John R. Feussner, M.D., MPH
Good morning Mr. Chairman and members of the committee. My name is John Feussner, and I am Professor and Chairman of the Department of Medicine at the Medical University of South Carolina in Charleston. I am also a volunteer staff physician at the Ralph H. Johnson VA Medical Center and was the Department of Veterans Affairs Chief Research and Development Officer from 1996 until 2002. I am testifying on behalf of the Friends of VA Medical Care and Health Research (FOVA), a coalition of over 80 organizations dedicated to ensuring that America’s veteran receive the highest quality health care by promoting the long-term sustainability of the VA Medical and Prosthetics Research Program.
On behalf of FOVA, I want to thank the members of the committee for the opportunity to present the coalition’s views on the importance of the VA research program and the challenges the program face in the upcoming years. In addition, I wish to thank the committee for its support of the VA Medical and Prosthetics Research program, as evidenced by your recommendation of a $480 million appropriation for VA research for fiscal year (FY) 2008. The support for this program across party lines is indicative of its success and the common understanding of the importance of the program for America’s veterans. FOVA encourages Congress to deliver the appropriations bill funding the VA medical care and research programs to President Bush quickly so veterans and researchers will not have to wait for access to appropriate resources.
The VA Medical and Prosthetics Research Program is one of the nation’s premier research endeavors, attracting high-caliber clinicians to deliver care and conduct research in VA health care facilities. The success of the VA program—which can be seen in the array of achievements attributed to VA researchers, such as the invention of the implantable cardiac pacemaker, the creation of a new vaccine for shingles, and the development of state-of-the-art prosthetics, including a new bionic ankle—is a function of its structure, leadership, and the secured availability of resources.
The VA research program is an intramural program; grantees must be VA employees with at least a five-eighths appointment to the VA. The program, therefore, offers a dedicated funding source to attract and retain high-quality physicians and clinical investigators to the VA health care system, who in turn provide first-class health care to our nation’s veterans. With this effective mechanism for attracting top researchers, VA has been able to make significant advances in areas of research that benefit the veteran population. VA investigators have been at the forefront of research that impacts newly returning veterans from Operation Iraqi Freedom and Operation Enduring Freedom, including research on post-traumatic stress disorder, polytraumatic blast injuries, and massive burns. In addition, VA has taken the lead on issues affecting the aging population of veterans who continue to constitute the largest portion of veterans seeking treatment in the VA system. Investigators in the VA research program have contributed to significant advances in pain management, substance abuse treatment, mental health disorders, respiratory medicine, diabetes, and Alzheimer’s disease.
FOVA would like to stress the importance and value of the VA program’s peer review system in articulating the agency’s research portfolio. Congress may encourage VA to consider new research areas; however, it is vital to the integrity of the program that scientific merit remains the predominant criteria for funding. Peer review of proposals ensures that VA’s limited resources support the most meritorious research. Additionally, centralized VA administration provides coordination of VA’s national research priorities, aids in moving new discoveries into clinical practice, and instills confidence in overall oversight of VA research, including human subject protections, while preventing costly duplication of effort and infrastructure.
While VA has been effective in its mission to provide the best possible care to the nation’s veterans, veterans from the current wars in Iraq and Afghanistan are returning with injuries and conditions that will require treatment over many years. Additionally, veterans are returning with injuries never before experienced in such severity, which require additional research, and in turn, additional resources. FOVA greatly appreciates this committee’s support for the program in FY 2008; however, the $480 million appropriation only provides a starting point when consideration is given to long-term inflationary pressures.
To fund new research while still supporting traditional research areas that benefit the majority of veteran patients, FOVA encourages Congress to support significant increases to the program over the next three years. Additional funding can support research into such issues as traumatic brain injury (TBI), mental health treatment of veterans, and the effects of limb loss on other co-morbid conditions. Research is needed to understand the physical and psychological effects of TBI injuries and long-term funding is required to conduct post-deployment surveillance for TBI. Research into the potential long-term effects of exposures and risk factors among veterans of hazardous deployments can offer potential treatments for returning veterans while leading to the development of preventative medicine for future deployments. Advances in VA’s rehabilitative research portfolio can improve treatment for paralysis and lead to greater limb function in injured veterans.
Additional funds could also restore previous funding levels for scientific awards. Due to previous years of inadequate funding, VA capped scientific awards at $125,000 annually. This level of grant support—which is barely enough to hire one laboratory technician and purchase necessary supplies¾is significantly lower than the average grant awarded by other federal granting agencies. The amount diminishes productivity, slows the translation of research from the bench to the bedside, and hinders recruitment to the VA program.
Moreover, while the promise of medical research lies in the potential to create new treatments and cures for diseases and injuries, these efforts are not achieved by one grant or project. Research is a long-term ambition that cannot be fully successful in one funding cycle but must be sustained if treatments are to be discovered. FOVA encourages the committee to consider the long-term needs of VA investigators when promoting future funding allocations for the program. As most VA research awards are three years in duration, the coalition encourages Congress to consider a planned growth for the VA research budget over the course of the next three years to continue the upward trajectory of the program in an orderly fashion.
However, even with sustained growth, VA will be ineffectual in advancing new treatments if it does not have the appropriate infrastructure in place. For years, VA has been aware of the inadequacies of its research infrastructure. An internal review of the infrastructure of VA laboratories was implemented in 2001 when I was at Central Office. The Research Evaluation Project assessed the state of the research infrastructure by surveying sites on the quality of the physical infrastructure, the organization structure in place to support research, and the availability of biomedical equipment. Based on that evaluation and the list of necessary improvements subsequently compiled, your predecessors and I reached an understanding that a dedicated funding allocation of $40 million a year was required to maintain VA research facilities. In May 2004, then Secretary of Veterans Affairs Anthony J. Principi approved the Capital Asset Realignment for Enhanced Services (CARES) Commission report that called for enhancement of VA research space, and this committee and appropriators have called on VA to update these studies.
Under the current system for funding infrastructure improvements, research must compete in the minor construction budget with other facility needs. This system has lead to an even greater accumulation of necessary research facility upgrades including improved ventilation, electrical supply, plumbing, and space configuration. FOVA applauds the committee for recommending a $15 million minor construction funding stream for research facilities in its views and estimates for the FY 2008 budget. This step certainly brings needed attention to this matter. FOVA recommends at least a $45 million allocation for research facilities improvements under the minor construction account. Considering the significant needs recognized in 2001, this level of funding would just begin to address the agency’s infrastructure problems.
While VA can take advantage of its relationships with affiliated medical schools and non-profit foundations to garner additional funding for infrastructure improvements, these funds are limited and VA must assume responsibility for the cost of its own research facilities. Based on preliminary accounts of yet another survey assessing VA research facilities, FOVA is under the impression that at least half of the facilities received failing grades, which signifies that dedicated minor construction funding is vital to sustainability of the program.
There are a number of examples of the poor state of research laboratories in the VA system. When an animal facility is too small, investigators bring the animals into their regular laboratories, exposing themselves and staff to occupational illnesses. Occupational Safety and Health Administration (OSHA) inspectors have expressed concerns about VA research facilities and, in one case, said that if it was up to OSHA, the building would be shut down. Meanwhile, a researcher in Seattle, Washington, received a grant that required storing tissue samples in sub-zero freezers. Space was allocated, but the facility was unable to provide $30,000 to upgrade the electrical system to support the freezers. VA researchers in Gainesville were unable to conduct certain types of research because their “wet lab” countertops are made of particleboard and Formica, rather than the standard stone, and are easily burned and stained from exposure to heat and chemicals.
Substandard facilities make VA a less attractive partner in research collaborations with affiliated universities, reduce VA’s ability to leverage the research and development appropriation with other federal and private sector funding, and make it difficult to attract cutting edge researchers to pursue careers in VA. Facility R&D Committees regularly disapprove projects for funding consideration because the facility does not have the necessary infrastructure and has little prospect of acquiring it. Upgrading facilities should proceed hand-in-hand with increasing funding for the VA research program to yield successful outcomes important to veterans and all patients.
Again, thank you for the opportunity to present FOVA’s views on the VA research program. I look forward to your questions.