recommends that an independent scientific entity nominate, for both the research-community and the community-at-large positions, twice the number of candidates as there are positions available.

The committee recommends that the functions of the Governing Board include:

• development of a coordinated research agenda;

• commissioning of new research;

• creation of policies for the conduct and dissemination of Center research;

• evaluation of the output and productivity of Center research;

• development of policy recommendations that emerge from Center research;

• development of the Center's proposed annual budget; and

• preparation and transmittal to Congress of an annual report.

The committee has designed the research network of the National Center with two major components: (1) federal research programs and (2) Center-initiated research. This structure provides minimum disruption to the ongoing research activities while adding a needed mechanism for research priority-setting and coordination, for dissemination of research results, and for undertaking tasks most appropriate for a central organization. Therefore, the committee recommends a broad-based Center-initiated research program that would solicit proposals from federal agencies, universities, and other research sites and that would be managed by the National Center.

Center-initiated research should be implemented through the announcement of a set of Requests for Applications (RFAs) and Requests for Proposals (RFPs). It is suggested that the National Center enter into an agreement with the National Institutes of Health (NIH) to use the NIH peer-review process, to the extent possible, to assess the scientific merit of the applications and proposals. The final research funding decisions remain, however, the prerogative of the Center's Governing Board.

The committee recommends that the National Center be responsible for the four core activities:

• research coordination and priority setting;

• research-related policy analysis;

• review and analysis of longitudinal monitoring of deployment-related health; and

• facilitating the use of national data sources for deployment health research.

To foster research coordination and priority-setting, the Center should sponsor conferences and workshops to gather input for the research agenda and to encourage collaborative exchange. To increase scientific input in the development of the research agenda, the Governing Board may establish advisory groups or use other mechanisms to receive technical advice. It is anticipated that as the Center grows, so will its need for additional mechanisms to accomplish its activities. Rather than attempt to dictate those mechanisms, however, the committee believes it is important to allow the Board and staff to devise their own creative responses to their future needs.

Developing policy recommendations based on research results requires the synthesis and analysis of relevant research. Some of the same mechanisms described above for use in agenda-setting can be employed in policy analysis.

The committee identified the need for a mechanism to monitor the longitudinal health of active-duty, reserve, and guard forces that goes beyond the self-selected service members who participate in DoD and VA registries. A recently released IOM report (IOM, 1999) describes a research portfolio and longitudinal

cohort study that could provide a model for a long-term tracking system of the health of veterans of military conflict. It is appropriate that the research described in that report fall within the purview of the National Center and become a cornerstone for its longitudinal monitoring efforts.

Given the numerous and varied data relevant to research on deployment-related health, the National Center should develop a process by which these data can be identified, inventoried, and described. Such activity will foster the effective use of these data.

The research issues involved in deployment-related health are complex and require long-term commitment if productive results are to be achieved. Significant funding resources will be needed for the National Center core activities, Governing Board, and Center-initiated research. The Center should propose a budget detailing the resources needed, and this budget should be a line item in the budget of the MVHCB. The Center Should include such budget information in its annual report to Congress in order to provide that body with information about the functioning and productivity of the Center. Therefore, the committee recommends that the National Center should have a clear and distinct budget for its core activities and its Center-initiated research. Further, this budget should be a line item in the budget of the MVHCB.

Many have begun to ask whether there are health consequences of service in military conflicts beyond the obvious war injuries and, if so, whether there are ways to prevent or at least mitigate the consequences of war-related illnesses and deployment-related health effects. Congress directed that the Department of Veterans Affairs contract with the National Academy of Sciences to assist in developing plans for a national center (or centers) for the study of war-related illnesses and postdeployment health issues that could focus research on answering these questions.

The committee has recommended the establishment of a National Center for Military Deployment Health Research, to be governed by an independent board composed of representatives of the scientific community, the veterans' community, and relevant federal agencies. Such a center would provide an opportunity to gather together the results of many individual efforts, to analyze and synthesize what this research can reveal, and to move the nation forward in ways that will help and protect those individuals who will participate in future deployments.

The committee urges that the recommendations in this report be implemented as rapidly as possible in order to gain much-needed knowledge about how best to protect and treat the men and women who participate in military deployments.