National Center for Military Deployment Health Research (1999)

This chapter^* summarizes information upon which committee deliberations were conducted. As a starting point, the committee held a workshop in March 1999 (Appendix A). During subsequent sessions members reviewed relevant scientific literature, received testimony regarding previous research on deployment health issues, and examined the legislative history of the congressional request for this Institute of Medicine study. The committee also reviewed the charter for the newly designated Military and Veterans Health Coordinating Board. Representatives of veterans' organizations shared their perspectives on the goals for a national center to study war-related illnesses and postdeployment health issues. Further, the committee explored a number of potential center models by examining the ongoing center activities in the DoD, the VA, and the National Science Foundation's Engineering Research Center Program.

Much has been learned from the rich literature examining adverse health effects of military conflicts. Elder and colleagues (1997) conducted a longitudinal study of the health effects of experiences during World War II. They examined how well-being changed across the postwar years and varied by prewar individ-

ual attributes. Their results indicated that, after controlling for the effects of self-reported physical health at war's end and for age, exposure to combat predicted a subject would experience physical decline or death during the postwar interval from 1945 to 1960. Rank and theater of engagement were of little consequence, and self-worth before the war did not moderate the risk of physical decline or death that was associated with combat.

A study of Australian veterans of the Vietnam conflict (O'Toole et al., 1996) found that combat exposure was significantly related to reports of recent and chronic mental disorders, recent hernia and chronic ulcer, recent eczema and chronic rash, deafness, chronic infective and parasitic disease, and chronic back disorders, as well as to symptoms and signs of ill-defined conditions.

Two major contributions to the investigation of war-related illnesses resulted from research into the health problems of Vietnam veterans: (1) the development of case criteria and a label for posttraurnatic stress disorder (PTSD); and (2) a "model" for thinking about the long-term health consequences of a specific exposure (Agent Orange), despite the absence of an acute response. While PTSD was not new, recognition of it and the eventual incorporation of PTSD into both ICD-9 (International Classification of Diseases, 9th revision) and DSM-III (Diagnostic and Statistical Manual of Mental Disorders, 3rd ed.) dates from the Vietnam era. Research on the effects of Agent Orange used in Vietnam also is enriching the understanding of health problems experienced as a result of participation in that conflict.

Other reported health problems are less well-defined and include poorly understood, multisymptom clusters. The literature regarding such reports was summarized by Hyams and colleagues (1996). They found that during the U.S. Civil War, the numerous reported health problems could be separated into two unique illnesses: irritable heart (first identified by J. M. DaCosta) and nostalgia. Irritable heart had no specific sign or pathology and was characterized by shortness of breath, palpitations, chest pain, headache, diarrhea, dizziness, and disturbed sleep. Dr. DaCosta hypothesized that this disease was caused by either an infectious process or strenuous military duties.

The second illness, nostalgia, which is sometimes referred to as an early form of PTSD, most often affected the youngest Civil War soldiers, those 15 and 16 years old. Nostalgia was characterized by excessive thoughts of home, as well as by apathy and loss of appetite. Some of those affected also had diarrhea or chronic fever. AS with irritable heart, there were no characteristic signs. Unlike irritable heart, which was thought to be a physiologic disease, nostalgia was attributed to psychological factors.

During World War I, irritable heart, commonly referred to as effort Syndrome, again became an issue when soldiers reported experiencing the same symptoms, still with no characteristic sign or pathology. The condition was thought to be due to multiple factors, including strenuous military duties, exposure to poison gas, infectious diseases, and psychological distress.

Another illness experienced during World War I was called shell shock, now known as acute combat stress reaction. Its symptoms included a dazed or

detached manner, blindness, and paralysis. A number of somatic symptoms also were associated with this illness and, by the end of the war, shell shock clearly was thought to be caused by stress.

Effort syndrome was reported again during World War II. A clinical case study conducted in 1940 by cardiologist Dr. Paul Wood concluded that the syndrome was not a physiologic disease, but rather was due to psychological factors.

During the Korean War, acute combat stress reaction (also referred to as battle fatigue, operational fatigue, or combat exhaustion) was reported. It was associated with the symptoms of fatigue, shortness of breath, palpitations, headache, diarrhea, disturbed sleep, forgetfulness, and difficulty concentrating. Its cause was thought to be stress (Hyams et al., 1996).

Health problems reported following the Gulf War include a wide variety of symptoms similar to those found in acute combat stress reaction, PTSD, and chronic fatigue. To date, no research or investigation of reported health problems has identified a single etiologic entity to account for these symptoms, and no generally accepted diagnostic label or clear set of clinical criteria has been developed to use in the assessment of health problems of veterans of conflict.

Ursano and Norwood (1996) wrote that "[U]nderstanding the demands of war requires broad conceptualization of the biological, psychological, and sociocultural events involved in moving from anticipation of war to reintegration home." Charles Engel also takes a broad conceptual view of the health problems of those deployed to conflict. According to Dr. Engel, physicians often take the view that if the latest technology and tests do not show a problem, there is no problem. There are many situations in clinical medicine, however, where one deals with things that do not fit such a clearly defined diagnosis. It is necessary to pursue these medically unexplained areas to fully address war-related illnesses and postdeployment health concerns of veterans.

In addition to research being conducted on the postwar health of veterans, there are studies of specific groups within civilian populations (e.g., police, fire-fighters, and emergency personnel) that may contribute to the understanding of the effects of traumatic situations on individuals at risk. While the nature of the risks differs, results of these investigations may contribute important information to those who are studying the effects of war on the health of veterans, and vice versa.

A major impetus for the establishment of a center to study war-related illnesses and postdeployment health issues came from the veterans' community, which proposed that Congress consider establishing a national center to study the health problems of veterans of conflict. On April 23, 1998, the Subcommittee on Health of the U.S. House of Representatives Committee on Veterans' Affairs held a hearing to receive input on draft legislation to establish a center

for the study of war-related illnesses. The proposal for such a center included three main functions:

1. promote the training of health care and related personnel in, and research into, the causes, mechanisms, and treatment of war-related illnesses;

2. serve as a resource center for, and promote and seek to coordinate the exchange of information regarding, research and training activities carried out by the VA, DoD, and other federal and nonfederal entities; and

3. coordinate with DoD and other interested federal departments and agencies in the conduct of research, training, and treatment and in the dissemination of information pertaining to war-related illnesses.

Testimony presented during the hearing supported the establishment of such a center. Dr. Matthew Friedman, Director of the National Center for Post-Traumatic Stress Disorder, suggested that such a center should become a repository of data related to deployment health and environmental surveillance, with close coordination between the VA and DoD to assure timely transfer of information. Several witnesses testified that such a center should be multidisciplinary and that coordination with the DoD was essential (U.S. House of Representatives, 1998).

H.R. 3980 was subsequently introduced; it directed the VA to establish a multidisciplinary National Center for the Study of War-Related Illnesses to carry out and foster research, education, and improved clinical care of war-related illnesses. The committee report accompanying H.R. 3980 concluded that evidence suggests combat experience is a significant risk factor in developing subsequent illness and that early treatment of war-related illness therefore is important in avoiding chronic illness. The report underscored the importance of increasing understanding of war-related illnesses and of ensuring that the VA is better prepared to treat veterans of future wars or military combat.

Meanwhile, the Committee on Veterans' Affairs of the U.S. Senate was pursuing a different approach. In the spring of 1997, the committee had initiated a bipartisan special investigation of Gulf War illnesses by a team of experts. During the course of that investigation, questions were raised about the ability of the DoD and VA to collect adequate information about, keep good health records on, and produce reliable and valid data to monitor the health care and compensation status of ill Gulf War veterans. Additionally, it was perceived that because public confidence and trust in these agencies was low, the value of the center might be impaired if it was housed or run by either department. The suggestion was made that the VA and DoD were not appropriate places to establish a center for the investigation of war-related illnesses.

Acknowledging these concerns but also suggesting that such a step requires careful study and thoughtful deliberation, Senator Rockefeller introduced legislation requiring the Secretary of Defense to enter into an agreement with the National Academy of Sciences, or another independent organization, to assess the feasibility of establishing as an independent entity, a National Center for the

Study of Military Health. In introducing the legislative amendment, Senator Rockefeller stated, ''[A]s ranking member of the Committee on Veterans' Affairs, there have been too many times when I have heard agency officials testify that poorly understood, unexplained illnesses are a common, inevitable occurrence of every military conflict.... I find the acceptance of these illnesses as an inevitability to be unacceptable. I hope that this amendment will offer an initial step to better prevention and treatment of these postconflict illnesses" (U.S. Senate, 1998).

The Center for the Study of Military Health envisioned in this legislation was to:

• evaluate and monitor interagency coordination on issues relating to postdeployment health concerns of members of the armed forces, including outreach and risk communication, record keeping, research, utilization of new technologies, international cooperation and research, health surveillance, and other health-related activities;

• evaluate the health care provided to members of the armed forces both before and after their deployment on military operations;

• provide and direct training of DoD and VA health care personnel in the evaluation and treatment of postdeployment diseases and health conditions; and

• recommend to DoD and VA ways to improve health care, including improvements in the monitoring and treatment of members of the armed forces.

With different versions of the legislation in the House and the Senate, and with very different perspectives on how to approach this issue, the legislation was referred to a conference committee. Ultimately, after much discussion and negotiation, a compromise was reached that authorized the VA to contract with the National Academy of Sciences.

In September 1998, President Clinton signed Public Law 105-368, the Veterans Program Enhancement Act of 1998. Section 103 of that legislation 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 (Appendix B). As stated in the legislation, the purposes of such centers might include: carrying out and promoting research regarding the etiologies, diagnosis, treatment, and prevention of war-related illnesses and postdeployment health issues; and promoting the development of appropriate record keeping, risk communication, and use of new technologies.

Additionally, the Act authorized the Academy to make recommendations regarding (a) design of an organizational structure or structures, operational scope, staffing and resource needs, establishment of appropriate databases, the advantages of single or multiple sites, mechanisms for implementing recommendations on policy, and relationship to academic or scientific entities, (b) the role or roles that relevant Federal departments and agencies should have in the

establishment and operation of any such center or centers, and (c) Such other matters as it considers appropriate.

The Academy was directed to report on its recommendations to the secretaries of Veterans Affairs, Defense, and Health and Human Services, and to the Committees on Veterans' Affairs of the Senate and House of Representatives, not later than one year after the date of the enactment of this Act.

In 1998, the Executive Office of the President issued a Presidential Review Directive that emphasized the need for a coordinated program of research that could include "deployment health-related research, population-based troop health assessments before, during, and after deployments, and epidemiological research to determine whether deployment-related exposures are associated with postdeployment health problems" (Executive Office of the President, 1998, p. 53).

A major recommendation of the directive was the creation of a Military and Veterans Health Coordinating Board (MVHCB), which would provide ongoing coordination of all agencies involved in maintaining the health of military members, veterans, and their families. According to the directive, "The MVHCB would make information available as needed to other Executive Branch agencies, the Congress, the medical and scientific community, and the public. It is critical to the success of the Board that it adopts an inclusive mode of operation" (Executive Office of the President, 1998, p. 50).

Members of the MVHCB are the secretaries of Veterans Affairs, Defense, and Health and Human Services. The work of the Board is to be carried out through three working groups that address issues related to deployment health, research, and health-risk communication (MVHCB, 1999). Working group membership will be comprised of representatives of the respective departments.

The Deployment Health Working Group (DHWG) is charged with monitoring and coordinating interagency activities related to health protection and joint medical surveillance programs of the DoD. It will monitor contingency and deployment health planning of the armed forces and, with guidance from military and civilian health care and health research communities, make recommendations designed to enhance force health protection and medical surveillance. The DHWG also is charged with making recommendations to the relevant agencies on their preparations for postdeployment health evaluation and health care needs of military members, veterans, deployed civilians, and their families. The DHWG conducts an ongoing review of compliance with the recommendations of external review bodies and provides recommendations to the Board to ensure that "lessons learned" from combat and other military deployments and research findings are translated into effective preparation for future operations (MVHCB, 1999).

The second working group of the Board is the Research Working Group. The RWG will provide recommendations and coordination for research activities on deployment health issues affecting military members, veterans, deployed

civilians, and their families. This group will coordinate deployment health-related research studies and, to prevent unnecessary duplication and assure that resources are directed toward high-priority studies, it will be the forum for information exchange within the research community at large and for research coordination among the three participating departments. The RWG is charged with encouraging independent, scientific peer review of research in all its activities. This group assesses the state and direction of research on deployment and postdeployment health issues, identifies gaps in knowledge and understanding of issues relevant to service member and veteran health, proposes testable hypotheses, recommends research directions for participating agencies, reviews research concepts as they are developed, and collects and disseminates information on scientifically peer-reviewed research. The RWG also makes recommendations concerning appropriate responses and actions to research findings and maintains an ongoing review of the status of compliance with recommendations of external review bodies regarding research.

The third working group of the Board is the Health Risk Communication Working Group which will provide recommendations and coordination for the health-risk communication efforts of the DoD, VA, and HHS for military members, veterans, deployed civilians, and their families. This group coordinates interagency advice to the DoD on health-risk communication strategies and research and coordinates interagency activities to provide health care providers with up-to-date guidance on health-risk communication about deployment and battlefield health-risks, preventive measures, and treatments.

The MVHCB is staffed by representatives of the DoD, VA, and HHS as designated by the members of the Board or their principal alternates. An executive director is appointed by the VA Board representative after concurrence from DoD and HHS. For administrative purposes, the executive director reports to the VA's Under Secretary for Health. Additionally, each department provides appropriate staff to ensure the efficient and effective functioning of the Board. At a minimum, the Board staff includes an executive director, three staff officers (in the areas of military public health, health science, and health-risk communication), and an administrator/program analyst.

Veterans' organizations were instrumental in developing the idea for a national center for the study of war-related illness and postdeployment health issues, and these organizations continue to support the national center concept. Representatives of three veterans' organizations attended the committee's March 1999 workshop to present their organizations' perspectives.

William Brew testified for the Paralyzed Veterans of America (PVA), emphasizing the need to adopt a broad definition of the term "war-related illness" that encompasses the prevention and treatment of traumatic injuries. Additionally, the PVA takes the position that the center should be run by an entity inde-

pendent of the VA or DoD, because of a general distrust by many veterans of the way that the VA and DoD handled prior military health issues, including the use of herbicides in Vietnam. The VA's role in the compensation of veterans also is problematic, since there is at least a perceived conflict between the role of the VA as researcher into war-related illnesses and its role as payor of disability benefits for veterans found to have war-related illnesses. Mr. Brew also emphasized the importance of including guard and reserve units when studying such illnesses.

The American Legion, represented by Matthew Puglisi, emphasized the need for multiple national centers that focus on prevention Strategies, risk communication, and treatment of war-related health concerns. According to the Legion, it is important that veterans and their families, legislators, and the general public have reliable information to make informed decisions. Characteristics of a national center could include:

• a multicenter approach (jointly sponsored by VA, DoD, and HHS) with at least one center located at a military hospital;

• independent oversight of any VA administration of the centers;

• an oversight coordinating board with a representative from the Joint Chiefs of Staff;

• a long-term commitment to the center(s); and

• an occupational health approach that focuses on the unique workplace issues of concern.

Paul Sullivan of the Gulf War Resource Center advocated the need for the national center to be as independent of the VA and DoD as possible. Issues of concern to Gulf War veterans include delayed responses by the VA and DoD in addressing potential exposures to hazardous chemicals and other substances, as well as Such data issues as the need in future deployments for collecting more thorough exposure data.

In early 1999, the Defense Authorization Bill for fiscal year 1999 (Public Law 105-261) was passed, authorizing the Secretary of Defense to establish a center devoted to "... longitudinal study to evaluate data on the health conditions of members of the Armed Forces upon their return from deployment on military operations for purposes of ensuring the rapid identification of any trends in diseases, illnesses, or injuries among Such members as a result of such operations." In response, the DoD Assistant Secretary of Defense for Health Affairs directed the service branches to establish and fund the Centers for Deployment Health.

These centers include: (a) a clinical center at Walter Reed Army Medical Center; (b) a research center at the Naval Health Research Center in San Diego; and (c) a surveillance center at the Army Center for Health Promotion and Preventive Medicine (CHPPM). The decision was made to use three centers in order to take advantage of existing operational capabilities, and to coordinate such efforts within the DoD and across agencies through the Military and Veterans Health Coordinating Board. The mission of the proposed centers is to:

• manage the Comprehensive Clinical Evaluation Program and the Specialized Care Program with related quality improvement, service evaluation, and continuing medical education efforts;

• conduct clinical research evaluating risk factors, etiologies, new treatments, and prevention strategies targeting deployment health concerns;

• develop risk-communication interventions and evaluations;

• conduct surveillance for patterns and risk factors for illnesses, injuries, and symptoms;

• plan, coordinate, and conduct epidemiological analysis of medical surveillance data relevant to specific deployments;

• conduct epidemiological studies investigating the longitudinal health experience of previously deployed military personnel, and develop and evaluate health surveillance strategies; and

• conduct longitudinal studies of health outcomes, including studies of reproductive outcomes, involving both personnel on active-duty and those who have left military service.

The first of the three centers identified by the DoD is the Deployment Health Clinical Center, located at Walter Reed Army Medical Center and built upon the work of the Gulf War Health Center. Funding for this center will be managed through the Department of the Army. The goals of this center are to:

• maintain and improve primary and tertiary health care for individuals with deployment-related health concerns;

• maintain, improve, and explore the use of health information systems to improve the continuum of deployment-related health care that the military offers and to improve military medicine's capacity for identifying emerging deployment-related illnesses;

• develop a program of military-relevant clinical research, including multicenter controlled clinical trials, risk-communication strategies, and clinical health services research;

• develop, implement, and sustain an evidence-based military medical education program to increase the volume, quality, rate, and ease of use of clinically

relevant research knowledge disseminated to military health care providers regarding deployment-related health care and communication strategies.

The center's system of care will involve population- and care-based communication approaches and innovative primary and specialty care treatment of Symptoms and concerns. It is intended that this be accomplished through development of an evidence-based medicine model and specific ways to disseminate that model to both providers and military personnel. Additionally, the center plans to develop a clinical research program that will evaluate postdeployment concerns and needs of military personnel, as well as how effectively those needs are met. Research foci would include health Services research, multicenter trials, and development of guidelines for care of individuals after they have been deployed.

The Naval Health Research Center in San Diego has been designated the DoD Deployment Health Research Center. Funding for this center is provided by the DoD Director of Defense Research and Engineering through the Army Medical Research and Materiel Command. The goals of this center are to:

• manage epidemiological studies investigating the longitudinal health experience of previously deployed military personnel, and develop and evaluate appropriate health surveillance strategies; and

• develop a research portfolio of studies of symptoms, hospitalizations, reproductive outcomes, mortality, and other health outcomes for all DoD beneficiaries, including those on active-duty as well as retirees, and dependents.

Research activities for this center are part of a larger program effort of epidemiological assessments that includes HIV studies, occupational epidemiology, and global surveillance for emerging infections, as well as research on health-behavior interventions for the prevention of musculoskeletal injuries, alcohol misuse, and sexually transmitted diseases/HIV.

While some of the work of this center overlaps with that of the other two components of the DoD Centers for Deployment Health, the health research center will focus on hypothesis testing, the application of scientific methods to particular issues (e.g., epidemiological methods), and the dissemination (journal publication) of results and findings of studies. The main requirement of all studies conducted in this center is that they be controlled epidemiological studies. Such studies will be collaborative within the armed services (Navy, Air Force, and Army), with other federal agencies, and with universities.

In the future, key factors in the conduct of deployment health research will include sites of future deployments, immunizations used, need for stored biological samples and improved exposure information, the development of out-

come measures, and the ability for improved information linkage with the goal of identifying causes and preventing future episodes of postdeployment health problems.

The major repository for data on military personnel is the Directorate of Epidemiology and Disease Surveillance of the Army Center for Health Promotion and Preventive Medicine. CHPPM has been designated as the DoD repository for all theater medical surveillance and treatment data collected by the armed services, the Unified and Specified Commands, and the individual commands within the services.

The Directorate has two major sections, the Epidemiology Division and the Army Medical Surveillance Activity (AMSA). AMSA maintains (a) the Defense Medical Surveillance System (DMSS), (b) the DoD serum repository, (c) the Defense Medical Epidemiology Database (DMED), and (d) the Medical Surveillance Analysis Contract.

DMSS will be designated as the DoD Deployment Health Medical Surveillance Center. The information contained in the DMSS ranges from preinduction data (including initial HIV tests, and limited medical information from the military entrance processing station) to postdischarge data. Ultimately, databases for assignments and deployments, inpatient hospitalizations, ambulatory data, reportable diseases, health-risk assessments, and pre-and post-deployment specimens and surveys will be linked through the DMSS.

The Defense Medical Epidemiology Database is a prototype system that provides the public with remote access to DMSS but does not permit the identification of individuals. It attempts to integrate the epidemiological capabilities of the Army, Air Force, and Navy into one system by using a standard methodology and standard data elements. The Phase I prototype includes longitudinal personnel data and hospitalizations for active-duty personnel. It is DoD's intent to expand the data Sources to include ambulatory data, and reportable disease and deployment information.

Currently, reportable disease data are being collected independently by each Service, but the DoD is working to implement a triservice (Army, Navy, and Air Force) reportable-disease database. Health-risk assessment has been an Army-only system that includes such behavioral factors as smoking, alcohol use, seat-belt use, and exercise. It eventually will be superseded by the Health Enrollment Assessment Review developed by the Air Force.

Environmental exposure information currently is not a part of the database. CHPPM maintains information on environmental exposures for deployment, but it is typically not population-based and cannot be linked with individuals. CHPPM has been designated as the repository for all theater medical surveillance and treatment data.

The DMSS database contains information on more than six million persons including all those on active-duty, in the Reserve, or in the National Guard for all five services (Army, Navy, Air Force, Marine Corps, and Coast Guard). The database includes such demographic data as assignment locations at specific points in time, military occupational specialty, marital status, and pay grade.

Without a DoD partner in the research effort, access to much of this information is limited. There are two working models for how such a partnership might take place. One approach is for a university to request that the DoD researchers join in a research partnership. The problem with that approach is that universities frequently do not address the operational issues that are of prime interest to the DoD. The alternative model is for the DoD to be the lead investigator and seek support from a university or other agency with needed expertise. That approach is more likely to receive funding.

The Department of Veterans Affairs serves an estimated 25.6 million veterans, of whom nearly 80 percent served during defined periods of armed hostilities (VA, 1999a). The VA is organized into three major divisions: the Veterans Health Administration, the Veterans Benefits Administration, and the National Cemetery System. It is the Veterans Health Administration that carries out the VA's health-related research and development activities.

Under the VA's chief research and development officer, there are four research services: medical research, health services research and development, rehabilitation research and development, and cooperative studies. Research at the VA is conducted as an intramural program, and principal investigators and center directors must have at least a 5/8ths full-time-equivalent appointment with the VA. The VA has developed formal affiliations with academic institutions throughout the country, and the strength and depth of these collaborations have enhanced the VA's research efforts. Research funding is awarded through a competitive peer-review process, and research is conducted at more than 100 VA medical centers nationwide. The VA focuses on research that will have clinical applications; as a result, approximately three-quarters of the principal investigators are clinician researchers.

In 1997, at the request of the VA Research Realignment Advisory Committee, the VA established the following designated research areas: acute and traumatic injury, military and environmental exposures, chronic diseases, sensory disorders and loss, mental illness, substance abuse, special underserved high-risk populations (including the homeless), aging and age-related changes, and health services and systems. The VA and DoD work collaboratively in a number of these areas, including prostate disease, emerging pathogens, military

operational stress-related illnesses, combat casualty and wound repair, and the physiological foundation of physical performance.

The VA's Environmental Epidemiology Section maintains a complement of data resources that are crucial for epidemiological research on veteran populations. Several registries have been developed (the Agent Orange, Ionizing Radiation, and Persian Gulf registries) that contain data on many veterans from specific conflicts or with specific exposures. Patient treatment files contain online patient discharge records for patients treated in VA health care facilities and can be used for hospitalization and case-control studies. The Beneficiary Identification and Record Locator Subsystem has approximately 40 million online records on veterans and dependents who have filed VA claims. This database can be used to track individuals for vital status; it also has death certificate information. Additionally, in order to locate individuals and process claims, the VA has access to the Social Security Administration's Death Master File and the Internal Revenue Service's Taxpayer Address File through interagency agreements. Records on retired military personnel are available through the National PerSonnel Records Center.

In 1990, the VA and DoD entered into an agreement to transfer directly to the VA the medical records of individuals separating from the military. The nature and extent of the data resources available through the VA make them valuable resources for epidemiological research on veteran populations. The complexity of the databases and concerns about preserving data privacy, however, have significant implications on how non-VA researchers can utilize this information.

In conjunction with its investigator-initiated research, the VA conducts research through a number of designated centers. The Medical Research Service funds research centers focusing on schizophrenia, AIDS, alcoholism, and diabetes. Additionally, four environmental hazard centers were established in 1994 to focus on health concerns of Gulf War veterans. The Rehabilitation Research and Development Service addresses the minimization of disability and restoration of function in veterans disabled by trauma or disease and funds six centers of excellence that focus on geriatric rehabilitation; functional electrical stimulation; healthy aging with disabilities; mobility; auditory research; and amputation, prosthetics, and limb loss prevention. Through the Health Services Research and Development Service, 11 Centers of Excellence are funded to address a wide variety of issues related to improving health services, including quality of care and primary care delivery. The VA's Cooperative Studies Program facilitates the use of multicenter clinical intervention studies and funds four coordinating centers and three epidemiology research and information centers.

The following examples provide information on potential models for a national center (or centers) on war-related illness and postdeployment health issues situated within the VA system.

Geriatric Research, Education, and Clinical Centers. The Geriatric Research, Education, and Clinical Centers were implemented by the VA in 1975 to address health care issues for the aging veteran population. The focus of the GRECC program is on enhancing research, education, and clinical care by integrating the three elements in each center. There are currently 18 GRECCs located throughout the country, with each center focusing on a specific research area in geriatrics or gerontology. A competitive peer-reviewed proposal process is conducted to select the centers. Priority areas in aging research that are not currently being sufficiently addressed are identified by the GRECC program; however, VA facilities have an open competition for research topics, and five pilot research projects may be submitted as part of the proposal.

Based on a core staffing model of 12 full-time-equivalent employees, the staff of each GRECC includes a director, three associate directors (research, education and evaluation, and clinical), five researchers, and three administrative support staff (Goodwin and Morley, 1994). All GRECCs are required to have close affiliations with medical and other health professional schools, and the centers have developed extensive fellowship training, professional health care training, and continuing education programs. GRECCs receive significant non-VA funding, primarily from the National Institutes of Health. From 1981 to 1991, funding from non-VA sources grew from 48 percent to 79 percent of the GRECCs' total research funding (Goodwin and Cohen, 1994).

A critical component of the success of the GRECC program has been independent evaluation. In 1980, Public Law 96-330 authorized the establishment of the Geriatric and Gerontology Advisory Committee, a committee of non-VA experts. The committee conducts site visits of each GRECC in three-year cycles, and its findings are presented to VA officials and Congress. Additional evaluation components include specific performance measures that were implemented in 1997.

National Center for Post-Traumatic Stress Disorder. Another model for a national center program operating within the VA is the National Center for Post-Traumatic Stress Disorder. Established in 1989 as a result of congressional mandate (Public Law 98-528), the center promotes research, education, and training on the causes, diagnosis, and treatment of PTSD and other stress-related disorders. The center is structured as a multisite consortium that unites existing VA centers, each with an area of unique but complementary expertise. The center's seven divisions focus on behavioral sciences (Boston, MA), education (Menlo Park, CA), women's health sciences (Boston, MA), clinical neurosciences (West Haven, CT), clinical program evaluation (West Haven, CT), cross-cultural issues (Honolulu, HI), and executive planning and information resources (White River Junction, VT). The center has developed extensive training programs for mental-health and

primary-care clinicians, and it works in conjunction with the academic community and with a number of other federal agencies, including DoD, the Centers for Disease Control and Prevention (CDC), the National Institute on Mental Health, and the National Institute of Justice.

The PTSD center serves as a national clearinghouse for information on the treatment, etiology, diagnosis, and prevention of PTSD. This information is available through a number of publications and venues, including newsletters, research publications and presentations, an Internet site, and the PILOTS (Published International Literature on Traumatic Stress) bibliographic database. The audience for information dissemination includes veterans and their families, VA and civilian health care providers, and the research community.

Another potential model of a program of national centers is the National Science Foundation's (NSF) Engineering Research Centers (ERCs). In the early 1980s, the NSF recognized a need for research centers in engineering that would encourage cross-disciplinary research and improve the training that engineering students received in the practical applications of engineering for industrial uses. At NSF's request, the National Academy of Engineering examined the issue and proposed guidelines for an Engineering Research Center program (NAE, 1983). The program was begun in 1985, and there are currently 21 ERCs located throughout the country.

While the topics are quite different, there are a number of cornerstone elements of this program that may be relevant for establishing national centers on war-related illness and postdeployment health issues. These elements include:

• Focused strategic goals.

• Defined deliverables.

• Long-term funding commitments. ERCs are funded in two 5-year increments, with reviews at the 3-year and 6-year points. It is expected that they will become self-sufficient after 10 years and not receive additional NSF funds after that time.

• Peer-review and competition for center sites and for research topics, including technical review and site visits by independent expert panels.

• Emphasis on interdisciplinary research, collaboration, and flexibility.

• Oversight and performance review. There is a strong evaluation component of the entire program and of individual centers, including evaluation studies by experts outside NSF and annual reviews of centers.

The VA presented its proposed plans for a national center (or centers) for the study of war-related illness and postdeployment health issues to the committee (VA, 1999b). Underlying the VA's concept of a national center is the need for (1) preventive strategies to minimize illness and injury that could be implemented prior to, during, and after future conflict; and (2) increased attention to improving the care of active-duty and veteran patients. The VA views a national center as an integrated approach that would contribute to improving the health of active-duty military personnel and veterans after peacekeeping missions and war.

The four major program components of the VA's plans for a national center (or centers) focus on research, clinical care, risk communication, and education. First, it is intended that each center implement a balanced program of epidemiological, clinical, health services, and basic research. The results of such research are to be disseminated through publications, scientific presentations, training, and education programs to the medical, scientific, and veterans' communities. Second, it is proposed that the center (or centers) would integrate new and existing knowledge and skills into medical practice through the use of education and training programs for students, residents, VA staff, and the medical community.

Design, implementation, and evaluation of clinical care models for postdeployment illnesses of veterans is the third major component of the center (or centers). Demonstration projects on new approaches to clinical care might include multidisciplinary clinics, postdeployment evaluation and management units, specialized clinics and consultation teams, case management in primary care, cognitive behavior therapy, sleep evaluation programs, and rehabilitation units.

Finally, each center would be responsible for developing and coordinating effective health-risk communication programs that provide military personnel, veterans, and their families with up-to-date information about postdeployment health issues. The center (or centers) would serve as a focus for coordinating health-risk communication efforts of DoD and the VA.

The VA plans require that each center be located at a VA medical center that has strong academic affiliations with medical and other health professional schools. Additionally, it is considered crucial for the center (or centers) to actively collaborate with the DoD, particularly the Centers for Deployment Health. Other affiliations would include HHS (particularly the Centers for Disease Control and Prevention and the National Institutes of Health) through memoranda of understanding and other mechanisms.

Center sites would be chosen through a competitive peer-reviewed selection process. Program evaluation and oversight of the selection process and center productivity would be conducted by a non-VA advisory committee composed of veterans, health care providers, and scientists. Centers would report to a central

VA program office that would coordinate the federal/academic collaborations, oversee the funding process, and work closely with the Military and Veterans Health Coordinating Board and the advisory committee.

The background information discussed in this chapter was useful to the committee as it deliberated on its findings (Chapter 3) and then went on to fully develop its recommendations for a National Center (Chapter 4).