National Center for Military Deployment Health Research (1999)

The committee conducted its deliberations with an acknowledgement of changes in the nature and breadth of deployment efforts, as well as with awareness of the increasing interest and concern about the health of military personnel and veterans. Contemporary military strategies call for a shift from a large standing force with forward-located bases to one comprised of smaller expeditionary forces. Such forces maintain a high level of military readiness when the need arises for low-to medium-conflict or for peacekeeping and humanitarian missions. The changing nature of warfare places a greater reliance on readily deployable forces, including an increased participation by guard and reserve members. Disruption in the lives of these members is particularly turbulent in that they are drawn from civilian communities where they must leave their jobs, families, and other commitments, and that they do not always have access to the support and resources available within a military community.

Active-duty, guard, and reserve forces experience profound life disruptions through the predeployment, deployment, and postdeployment phases, and these disruptions, despite the relatively rapid and short-term experience, may have long-standing emotional and social consequences. Additionally, there is a component of deployed civilian workers who are similarly impacted by military deployment. Research is needed to better understand the impact of deployment experiences on the well-being of individual service members, as well as on their families, and to inform policy regarding the social and organizational responsiveness to these significant life disruptions. These issues span the purview of federal departments and have a breadth that encompasses biomedical and social sciences research.

Committee recommendations were developed with these factors in mind. The recommendations are intended to maximize productivity of current re

sources and efforts; encourage interdepartmental coordination at the federal level; encompass the deployment-related health concerns of all interested parties, including veterans, active-duty personnel, guard and reserve forces, deployed civilians, and their families; and foster relevant interdisciplinary research in the biomedical, epidemiological, and social sciences. To the extent possible, committee recommendations incorporate existing efforts, structures, and plans, while striving to provide a model that will enhance trust in the scientific integrity of research results.

The committee analyzed the VA's proposal to establish Centers for the Study of War-Related Illnesses and Postdeployment. Health Issues. As described in Chapter 2, this proposal calls for establishing centers that have four distinct program components (research, treatment, education, and risk communication) and that are similar in structure to the VA's Geriatric Research, Education, and Clinical Centers. Such an approach has proven quite successful in the areas of geriatrics and gerontology, and the committee believes that comparable centers focused on deployment-related health also will contribute greatly to the nation's knowledge and ability to care for military veterans.

The committee, therefore, strongly supports the emulation of the GRECC program as it has been successful in training health professionals, conducting cutting-edge research in the field, and implementing effective treatment programs. Strengths of the GRECC program include close collaboration with medical schools and universities, as well as the establishment of multiple centers (each drawing on the research expertise of the host VA medical center and integrating a variety of scientific disciplines).

Further, the GRECC program has an active advisory committee, the Geriatrics and Gerontology Advisory Committee, which is composed of experts from outside the VA and is charged with evaluating the centers and providing scientific expertise on all aspects of caring for aging veterans (Goodwin and Cohen, 1994). The committee encourages the implementation of each of these features to help ensure the success and effectiveness of the VA's work on deployment-related health concerns. Further, the committee urges the VA to incorporate university-based research in its centers in order to expand the research base and foster new approaches and initiatives. VA centers structured in such a manner would play a major role in the broader National Center effort described in the following section. 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.

A deployment-related health research agenda must be broad if it is to improve the health of deployed personnel and minimize adverse health impacts of future deployments. It will require the creativity and scientific ingenuity of researchers from multiple disciplines and varied research settings to address the wide range of health issues related to military deployments. Additionally, the changing nature of military deployment necessitates the inclusion of research that encompasses the health concerns of all deployed populations, including veterans as well as active-duty, guard, and reserve forces.

There is a tremendous amount of deployment-related health research currently underway both within the federal government and in the academic community. As described earlier, the DoD already has established its Centers for Deployment Health. Since the end of the Gulf War, more than 120 research projects on Gulf War veterans' health have been funded by the VA, DoD, and HHS. Such research is being carried out in universities, at federal research centers, and by private investigators in a variety of locations. Research on the health effects of other specific conflicts (World War II, Korea, Vietnam) has been ongoing and is anticipated to continue.

The committee concluded that the contributions of such deployment-related health research efforts would be enhanced if a mechanism were developed to integrate, coordinate, and synthesize the research. Further, an overarching research agenda is needed to identify gaps in current research, assure that missing but required research efforts are undertaken, and focus the infusion of new research funding. The committee determined that a new National Center for Military Deployment Health Research should be established to accomplish the following goals:

• facilitate a coordinated research program through development of a research agenda;

• identify research gaps and commission research to fill those gaps;

• monitor the conduct of research; and

• develop policy recommendations resulting from research.

Therefore, the committee recommends that Congress establish a National Center for Military Deployment Health Research that win focus on the health of active, reserve, and guard forces, and veterans and their families.

The committee assessed the potential scope of the National Center and determined that the terms ''war-related illnesses and postdeployment health issues" are encompassed by the broader concept of "deployment-related health." The traditional consideration of these issues focuses on the injuries and illnesses re-

sulting from combat, training, infectious diseases, and environmental exposures. However, the very nature of deployment involves disruption of everyday life, and the committee encompasses in its definition of deployment-related health the numerous impacts on service members and their families during the deployment, upon return home, and when reintegrating into society. Further, issues may be considered that address concerns revolving around the time prior to deployment, when individuals and families are preparing for deployment and often are uncertain about the timing and nature of the deployment. Therefore, the committee recommends that the Center encompass a broad research agenda that addresses conditions that emerge both during and following deployment, including:

• diagnosable conditions;

• medically unexplained symptoms (both physical and mental);

• effects on health-related quality of life, (e.g., death and duration of life, impairment, physical and mental functional status, health perceptions, and opportunity [the capacity for health, the ability to withstand stress, and physiologic reserves]);

• family impacts; and

• sequelae of combat injuries.

In order to address adequately all aspects of these conditions, it will be necessary for the Center to encompass diverse types of research, including epidemiological, clinical, basic biomedical, health services, social and behavioral, ethical, and risk-communication research. The committee acknowledges the breadth of the research challenge, but feels that the Center's proposed structure can encompass relevant research. To date, efforts have had to be more narrowly focused because of the missions of the individual federal departments (e.g., the emphasis on postdeployment issues by the VA because of its mission to serve veterans). A coordinated National Center program will broaden the perspective and facilitate a more coordinated approach to addressing deployment health concerns.

In considering how to most effectively implement the National Center, the committee considered a variety of ways that the Center might be placed within the federal government or the private sector. The following general guidelines, based on committee findings, guided committee discussion. The location of the Center should:

• facilitate coordination;

• ensure credibility with all relevant agencies and constituencies; and

• span the breadth of applicable research.

For each of the options considered, the committee delineated the strengths and limitations while emphasizing the important role for each of the organizations in carrying out the mandate of the National Center.

As discussed in Chapter 2, the DoD has implemented a deployment health program using three centers and has an extensive array of research under way. The advantages to placing the National Center within the DoD would include an existing infrastructure, extensive research expertise, and the willingness to commit resources to address the research issues. However, several concerns limit this approach. The focus of DoD's health-related mission is to address the health of active-duty personnel. Although the DoD does conduct a range of health-promotion, disease-prevention, treatment, and rehabilitation research, its mission is narrower in focus than that envisioned for the National Center. The Center's broader focus would span active-duty, guard, and reserve forces, and veteran and deployed civilian populations. Additionally, as discussed previously, the DoD lacks credibility with the veteran community.

The committee believes that the DoD must, however, play an integral role in the National Center. As discussed below, the DoD research centers on deployment health are vital components of the military deployment health research network. The committee commends the DoD's initiative in establishing these centers and encourages the DoD to continue to expand the breadth of its research efforts to encompass guard and reserve forces.

The committee concluded that there are similar strengths and limitations to locating the National Center wholly within the VA. The VA has strong research on deployment health issues. Further, as evidenced by its recent plans for Centers, for the Study of War-Related Illness, the VA has the commitment and willingness to address these issues, and it has much of the research expertise needed to carry out this work. Additionally, the DoD and VA have collaborated on recent studies, particularly those related to the health of Gulf War veterans. However, the VA's mission focuses on veterans' health and does not address the active-duty component that is fundamental to the nature of the National Center. Further, there are credibility issues that again would limit the VA in serving as the locus for the National Center. The committee considered the possibility of dividing the Center between two federal departments (e.g., DoD and VA) but felt that this would not be the best option. In addition to the credibility issues, the mission of the Center requires that the Center fund research comparing the health of deployed forces with the general population, and a broader-based location for the Center with access to general population research is optimal.

The VA does have an integral role in the National Center, however. As discussed above, the committee endorses the VA's plans for Centers for the Study of War-Related Illnesses and believes that these centers will be vital to the research network on deployment health. The committee encourages the VA to move forward with implementing these centers but does not believe that these centers can carry out the functions of a National Center.

The committee considered the feasibility of locating the National Center within the National Institutes of Health, because of its biomedical research expertise and its sterling reputation regarding research on health issues. The NIH is acknowledged worldwide for the impressive breadth and quality of its basic biomedical research. Further, NIH has an extensive infrastructure in place for its highly respected, scientific merit, peer-review of research grants and contracts. However, each of the 25 institutes and offices within NIH has a specific mission that focuses on a particular organ or organ system (e.g., National Eye Institute), population (e.g., the National Institute on Aging), or health issue (e.g., National Institute of Environmental Health Sciences). Although many of the NIH institutes are conducting research that is relevant to military deployment health, no single institute has the comprehensive breadth of mission needed for the National Center. The option of adding another institute or office that would focus on military deployment health was considered but rejected. The committee recognized that this option would require considerable resources for infrastructure and yet would still not accomplish one of the goals of a National Center-to coordinate research efforts across federal departments.

The committee does consider NIH an integral part of its plan for a National Center. NIH research that is relevant to military deployment health should be included in the Center's overarching research agenda. Additionally, as will be discussed below, the NIH peer-review process for research grants and contracts could be utilized by the National Center.

In considering the placement of the National Center within the Centers for Disease Control and Prevention, the committee acknowledged CDC'S strengths in a number of relevant areas, including occupational health research, prevention efforts, and health surveillance. Additionally, CDC continues to excel in dissemination of health information. CDC has worked extensively and successfully with the DoD and VA on research related to the health of Gulf War veterans. However, the goals and mission of the National Center are not central to the mission of CDC, and it would be difficult for CDC to coordinate research efforts

across the federal government. Further, CDC'S mission does not include the basic biomedical research that is a necessary component of the National Center.

CDC also is considered an integral part of the National Center. The relevant CDC research (e.g., occupational health research) should form part of the research network on military deployment health research.

The committee considered the option of locating the National Center outside of the federal government, within a university. Advantages of such an approach include increased credibility due to the independence of the research, the ability to have a broad collaboration of disciplines from across the university, extensive research expertise, and a willingness by universities to expand their research capabilities. However, the disadvantages of being outside the federal government outweigh the advantages.

It would not be feasible for a university-based center to coordinate federal research. Additionally, data access to relevant VA and DoD databases would be problematic. Further, this approach would isolate research from the treatment and surveillance efforts in active-duty and veteran populations. As will be discussed below, the committee views university-based research as crucial to the research network of the National Center, but does not believe that the primary location of the National Center should be in a university.

The Military and Veterans Health Coordinating Board (see Chapter 2) offers many of the advantages of the federal government agencies, with the added strength of being a cross-departmental effort. Formed in response to a Presidential Review Directive, the MVHCB enjoys high-level federal support. The Board's charter calls for it to be chaired by the secretaries of Defense, Veterans Affairs, and Health and Human Services. The MVHCB has a broader mission than would be found in any one of the federal departments and is by its nature a collaborative effort.

The draft charter for the MVHCB calls for it to have three working groups-on research, on deployment health, and on health-risk communication. Since the mission and objectives of the Research Working Group (see Chapter 2) are encompassed in the proposed National Center for Military Deployment Health Research, the committee suggests that the new Center replace the RWG, rather than duplicate its efforts (Figure 4.1). Such an approach would increase credibility because the National Center would include all of the relevant constituencies in the research agenda-setting.

FIGURE 4.1

Organizational placement of the National Center for Military Deployment Health Research

Further, as will be described below, the National Center would have the additional responsibilities to set a research agenda, identify research gaps, and provide funding for needed research. Independence of the National Center is enhanced by the requirement that it annually report directly to Congress, as well as by the constituency of its governing body. Therefore, the committee recommends that the National Center be placed under the auspices of and report to the Military and Veterans Health Coordinating Board. Further, the committee recommends that the National Center replace the Research Working Group of the MVHCB.

The following section discusses the Structural elements of the National Center recommended above.

The committee has designed an organizational structure for the National Center for Military Deployment Health Research that will facilitate the goals of coordinating research, identifying and filling research gaps, and developing policy recommendations resulting from research, in a way that will be deemed credible with both the research communities and the public. This structure has three key components (Figure 4.2):

• 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 MVHCB director.

The committee concluded that current and future resources would be used most effectively if the National Center were structured to coordinate and supplement existing research efforts of DOD, VA, and HHS, rather than to replace them. Consequently, the relevant federal departments are encouraged to continue to plan for and implement research programs perceived necessary to fulfill their missions.

One of the major benefits of the proposed structure is the participation of a broad set of constituencies, including veterans groups and the general public, on the Governing Board. This breadth of input will increase the credibility of the research process and expand the range of issues comprising deployment health as addressed by the VA, DoD, and HHS. Further, the independence of the Center is enhanced by the requirement that it report directly to Congress, in addition to reporting to the MVHCB.

FIGURE 4.2

Structure of the National Center for Military Deployment Health Research.

Working within the structure of the MVHCB will provide the input of the federal departments. However, in order to assure the public, the Congress, the scientific community, and others that all of the Center's efforts are being conducted with the greatest degree of 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. These constituencies include researchers, veterans and their families, the general public, and representatives of the VA, DoD, and HHS. The input of an independent scientific body should be sought in obtaining nominations for the nonfederal representatives on the Governing Board.

The research and constituency membership should be in the majority on the Board so as to ensure maximum scientific quality, broad-based decision making, and public accountability and acceptability. Therefore, the Governing Board should be composed of 21 members (three each from VA, DoD, and HHS; six from the research community; and six from the community of veterans, their families, and the public at large). The committee emphasizes the need for the researchers to represent the breadth of relevant research, including the biomedical and social sciences and ethics. As noted above, the committee encourages the involvement of CDC and NIH in the Center and hopes that these agencies will be involved through participation on the Governing Board.

Further, the committee believes it is crucial that Governing Board members serve on a rotating long-term basis, thereby allowing adequate time for them to become familiar with the complex issues and to develop a view of the evolving needs for research. 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 Military and Veterans Health Coordinating Board Should select, from the list of recommended candidates, the six representatives from the research community and the six representatives from the community at large to serve on the Governing Board.

The Governing Board will serve as the Steering body for the National Center, performing several critical functions. The Board will be responsible for establishing a broad research agenda encompassing the wide scope of deployment health issues, coordinating research across agencies and institutions, commissioning new research to fill in research gaps, and developing policy recommen-

dations that emerge from Center research. Further, the Board should develop policies for guiding the conduct and dissemination of center research and should develop a plan to evaluate the output and productivity of center research.

Due to the Governing Board's major responsibilities, it will need to function as a working board and divide into subcommittees to address the various tasks. Thus, it is important for the Board to have a large membership (21 members) so that each subcommittee will have representation from each of the constituencies.

The Governing Board will have reporting responsibilities to both the MVHCB and to Congress. In its annual report, the Board should provide an update on the research agenda, an overview of ongoing research activities and completed research results, and policy recommendations based on Center research. Further, the Board, as will be discussed in a subsequent section, should assess the resources necessary to carry out the work of the Center and to fill gaps in research. In its annual report, the Board should propose a Center budget.

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 scope of current deployment health research, along with the changing nature of deployment, were key factors in determining the need for a broad research agenda. In addition to the breadth of biomedical research that should be undertaken, a comprehensive portfolio of relevant social sciences research is needed. Further, the research agenda should include an emphasis on the health-related ethical issues that surround war and other military deployments. As the nature of conflicts and events that trigger deployment change, and as health-related decisions and issues become increasingly complex, research on the ethical implications is crucial. The Ethical, Legal, and Social Implications Program at the National Human Genome Research Institute is successful at encouraging research on ethical and social issues and provides examples of the ways in which research on the ethics of deployment-related health issues could be fostered.

Since there is a great deal of ongoing research on deployment health issues, the committee structured the Center so as to take full advantage of current ef-

forts while ensuring a coordinated credible research agenda that addresses research gaps. Thus, there are two components to the research portfolio of the Center: federal research programs and Center-initiated research. This structure will provide 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. It is hoped that this structure will encourage more independent investigators (funded directly by federal agencies or through Center-initiated research) to be involved in military deployment health research and thereby stimulate the breadth and creativity of scientific inquiry.

The committee acknowledges and commends current federal efforts to research deployment-related health issues. Current and future deployment health research by the VA, DoD, and HHS would be considered in the work plan of the Center, but the Center would not take over administrative or professional responsibility for its conduct. Rather, such research would remain the responsibility of the relevant federal agency. AS part of the process to develop and coordinate a research agenda, the Center would conduct an inventory of ongoing research, and federally sponsored researchers (intramural and extramural) would be involved in developing the Center's research agenda. The committee strongly encourages the federal departments to continue their deployment health research programs and to work through the Center to facilitate coordination across the departments.

One of the tasks of the Center's Governing Board will be to identify gaps in current research. The committee believes that the Center should accept operational responsibility for commissioning, funding, and overseeing a program of Center-initiated research that would fill the gaps in the research agenda. This research would be carried out by university or government researchers who would compete for awards to conduct the research.

The Center-initiated research program should be implemented through the announcement of a set of Requests for Applications and Requests for Proposals that would specify the nature of the needed research projects. Given its expertise and existing infrastructure for scientific merit review, the NIH Center for Scientific Review should be tasked with processing the grant and contract applications. Further, the peer-review process of the NIH should be used, to the extent possible, to assess the scientific merit of the applications and proposals. The final research funding decisions would be made by the Center's Governing Board, which would focus on the programmatic considerations of whether proposals receiving a high

scientific rating would further the research agenda of the Center. 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.

It is the committee's hope that establishing a network of research sites with an overarching research agenda will bolster ongoing activities, foster creativity for new projects, encourage the use of established peer-review mechanisms for evaluating and funding intramural and extramural research, and promote wide dissemination of research results. Further, it is important for the research network to encompass interdisciplinary work in the biomedical and social sciences, including ethics. Such research should not be limited to academic medical centers but should be expanded to encompass relevant university-wide research resources.

The committee concluded that each of the federal departments should expand its funding of university-based research on deployment-related health in order to widen the base of researchers involved in this field. HHS is encouraged to focus specific extramural NIH funding on these issues. One of the benefits of promoting university-based research is, of course, the enhancement of educational programs to provide the next cohort of medical and social science researchers in this area.

The committee strongly urges that all Center-initiated research be conducted using a core set of principles:

• utilization of a scientific peer-review process for all research;

• dissemination of research results to the scientific community through conventional scientific venues of communication, including presentation at scientific conferences and publication in peer-reviewed journals; and

• encouragement of interagency, interdepartmental, and federal-academic sector collaboration, including collaborative proposals with principal investigators and colleagues from several federal departments and universities.

To fully implement the work of the Center and to ensure coordination of efforts, the Center must carry out four core activities that will facilitate the work of researchers from across federal departments, universities, and other institutions. These key core functions are:

• research coordination and priority setting;

• research synthesis for the purpose of developing policy recommendations;

• oversight of longitudinal monitoring efforts on veterans' health; and

• facilitating the use of national data resources available for deployment health research efforts.

These activities are viewed by the committee as the intramural work of the National Center and should be carried out under the Governing Board's direction by the Center staff and with the input of all of the relevant constituencies.

A full complement of core staff is crucial. There should be sufficient fulltime staff members to work with the Governing Board and to carry out the Center's four core activities. It is envisioned that the size of the staff will grow as the Center becomes fully implemented. As described below, the core activities of the Center will require considerable staff time and expertise. Staffing expertise needed includes health policy analysis and development, deployment-related health research, research program management, and research administration.

In keeping with the staffing structure suggested for the MVHCB, the committee suggests that the National Center be directed by a deputy director of the MVHCB who reports to the executive director of the MVHCB. The deputy director for the National Center should have the experience and Seniority necessary to enhance interdepartmental coordination and should have relevant research expertise. This individual should be selected by the Governing Board and approved by the MVHCB.

The draft charter for the NIVHCB calls for it to be an administratively housed unit within the Department of Veterans Affairs. Such placement also would be appropriate for the National Center. It is crucial that the Center be given central office space in order to establish the location and visibility of the Center.

An effective National Center must perform some central and key functions that cannot be performed by individual federal agencies or researchers because of the overarching nature of the tasks.

Research Coordination and Priority Setting. As discussed above, the Center will function to set a research agenda, establish research priorities, coordinate research efforts, and serve as an intellectual gathering exchange for researchers. Further, the Center will initiate and fund new research projects to fill the gaps in the research portfolio.

To fulfill these responsibilities, the Center should sponsor conferences and workshops to gather input for the research agenda and to bring researchers together in ways that encourage collaborative exchanges and stimulate new research

initiatives. To increase scientific input in the development of the research agenda, the Center's Governing Board may establish advisory groups or use other mechanisms to receive technical advice on each of the major areas of research.

To ensure that all aspects of the research agenda are addressed, the Governing Board and Center staff will need to determine the research gaps and initiate and fund research grants and contracts. This work may be done in collaboration with NIH as discussed above, but final funding decisions will be the responsibility of the Governing Board.

It is envisioned that the Governing Board's annual report to Congress will serve as a mechanism for outlining the research agenda, specifying the ongoing work of the federal agencies and universities, and identifying how the research gaps are being filled.

Policy Analysis. The Center's research results should be used to guide development of policies for prevention and treatment strategies aimed at mitigating potential health consequences of deployment and improving the health of those participating in such engagements. Developing policy recommendations based on research results requires the synthesis and analysis of relevant research. The expertise of the core staff and the guidance of the Governing Board should provide the expertise necessary to perform this function. The responsibility for policy recommendations related to research should remain the purview of the National Center Governing Board.

Longitudinal Monitoring. One of the current difficulties inherent in researching deployment health concerns is the lack of a system for monitoring the longitudinal health of active, reserve, and guard forces, as well as the health of veterans and their families. The VA and DoD have developed health registries for active-duty service members and for veterans involved in specific events and deployments. While these registries serve useful purposes, they reflect the health of a self-reported sample of service members and veterans, and thus they are not representative of the active-duty and veteran population in general. Of fundamental importance is the development of a longitudinal monitoring system that is representative of active-duty, guard, and reserve troops, and veterans; that measures health at specific time points; and measures changes in health over time.

The recent IOM report Gulf War Veterans: Measuring Health (IOM, 1999) describes a research portfolio and prospective cohort study that could, with appropriate extension, provide a model for a long-term tracking system of the health of veterans of military deployments. The portfolio encompasses three principal categories of research: population studies, health-services research, and clinical and biomedical investigations. An essential feature of the research portfolio is facilitating linkages across individual studies through the collection of a core set of key data elements (describing health, individual, and cultural characteristics) in order to provide for comparisons across all research.

It is appropriate that the research described in Gulf War Veterans: Measuring Health fall within the purview of the National Center. That is, the Center

could develop the RFP, review submitted proposals, provide funding, and monitor the progress of the studies. Data collected from such efforts could be incorporated into a national database on deployment-related health. The Center would not be directly involved in conducting the longitudinal monitoring, but would review the progress of its implementation.

Additionally, future efforts to measure the health of those individuals deployed to military conflicts and peacekeeping missions should include, to the extent possible, information obtained before, during, and after deployment. The National Academy of Sciences currently is conducting a study on strategies to protect the health of deployed U.S. forces, and a component of this study examines improvements in keeping medical records and documenting exposures, treatment, tracking of individuals through the medical evacuation system, and health/administrative outcomes. Data obtained before, during, and after deployment through the kinds of systems reviewed in this forthcoming Academy report will be important components of research on deployment-related health.

National Data Resources. As described in Chapter 2, there are a number of existing data resources relevant to research on deployment-related health. The DoD and VA have numerous databases that include such information as demographics, health outcomes, risk assessment, and compensation. Individual research projects also generate data that are important to future efforts aimed at understanding the health consequences of deployment.

Given the numerous and varied databases that exist, as well as the likelihood that others will be created in future efforts to study deployment-related health, a mechanism is needed to identify, inventory, and describe data sources and to analyze ways to foster their effective use. The committee believes that the National Center should perform these functions.

There are a number of issues involved in enhancing the effective use of these data sources. These issues include dealing with patient confidentiality concerns and legal stipulations on access to VA and DoD data. It is the committee's hope that as the National Center addresses data issues, one of the goals will be to develop and coordinate end-user databases that can provide relevant and privacy-protected data to Center researchers.

Therefore, 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.

The research issues faced in examining deployment-related health are complex, and it should be emphasized that a long-term commitment is needed from Congress and from the relevant federal departments in order to nurture and sustain the research efforts that will lead to productive results. Resources for the National Center will be used to fund the core activities, the Governing Board, and Center-initiated research. Funding levels for such efforts are significant.

Since this Center will involve the work of three federal departments and will require close coordination in order to ensure its success, the committee believes that the Governing Board in its annual report to Congress should recommend a proposed funding level for the Center. This proposed budget should detail the resources needed by the Governing Board and staff as they fulfill the work of the Center by carrying out its core activities and funding the Center-initiated research. National Center funding should be a line item in the budget of the MVHCB to ensure the visibility of the Center's work. 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 fine item in the budget of the MVHCB.

Perhaps the greatest potential challenge to be faced by the National Center is sustaining its long-term presence and viability. Deployment health concerns are raised to the level of national issues only sporadically (e.g., illnesses of Gulf War veterans and Agent Orange concerns of Vietnam veterans). Given the inter-departmental responsibility of the MVHCB, the National Center could become lost in the midst of large bureaucracies. It is imperative that commitment to the Center be long-term. The committee has, therefore, developed several safeguards to help secure the Center's sustainability.

First, all relevant constituencies, particularly active, reserve, and guard forces and veterans, would be represented on the Governing Board. Additionally, it is proposed that the Governing Board report directly to Congress, in addition to reporting to the MVHCB. The establishment of a National Center has received a great deal of congressional interest and support to date, and it is hoped that continued congressional involvement will be a driving force in sustaining the Center. Further, the Center, as part of the MVHCB, would have high-level federal involvement, as it would be part of the responsibility of the secretaries of the three federal departments. Funding for the Center would have visibility because it would be a specific line item in the budget.