Joy J. Ilem
Mr. Chairman and Members of the Subcommittee:
Thank you for inviting the Disabled American Veterans (DAV) to provide testimony on Department of Veterans Affairs (VA) research programs. As an organization of more than one million service-disabled veterans, DAV has a genuine concern about the health and well-being of the men and women who are serving today or who have served our country and suffered physical and mental disabilities as a result of military service.
VA’s research program, developed following World War II, has a rich and robust history with a clear mission, “To discover knowledge and create innovations that advance the health and care of veterans and the nation.” The program is distinguished by three Nobel Laureates, six Lasker Prize winners and a number of important discoveries and inventions. Today, VA’s offices of Health Services Research and Development and Rehabilitation Research and Development are focusing on a number of important areas including: posttraumatic stress disorder (PTSD); mental health and substance abuse; spinal cord injury; genomic medicine, and women’s health. The complex and unique injuries sustained by troops serving in Iraq and Afghanistan have created the need for new research and treatment strategies focused on addressing the unique needs of the newest generation of combat disabled veterans who have traumatic brain injury (TBI); polytrauma; spinal cord injury; burns; amputations, and hearing and vision loss. Although VA has been the leader in conducting research on many war-related injuries in the past, it is critically important that proper funding be made available for VA to expeditiously conduct research and effectively implement related advances in treatment for all of these devastating injuries. My testimony will focus on several of these areas in more detail.
Many veterans who served in Operations Enduring and Iraqi Freedom (OEF/OIF) have sustained catastrophic or polytraumatic injuries during their military service to include severe brain injury, spinal cord injury and traumatic amputation. Most servicemembers begin the recovery and rehabilitation process at Walter Reed Army Medical Center (WRAMC) or other specialty military treatment facilities. “Warrior Rehab” as it is known is an extraordinary example of the incredible journey many severely injured veterans travel as they are rehabilitated, fitted and trained to use state-of-the art prosthetics. The new rehabilitation center at WRAMC and the extraordinary Center for the Intrepid (which was sponsored by DAV and our contributors), are two of the world’s most technologically advanced rehabilitation centers for amputees. As servicemembers transition to veteran status and into VA care, we encourage VA to significantly increase research on amputation, prosthetics and orthotics to help improve health outcomes and make available the newest technologies for this unique patient population. A significant number of servicemembers and veterans returning from OEF/OIF today are young—and aggressive rehabilitation programs are helping them return to very active lifestyles. VA will be responsible for the long-term health maintenance of this population for decades; therefore, it is appropriate that VA develop research initiatives that ensure VA is the leader in advancing new technologies and prosthetic and orthotic items, and rehabilitation models that promote good health outcomes for veterans with amputations. Any research should also include older veterans from previous generations who could benefit from these studies.
Traumatic Brain Injury
Mr. Chairman, Traumatic Brain Injury (TBI) and spinal cord injury account for almost 25% of the combat causalities sustained by our soldiers in OEF/OIF. Blast injuries that violently shake or compress the brain within the closed skull cause devastating and often permanent damage to the brain—and veterans with severe TBI will likely need a lifetime of care for their injuries.
Military service personnel who sustain catastrophic physical injuries, and suffer severe TBI, are easily recognized and the treatment regimen is well-established. However, VA experts note that TBI can also be caused without any apparent physical injuries when a veteran is in the near vicinity of improvised explosive device (IED) detonation. Veterans suffering a milder form of TBI may not be detected so readily, but symptoms can include chronic headaches; irritability; disinhibition sleep disorders; confusion; memory problems; and, depression. With nearly 15,000 IEDs now reported in Iraq alone, it is believed that many OEF/OIF servicemembers have suffered mild brain injuries or concussions that have gone undiagnosed, and that symptoms may only be detected later, when these veterans return home.
We are concerned about emerging literature that strongly suggests that even “mild” TBI patients may have long-term mental health and other health consequences. According to VA’s mental health experts, mild TBI can produce behavioral manifestations that mimic PTSD or other symptoms. TBI and PTSD can also be co-existing conditions. Much is still unknown about the long-term impact of these injuries and the best treatment for mild/moderate TBI. The influx of OEF/OIF servicemembers returning with brain injury and trauma has increased opportunities for research into the evaluation and treatment of such injuries in newer veterans; however, we suggest that any studies undertaken by VA include older veterans of past military conflicts who may have suffered similar injuries that thus far have gone undetected, undiagnosed, and untreated. Their experiences could be of enormous value to researchers interested in the progression of these injuries on a long-term basis. Likewise, such knowledge of historic experience could help both Department of Defense (DoD) and VA better understand is the procedures and policies needed to improve screening, diagnosis and treatment of mild TBI in the newest generation of combat veterans.
We are pleased that VA has designated TBI as one of its special emphasis programs, and is committed to working with DoD to provide comprehensive acute and long-term rehabilitative care for veterans with brain injuries. We urge Congress to remain vigilant to ensure that VA research programs are sufficiently funded and are adapted to meet the unique needs of the newest generation of combat service personnel and veterans with TBI, while they continue to address the needs of older veterans with severe physical disabilities, as well as posttraumatic stress disorder (PTSD) and other combat-related mental health challenges.
Current research findings indicate that OEF/OIF combat veterans are at higher risk for PTSD and other mental health problems caused by their experiences and exposure in these wars.
VA reports that veterans of these current wars have sought care for a wide range of possible medical and psychological conditions, including mental health conditions, such as adjustment disorder, anxiety, depression, PTSD, and the effects of substance abuse. Through July 2007, VA reported that of the 252,095 separated OEF/OIF veterans who have sought VA health care since fiscal year 2002, a total of 94,921 unique patients had received a diagnosis of a possible mental health disorder. Over 45,000 of the enrolled OEF/OIF veterans had a probable diagnosis of PTSD, and almost 38,000 reported nondependent abuse of drugs. Also, critically, 31,000 OEF/OIF veterans have been diagnosed with depression.
In a recent study, VA New Jersey-based researchers examined substance abuse and mental health problems in returning veterans of the war in Iraq. Researchers noted that although increasing attention is being paid to combat stress disorders in veterans of the Iraq and Afghanistan conflicts, there has been little systemic focus on substance abuse problems in this cohort. In the group studied (292 New Jersey National Guard members who had returned from Iraq within the past 12 months) there was a 39.4 percent prevalence of a substance abuse problem; 37.1 percent reported problem drinking; and a 21.2 percent prevalence of alcohol abuse or dependence. Highlights of the study included the following findings: nearly 47 percent of veterans studied had reported a mental health and/or substance abuse problem. Substance use problems were found to be higher among veterans with mental health problems; access to treatment both during and after deployment was especially low for those needing substance abuse treatment (among veterans with dual disorders—41 percent received mental health treatment but only 9 percent received treatment for substance abuse). We urge VA to continue research into this critical area and to identify the best treatment strategies to address substance abuse and other mental health and readjustment issues collectively.
We urge VA to continue research that is veteran-centered and specifically focused on rehabilitation of veterans with physical and cognitive impairments related to military service and studies to identify and promote effective and efficient strategies to improve the delivery of healthcare to veterans. We believe VA’s research priorities should include:
- A study to objectively and systematically measure the expectations of OEF/OIF veterans to help VA better serve this population. These veterans are younger, have family and community support systems in place, and are frequently dealing with complicated post-service readjustment, employment, education and other issues. VA should conduct health services and other research to identify services to meet their mental health needs.
- Studies to address access issues for this new population including tracking of OEF/OIF veterans to learn what services they utilize. VA should also examine barriers to care, especially those that relate to attitudes of veterans and their families toward being treated in the VA, and any breakdown in access this may cause.
The DoD and VA share a unique obligation to meet the health care—including mental health care—and rehabilitation needs of veterans who are suffering from readjustment difficulties and various injuries as a result of combat service. Both agencies need to ensure that appropriate research is conducted and that federal mental health programs are adapted to meet the unique needs of the newest generation of combat service personnel and veterans, while continuing to address the needs of older veterans with substance abuse problems, PTSD and other combat-related readjustment issues and other mental health challenges. Congress must remain vigilant to ensure that research and treatment programs are authorized and sufficiently funded.
With increasing numbers of women serving in the military, and with more women veterans seeking VA health care following military service, it is essential that the VA be responsive to the unique demographics of this veteran population cohort. In addition, VA must ensure that its special rehabilitation programs are tailored to meet the unique health concerns of women who have served in combat theaters and those who have suffered catastrophic disabilities as a result of military service. Women’s’ health research is essential to achieving these objectives—specifically to fully understand the healthcare needs of this population and to develop high quality services and treatments.
In 2004, VHA’s Office of Research and Development held a groundbreaking conference, “Toward a VA Women’s Health Research Agenda: Setting Evidence-Based Research Priorities for Improving the Health and Care of Women Veterans.” The participants of the conference were tasked with identifying gaps in understanding women veterans’ health and health care, and with identifying the research priorities and infrastructure required to fill these gaps. In April 2005, a special solicitation was issued for intramural VA research proposals to assess health care needs of women veterans and demands on the VA health care system in targeted areas, such as mental health and combat stress, military sexual trauma (MST), PTSD, homeless women veterans, and differences in era of service (e.g., Iraq vs. Gulf war service periods). An entire issue of the Journal of General Internal Medicine was dedicated to VA research and women’s health in March 2006. Published findings included articles on why women veterans choose VA health care; barriers to VA health care for women veterans; the health status of women veterans; PTSD and increased use in certain VA medical care services; and, MST.
We have strongly encouraged VA, as it takes steps to advance this agenda, to focus on research and programs that enhance VA’s understanding of women veterans’ health issues and discover new ways to optimize health care delivery and improve health outcomes for this special VA patient population.
Mr. Chairmen, one area of particular interest to DAV is the incidental impact of VA’s primary care model on women’s health. There has been a trend in the Veterans Health Administration (VHA) to move away from dedicated women’s health clinics, to general primary care, for the purpose of providing both primary, and gender-specific health care to women veterans within unified clinics. According to VA, less than half of its facilities surveyed provide care to women through mixed gender primary care teams, referring women to specialized women’s health clinics for gender-specific care. In the mid-1990s, VA reorganized from a predominantly hospital-based delivery care model, to an outpatient health care delivery model, focused on preventative and health maintenance care. While we believe that shift was appropriate, we are concerned about the incidental impact of the primary care model on the quality of health care delivered to women. VA’s 2000 conference report, “The Health Status of Women Veterans Using Department of Veterans Affairs’ Ambulatory Care Services,” noted that with the advent of primary care in VA, many women’s clinics were being dismantled and that women veterans were assigned to primary care teams on a rotating basis, without regard to gender. Findings from that report indicated that this practice further reduced the ratio of women to men in any one practitioner’s caseload, making it increasingly unlikely that an individual clinician would gain the clinical exposure necessary to develop and maintain expertise in women veterans’ health. We understand that a follow-up study is currently being conducted and that VA researchers will study the impact of the practice structure on the quality of care for women veterans, are fragmentation of care including unmet health care needs of those with chronic physical and mental health conditions.
VA acknowledges that full-service women’s primary care clinics that provide comprehensive care, including gender-specific care, are the optimal milieu for providing care to women veterans. Or, in cases where there are relatively low numbers of women being treated at a given facility, it is preferable to assign all women to one primary care team, or provider, in order to facilitate the development and maintenance of provider clinical skills in women’s health. VA also notes that the health care environment directly affects the quality of care provided to women veterans and has a significant impact on a patient’s comfort, privacy, feeling of safety, and sense of welcome.
According to VA researchers, although women veterans surveyed reported that they prefer receiving primary and gender-specific health care from the same provider or clinic, in actuality, their care is often fragmented, with different components of care being provided by different clinicians with variable degrees of coordination and expertise in caring for women. Additionally, researchers have found a number of barriers to delivering high quality health care to women veterans. Specifically, insufficient funding for women’s health programs; competing local or network priorities; limited resources for outreach; inability to recruit specialists; lower numbers of women veterans’ caseloads; limited availability of after-hours emergency health services; and, an insufficient number of clinicians skilled in women’s health, have been identified as current barriers to care for women veterans.
VA Researchers made several recommendations to address these barriers, including concentrating women’s primary care delivery to designated providers with women’s health expertise within primary care or women’s health clinics; enhancing provider skills in women’s health; providing telemedicine-based access to experts to aid in emergency health care decision making; and, increasing communication and coordination of care for women veterans using fee-basis or contract care services. We urge this Subcommittee to provide oversight and to monitor VA’s progress in this area. We also encourage VA to continue to make women’s health a research priority and to develop new knowledge about how to best provide for the health and care of women veterans.
Addressing the Needs of Women Veterans Who Served in OEF/OIF
The challenge of addressing the health care needs of the growing number of women veterans exposed to combat with and without obvious injury is daunting. In the future, the needs will likely be significantly greater with more women seeking access to care, increased health care utilization, and a more diverse range of medical conditions. It is unlikely the past experience of women veterans in the VA will serve as an accurate guide because of the unique experiences and exposures of women veterans who served in OEF/OIF.
Given the increasing role of women in combat deployments, and with more than 70,000 women now having served in the OEF/OIF combat theaters, we are pleased that the Women’s Health Science Division of VA’s National Center for PTSD (hereinafter Center) is evaluating the health impact of combat service on women veterans, including the dual burden of exposure to traumatic events in the combat theater and the potential of MST. According to the Center, although there is no current empirical data to verify MST is occurring in Iraq at a higher rate than expected, there have been numerous reports in the popular press citing cases of sexual misconduct in theater. In the Center’s Women’s Stress Disorder Treatment Team, of 49 returning female veterans, 20 (41 percent) reported MST. This is very disturbing to DAV and we believe it warrants greater attention by VA in its research portfolio.
Additionally, the Center notes that anecdotal reports from OEF/OIF veterans suggest a number of unique concerns that have a more direct impact on women than on their male counterparts returning from combat theaters, including lack of privacy in living conditions, sleeping and showering areas; limited gynecological healthcare in theater; healthcare impact of women choosing to stop their menstrual cycle; and, health consequences of dehydration and chronic urinary tract infection. Findings also suggest distinct differences occur in homecoming, including that women may be less likely to have their military service recognized or appreciated by their communities; possible differential access to VA treatment services; and, increased parenting and financial stress that they must endure.
DAV is pleased that the Center is examining gender differences in mental health; MST in the combat theater; gender differences and other stressors associated with OEF/OIF service and homecoming, including treatment of PTSD in women; enhancing sensitivity toward, and knowledge of, women veterans and their healthcare needs among VA staff; and, MST among reserve components of the armed services.
We also understand a number of VA research projects are focused on evaluation of the VA’s MST screening and treatment programs including identifying the prevalence of MST and the associated mental and physical health conditions (especially among all VA users and OEF/OIF veterans), establishing the association between MST screening and later use of MST-related treatments, and identifying key characteristics of VA facilities that influence successful implementation of MST screening and treatment practices.
Some women suffer from severe PTSD and will require intensive evidence-based treatment. VA has conducted ground-breaking research on evidence-based treatment for PTSD, including a recent study that established its efficacy for women. While these developments are an important first step, they will only have an impact on the thousands of women veterans affected when these techniques are fully deployed throughout the VA system and easily accessible to providers and patients. This is not currently the case, as acknowledged by the National Center representative in recent testimony before the President's Commission on Care for America’s Returning Wounded Warriors.
We acknowledge that VA is attempting to address the needs of women veterans returning from combat theaters in a variety of ways, and has provided guidance for medical facilities to evaluate the adequacy of programs and services for returning OEF/OIF women veterans in anticipation of gender-specific health issues. However, additional research including improvement in sharing data and health information between DoD and VA is essential to understanding and best addressing the health concerns of women veterans. At this time we do not fully understand the barriers that may prevent OEF/OIF women from accessing VA care. We do know from recent studies of OEF/OIF active duty and reserve component personnel that stigma is a major barrier in accessing mental health services; with over 40% reporting that stigma would impact their decision to seek care. We believe further research is necessary that looks at the barriers that women veterans perceive or have experienced in seeking VA health care.
VA needs to ensure priority is given to women veterans’ programs so quality health care and specialized services are made available equally for women and men. VA must continue to work to provide an appropriate clinical environment for treatment, even where there is a disparity. Given the changing roles of women in the military, VA must also be prepared to anticipate the specialized needs of women veterans who were sexually assaulted in military service and/or catastrophically wounded in combat theaters. Although it is anticipated that many of the health problems of male and female veterans returning from combat operations will be similar, VA facilities must address the health issues that pose special challenges for women. DAV has recommended that VA focus its women’s health research on finding the health care delivery model that demonstrates the best clinical outcomes for women veterans. Likewise, VA should develop a strategic plan, in conjunction with DoD, to collect critical information about the health status and continuing care needs of women veterans with a focus on evidence-based practices to identify other strategic priorities for a woman’s health research agenda.
DAV makes the following research recommendations to better serve women veterans returning from combat theaters.
- VA should conduct research involving recently discharged active duty women and recently demobilized female Reserve component members, to assess the barriers that they perceive, or have experienced, to seeking health care through VA. Research should include assessments of the effect of stigma, driving distance to the nearest source of care, lack of child care, understanding of VA eligibility and services, user friendliness of VA services for those who have attempted to access care, cultural sensitivities that differentially affect women, and other key potential barriers.
- VA should quickly disseminate and deploy resources to make evidence-based PTSD treatment easy accessible for women veterans across the country, and explore options for providing child care for those needing it to enable them to achieve access to treatment.
- DoD should fund a prospective, population-based health study of women who served in OEF/OIF. An epidemiologic study with at least a ten-year follow-up period is needed. This study should be carried out by DoD, VA and University researchers collaboratively.
- VA should conduct a comprehensive assessment of its Women Veterans’ Health Programs, including specialized programs for women who are homeless or have substance-use and/or mental health challenges, and develop an action plan to improve services for this population and projected future needs of OEF/OIF women veterans.
- VA should conduct research to fully understand the dual burden of military sexual trauma and combat-related PTSD, and develop the best treatment practices and programs for this population.
Other areas relevant to MST that could benefit from additional research resources:
- Expand evidence-based treatment for mental health conditions associated with MST, beyond PTSD (e.g., depression, substance abuse, eating disorders, and difficulties with sexual functioning).
- Increase research into the physical health co-morbidities associated with MST and how to more effectively work with MST and veterans in the primary care setting.
- Focus on ways in which existing MST treatments can be adapted to for men (In general, men are an understudied population when it comes to MST.)
- More research into barriers both male and female veterans face when trying to access MST-related treatment services.
- Research into the prevalence and consequences of MST during OEF/OIF combat deployments.
- Greater understanding of the phenomenology and dimensions of MST within VA (e.g., what specific harassment and assault experiences are captured by the existing MST screening mechanism.)
- Program evaluation research focused on demonstrating the effectiveness of innovative treatment programs prior to exporting the programs to additional facilities and programs.
Aging Veteran Population
While additional research and resources must be provided to better treat our newest generation of combat veterans, VA stills has a large cohort of aging veterans who served in earlier periods. In that respect, research focused on diabetes, hypertension, heart disease and other chronic illnesses affecting older populations must continue. Also, we are concerned that VA research address the needs of elderly veterans with co-morbid mental health and substance-use disorder problems.
DAV recommends that VA consider research for this population that:
- Addresses the health care needs of aging veterans with traumatic injuries (spinal cord injury, amputations, sensory loss), who now also must cope with the diseases of old age (such as heart disease, diabetes, chronic obstructive pulmonary disease, hypertension, etc.). Clinicians report they are seeing Vietnam veteran population cohorts who are already beginning to experience these problems;
- Develops innovative interventions to aid family caregivers who are providing home-based care for service-injured veterans. This caregiver burden needs to be evaluated to look at ways that the VA can best support them—from the perspective of caregivers who are elderly themselves to our newest generation of family caregivers of severely injured OEF/OIF veterans (e.g., parents, siblings, grandparents and spouses); and,
- Supports genomic medicine—additional resources should be provided for VA to expand its new Genomic Medicine Program. VA’s electronic medical record system allows VA to longitudinally follow its patient population and is uniquely positioned to develop this new science. Genomics offers the possibility of new, highly targeted patient treatments in the areas of mental health and chronic disease that minimize the effect of adverse reactions to clinical interventions.
Gulf War Veterans
Studies indicate about 30 percent of veterans who served in the Gulf War suffer from unexplained medical symptoms and illnesses termed Gulf War Illnesses. In 2004, then VA Secretary Principi committed up to $15 million per year for 5 years for Gulf War Illnesses research. The following year VA Secretary Nicholson announced a funding increase and establishment of a research treatment center and a pilot program to further study and treat veterans suffering with Gulf War Illnesses. Additionally, the Fiscal Year 2006 Defense Appropriations Act provided $5 million to DoD’s Gulf War Veterans’ Illnesses Research Program administered through the Office of Congressionally Directed Medical Research Program. The seed money for this program attracted a remarkable number of proposals (80) indicating significant interest to find effective and immediate treatment for Gulf War illnesses; however, DoD has excluded additional funding for the program from its proposed 2008 budget.
VA’s own Research Advisory Committee for Gulf War Veterans Illnesses notes little effort has been made to utilize VA’s heralded group of research clinicians currently treating Gulf War veterans. No mechanism is currently in place for compiling data on treatments and outcomes documented in the medical records of ill veterans seen by these VA clinicians. Additional research is needed to explore and compile good health outcomes related to efficacious treatments that are used in treating ill Gulf War veterans and to share best practices with other VA facilities.
We believe that while research into causative factors should continue, efforts should be made towards more research into treatments and interventions that take into account all effective treatments being used by VA clinicians for this population, since roughly 200,000 veterans have been suffering from Gulf War illnesses for over 16 years.
For many years, the VA has expressed its commitment to eliminating ethnic and racial disparities in health care to ensure equal access and quality health care for all veterans using VA services. In June 2007 the VA Health Services Research and Development Service (HSR&D) released a new report, Racial and Ethnic Disparities in the VA Healthcare System: A Systematic Review. This research examined a number of clinical interests including: arthritis and pain management; cancer; cardiovascular diseases; diabetes; HIV and Hepatitis C; mental health and substance abuse; preventative and ambulatory care; and rehabilitative and palliative care. The study concluded that disparities appear to exist in all clinical arenas, and a number of hypotheses were suggested to explain why disparities exist. More notably, researchers commented in nearly each case that the underlying causes of disparities in care and outcomes were not fully explored or remained unclear. One key finding was that in studies examining quality indicators representing immediate health outcomes—such as control of blood sugar, blood pressure, or cholesterol—minority veterans generally fared worse than Caucasians. The researchers noted that this finding was especially troubling since it may indicate that disparities in health care delivery contribute to disparities in health outcomes. It was also noted that fewer studies examined Hispanics, American Indians, and Asians and that in general, disparities in the VA appear to impact African American and Hispanic veterans most significantly.
The study relates specific sources of disparities and offers a number of future research recommendations to further elucidate and reduce or eliminate racial disparities in VA health care. It is clear from this study that much more needs to done in this area; therefore, we encourage VA to continue this important research.
In closing, the Veterans Health Administration is a unique health care system with much to offer its large and diverse patient population. And from its earliest days, research has been an integral part of VA’s overall mission, while maintaining a veteran-centric focus. Today, the VA system offers veterans the “best care anywhere” as reported by independent researchers, the Institute of Medicine, health industry experts and numerous media outlets. Millions of the nation’s sick and disabled veterans need and depend on the VA health care system to help them overcome severely disabling injuries suffered during their military service. We urge VA to press forward and to remain on the cutting edge of health care through its esteemed research program, and we encourage this Subcommittee to maintain necessary oversight of VA’s research and to provide sufficient funding so that VA can improve services and health outcomes for sick and disabled veterans as it continues its quest for excellence.
Mr. Chairman, this concludes my testimony and I will be happy to address questions from you or other Members of the Subcommittee.