[House Hearing, 109 Congress]
[From the U.S. Government Publishing Office]







 
                  OVERSIGHT HEARING TO REVIEW THE DEPARTMENT
                 OF VETERANS AFFAIRS MEDICAL AND PROSTHETIC
                                 RESEARCH PROGRAM

                                 ----------------
                                Wednesday, June 7, 2006

                                            House of Representatives,
                                       Committee on Veterans' Affairs
                                                     Washington, D.C.



The Committee met, pursuant to call, at 12:37 p.m., in Room 334, 
Cannon House Office Building, Hon. Steve Buyer [Chairman of the 
Committee] presiding.
 

Present:  Representatives Buyer, Brown of South Carolina, Turner, 
Michaud, Berkley, Reyes, Brown of Florida, Stearns, Snyder.
 

The Chairman.  The full Committee of the House Veterans' Affairs 
Committee will come to order on June 7th, 2006.  Today we are meeting 
to review the Department of Veterans Affairs medical and prosthetic 
research programs.
 

The hearing will focus on:  One, the relevance of VA research to the 
clinical treatment of veterans; two, special research projects 
identified in the department's fiscal year 2007 budget submission, 
Operation Iraqi Freedom and Operation Enduring Freedom initiatives, 
genomic medicine, and the need for upgrading and modernization of VA 
research facilities.
 

The VA conducts an extensive array of research and development as a 
complement to its affiliations with medical schools nationwide.  
While these programs are specifically targeted to the needs of 
veterans, they are intentionally recognized and have made important
 contributions across the spectrum of healthcare.
 

The department's researchers have played key roles in innovating and 
improving artificial limbs, lifts, wheelchairs, establishing better 
treatment for tuberculosis, and developing the cardiac pacemaker, 
the CAT scanner, the MRI, and others.
 

The first kidney transplant in the United States was performed at a 
VA medical center and so was the first multi-organ transplant.  VA
 contributions to medical knowledge have won its scientists many 
prestigious awards.
 

The VA's Office of Research and Development oversees a broad research 
program that focuses on biomedicine, rehabilitation, health services, 
and clinical trials.  Targeted research centers focus on specific 
conditions or methods of improving quality care throughout the VA.
 

Four services organized their efforts in the organization of 
healthcare systems around the disease and health conditions that 
are prevalent among veterans, such as the treatments for mental 
illness, rehabilitation of those who have suffered loss of limb, 
spinal cord injury and traumatic brain injury, organ transplants, 
and kidney dialysis.
 

The Committee values the research performed by the VA.  While veterans 
are the direct stakeholders in the VA R&D mission, VA research has 
defined new standards of care that benefit all Americans.  In the 
past year alone, dozens of major research findings have been reported 
in scientific literature and in the news media.
 

Good research is expensive.  The Administration asked for $399 million 
for medical and prosthetic research for 2007, $13 million below the 
preceding year.  The Administration relied on federal and nonfederal 
resources such as grants to make up the proposed difference.
 

On May 19th, the House passed the Military Construction, Military 
Quality of Life, Veterans' Affairs Appropriation Act appropriating 
$412 million for medical and prosthetic research, the same level as 
last year and a $13 million increase over the Administration's request.
 

While that figure is less than this Committee has recommended, time 
will tell if the awards for the federal and nonfederal sources will 
pan out as hoped.  Now, we want to discuss that with the first panel.
 

The Administration's fiscal year 2007 budget submission identified 
two specific research projects:  the OIF/OEF initiative andin the 
genomic medicine.  This initiative will allow all parts of VA's 
research office to provide new tools for clinicians to treat the 
physical and psychological pain of these veterans, determine how 
to improve access to healthcare and accelerate applications, 
especially for PTSD diagnosis and treatment, state-of-the-art 
amputation and prosthetic methods, and polytrauma.
 

The VA's Genomic Medicine Program, participation in which is 
strictly voluntary among veterans, will link patients' genetic 
information with their existing electronic health record.  This 
will help us understand the role of genetics in prevention and 
cure and potentially even enabling the mass customization of 
medical treatment.
 

I am pleased to hear that this program will also address subjects' 
rights, informed consent, privacy, and ownership of genetic 
material involved with genetic tissue banking.
 

The program will be administered and overseen by a Scientific 
Advisory Committee, an Ethical Oversight Committee, and Veterans' 
Advocacy Group.  And so we are interested in that, Dr. Watson.  
That is the purpose of your presence.
 

Additionally, in March, Secretary Nicholson formed this Advisory 
Committee of internationally-recognized scientists and veterans' 
advocates to advise the department on emerging issues in this field 
of medicine.
 

We are interested in hearing from the department on how they intend 
to prioritize these new initiatives against those areas that VA's 
currently engaged in such as diabetes and cardiovascular disease.
 

VA research has long benefited from collaboration with teaching 
schools and other entities, and this Committee has promoted a wider 
use of innovative collaboration in healthcare delivery generally.
 

As we enhance how we conduct research and provide care, we must be
 mindful of the infrastructure we rely on.  VA's healthcare and 
research infrastructure continues to age and will require 
additional attention.
 

The Appropriations Committee has recently recommended $12 million to 
begin an effort to modernize and upgrade research facilities to 
ensure the state-of-the-art technology, equipment, and facilities 
are provided to support state-of-the-art research.
 

And I will note and I appreciate, Dr. Perlin, my visit to the 
collaborative research facility in Charleston.  The Hollings?  It 
is for cancer, isn't it?
 

Dr. Perlin.  Yes.
 

The Chairman.  All right.  Thank you.
 

I look forward to hearing from the witnesses.
 

At this time, I will yield to Mr. Michaud for any opening statement 
he may have.
 

Mr. Michaud.  Thank you very much, Mr. Chairman.
 

I, too, want to welcome each of the witnesses here today on both 
panels and want to thank you, Mr. Chairman, for holding this hearing.
 

The VA has long been at the forefront of needed and innovative 
research.  The work performed by the VA helps perhaps the most 
deserving population in our society -- veterans and their families.
 

Breakthroughs have often helped VA and nonveterans alike.  VA 
medical research is an effort that we all support and all wish to 
enhance as well.  Unfortunately, dollars needed to maintain the 
quality of research are becoming more and more scarce as medical 
inflation and flat funding erodes budgets.
 

I look forward to hearing how the VA will prioritize the many 
research initiatives underway and how VA plans to keep its research 
facilities on the cutting edge of technology.
 

VA has a responsibility to focus its research so that it will best 
assist those that it is supposed to help.
 

For example, we have, among others, two distinct populations that 
need medical research to produce results immediately.  Our aging 
veterans are dealing with end-of-life complications.  VA medical 
research can improve the golden years for these veterans.  Operation 
Enduring Freedom and Operation Iraqi Freedom veterans have 
significantly different challenges related to the war in which they 
served.  Again, VA research can make breakthroughs and can improve 
the quality of their lives.
 

Given the current funding level, I am concerned for the ability of VA 
to fund research that helps VA's traditional patient base and also 
returning servicemembers.  We need to look at greater collaborations
, strengthening of bonds between VA and non-VA public and private 
entities.  We need to encourage researchers to pursue and win grants. 
 But these efforts cannot be a replacement for appropriating 
additional dollars.
 

We need to do better than flat funding to ensure that VA continues to 
attract the best personnel and stays at the forefront of medical 
research as well.  VA research is not an academic endeavor.  It is 
essential for improving the quality of care available to our veterans.
 

Lastly, on the front page of today's Washington Post, there is an 
article entitled Data Theft Affects Most In Military.  This data 
breach affected the sensitive personal information of 26.5 million 
veterans and servicemembers.
 

In light of this, I would like the VA to address what steps it has 
taken to safeguard sensitive personal information in its research 
program and what steps it plans on taking to protect the privacy 
and security of the genetic information it obtains as part of its 
Genomic Research Program.
 

So, Mr. Chairman, again, I would like to welcome each of the 
panelists.  I look forward to their testimony.  And I want to thank 
you for having this very important and meaningful hearing.
 

The Chairman.  Thank you, Mr. Michaud.
 

Mr. Brown, you are recognized for an opening statement.
 

Mr. Brown of South Carolina.  Thank you, Mr. Chairman.
 

I also would like to express my thanks to you for holding this very 
important hearing today and thank you to all of you who have agreed 
to testify.  I look forward to working with you on appropriate 
prioritization of the research projects and infrastructure needs in 
the coming years.  Again, thank you for being here.


We have a critical oversight role on this Committee as it relates to 
research.  While we tend to focus most squarely on the direct medical 
care the VA provides to our service men and women, research is a key 
mission of the VA, and our veterans have come to rely on the many 
advances that we have developed inside VA's walls and in 
collaboration with other public and private entities.
 

I am eager today to accomplish a few things:  Number one, first to 
welcome the new Chief of Research before this Committee, 
Dr. Kupersmith; number two, explore the emerging priorities, some of 
which have been laid out in the Administration's fiscal 2007 budget 
request, and to better understand the practical clinical application 
of the proposed initiatives; and, finally, number three, get a better 
sense of what the research infrastructure requirements will look like 
in the future.
 

We are all very aware of the great many successes VA has had in the 
area of research, but today we are taking a somewhat rare opportunity
 to showcase it.
 

As I said at the offset, Mr. Chairman, both of us here on this 
Committee and the veterans we represent have become increasingly aware 
of the fruits of VA's research efforts.  However, I think that the 
public in general has had little exposure to just how much the 
department has contributed to the national research efforts and debate.
 

Today Dr. Perlin and Kupersmith will have the opportunity to share 
that in a very public forum.
 

Again, I welcome everyone here today and thank you, Mr. Chairman, for
 doing what has been entitled Innovative Week here in the Congress 
holding a hearing on this very important subject.  And I yield back 
the balance of my time.
 

The Chairman.  Thank you, Mr. Brown.
 

Ms. Berkley, do you have an opening statement?
 

Ms. Berkley.  If I may, thanks.
 

The Chairman.  Yes.
 

Ms. Berkley.  Thank you.  Thank you, Mr. Chairman.
 

Good afternoon, gentlemen.  It is always a pleasure to have you, 
Dr. Perlin.  I am anxious to hear your testimony, so I am not going 
to talk very long.  But I did want to share with you an experience I 
had and have somebody comment on it.
 

Since I voted to go into Iraq or give the President authority to go 
into Iraq, I think it is important to be here when our troops come 
home.  So whenever I have an opportunity -- it is not very often -- I 
go to Walter Reed and I visit with our troops that have been injured.
 

There was one in particular the last time I was there a few months back 
that I visited with.  And here is a young man, 24-year-old lieutenant, 
lost his arm and his leg in an operation in Baghdad and the arm and 
leg that he has remaining are not working.
 

 

And when I went into the hospital room, his young wife was by his bed 
and his dad, who is a retired school teacher, was at the foot of his 
bed.  And we started talking and, you know, it never fails to amaze 
me how extraordinary these people are.  And rather than talking to me 
about what happened to him, he shared with me information about the 
two men that he unfortunately lost in this operation where he lost 
his arm and his leg.
 

On top of his bed, there was a chalkboard and there were monthly 
goals.  And it was like March, sit up; April -- and these may not be 
the ones, but close enough -- April, stand up; May, fitted for 
prosthetic devices.  And I walked out of the room feeling that, you 
know, this kid is going places and just a wonderful attitude and a 
tragedy, however.
 

Imagine my chagrin when I get the VA budget and the Administration 
cuts $13 million out of prosthetic research.  Now, I understand that 
we have moved that up, so now I think we are flat to where we have 
been in the past.  But give me a break.
 

 

I mean, we have people coming home that are catastrophically injured.  
They are missing arms and legs.  The least we could do for these 
people is give them state-of-the-art prosthetic devices and continue 
this research so that these people can live as normal a life as they
 possibly can and go on to a great future in this country.
 

Now, I would like an explanation of why we would possibly be provided 
with a $13 million cut in prosthetic devices when we are getting men 
being blown apart thousands and thousands of miles away from home.  
And that is one of the many cuts that I found particularly egregious.
 

So I would appreciate if you would address that concern that I have 
because I suspect that this war is going to be with us for many years 
to come and when this war is over, the results of this war are going 
to be with us many, many, many decades later.  And are we providing 
for that and preparing for that, because this is the cost of war.  
Prosthetic devices are as much a cost of war as flak jackets as far 
as I am concerned.
 

So I would appreciate that and thank you for coming.
 

The Chairman.  Thank you very much.
 

Ms. Berkley.  Thank you, Mr. Chairman.
 

The Chairman.  Anyone else have an opening statement?
 

All right.  Dr. Perlin, you are now recognized.


STATEMENT OF JONATHAN B. PERLIN, UNDER SECRETARY FOR HEALTH, 
DEPARTMENT OF VETERANS AFFAIRS

 

Dr. Perlin.  Thank you, Mr. Chairman, members of the Committee.  
Good afternoon.  Thank you very much for the opportunity to 
discuss VA research.
 

Accompanying me today are to my far left, Dr. Robert Ruff, Acting 
Director of our Rehabilitation Research and Development Service.
 

To my immediate left is Dr. Matthew Friedman, Director of VA's 
National Center for Posttraumatic Stress Disorder.
 

At the far right is Dr. Michael Watson, member of the Genomic 
Medicine Program Advisory Committee and Executive Director of the
 American College of Medical Genetics Foundation.
 

And I am also very pleased to be able to introduce to the Committee 
Dr. Joel Kupersmith, VHA's new Chief of Research and Development, 
Chief Research and Development Officer.
 

Dr. Kupersmith joined VA last year after a distinguished career as 
a cardiologist, faculty member, and researcher at the Methodist Real 
Medical Center or Medical School and the Mount Sinai School of 
Medicine, University of Louisville, Michigan State University, and 
serving most recently as the scholar in residence at the Institute 
of Medicine and the American Association of Medical Colleges.
 

In fact, he served as well as the Dean of the School of Medicine and 
Graduate School of Biomedical Sciences at Texas Tech University, and 
this is Dr. Kupersmith's first opportunity to meet with you 
officially.  In a few moments, he will provide testimony to you on 
the Office of Research and Development and the activities within 
VA's Research Program.
 

VA research is, as was said, not an academic exercise.  It is 
focused around the mission of improving the health and well-being 
of America's veterans.  As also recognized, the benefits created 
by VA research extend to literally everyone, and I hope we will 
have the opportunity to discuss some of the circumstances that 
were created that provide service to all Americans and, in fact, 
all citizens of the world.
 

The VA Research Program has been tremendously productive.  It has 
fostered three Nobel laureates and six individual researchers were 
awarded the Lasker Prize which some consider a sort of pre-Nobel 
type of recognition.
 

Before I turn to Dr. Kupersmith, I would like to address an issue of 
great significance to the future of VA research and healthcare and 
that is our plans for genomic research.  Genomics is not fantasy.  
Rather genomics supplements what we already know and do today in 
medicine to focus on and improve care to veterans.
 

In fact, we already use genomic medicine in patient care in a number 
of areas.  We used genetic testing to identify cancer patients who 
react better to reduced doses of chemotherapy resulting in lower 
toxicity.
 

Patients with the gene for abnormal clotting factor are identified 
through testing so that we can reduce the chance for stroke or 
embolism.
 

Genetic information allows us to lower the number of drug-induced 
bleeding episodes resulting from warafin, a widely-used drug for 
thinning blood.
 

In cancer screening based on molecular, genetic, and proteomic tests
 identifies the disease earlier in many patients, giving us the 
opportunity to save many patients who, in fact, once could not be 
cured.
 

The first priority of our newly-appointed Genomic Medicine Advisory 
Committee will be to provide expert counsel on protecting veterans' 
privacy.  They will also establish a strong ethical foundation for 
VA's use of genetic information.
 

Our Committee members who are nationally renowned medical experts in 
genomic research, bioethics, and disease management will assess the 
potential impact of genomics on existing VA patient care services, 
recommend policies and procedures for tissue collection and storage 
and analysis, and develop a research agenda to optimize knowledge 
and improve patient care and the health of our veterans.
 

They will also help us conduct focus group surveys and provide other 
direct contacts with veterans to learn about and appropriately 
address issues of importance to them and their families.
 

Our integrated research program, our benchmark care quality, and our 
robust Genomic Medicine Program will allow us to maintain our 
leadership in providing veterans with the state-of-the-art care that 
they have earned through their service and sacrifice.
 

We recognize, however, that we must construct a strong and ethical 
foundation, scientific foundation in partnership with veterans and 
their families in order to be successful.
 

At this time, I turn to Dr. Joel Kupersmith to provide his testimony 
on the current status of VA research.  Thank you.
 

Dr. Kupersmith.
 

[The statement of Jonathan B. Perlin appears on p.  ]
 


**********INSERT**********


STATEMENTS OF JOEL KUPERSMITH, CHIEF RESEARCH AND DEVELOPMENT 
OFFICER, DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY ROBERT L. 
RUFF, ACTING DIRECTOR, REHABILITATION RESEARCH AND DEVELOPMENT 
SERVICE, DEPARTMENT OF VETERANS AFFAIRS; MATTHEW J. FRIEDMAN, 
EXECUTIVE DIRECTOR, NATIONAL CENTER FOR PTSD, DEPARTMENT OF 
VETERANS AFFAIRS; AND MICHAEL S. WATSON, MEMBER, GENOMIC MEDICINE 
PROGRAM ADVISORY Committee, EXECUTIVE DIRECTOR, AMERICAN COLLEGE 
OF MEDICAL GENETICS

STATEMENT OF JOEL KUPERSMITH

 

Dr. Kupersmith.  Mr. Chairman and members of the Committee, thank 
you for the opportunity to discuss specifics about VA research and 
share some of my thoughts about our future vision.
 

Although I was aware of the importance of VA research before I took 
this position, I did not fully appreciate what VA research has 
contributed to veterans and the nation as a whole.
 

Veterans who returned from World War II with tuberculosis faced a 
bleak future until VA research identified and tested new highly-
effective treatments.
 

Veterans wounded in all wars have benefited from VA's work to develop 
the next generation of Seattle Foot and other prosthetics allow young 
men and women to become high-performance athletes
 

The quality of life for our aging veteran population is enhanced 
because of CT scanners, MRIs, implantable cardiac pacemakers, a 
vaccine for shingles, and countless other discoveries by VA 
clinical researchers.
 

VA research nested within a healthcare system used by more than five
 million veterans is a unique national laboratory where research is 
translated into clinical practice daily and effectively.  VA 
clinicians also initiate and conduct research projects that are 
directly relevant to the clinical care they provide.
 

The written statements includes many examples of what I will discuss 
today, but I would like to highlight one project that shows exactly 
how VA clinician investigators use VA's unique intramural program.
 

Clinicians have long noted that individuals with schizophrenia 
medicate themselves with tobacco to try to clear their brain 
abnormality.  VA research discovered a gene linked to schizophrenia 
with an additional aspect.  It is also linked to the brain center
 for smoking.
 

VA research then identified a new drug approved by the FDA for 
experimental use in humans as a possible treatment.  It is now in 
phase two trials.
 

VA clinician researchers note something at the bedside, take that 
observation to the bench, find and test a treatment, move the result 
back to the bedside in a full circle of translation and a unique 
system where research is linked to clinical care.
 

Each year, we are challenged to meet priorities based on the changing 
needs of the veterans we serve with high-quality science.  For the 
needs of returning Operation Iraqi Freedom and Enduring Freedom 
veterans, VA has responded with the following:
 

Neurotrauma research, including work related to traumatic brain 
injury, which occurs in approximately 30 percent of injured veterans 
and spinal cord injury; research related to polytrauma and blast 
injuries; amputation and prosthetic research, including use of 
futuristic microelectronics, robotics and tissue engineering to 
create lighter, more functional prostheses; many PTSD and other 
mental health projects, collaborations with Department of Defense, 
Walter Reed Army Medical Center, Brook Army Medical Center, and 
others; research about rehabilitation for the visually impaired, 
burn treatments, hearing loss, natural neural regeneration to 
return function to paralyzed veterans and those with brain injuries; 
and plans to study advanced tissue engineering and the manufacturing 
of artificial skin to accelerate wound healing.
 

Regarding our infrastructure, it is crucial that VA investigators have
 the equipment and facilities necessary to conduct cutting-edge 
research in the 21st century.  To identify where improvements may be 
needed, the Office of Research and Development has initiated a 
comprehensive review of VA's research facilities, including physical 
and operational infrastructure and major equipment to identify 
deficiencies and corrective action.  The written statement provides 
details of this project.
 

In conclusion, the vision for VA research is simple.  VA research has 
made substantial contributions to the health and well-being of 
veterans and the nation and can do so in the future.  We must 
constantly make certain that our research meets the needs of 
veterans, is of the highest scientific merit, and adheres to the 
strictest standards of human subject protection.
 

The goal is to quickly and efficiently translate research into 
clinical care and thereby address the pressing needs of our veterans.
 

Thank you for this opportunity.
 

The Chairman.  Thank you very much for all of you being here today.
 

In my years here in Congress, I have served on three Committees that 
have had oversight jurisdiction over health research from the Armed 
Services Committee with the military health delivery system.  I serve 
on the Health Subcommittee of Energy and Commerce and now this 
Committee.
 

And Congress has been very careful with all three Committees not to 
direct.  We will send you the funds, but we are not the experts.  We 
have our areas of interest, but we turn it you, the experts, to make 
competent decisions and come up with a series of prioritizations.
 

I am going to ask this question though.  When I use the term veteran 
centric research, how would you interpret that? I am going to ask two 
of you, Dr. Perlin and Dr. Kupersmith.  How would you define veteran 
centric research?
 

Dr. Perlin.  Mr. Chairman, thank you very much for holding this 
hearing and asking that very central question.
 

Veteran centric research is research that in my estimation improves 
the health and well-being of veterans.  It allows us to focus 
specifically on those issues that are unique to the veteran experience 
which, of course, is predicated on military service and military 
occupational health exposures.  It also is predicated on the issues 
that are concentrated in the veteran population that we serve.
 

As you know, our population -- while veterans at large do generally 
better than the average American, the veterans who come to VA for 
healthcare happen to be older, sicker, and poorer.  In fact, they 
have three additional physical diagnoses and one additional mental 
health diagnosis.
 

And as 49 percent are over age 65, you see very quickly in that 
demographic that there are certain vulnerabilities conferred upon 
the population.  Chronic illness and age as a mechanism of frailty 
become two central areas.
 

So military occupational health exposures, those things unique to 
combat service and military service, and those things that are 
concentrated in the veteran population which we serve are the things 
that I define as relevant to veterans as veteran centric.
 

The Chairman.  Dr. Kupersmith.
 

Dr. Kupersmith.  Yes.  I think it is the spectrum of the issues and 
conditions that are related to returning veterans of current wars 
and the issues and conditions related to the aging veteran population 
as it passes through middle age to older age.  And this includes a 
spectrum of mental health, rehabilitation research, prosthetics, and 
so forth.
 

We have an insight, I think, that others may find it more difficult 
to have because most of our investigators are clinician scientists 
who are actually taking care of patients and have direct knowledge 
of what conditions they face.  So I think this gives us added 
insight into dealing with veteran centricity.
 

The Chairman.  The reason I ask that question is that we have a VA 
system today that is much different than it was a decade ago.  The 
reason I make this comment is VA research, I believe, needs to be 
veteran-centric and it cannot be all things to all people.
 

In other words, you cannot let the - whatever physical ailments or 
whatever may depreciate the human body from a nondisabled veteran, a 
category seven or eight who is very similar to people in the normal
 population, cannot drive VA research.
 

That is the reason we here in Congress fund NIH and have doubled NIH 
funding.  And I want to make sure that with our centric meaning we 
are focusing on every war having different types of injuries and 
ailments.  And so when I use the term veteran centric research, that 
is what I think of.
 

Our polytraumas, the blast injuries, the brain trauma, continuing on
 spinal cord, all these things to me, yes, are combat related, but 
there are also some workplace injuries that are unique by what we do 
and the environment in which our servicemembers work.  And I want to 
make sure that in our priorities and how you come to judgment, you 
keep that in mind.
 

Mr. Michaud, any questions you may have.
 

Mr. Michaud.  Thank you very much, Mr. Chairman.
 

A couple of questions.  The National Vietnam Veterans' Longitudinal 
Study was mandated by statute.  The report was supposed to be due to 
Congress no later than October 1, 2004.  It is now approaching two 
years since that report is due.
 

In light of the mandate and the law, when will we be able to see 
results from that report?
 

Dr. Perlin.  Well, thank you, Mr. Michaud, for your focus on this 
incredibly veteran centric research in the terms that our Chairman 
just described.
 

The National Vietnam Veterans Longitudinal Study is the product of a 
cohort that has been followed over a long period of time.  
Dr. Matthew Friedman, who is here with me today, was one of the 
early founders of the preceding study that gave rise to NVVLS.
 

As I believe you may know, the Committee may know, the study was 
stopped by the Office of the Inspector General after significant 
cost overruns.
 

I think that within the department, there is an absolute commitment 
to understanding the needs both in terms of mental health needs and 
the physical health outcomes of Vietnam era veterans, but there are
 significant questions about the power of the remaining cohort's 
data to answer those questions.
 

There have been briefings to members and staff serving this 
Committee, and they have discussed a number of alternative approaches 
both with respect to Vietnam veterans as well as other veterans in 
terms of looking at health outcomes and PTSD in particular.
 

One is the use of a Vietnam Era Twin Registry which allows one to 
compare environmental and genetic exposures and be able to understand 
both risk and outcomes.  Another is something that we have today, but,
 frankly, we did not have when NVVLS was initiated, and that is the 
electronic health record.
 

So rather than being able only to focus on a small group of veterans 
that sadly diminishes over time, one can actually look at an entire 
population or sample of that population and look at all health 
outcomes.  And these are proposed mechanisms to get to the intent of 
that legislation.
 

Dr. Matthew Friedman has been very closely involved with this study, 
and I turn to Dr. Friedman to offer any additional comments.
 

Mr. Michaud.  Are the results forthcoming?
 

Dr. Perlin.  It is in a bit of a holding phase after the Inspector 
General's investigation of the study.  And I would say to you again 
that there are methodologic issues with the size of the cohort that 
is left to be able to offer significant insight.
 

I would think that one could get to those answers as well through use 
of electronic health records for the Vietnam Era Twin Study, and I 
would ask Dr. Friedman perhaps to elaborate on that.
 

Dr. Friedman.  Good day.
 

As Dr. Perlin has indicated, the NVVLS was discontinued based on the
 background that he has given you.  So what I would like to review 
with you are the goals of the study which were to really understand 
the longitudinal course of PTSD, the severity of the problem, and 
one of the unique questions in the NVVLS that was not addressed in 
the earlier National Vietnam Veterans Readjustment Study, the 
relationship between PTSD and physical health.
 

So after the study was discontinued, the Secretary of VA asked 
Dr. Perlin and his staff to look at alternatives.  And the two 
alternatives that he has mentioned, which I will go into a little 
more detail about, have been the Vietnam Era Twin Registry and this 
very exciting OIF Prospective Pre-deployment, Post-deployment Study.
 

The Vietnam Era Twin Registry is actually a remarkable database.  
There are now about 4,000 monozygotic and dizygotic twins.  Most 
importantly, 1,700 of them are discordant for service in Vietnam.  
What that means is that -- and these are all males, so that is -- 
one brother was in Vietnam.  The other brother was not.
 

The sample has been surveyed twice, once in 1987 and once in 1997.  
And two very important findings have been published from this study.  
One concerns the chronicity of PTSD, and the other concerns brain 
imaging among Vietnam veterans.
 

With regard to chronicity, there was a robust dose response curve, 
showing that the more severe the combat exposure, the greater the 
likelihood of PTSD.  And among the Vietnam veterans with severe 
exposure, their PTSD remained highly chronic ten years later.  So 
obviously a continued follow-up is important.
 

Another very important study from this cohort was some of the brain 
imaging work, looking at hippocampal volume which is one of the 
structures of the brain that seems to be affected and altered among 
people with PTSD.
 

So this is a very valuable research.  As you all know, in animal 
research, one of the things any investigator does is they use inbred 
genetic strains so that you can control for whatever variability a 
different genetic endowment might have.  We can control for that 
with the Vietnam Era Twin Registry.
 

So this is a very extraordinary cohort in which we can follow medical
 problems, look at risk factors, resilience factors, et cetera.  So 
this is one option that is being looked at very, very carefully right 
now.
 

The second option which is, as Dr. Perlin indicated was not on the 
screen when the NVVLS was first thought about, is a pre-deployment 
study that is being done mostly at Ft.  Lewis and Ft. Hood where at 
this point in time, over 1,500 men and women have been evaluated 
with respect to neurocognition, because that was a big concern 
following the first Gulf War, and given our concerns about traumatic 
brain injury, it is obviously a very important concern following 
these current wars.  They have also been assessed regarding pre/
post-deployment psychological factors including depression, anxiety 
disorders and PTSD.
 

So over 1,500 men and women have been assessed prior to deployment.  
And what is really important, they have been assessed shortly after 
their return and will be assessed longitudinally into the future.  
We can really look at the longitudinal course.  Also several hundred 
Guard and Reserve men and women are also in this cohort.  So this is 
a very, very valuable cohort.
 

So at this point in time, VA sees these two studies as preferable 
options to the NVVLS.
 

Mr. Michaud.  Could you provide the Committee, Dr. Perlin, with the 
list of research that VA is currently doing, what you would like to 
do as far as research, and what you are doing collaboratively with 
other areas as far as research in this area?  If you can provide 
that information to the Committee.
 

Dr. Perlin.  Yes, sir.  We would be happy to provide that.
 

The Chairman.  Could the gentleman be just a little more specific 
with regard to which area.
 

Mr. Michaud.  I am interested in all the research that the department 
is doing, if they have a list.
 

Dr. Perlin.  We would be happy to provide a summary of all of the 
research programs.  And I believe you were also seeking the 
collaborative activities specifically about mental health as well, 
the focus?
 

Mr. Michaud.  Yes, as well.  I am trying to understand better what you 
are doing and to make sure that the research is prioritized.
 

My last question, if I might, Mr. Chairman, is, if you look at what is
 happening, almost 30 percent of the patients admitted to Walter Reed 
Hospital has a brain injury, and I know it is very difficult to try 
to diagnose brain injury, if you could very briefly tell me what the 
VA is doing to improve diagnostic and screening for brain injuries.
 

Dr. Kupersmith.  Yes.  We have an RFA that we have just on that topic.  
And our projects that we have received span the spectrum from imaging 
to make a better diagnosis, various kinds of therapy, various other 
diagnostic techniques, biomarkers, cellular studies to see if we can 
come up with some basic treatments for it, and a variety of other 
projects that span from basic science to clinical.
 

So we are anticipating to fund these about the end of this year, and 
we will be very heavily into this area.
 

Dr. Perlin.  If I might just elaborate on your question in that you 
have identified a significant issue which is head trauma and brain 
injury.
 

The very significant trauma that someone experiences with other 
multiple traumas is very obvious.  And, of course, one appreciates 
very quickly that the individual sustained brain injury.
 

I believe what you may also have been alluding to are the concussive 
injuries that some may experience that are very subtle in terms of 
detection.  Frankly, VA, DoD, no one at this point has a gold 
standard for diagnosing very subtle brain injuries, yet it is 
fairly clear there are some individuals who experience a minor 
concussion and do have some cognitive disruption.  It is unknown 
what the duration of that is.  It is unknown what the best recovery 
strategies are.
 

What is clear is that all of us in all segments need to be better at 
diagnosing it and that specifically is one of the areas of research 
both of Department of Defense and Walter Reed as well as VA in this 
request for applications.
 

The Chairman.  I thank the gentleman.
 

Mr. Brown, you are recognized for five minutes.
 

Mr. Brown of South Carolina.  Thank you, Mr. Chairman.
 

Dr. Perlin, we have had several veterans come to my office that have 
ALS and they brought statistics that shows that it is a 
disproportionate number of pilots that flew over, I guess, Vietnam 
and the Gulf that have, you know, come down with ALS.
 

And I was just wondering if you were doing more in your research to 
try to find a cure for ALS and could you give us an update of where 
we are on that research.
 

Dr. Perlin.  Well, thank you, Chairman Brown.
 

This is a tremendously important observation is that the rates of 
amyotrophic lateral sclerosis or Lou Gehrig's Disease were found 
initially to be higher in pilots.  And then subsequent research 
actually found that there were higher rates in military at large.
 

And so this is an area of a very specific enterprise, and I am going 
to ask Dr. Kupersmith to elaborate on that.
 

Dr. Kupersmith.  We have a number of projects related to ALS.  It is 
certainly a focus of our interest.  And as Dr. Perlin mentioned, 
there have been reports of increased incidence with various wars and 
with the military as a whole.
 

So this is an area of interest.  I do not have a list of projects here, 
but can certainly provide you with such a list.
 

Mr. Brown of South Carolina.  Well, I guess that kind of leads me to 
my next question, is how you establish in your funding the priorities, 
you know, which area has more funding or more attention put than other 
areas.  How do you go about establishing prioritization and where those 
monies will be addressed or directed?
 

Dr. Perlin.  Let me start that question and then I will ask 
Dr. Kupersmith to add to that, is that we have a rubric called 
designated research areas.  And these research areas range from those 
things that are absolutely central to the combat experience, brain 
injury and multiple trauma and sensory injuries, central nervous 
system injuries, spinal cord injuries and the accompanying bone loss 
and degenerative diseases and rehabilitation.
 

Those are the designated research areas.  A lot of these overlap.  If 
you have mental illness, of course, you do not get a bye, you do not 
get a pass from physical disease.  In fact, it may be worse.  We have 
areas that focus on the mental health and well-being in the context of 
these other areas.
 

And so we actually have a list of designated research areas and we try 
to take a look within the dollars that you appropriate to us for VA 
research to make sure that we are doing as good a job possible as in 
the words of Chairman Buyer, being better and veteran-centric.
 

At a time of conflict as we are in now, in fact, the budget increases 
from 66.8 to $74.9 million in the 2005 to 2007 period focusing on just 
these sorts of issues.
 

We also look at the experience.  As Dr. Kupersmith said, the very 
clinicians who are taking care of veterans and servicemembers are also 
the researchers.  So one of the most important things about the VA
 research is that we are not NIH.  We are not all things to all 
people.  It is not our aspiration to be that.
 

And as you may know, I served a brief tenure as the Acting Chief of 
Research and Development and my litmus test was, "show me that the 
work is relevant to the care of veterans."  And this is our litmus 
test.
 

And the great value of VA in contrast to virtually anywhere else is 
that the clinicians caring for veterans go back to the laboratory, 
whether it is basic science or clinical research, armed with the 
picture of veterans experiencing illness, needing help improving 
their health and well-being and generate the questions.  And they 
bring forward that knowledge from the bench, from the laboratory, 
from the research studies to the patient care.
 

Dr. Kupersmith.
 

Dr. Kupersmith.  Yes.  And I would like to elaborate, give you an 
example of that.  It has been the observation that disabled 
individuals, paraplegics for example, have obesity as both 
apparently a metabolic problem and a problem related to their level 
of activity.
 

So we have an RFA on that very topic.  This is a clinician's 
observation, very relevant to the VA, very veteran centric, that 
we turn around.  And then as we have the research projects, we have 
ways of translating those directly to the patient by several of our 
research implementation programs.
 

And I think the VA has really been a pioneer in part because the 
clinical and the research enterprise are together in how to implement 
the findings of research to the bedside.
 

So whatever observations that are made in research in obese, disabled
 individuals, we can translate directly to the bedside.  And this has 
a tremendous impact.  These metabolic conditions have a tremendous 
impact on their long-time survival.  So it is just an example of that.
 

Mr. Brown of South Carolina.  Mr. Chairman, I know my time is expired, 
but just one further question to follow-up on that.
 

I know that in the Medic University and the VA, they have a cooperative
 research lab there, the Thurman and Nagesi Heart Center.
 

And I was just wondering with ALS, are we partnering with anybody in the
 private sector to try to find a cure for this terrible disease?
 

Dr. Perlin.  Let me ask Dr. Ruff.  Dr. Ruff actually wears two hats.  
He is our Chief of Neurology.  He is also the Acting Chief of 
Rehabilitation Research and Development.
 

Dr. Ruff.
 

Dr. Ruff.  Let me address ALS first.  ALS is a chronic degenerative 
condition that comes under the auspices of neurology and also under 
the auspices of rehabilitation.
 

From the clinical side, we are working with to try and enhance the 
treatment of people with ALS so that people with ALS are able to get 
treated on spinal injury units when they have advanced to the point 
of becoming functionally totally dependent for care.
 

The VA researchers are -- there are several research projects that 
are jointly funded by the VA and NIH looking at the mechanism of
 neurodegeneration associated with ALS.  And these are projects that
 are funded through -- most of them are funded through basic science.  
Some are through rehab.
 

But one thing I would just like to say without taking too much time 
is that one of the things that I personally found very exciting and 
very encouraging about what is going on in the VA is that walls that 
existed between clinical service, research, and within research are 
coming down so that we are directing our efforts towards veteran 
problems rather than being stuck in specific silos.
 

And I think that Dr. Perlin and Dr. Kupersmith have had a great deal 
of influence in terms of trying to get a more integrated approach so 
that there is integration of clinical and research activities and 
integration within the clinical services.
 

With respect to the question that was raised about detection of brain 
injury, this is a very difficult and serious problem.  Minimal 
traumatic brain injury is something that is being recognized as a 
serious problem for people in the Middle East right now in OIF, OEF.
 

The PDRECCs, which are the Parkinson's Disease Research and Education 
Clinical Centers, are working with Department of Defense to explore 
the utility of a very simple but sophisticated test of all faction as 
a means of early detection of brain injury and sensitive detection of 
brain injury.
 

The nerves that are involved in smell are very fine.  They go through 
a screen-like structure at the base of the skull and they are very 
easily damaged in head injury.  And so it may be possible to use those 
changes in smell as a way of picking up otherwise very subtle brain 
injury.
 

Thank you.
 

The Chairman.  Dr. Ruff, I would ask you to be responsive to Chairman 
Brown's question on whether you have any knowledge whether you are 
partnering with any outside private entities with regard to ALS.
 

Dr. Ruff.  Yes.  We are working with Paralyzed Veterans of America 
which has a strong interest in ALS.  There is also the ALS Foundation. 
 We do not have any direct grants with the ALS Foundation, but I met 
with people from that foundation in order to try and make sure that 
what we are doing is relevant to their needs and our needs.
 

The Chairman.  Mr. Brown.
 

Ms. Berkley, you are now recognized.
 

Ms. Berkley.  Thank you, Mr. Chairman.  I have three different 
questions on three different issues, the first directed to 
Dr. Kupersmith.
 

I listened to your testimony and this 24-year-old lieutenant that I 
spoke of when I did my opening statement, when I left Walter Reed, I 
invited him to come to Las Vegas when he was well enough to get out 
of the hospital.  And he is coming.
 

So the good news is that he is well enough to come to Las Vegas with 
his wife.  And I want to be able to look this kid in the face when I 
see him.
 

You mentioned in your testimony about cutting-edge research and I so 
regard and respect what you are doing, but are you going to be able 
to do cutting-edge research with a $13 million cut in prosthetic 
research?
 

And perhaps Dr. Perlin would like to -- I do not care who answers, but 
I want to make sure you get enough resources so you can do your job,
 so I can do my job with my veterans.
 

Dr. Kupersmith.  Yes.  We are looking at how to essentially make cuts 
in certain areas and certain programs.  For example, we are evaluating 
our centers to see that they are being productive, that they are 
leveraging money the way they should, and that they actually are doing 
what is set out.  This is something that all research institutions do. 
 But that is one way that we are looking at trying to conserve some 
resources for other areas which are important.
 

Certainly we have an extensive program in prosthetics.  I think we 
have probably led the country in prosthetic research.
 

Ms. Berkley.  And you can continue this with a $13 million cut?
 

Dr. Kupersmith.  Well, we calculated -- 
 

Ms. Berkley.  Do you want a $13 million cut?  Do you want the money 
back?


Dr. Kupersmith.  Well, we have calculated a certain number of projects 
less based on that, but we will be looking at how to conserve resources 
in other ways, particularly looking, as I said, at our centers.  We
 are making a review of our cooperative studies program centers and 
other similar endeavors.
 

Dr. Perlin.  If I might, let me thank all members of this Committee 
for your support of VA research as demonstrated in the increase of 
resources for the research program.
 

Second, let me note that when we provide services to veterans who need 
a prosthetic device, that does not come out of the research budget.  
That comes out of the prosthetics budget.  And I want to again thank 
this Committee for your support and leadership in ensuring that we 
have those resources.
 

In 2005, we spent $1.039 billion on prosthetics and assistive devices. 
 That was increased by 188 million for this year's budget of 1.227 
billion.  And the budget that you have supported adds another 160 
million in 2007 to bring that to 1.387.  So I can assure every 
injured servicemember they will have the state-of-the-art device.
 

As to the research, if I might, this is an area of tremendous focus. 
 Again, the test is veteran centricity, whether it is limb loss
 prevention, prosthetics engineering, abilities to make the devices 
more effective, less damaging, the ability to provide rehabilitation,
 socialization, to advance techniques.
 

Right now a lot of prosthetics sit on the end of a limb.  We have 
tissue engineering laboratories that will seek to create a different 
sort of interface, to actually allow people greater function.  The 
list goes on and on.  And Dr. Kupersmith makes no exaggeration saying 
the VA is the leader in the prosthetic device research.
 

Ms. Berkley.  No doubt.  I just want to make sure you have got the 
resources to do the job that we have tasked you with.
 

Dr. Perlin.  Thank you.
 

Ms. Berkley.  All right.  The second question or second query.  As you 
know, we have been talking for the last couple of years about the 
Nevada Cancer Institute partnering with the VA in Nevada.
 

After two years of being at cross purposes and hearing two different 
stories from the VA and the Nevada Cancer Institute, I took it upon 
myself to bring both parties into my office this past week when we 
were home for our Memorial Day break.
 

 

And, of course, Ken Clark, the VISN 22 Director, came in, John Bright.  
Both men I have tremendously high regard for and I have worked very
 closely with them.  We also had Heather Muran and other people from 
the Nevada Cancer Institute there.
 

It seems as if we have broken through whatever issues there were, but
 can I ask you to please keep on this and report back to me so I know 
that we are on board because I do not want to be talking to you about 
this two years from now and we have not moved from, you know, the 
starting line on this issue.
 

And I agree with you 100 percent that there should be a separate VA 
healthcare system.  I have not been fighting the last several years 
for a VA hospital clinic and outpatient clinic and long-term care 
facility for my veterans exclusive of anything else because I do not 
agree with you.
 

But on the other hand, when we have an opportunity to partner with a 
state-of-the-art group like the Nevada Cancer Institute, I would like 
to do this if it is a benefit to the veterans.
 

So are you going to keep in touch with me and let me know what is 
happening?
 

Dr. Perlin.  Absolutely.  I appreciate your help in bringing folks 
together.  I have spoken with both Ms. Muran a number of times as well 
as Mr. Clark.  And they understand the ways in which they can partner 
and they are excited about the potential for collaboration.
 

Ms. Berkley.  Now, they talked about a number of things in my 
conference room.  Can you check with Ken Clark and make sure that we 
are going forward?  And, you know, it seems like just a series of
 miscommunications.  Have you already done that?
 

Dr. Perlin.  Yes.  In fact, Congresswoman, I am pleased to report that 
I have spoken to Mr. Clark the issues related to -- 
 

Ms. Berkley.  I am pleased to hear it.
 

Dr. Perlin.   -- VA research policies.  And I think there is common
 understanding and enthusiasm.
 

Ms. Berkley.  Great.  The third thing and very quickly, I know in your
 opening statements, you were talking about the VA's plan for a genetic
 database with information on potentially millions of VA patients.  
And obviously we all know that raises several privacy concerns, 
ethical concerns.
 

In light of the latest issue with the theft of 26 million veterans' 
personal information, what are you going to do to keep this 
information out of the hands of healthcare and insurance companies 
and what safeguards are you going to implement to ensure that the 
veterans' genetic health information remains private and a floppy 
disk does not go home with some idiot employee?
 

Dr. Perlin.  I want to thank you for asking this very important 
question -- 
 

Ms. Berkley.  You are welcome.
 

Dr. Perlin.   -- because it needs addressing.  And with the 
Chairman's permission, if I could have a moment to answer this.
 

Mr. Brown of South Carolina.  [Presiding]  I would just identify 
that her time has expired, Dr. Perlin, but you certainly may 
continue if you would.
 

Dr. Perlin.  Well, thank you because I know everyone is curious 
about this.
 

First, I want to make very clear the point that the circumstances 
that occurred are tragic and should never have nor should they ever 
occur again.
 

Let me assure as well, the Secretary, Deputy, entire leadership 
team, every VA employee takes this very, very seriously.
 

As a third point, I want to also make very clear this did not involve 
VA's electronic health records, VHA health data, or anything within 
VHA.  These were departmental administrative data resources.
 

The reason I make this distinction is because in the health setting, 
all of us have an ethos that really focuses on the privacy of 
patients, the privacy of health information.  This dates back to 
the Hippocratic oath which actually includes keeping private a 
patient's health information.
 

So, in fact, in the health setting, in the health administration, we 
start with an advantage.  We start with an ethos that is directed at 
security of health information.
And that is not sufficient though.  We actually have a significant 
amount of policy within the healthcare setting as relates to things 
like HIPPA and privacy laws.  And it is not just that policies exist.
  We are also inspected and there is significant oversight in this 
area.
 

That oversight includes in the clinical area the Joint Commission 
which has an entire chapter devoted on patient privacy and 
information security.  It includes our own internal inspection 
process, the SOARS process, Systematic Oversight Assessment and 
Review System, which is like an internal IG.  And, of course, the 
Inspector General also surveys on CAHP reviews our protection of 
security.
 

In the area of research, there are handbooks that derive from the 
departmental policy, significantly amplified by those things unique 
to healthcare that I have mentioned that require different levels of 
data security, different data systems, different system of records, 
different context, different training requirements, and different 
oversight that are added to again by policy for data protection in 
the research context.
 

The Genomic Program is one element that provides the opportunity for 
research and insight.  Another element is simply for treatment.  
Today there are 14,000 genetic tests that are available.  And, in 
fact, they allow us to choose better medications for mental illness.  
They allow us to prevent horrible drug toxicities.
 

For instance, for 299 out of 300 kids with childhood leukemia, 299 
will do well.  One out of three hundred will die.  That outcome is 
something that is avoidable with genetic information, with one of 
the tests that is, in fact, available today, and we can know that.
 

We have a good track record in the health system of keeping private 
very sensitive information, information about mental illness, 
information about substance use, information about infectious disease, 
HIV as an example, sexually transmitted diseases.  These are things 
we keep private.
 

And it would be on that background that in the clinical context, this 
privacy would be secured and it would be in the context of the 
additional oversight provided by institutional review boards and 
accreditation of VA research programs and the human subjects 
protections, the Office of Research Oversight, that any data would 
be generated in the Genomics Program with the additional oversight 
of the Genomics Advisory Program that Dr. Watson might wish to speak 
to, and the additional ethical oversight, the veteran input, the 
service organization input, and what I hope is ever more vigilant 
management.
 

Ms. Berkley.  But when you embellish on this answer, I mean, I 
appreciate that, but with all the track record, the ethos that goes 
back to the Hippocratic oath, with all the oversight and the 
regulations and the handbooks, we still ended up with an employee 
taking these records home.
 

How do you protect against something like that?
 

Dr. Perlin.  Let me again distinguish.  The track record of the 
health system -- 
 

Mr. Brown of South Carolina.  Dr. Perlin, I hate to interrupt this 
proceeding, but the five minutes has been ten minutes now and we 
must have other folks that want to ask questions.  And I know this 
is an important subject.  Maybe Ms. Berkley can have a private 
meeting with you to discuss these issues.
 

Ms. Berkley.  You are always welcome in my office.
 

Mr. Brown of South Carolina.  Sorry to interrupt you, Ms. Berkley, 
but we must proceed on.
 

Mr. Stearns.
 

Mr. Stearns.  Thank you, Mr. Chairman.  And I appreciate that because 
like many members, I have another appointment and I did want to come 
here to talk to you.
 

And I really had a question like Ms. Berkley mentioned, but I would 
like to go a little bit more definitive in this.
 

Is the genetic information encrypted?  Just yes or no.  Just yes or no.
 

Dr. Perlin.  You are asking a question about clinical information or 
research information.  The answer is -- 
 

Mr. Stearns.  The research information that you have collected on 
veterans, is it encrypted?
 

Dr. Perlin.  Well, we have not collected any for this specific 
program yet.
 

Mr. Stearns.  Okay.
 

Dr. Perlin.  So it is a theoretical question.
 

Mr. Stearns.  So right now you do not have any information on 
genetic -- 
 

Dr. Perlin.  We have genetic information.
 

Mr. Stearns.  When a veteran comes in, when a veteran comes in, he 
signs a form and he or she signs this form and you can do tests and
 automatically if you have blood samples, you have a lot of 
information on that veteran including his genetics.
 

Dr. Perlin.  Yes.  Health information -- 
 

Mr. Stearns.  So the question is, is that information that you 
collect, which can be tied to its genetics, is that encrypted?
 

Dr. Perlin.  No.  It exists behind a firewall.
 

Mr. Stearns.  Okay.  And what is this firewall?
 

Dr. Perlin.  A firewall is a system to prevent unauthorized use of 
data, unauthorized use of data.
 

Mr. Stearns.  But let us say someone got access through that firewall,
 then it is legible?  It is not encrypted?
 

Dr. Perlin.  Yes, for a single record.
 

Mr. Stearns.  Okay.  Do you have someone identified who is a Chief 
Security Officer?
 

Dr. Perlin.  Let me answer that in two ways.  First, within VA, VHA, 
we have individuals at every medical center who deal with patient 
privacy because it is that significant an issue.
 

Mr. Stearns.  So there is a Chief Security Officer at every medical 
facility?
 

Dr. Perlin.  There is an Information Privacy Officer.  The other is 
that VA as of about two and a half years ago centralized the 
information in a cyber security program.  And so, in fact, for the
 architecture of the entire system, there is a central oversight of 
cyber and information security.
 

Mr. Stearns.  And where is that geographically located?
 

Dr. Perlin.  That is right here in Washington.
 

Mr. Stearns.  Okay.  So in Washington, we have all the genetic 
information collected?  Is that true?
 

Dr. Perlin.  No, no, no.  I thought you were referring to the cyber 
security offices here in Washington.
 

Mr. Stearns.  So what is collected here in Washington?  All that 
information?
 

Dr. Perlin.  Well, no.  Nothing exists here in Washington.  There is 
clinical information at each medical center.
 

Mr. Stearns.  No.  But I am talking about the genetic information is 
at various hospitals throughout the country; is that correct?
 

Dr. Perlin.  All clinical information -- 
 

Mr. Stearns.  Yeah, correct.
 

Dr. Perlin.   -- is at hospitals through the country.
 

Mr. Stearns.  And in each one of these hospitals, there is a Chief 
Security Officer?
 

Dr. Perlin.  There is an information privacy person.  There may be 
one that supervises two consolidated facilities.
 

Mr. Stearns.  Would that same person be the one that was supposed 
to protect the information that got lost, the 26 million?
 

Dr. Perlin.  No.
 

Mr. Stearns.  It is a different person?
 

Dr. Perlin.  We are talking about health information within the 
Veterans Health Administration.
 

Mr. Stearns.  So they are not combined?
 

Dr. Perlin.  They are not.  The information that was lost was a 
departmental administrative data set.
 

Mr. Stearns.  Okay.  And the information that we are talking about 
is in a different -- 
 

Dr. Perlin.  One hundred percent -- 
 

Mr. Stearns.   -- under a totally different -- 
 

Dr. Perlin.   -- totally different.
 

Mr. Stearns.   -- security?
 

Dr. Perlin.  Yes.
 

Mr. Stearns.  And with its own Security Chief, Information Privacy 
Officer?
 

Dr. Perlin.  Again, if I might distinguish, there are Privacy 
Officers that are germane to health.
 

Mr. Stearns.  Right.
 

Dr. Perlin.  There are Information Security Officers that oversee 
system intrusion, et cetera.  The Privacy Officers would establish 
and enforce the policy for protection of health information and 
adjudicate questions about access.
 

Mr. Stearns.  Okay.  Is that a policy that you have with this 
Security Officer?  Is that ever audited by you and management or 
anyone else?
 

Dr. Perlin.  The privacy of patient records is absolutely audited.  
Every Joint Commission inspection requires an audit of protection of 
patient privacy.  The CAHP reviews -- 
 

Mr. Stearns.  And is that audit inside or out?  Is it people from 
outside the VA or is that people within the VA who audit it?
 

Dr. Perlin.  Well, the Joint Commission is entirely outside.  The 
Inspector General, of course, reports to the President.
 

Mr. Stearns.  Okay.  So in answer to Ms. Berkley's question, you do 
not think what happened to the administrative information could ever 
happen to this hospital clinical genetic information, could never 
occur?
 

Dr. Perlin.  Well, let me answer this way, is that as we go forward 
in constructing what will be a relational data set, let me assure 
you that while we believe our systems are very secure, while we 
believe our ethos is different, there are clearly some lessons, 
wider lessons.
 

 

If a data set exists free-standing, which is not how the electronic 
health record works, it brings together a bunch of information that 
is visible for that moment that someone is looking at the screen 
from different sets, that any data set that exists free-standing is 
encrypted and secure, that is a lesson.
 

We believe that our systems are good, but I would be inappropriately 
assertive if I were to say that we did not learn some lessons that 
we would apply, and this is a focus area of attention within an 
entirely different system of records.
 

Mr. Stearns.  Let me just conclude, Mr. Chairman.
 

What is one of the greatest lessons that you have learned from that
 information that was lost that applies to your information privacy 
of this health information?  What is one lesson, the greatest lesson 
that you learned?
 

Dr. Perlin.  Congressman, that is a fantastic question and it comes 
down to this, which is that however hard the systems are, however 
strong the policies are, however the great the oversight is, we 
cannot make up for human error.
 

That is where the ethos of healthcare helps us focus on the 
"warm-ware," and we will be coming forward with a number of policies 
to work on the warm ware, the people, to understand what their
 responsibilities are and the context of the privilege that they 
operate in in providing healthcare to veterans.
 

And with that, whatever the strength of the hardware protections we 
place, whatever the strength of the oversight, whatever the strength 
of the polices, all of the forcing functions, human error is still 
possible.
 

And we want to create systems that are as resistant as possible, but 
we also want to work on the way people think about this and make 
sure that every last person, even in the Veterans Health 
Administration, which has not experienced this type of data loss, 
even in that, understands that it's their individual responsibility 
as part of the privilege of serving veterans.
 

Mr. Stearns.  Thank you, Mr. Chairman.
 

The Chairman.  Thank you, Mr. Stearns, for your contribution.
 

Ms. Brown, you are now recognized for five minutes.
 

Ms. Brown of Florida.  Thank you, Mr. Chairman.
 

Dr. Perlin, you and your staff, we are very lucky to have you in the 
position.  The veterans are very lucky to have you with your 
credentials.  And, you know, I am very impressed with your 
commitment to the veterans and making sure that they get quality care.
 

In this light, I am concerned as what was raised earlier that the 
Bush Administration has sent us two budgets in a row that cut 
appropriation dollars, in 2006 by nine million and 2007 request 
by $13 million.
 

In light of this request, how important is recruitment of physicians 
and other medical health people, retention as a priority of the VA?
 

Dr. Perlin.  Thank you, Ms. Brown, for just a tremendously important 
question.
 

The research dollars allow us not only to perform the research in the 
interest of improving the health and well-being of veterans, but 
because the researchers are the very same clinicians and 
subspecialists who provide the care, it is tremendously important.  
It is one of the reasons that many people decide to come to VA.
 

They come for the mission of serving veterans.  They come for the 
model of care that we practice.  They come for the ability to really 
be at the top of the field in terms of advancing the knowledge.  And 
so it is tremendously important in terms of recruiting the best and 
brightest for the care of veterans.
 

Ms. Brown of Florida.  Yes.  And I know it is not because of the pay 
that you get, but it is because of the commitment that you have.  And 
I think that is important.
 

Second question, I was watching the news yesterday where the veterans
 organization is suing the VA.  And I am going to look at filing a 
friend of the court because I think that there is major problems 
with - and we have been discussing that - regarding the 26 million 
veterans and servicemen, the policies and procedures of the Office 
of Research and Development.  You have explained that.
 

But what about the other additional procedures and concerns?  You 
talked a little bit about that, but can you assure us today that we 
will not later learn that some of that information pertaining to VA 
medical records was lost?
 

When we heard from the Secretary last week, I was very concerned that 
it could be others out there that could have taken information and we 
just happened to find out about this particular data.  Go ahead.
 

Dr. Perlin.  I am sorry.  Congresswoman, this absolutely positively 
was not veterans' electronic health records.  This was departmental 
data, administrative data, not veterans' health records.
 

Ms. Brown of Florida.  So you are assuring me that I will not find 
out later that any veterans' health records are just floating out 
there?
 

The Chairman.  Will the gentle lady yield for a second?
 

Ms. Brown of Florida.  Yes, sir.
 

The Chairman.  The leadership of the Committee have worked together 
to lay out a series of hearings in the month of June that is just 
being announced and one of those -- I know Chairman Reyes just 
left -- the Subcommittee on Health along with the Ranking Member 
Michaud will be holding a specific hearing with Dr. Perlin to cover
 the very same issues that you are covering.
 

Ms. Brown of Florida.  Okay.
 

The Chairman.  And I am sure that you will be able to go into great 
depth -- 
 

Ms. Brown of Florida.  All right.
 

The Chairman.   -- at that Subcommittee hearing.  I wanted the 
gentlelady to know.
 

Ms. Brown of Florida.  Well, thank you.
 

And so then I will just follow-up that I have a letter for you, 
Dr. Perlin.  I have had a couple of meetings on the issue that we 
have about the VA clinic in Jacksonville.  And we have had two 
meetings and I am requesting a third that we will have here in 
Washington.
 

I know in Washington, a million here and a million there is not any 
real dollars.  But my city, we have spent over $3 million trying to
 accommodate the Veterans Administration.
 

And the people that you have sent down are arrogant.  They are 
basically -- you know, I am trying to be nice, but that is not 
something that this gentle lady is used to being.  I just need a 
meeting with someone that is not just -- do not care anything about, 
you know, the veterans.  You know, it is just not working in a manner 
that is acceptable to me, the city, or the veterans who are calling me.
 

And in Orlando it has been 25 years and we still do not have a 
hospital.  And I am not going to have this happen in Jacksonville.
 

Dr. Perlin.  Well, Congresswoman, I may be the other person in the 
room who is equally frustrated at the inability for all of us to get 
together.  It is our desire to serve the veterans that are in 
Jacksonville.
 

Let me thank you for your trying to bring together all of the 
different people and the city and VA to make it work out.  I have 
some information and maybe it would be good for you and I to get 
together and just compare our notes on what is needed.
 

I think it will take both of our work to get things together, but 
our goal is the same, to make sure that we have the clinic sized 
adequately with adequate parking, able to provide the care to your 
veterans there in Jacksonville.
 

Ms. Brown of Florida.  Any time.
 

Dr. Perlin.  Thank you.
 

Ms. Brown of Florida.  Thank you.
 

Thank you, Mr. Chairman.
 

The Chairman.  Thank you.
 

Dr. Watson, I have a series of questions for you.  What is your role 
at the American College of Medical Genetics?
 

Dr. Watson.  I am the Executive Director of the American College of 
Medical Genetics.  I am a Board Certified Medical Geneticist by 
training.
 

The Chairman.  And you are a member of the Genomic Committee?
 

Dr. Watson.  Yes, recently appointed.  The group has yet to meet, so 
I cannot express any opinions of theirs yet.  However, I can express 
my own and those of the genetics community.
 

The Chairman.  And as you go to this Committee, what are your 
priorities?
 

Dr. Watson.  Well, certainly to -- well, there are multiple, frankly.  
I think the opportunity that the VA system offers is tremendous for 
both the veterans and for genetics.
 

Genetics is really a translational medicine area of practice now.  It 
is not this research box that sits, that people think of as a basic 
science entity.  It is not necessarily always hardcore, standardized 
clinical service.
 

It is using the best systems we have, and certainly the VA has one of 
the best electronic medical records systems available where we are 
now able to really validate what we do in genetics and across the 
spectrum of healthcare.  And I think that is the benefit of these 
systems.
 

Much of what we practice in medicine today is not well validated and 
there are many questions as to whether we actually know what we 
should be doing all the time.  And the opportunity to use an 
electronic medical record to inform us about what is the best of 
multiple options that might be available to us when we manage a 
particular condition is significant.
 

The ability to use the systems to educate physicians who by and large 
have not been exposed to much genetics, it has broken lose 
tremendously over the past decade.
 

So our ability to bring point of care education through electronic 
systems is tremendous and to really get at the chronic diseases 
which I think the veterans allow us to really get at in genetics.  
And we have done pretty well in rare diseases, you know, the things 
that have very powerful genetics behind them.  But the chronic 
disease side has been quite difficult to get at.
 

And I think first starting with a population that has certain 
environmental or other exposure factors that increase their 
chances of particular diseases being expressed makes them a very 
valuable resource for understanding the chronic diseases, and then 
to really be able to develop how we practice because genetics is 
going to be an ongoing evolutionary area of practice.  We will 
learn as we go as we have for the past 30, 40 years.
 

The Chairman.  Describe what pharmacogenomic profiling is.
 

Dr. Watson.  Pharmacogenomic profiling is really -- it is going to
 be more than I think what people think it is today.  Today when we 
talk about pharmacogenetics, we do a test to determine whether or 
not somebody is going to metabolize a particular drug in the way that 
we would expect them to to get the response that we expect from
 having been treated.
 

We know that many people may have an enzyme defect that does not 
allow them to metabolize that drug appropriately so that we can then 
determine whether that drug is right for that person.  We can also 
use it to determine whether or not dosing is the issue for that 
particular person.
 

I think what -- that is sort of the classic model, I think, of
 pharmacogenetics today.  But I think where it is going is something 
that Dr. Perlin alluded to which is the Gleevac story in CML where 
based on the molecular nature of an abnormality that led to a 
particular condition, we now have molecular treatments that target 
the very specific molecular abnormality that led to that disease.
 

And I think that is a very personalized directed kind of 
pharmacogenetic approach that is not -- there is not a lot of it
 available right now.  Probably three, four drugs that very directly 
target a molecular structure.  That is an acquired abnormality of 
the genetic material, different than pharmacogenetics now which is 
an inherited defect in an enzyme that does not allow you to 
metabolize a particular drug as most people might.
 

The Chairman.  All right.  Now, let us go to the tough question, and 
that is how we balance our interests - and we will go to the 
beginning - how we balance our interests to be veteran centric in 
our research while being cognizant of something that is on the 
cutting edge that is so beneficial to our general population.  
Right?  I mean, that is what we have here.
 

At the same time, because it could leverage into tremendous benefit 
to us and you have to make a decision here, Dr. Kupersmith, with 
regard to limited dollars, everybody is in competition for them.  
Okay?  So I am curious here as we do our balancing test.  Let me 
yield to you.
 

Dr. Perlin.  Mr. Chairman, that is a terrific question.  First, I 
would have to say that it is not a question if genetic medicine is 
coming.  It is coming.  As Dr. Watson said there is right now the 
ability to choose medications, and certain patients' pain medicines 
do not work as well.  So in most African-Americans, metabolism of 
pain-relieving, opiate-type drugs is faster and pain dosing is 
typically under-dosed.
 

But to the second part of your question, how is this specifically 
veteran centric?  Well, this is really the window to understand how 
some people may be differentially susceptible to nerve gas or 
pyridostigmine bromide or development of PTSD or the treatment.
 

In fact, I might ask Dr. Friedman to talk about some of the advances 
in psychopharmacology, treatment for mental health based on genetic
 differences.
 

Do you want to elaborate on that as we talked yesterday?
 

Dr. Friedman.  Well, I mean, everyone is different.  Everyone is 
different genetically.  That is one of the reasons why the Twin 
Study is such an important resource.  They are different in terms 
of how exposure to combat trauma might affect them.  Are they going 
to be resilient and be able to do just fine or are they going to be 
quite vulnerable and develop PTSD or other kinds of problems?
 

We really feel that the question of resilience is one of the most 
important questions in the PTSD field.  We have studies, 
collaborative studies at Ft. Bragg right now trying to understand 
what are the molecular differences as well as the psychobiological 
difference between people who are resilient and people who are not.
 

As Dr. Watson said and Dr. Perlin emphasized earlier, these studies 
also have implications in terms of who is going to be a good 
candidate for what treatment, whether it is a pharmacological 
treatment or a psychotherapeutic treatment.
 

The Chairman.  I know we have Dr. Snyder here, but let me finish 
this.  I use the word balance, but there are also tradeoffs.  So 
when you propose to us a decrease in funding and then appropriators 
would come back and we put that back in.  Somewhere you are making 
some judgments and you are making some judgments here to say, okay, 
we are going to decrease our research on heart disease.  Maybe you 
made that judgment.  I can only do supposition to say well, maybe 
that is where NIH is pushing over there; therefore, we can go here.
 

I am trying to get into the analysis of your professional judgment.  
Dr. Kupersmith, what are you doing here?  How are you making these 
judgments to say, okay, Dr. Watson, we like what you are doing, we 
are going to make some investments here?  A decision was made.  You 
made a priority judgment.  You testified on this before, Dr. Perlin. 
 So now Dr. Kupersmith, how are you carrying this out?  Let us know 
where the puts and takes are.
 

Dr. Kupersmith.  Let me just first say that this is not a choice 
between doing research in heart disease and doing research in
 genomics.  I am a cardiologist.  Genomics is the future treatment 
of heart disease.  The very same pharmacogenomics that Dr. Watson 
was talking about has already applied in some ways to heart disease 
in the use of anticoagulants and other drugs.
 

So this I see as the future of caring for patients with heart disease 
just as you raised that example.  And if we are to look at the future 
of what is the best way that we can improve the care of veteran 
patients with heart disease, the judgment here is that this is going
 to be at the forefront.
 

So I think that that is part of it.  I also think that this is 
ultimately the most veteran centric kind of research that we can do 
because it involves the genetic makeup of our veteran populations 
and how that relates to the diseases we have.
 

As you know, there has been a tremendous amount of work looking at 
exposures to various insecticides and other agents.  It is not a 
bad hypothesis that this has a genetic basis, that some people are 
more susceptible and, therefore, have symptoms from it or diseases 
from it so that it is another area where we can make advances where 
there has been really, I think, road blocks to getting ahead in that
 area of research.
 

There are many, many - we can go through the entire spectrum of 
diseases in this way.
 

The Chairman.  Dr. Snyder, Dr. Watson has to take off.  If you have 
a question on genetics, genomics, he is our man.
 

Mr. Snyder.  I do not.  I do not for Dr. Watson.  I do for Dr. Perlin.
 

The Chairman.  My last question then on this topic is, as you make 
these budgetary decisions here, what are you asking for?  I mean, 
what did you ask for, Dr. Kupersmith?
 

Dr. Kupersmith.  In terms of genomics?
 

The Chairman.  Yeah, in terms of genomics.
 

Dr. Kupersmith.  Yes.  Well, this is our -- 
 

The Chairman.  With regard to dollars.  How much in dollars are you 
now putting toward this?
 

Dr. Kupersmith.  There are a number of items of cost that are related 
to this.  We are embarking on a pilot study over next year to determine 
how we are going to collect the samples, how we are going to ask for 
consents.  For example, how we ask for consents has a tremendous 
impact on budget.
 

So we have not established the final dollar, just to say that this is
 collection of blood and possibly other tissues which has a limited 
expense and a number of other aspects to it where the expense may 
not be as large as one thinks.
 

One of the ways we are going to cope with this is to decrease less 
productive research.  And as I said before, looking at our centers 
is one of the ways of doing this.
 

But I think that we need to establish the banking of this and many 
other features of this.  We need to work with the Advisory Committee 
to look at how the consents should be done, what we are going to do 
to assure special privacy for this.
 

This is probably not the kind of information that should be available 
the way the rest of the medical record is.  We do this in some ways 
with psychiatric information.  So there are many, many questions 
about this that we are going to be looking at our Advisory Committee 
to ask before we can give you the final on that.
 

The Chairman.  Dr. Kupersmith and Dr. Watson, as you proceed on this, 
this is an area of interest also at NIH.  And we do that funding.  So 
we are laying appropriate dollars there?
 

So let me go back to the statement of being all things to all people. 
 When trying to remain centric, taking care of those injuries and 
diseases specifically related to that military service, at the same 
time, you have something here that helps the general population of 
a country and a world really.
 

What of limited dollars do we begin to take away at the same time we 
want to press those bounds?  We want to be good listeners to you.  
Okay?  And I want you to work with Mr. Michaud and Chairman Brown as 
we formulate this, as we go into next year's budget.
 

Dr. Perlin, you may say to us here is our budget, this is our ongoing
 research, this here, this is so valuable, your Committee may come 
back and lay down something specific.  We do not really do that.  We 
do not really come in here and go, okay, we are going to lay specific 
dollars on a specific disease.  But we want to be open to you.
 

Dr. Kupersmith.  So much of what we have done in research has 
benefited everyone, probably most of it.  And treatment of 
tuberculosis, one of the first great veterans' projects, veterans' 
research projects.  This is directed at veterans.  This is our 
purpose.  If it helps other people, that is obviously an added 
advantage and it will help other people.
 

Our research in prosthetics, our research in traumatic brain injury 
will help automobile accident victims in this country.  So all of 
our research does that.  But I think it is really important to think 
of this as a -- at least we think of it as a veteran centric 
intervention.  And I think the future will be for veterans to get 
a tremendous amount of benefit from this.
 

The Chairman.  Dr. Snyder.
 

Mr. Snyder.  Thank you, Mr. Chairman.  I appreciate you holding this 
hearing.
 

I am sorry I was unable to be here for the first part of it.  I may
 ask you some questions that have already been covered.
 

To bring this home, this business about research, for me, I was 
reminded just these last few weeks, Dr. Perlin.  My wife and I had a 
baby 15 days ago, two weeks.  He was a big boy, nine pounds, seven 
ounce boy.  And we ended up having to have a C section partly because 
of his size.
 

And I called up my 90-year-old aunt and told her about we had a nine 
and seven ounce baby boy.  And she told me when she had her first son 
like 60 some years ago, she said I did not think anybody could have 
a bigger baby than Johnny who was nine pounds, five ounces.  But she 
said that the labor was terrible, the delivery was terrible.  After 
he was born, she had to spend 13 days in the hospital.  The whole 
experience was so bad she did not think she would ever want to have 
another kid again.
 

Well, so my wife goes in.  We try laboring for a while.  Doctor said 
it is not cutting it.  We have the C section.  We are home in three 
days.  That is not just an accident.  You and I know that.  And it 
is because of the great work that has been done by researchers 
through the years and said here is how we do it and here is how we 
prevent these terrible problems.
 

So I think what you all are working on is so important.  I have 
several questions I want to ask.
 

The Chairman.  Dr. Watson, you may be excused if you like, if you 
need to leave.  Thank you.
 

Dr. Watson.  Thank you.
 

The Chairman.  Dr. Snyder.
 

Mr. Snyder.  Thanks.  The issue of when you set the number in the 
budget, in the President's request, whether it is for this past year 
or the years to come, this whole issue of the biomedical research 
inflation rate, it is estimated, I think, at five and a half percent 
for fiscal year 2005 and a little bit lower than that, a little over 
four percent for fiscal year 2006, which has reduced in real dollars 
the VA research budget over those two years by almost $40 million.
 

Now, shouldn't we when we are doing this, in fairness to everyone, 
the veterans, to you, to researchers, to the Congress, shouldn't we 
start out and say our baseline budget includes an inflationary 
increase so we will be talking in terms of real dollars from the 
get-go?  Shouldn't that be the way we do this?
 

Dr. Perlin.  Well, first, Dr. Snyder, congratulations on your new baby.
 

Mr. Snyder.  Thank you.
 

Dr. Perlin.  And I am glad the results of research are what they are.
 

I am, I believe, the first M.D., Ph.D. Under Secretary or Chief 
Medical Director of the Veterans Health Administration.  I am a 
researcher and I believe passionately in research.
 

Mr. Snyder.  I know you do.  I know you do.
 

Dr. Perlin.  The budget was purposefully a lean budget.  It was also 
a budget that looked at the needs of veterans and said, okay, what 
is veteran centric, where are our priorities.  It is a budget that 
actually raises the amount of focus on those things that are 
directly veteran centric.
 

I think one of the things that whatever the budget line is, and let 
me acknowledge this Committee for your robust support not only of 
the request but your acknowledgement of the importance of VA research 
by recommending additional funds, whatever the investment that the 
American taxpayer on their behalf, you help us make in VA research, 
it is leveraged substantially.
 

One of the things that I think is testament to that is that the seed 
money that is provided actually pays back a 150 percent return on 
investment.  For example, in 2006, this year, $412 million will 
actually provide a core of research activity that allows 
investigators to bring in, if my number is correct, 
Dr. Kupersmith, $662 million of additional cost of research.
 

Mr. Snyder.  But that leads to my second question, Dr. Perlin.  I 
will accept what you said.  The budget was purposefully lean.  The 
budget was purposefully lean.  And I would contend this is the wrong 
time in our history given both our economic competition and the jobs
 of the future and the technology of the future but also as a nation 
at war, that this is the wrong time to be "purposefully lean" in the 
VA research budget.
 

My second question, Dr. Perlin, is this.  When you talk about 
leveraging funds, other parts of the budget are held constant also. 
 NIH budget, which you do not have anything to do with, it is held 
constant in the President's proposal also.
 

So does it not give kind of a false sense of security to those of us 
who read these things very quickly when we read, oh, this is going to 
help us to leverage other funds?  Oh, by the way, the funds that we 
are going to try to leverage, they are being held constant also and 
sooner or later, somebody has got to take a hit or the purposefully 
lean idea is not going to be carried out.
 

Dr. Perlin.  Well, let me rephrase.  That was a poor choice of 
words.  A better choice is we wanted to be as responsible in assuring 
that the dollars were maximized for veteran centric research.
 

And I think the track record is is that investment actually begets a 
continuing increase in extramural funding and that year over year, 
2007 over 2006, 2006 over 2005, there are significantly more external 
dollars that are brought in to augment the entire VA research portfolio.
 

Mr. Snyder.  By external, you are including dollars from NIH and other
 federal research?
 

Dr. Perlin.  Yes, I am.
 

Mr. Snyder.  Well, I think I made my point.  Those budgets have also 
been drawn "purposefully lean" and so it is going to be harder for 
you to leverage that.
 

My time is up.  I had actually several other things.
 

What is the state of VA research facilities?  We have some money that 
was spent recently.  It is for some new square footage in Arkansas, 
the VA there.  It is very nice.  But my concern is this.  Upgrading 
facilities takes money.  Good research takes good modern facilities.
 

We have got this lean budget going on.  Are we having problems?  Are
 we going to have to take money out of personnel in order to do 
research facilities or are we going to ignore expansion and 
modernization of research facilities in order to keep our personnel
 up?  What is the status of research facilities and does the Committee 
need to do a better job of looking at square footage and kind of the 
bricks and mortar of research?
 

Dr. Kupersmith.  Well, I appreciate that question and appreciate the 
money that I think the Committee has indicated it wishes to spend on 
that.
 

First of all, there is clearly an issue throughout the VA system with 
our research infrastructure.  It needs improvement in many areas.  I 
do want to say, though, just briefly that while that is true, the 
quality of the research is outstanding.
 

Mr. Snyder.  I agree with that.  I agree with you.
 

Dr. Kupersmith.  What we are doing is, first of all, we are gathering 
together all of the information that has already been provided to us 
on our research facilities over the past few years.  We are 
organizing that information.
 

We have sent a questionnaire to research facilities concerning the 
status of their research.  We are going to have a number of site 
visits before the end of the year.  We have a group out of the 
Gainsville VA that we have detailed to do this, to make a number of
 site visits to look at the correlation of the information we have 
with what is happening actually in a number of facilities.
 

And we intend to survey our 75 major research facilities over the 
next three years after that.  We will have a report in early 2007 
on this initial phase that will essentially look at what we are 
going to have to do.
 

Mr. Snyder.  I hope that the report, and I assume it will be, will 
be very straightforward with us and will not kind of get lost in 
the budgetary year stuff of, oh, yeah, we do not really need this.
 

I mean, the Committee - I am sure I speak for the Chairman -- we 
just want to know what you need and what you can live with and 
what has just absolutely got to be improved.
 

Dr. Kupersmith.  You know, I make site visits as one of my jobs.  It 
is more informal site visits to see a facility and the first thing 
they show me are research facilities that are dated.  So I 
understand that we have to really look at this.
 

And that is why we are doing these site visits ourselves, to really 
get our own look at this and not just what people's impressions may 
be.  You know, as honest impressions as they are that we want to 
look at this carefully.
 

Mr. Snyder.  Dr. Perlin, given that anyone out there who follows this
 business and is paying attention to where your budget number is on 
research and paying attention to where we are with facilities and so 
on, you all, you know, are always competing with the private sector 
for good clinical staff, good research staff, those delightful people 
that do both research and clinical work.
 

What kind of a message does it send in terms of your recruitment and 
trying to recruit somebody to stay with you for ten or fifteen or 
twenty years when we kind of play -- I do not know, whatever the 
metaphor is -- Russian roulette or something each year that, well, 
our budget is going to be lean this year, some people may be cut, 
some people may not be cut, we are hoping the Congress, nudge, nudge, 
wink, wink, we are hoping the Congress will add some money so that 
nobody will actually get cut?  Doesn't this have a negative impact 
on the way you do your recruiting and retention of physicians when 
those top-rated researchers that you are trying to keep and recruit 
for your facilities?
 

Dr. Perlin.  In fact, we want to bring forward each year an entire 
budget that is responsible and meets the needs.  We want to make 
sure that -- and I testified earlier before you arrived that when I 
was the Acting Chief of Research and Development, my litmus test was 
that we lived the mission of VA research, improving the health and 
well-being of veterans.
 

We have the stewardship responsibility as well which is to make sure 
that the research that is conducted is valuable.  And the Chairman 
said veteran centric.  With all that in mind, we continue to have a 
growing overall research budget.  In fact, within the research 
budget, we make priorities.  In any budget, one makes priorities.
 

And one of the priority areas has been career development awards to 
attract today's emerging stars as both the researchers and clinicians 
for veterans.  And this budget, budgets that proceed show an 
increasing number of career development awards just for that 
purpose of attracting and recruiting.
 

We also do want productive researchers, researchers who can compete 
 intramurally and extramurally demonstrating that their research by 
all merit review is the best research that can possibly be done to 
answer and address those questions that are relevant to improving 
veteran health.
 

Mr. Snyder.  I agree with that.  The question is, with additional
 funds, could you do more top-flight research that meets that 
standard?  And I think that you could.
 

But the last question I want to ask has to do with your discussion 
and your written statement on neurotrauma.  And I was struck by what 
you say here, that traumatic brain injury accounts for almost 
25 percent of combat casualties.
 

Is that 25 percent of all casualties or those that are hospitalized?
 

Dr. Perlin.  I would have to get you that number.
 

Dr. Kupersmith.  Yeah.  Dr. Ruff may know that offhand.
 

Mr. Snyder.  That seemed a little high to me for 25 percent of all 
combat casualties.  I would have thought there would have been a lot 
of superficial shrapnel.
 

Dr. Perlin.  Well, maybe the way I can come to that is that -- and we
 will check on the exact -- but one of the statistics that is 
absolutely incredible is that if you are injured in combat and you 
make it to a critical support hospital at the front lines, you stand 
over 98 percent chance of survival.  As you have seen, the injuries 
are multiple and often include that.
 

Let me ask Dr. Ruff if -- 
 

Mr. Snyder.  Well, let me get to my question.  The Chairman is being 
very patient here, if I might.
 

My question is this.  So in your statement, you say 25 percent of 
combat casualties in both Iraq and Afghanistan are traumatic brain 
injuries.  And I appreciate your accentuating that because that is 
so important to those veterans and to their families.
 

And then in your written statement, you say 85 letters of intent to 
submit a research proposal were received indicating a high level of 
interest amongst our investigators.  Complete proposals will be 
reviewed in the next several months and we plan to fund as many 
high-quality projects as the budget will allow, as the budget 
will allow.
 

Dr. Perlin.  Yes.
 

Mr. Snyder.  And so my question and my comment would be, if you 
review those 85 and you conclude you can only fund -- or that there 
is only 30 there that are worth funding, you have plenty of extra 
money, you are going to fund the 30, that is fine.
 

My concern is you review those 85 and say, you know, 73 of those are 
top-flight research, but we only have funding this year for 42.  I am 
just making up numbers.  I think that the Committee would be 
concerned.  I think the Veterans' Committee would be concerned.  I 
think those families would be concerned if -- unless you would be 
very straightforward with this as this process goes along, if you come 
back to us and said, if we had additional monies, you know.  Maybe 
Mr. Snyder was right.  We could have used additional money because 
we could then fund this additional ten, fifteen, or twenty proposals  
that would meet our standard for top-flight research because this is  
so important to the future livelihood and quality of life of these  
veterans and their families.
 

And I was really struck.  I mean, I appreciate your candor.  As the  
budget will allow.  Well, budgets are set by this Congress and I  
will want to know if you come back to us and say we could have funded  
23 more top-flight research projects with good personnel if you had  
given us more money because you make the proposal, but eventually we  
do the appropriations.
 

And so I hope you will share with us that information so that we can -- 
 

The Chairman.  Will the gentleman yield?
 

Mr. Snyder.  I am finished, Mr. Chairman.  I appreciate your indulgence.
 

The Chairman.  This is an area where -- I will choose the word  
collaboration -- this is a great area of collaboration for research  
between Dr. Perlin and DoD.
 

Dr. Perlin.  Yes.
 

The Chairman.  And that is what you need to do is have that kind of 
 conversation because these are active-duty patients.  You know, you 
 have them, Dr. Snyder, in your responsibilities on the Personnel 
 Subcommittee.  And you make those decisions on medical research  
in DoD.
 

I mean, this is an area, when you talk about the funding of combat  
casualty neurotrauma, this is one that should be a cooperative  
effort, I would think, between VA and DoD, Dr. Snyder.  Would you  
concur?
 

Mr. Snyder.  Yeah, absolutely.  And it is to everyone's interest  
that it be well funded, I mean, because we want to be able to look  
back five and ten, fifteen years from now just like I look back on  
my Aunt Lois and her 60-year-old pregnancy, that we look back and  
say look at the remarkable things that we did.
 

But when I see we are only going to do what the budget allows when  
this Committee, I think -- I think the Congress will be very  
receptive if you said, you know, we could really do some more  
top-flight research in traumatic brain injury to help these 25 percent  
of our injured veterans.
 

The Chairman.  Let me bring up the area that I had a conversation  
with Dr. Perlin about.  So I want you to hear this, Dr. Kupersmith.   
And it deals with the helmet.
 

Dr. Kupersmith.  Yeah.
 

The Chairman.  So Vic Snyder is over there on the Armed Services  
Committee and we are doing everything we can to give him that body  
protection.  So generally in the past when you have that blast, part  
of the blast is absorbed by the body.
 

Now we give them the body armor and they have got on that new kevlar 
 helmet that is strapped onto the head.  When the blast comes in, it  
hits the extremities and part of the force goes up the face.  You get 
 maxillofacial injuries.  You get blindness, severe traumas to the  
eyes, takes off part of the nose.  And when the force goes up into  
the helmet, it cannot escape and we end up with all this traumatic  
brain injury.
 

And so, number one, what I am hopeful here is when you look at this  
combat casualty neurotrauma research that you also do not look and  
say are we not also contributing to a problem here.  We saved the  
torso and lose the brain.  And should this helmet have vents in it  
or some type of vent system to allow part of that force to go out?
 

And I am not a doctor.  I am not one of these.  But I am just saying  
common sense is saying to me if we can put a man on the moon, we can  
try to figure out how to provide some relief to a force causing brain  
trauma.
 

So I just throw that back to you.  And I will work with you, Vic, on  
something like this.
 

Dr. Kupersmith.  Let me just first say that our collaboration with DoD  
in many ways -- I can just speak about the research area -- has  
increased enormously just since I have been there, but it began to  
increase well before.  And we are collaborating in this, in burns,  
in prosthetics, in many, many other areas.
 

And we certainly consider this very high on our agenda, at the top of  
our agenda to collaborate with the Department of Defense in these.   
And certainly a collaboration that could evolve in the future is to  
look at our data on traumatic brain injury in the veterans some years  
later and what sort of armor, what is one's approach to armor, taking  
that in light.
 

So those are a number of research areas that we can get into.  I think 
 our funding line is usually about 25 percent.  And we will certainly  
look at these projects and I think -- 
 

Mr. Snyder.  I am sorry, sir.  I did not know, 25 percent -
 

Dr. Kupersmith.  On a usual RFA, we fund about 25 percent of the  
research projects that come in.
 

Mr. Snyder.  Oh, okay.
 

Dr. Kupersmith.  We consider of high enough scientific merit to fund.  
 We do not know how it will come out on this.  So when we do know,  
what we can do in our own sphere is to try to, as I said before,  
obviously save money in other areas so that we can provide more here.
 

This is our highest priority.  There is no question about that.   
Perhaps in future budget submissions, some of this will be reflected,  
but that is essentially how we can work with it at this point.
 

Mr. Snyder.  Well, but I appreciate -
 

Dr. Kupersmith.  Can I add one more thing to my answer?
 

Mr. Snyder.  It is the written statement here that says as the  
budget will allow, so that is where my question was coming from.
 

Dr. Kupersmith.  Okay.
 

Mr. Snyder.  Yeah.  You are welcome to augment.
 

Dr. Kupersmith.  I just want to make the point, and Dr. Ruff made  
this point also -- it is very important -- we are looking upon this  
as taking on a problem and we are going to do this more and more in  
research, not looking at whether it is health services research or  
basic or clinical.  This is a problem we want to address.  We want  
to address it from the cellular level through to the health system  
level that we study.  And I want to make that point.
 

Mr. Snyder.  Thank you, Mr. Chairman.  Thank you for your indulgence.
 

The Chairman.  Dr. Perlin, if you could get back to me.  I am sort  
of struggling with really where do I really need to go?  Do I need  
to go over to material command at DoD to say I want you to study  
the helmet?
 

If you have an idea here on who I need to touch or how we need to  
fund or how we want to examine - if you have your studies out  
there - I know you are going to be looking at other things.  But if  
we have a helmet - if, in fact, there is body armor with this - we  
are contributing to a problem here, I really do not know who to go  
to to examine this issue.  I really do not.
 

Dr. Perlin.  You raise an important issue that the rate of survival  
from a forward injury is now greater than ever before.  And that is  
a good thing.  But the injuries that are sustained are brutal.  The  
body armor saves lives.
 

But as you have seen when you visited at Walter Reed, you have  
learned that the trauma is multiple.  It can lead to amputation,  
spinal cord injury, brain trauma, loss of vision, loss of hearing,  
all of the mental health issues that are associated with that tragic  
loss.
 

And that is the challenge of today's patient and that is where VA  
is investing its resources, areas like polytrauma.  In fact, there  
are projects that look at mechanisms of traumatic brain injury, the  
skull interface with the helmet.
 

In DoD, there is a colonel I know who has been doing some work to  
try to advance the helmet recognizing that the percussive injury  
occurs twice, once with the explosion and once with the repercussion  
with the helmet itself just as you have identified.
 

The Chairman.  Dr. Ruff, you passed that note.  Do you know the name  
of the colonel?  Will you get it to the Committee?  Do you know who  
is doing this specific type of repercussion research?
 

Dr. Ruff.  I do not know the name of the colonel, but I know that  
there are three projects that we are looking at that look at the  
skull interface to the source of the pressure, basically what you  
are talking about in terms of the helmet, how the pressure is  
delivered and how the pressure is dissipated in terms of what  
effect that has on the brain.
 

So that is being looked at in animal models.  We are not doing it  
with people.  There are some people I would like to do it with,  
but that is not ethical.
 

Dr. Perlin.  Mr. Chairman.
 

The Chairman.  Yes.
 

Dr. Perlin.  I might suggest, Mr. Chairman, we might want to have a  
closed joint briefing with the DoD and these folks because some of  
the stuff we talk about probably ought to be in a closed session in  
terms of what are the vulnerabilities of our armor.
 

The Chairman.  All right.  We will do that.
 

If you will be in touch with the Committee, Dr. Ruff, I would  
appreciate that.
 

Thank you very much for your testimony and for the judgments that  
you are making.  This panel is now excused.
 

All members of the Committee will have five legislative days to enter  
their statements into the record.
 

Our second panel, if you could come forward.  Our second panel  
represents the veterans service organizations and groups familiar  
with medical research.
 

The first member of the panel is Mr. Carl Blake, Senior Associate  
Legislative Director for Paralyzed Veterans of America.  Mr. Blake  
is a graduate of the United States Military Academy at West Point.
 

After graduation, he was commissioned as a Second Lieutenant in the  
United States Army, assigned to the First Brigade of the 82nd  
Airborne at Ft. Bragg, North Carolina.  He was retired from the  
military in October of 2000 due to a service-connected disability.
 

Our second member of the panel is Rick Weidman who is Executive  
Director of Policy & Government Affairs for Vietnam Veterans of  
America.  Mr. Weidman served as a medic with the Company C 23rd  
Med, America Division, located with ICOR of Vietnam in 1969.
 

Mr. Weidman was part of the staff of VVA from 1979 to 1987, serving  
variously as Membership Service Director, Liaison, and Director of  
Government Relations.  He left VVA to serve in the Administration  
of Governor Uma as Director of Veterans Employment and Training in  
the New York State Department of Labor.
 

Congratulations on your new title.
 

Mr. Weidman.  Thank you very much, sir.
 

The Chairman.  Our third and final panelist, Dr. Dennis Niewoehner,  
a Member of the American Thoracic Society and Chief of Pulmonary  
Section of the VA Medical Center, Minneapolis, Minnesota.  He is  
here testifying on behalf of the Friends of VA Research.
 

Gentlemen, your written statements, if you have them -- do all three  
of you have written statements?  All but one.  Rick Weidman, do you  
have a written statement?
 

Mr. Weidman.  Yes, sir.
 

The Chairman.  All three have written statements.  If you offer  
your statements, they will all be submitted for the record, and you  
each are recognized for five minutes for oral testimony.
 

Mr. Blake, you are now recognized.


STATEMENTS OF CARL BLAKE, SENIOR ASSOCIATE LEGISLATIVE DIRECTOR,  
PARALYZED VETERANS OF AMERICA; ACCOMPANIED BY RICHARD WEIDMAN,  
EXECUTIVE DIRECTOR, POLICY & GOVERNMENT AFFAIRS, VIETNAM VETERANS  
OF AMERICA; AND DENNIS E. NIEWOEHNER, MEMBER, AMERICAN THORACIC  
SOCIETY, TESTIFYING ON BEHALF OF VA RESEARCH, CHIEF, PULMONARY  
SECTION, VAMC, MINNEAPOLIS, MINNESOTA

STATEMENT OF CARL BLAKE

 

Mr. Blake.  Thank you, Mr. Chairman.  Mr. Chairman, Mr. Michaud, I  
would like to thank you for the opportunity to testify today on the  
VA Medical and Prosthetic Research Program.
 

Before I begin, I would like to introduce someone who is here with  
me.  I would like to introduce Mr. Thomas Stripling.  He is PVA's  
Director for the Research, Education, and Clinical Practice  
Guidelines Program.  He is our subject matter expert on these  
issues at PVA and he will be available for questions also.
 

The Chairman.  Please come up here and have a seat.
 

Mr. Blake is here testifying.  He answers the questions asked.  But  
you know what?  I do not have the subject area of that -- 
 

Mr. Blake.  I learn quickly, sir.
 

The Chairman.  You had a very good answer.  Something you learned  
probably at West Point.
 

Mr. Blake.  It had to do with the IT section, sir -
 

The Chairman.  It was IT.
 

Mr. Blake.  - and not knowing where it was in the IT.
 

The Chairman.  Yes.  It was a great question, but this is not a  
subject area for which I have great expertise, I think.  Now you  
have him to your right.
 

Mr. Blake.  Yes, sir.
 

The Chairman.  We have you covered.  You are recognized.
 

Mr. Blake.  The VA healthcare system is a unique environment  
combining clinical care, education, and research.  VA currently  
supports approximately 3,800 researchers at 115 VA medical centers.
 

According to the VA, nearly 83 percent of these VA researchers are  
practicing physicians.  Because of this dual role, VA research often 
 immediately benefits patients.
 

For example, functional electrical stimulation is a technology using 
 controlled electrical currents to activate paralyzed muscles and is  
being developed at VA clinical facilities and laboratories throughout  
the country.
 

This technology is now being applied to many PVA members receiving  
healthcare service and rehabilitation therapy at SCI centers.   
Through this technology, tetraplegic patients have been able to  
grasp objects, stand and pivot to assist transfers, and control  
bladder function.  We even anticipate greater capacity for walking  
short distances.
 

Through the system's scope of primary, secondary, and tertiary care  
as well as long-term care, with multi-disciplinary academic  
affiliations, the VA brings validation and innovation to the  
delivery of the best care for today's veterans.
 

Perfect examples of this idea are the Parkinson's Disease Research,  
Education, and Clinical Centers and the MS Centers of Excellence.   
These centers represent a successful strategy to focus the VHA's  
system-wide service and research expertise to address two critical  
care segments of the veteran population.
 

Since 1997, PVA has worked with VA MS clinicians and administrators  
as well as with private MS providers and advocates to address the  
then patchwork service delivery by VHA towards veterans with MS.   
While we identified the scope and range of these services, it became  
very apparent that vital elements indeed did exist.
 

The designation by VA of two MS Centers of Excellence located in  
Baltimore and Seattle/Portland represents centers without walls  
engaged in marshaling VA expertise in diagnosis, service delivery,  
research and education, and making the same available across the  
country through the hub and spokes' approach.
 

PVA supports this approach for both Parkinson's disease as well as  
multiple sclerosis.  In fact, there is a similar approach that is  
used for spinal injury care through the VA.
 

We would urge the Committee to consider legislation which would  
permanently authorize these centers because they represent the true  
value of VHA as a national healthcare system's success story.
 

PVA recognizes the fact that much like the greater VA infrastructure,  
research facilities are aging and in need of repair or renovation.   
For decades, insufficient construction funding has been provided to  
maintain, upgrade, and replace the VA's aging research facilities.   
The result is a backlog of research sites that need major and minor 
 construction funding.
 

Five years ago, the VA received $25 million specifically for upgrades  
and enhancements to these facilities.  However, no specific funding  
has been provided since.
 

We do appreciate that this Committee and the House of Representatives  
earlier this year has earmarked $12 million for minor construction at  
VA research facilities.  However, we believe a steadier stream of  
funds must be provided.
 

We urge Congress to begin investing dedicated funding into the  
rapidly deteriorating infrastructure in which VA clinicians and  
researchers conduct their daily activities.
 

The VA has stated that it will need three years to complete a  
research facility's assessment before it can invest new money into  
its research infrastructure.  However, an assessment was just  
completed in 2003 and we believe that this assessment could be  
used as the baseline for a faster reevaluation so that much needed  
upgrades are not held hostage to this process.
 

In conclusion, Mr. Chairman, our greatest concern with the Medical  
and Prosthetic Program is chronic under-funding.  VA research has  
been grossly under-funded in comparison to the growth rate of other  
federal research initiatives.
 

Although the Administration's budget request called for only $399  
million for this account, we appreciate your efforts and the  
Committee's efforts to provide the additional funding to the  
program.  However, we believe more can be done.
 

In accordance with the recommendations of the Independent Budget,  
we believe that the Medical and Prosthetic Research Program requires  
$460 million.  This would allow the VA to expand the scope of many of  
its research projects and begin upgrading and expanding its research 
 infrastructure.
 

Mr. Chairman, I would like to thank you again for the opportunity  
to testify.  And myself and Mr. Stripling will be happy to answer  
any questions that you might have.
 

The Chairman.  Thank you.
 

Mr. Weidman, you are recognized.
 

[The statement of Carl Blake appears on p.  ]
 


**********INSERT**********


STATEMENT OF RICHARD WEIDMAN

 

Mr. Weidman.  Thank you, Mr. Chairman.  On behalf of Vietnam Veterans  
of America and our National President, I want to thank you for this 
 opportunity.
 

We also wish to salute you for your continued emphasis on trying to  
get VA to focus on the wounds of war and the maladies and wounds of  
military service per se.  It is something that Vietnam Veterans of  
America since our inception has focused upon and something that seems  
to be very difficult.
 

Just one example, even though it has been on the books now for some  
24 years, we seem to have difficulty and so does the VA in getting  
each primary healthcare physician to do something as simple as take  
a military history on each and every veteran whom they see and relate  
it back to what maladies should they be testing that individual for,  
what other conditions, as an example, frostbite if the person served  
on the ground in Korea.
 

The VVA strongly supports increased funding for all parts of VA and  
I think it is indisputable and VVA believe it is indisputable that VA  
has made many extraordinary contributions to the world of research  
and medical research today that have spilled over to the rest of  
medicine and to the rest of the society.
 

However, we strongly agree and applaud you for saying it has to be  
veteran specific and veteran centric.  It will have applications to  
other human beings, but it should be focused on what is it as it is  
going to directly help improve care at VA.
 

The Genomic Project that they have underway, in fact, may be useful  
to the entire nation.  If so, we should think of it in light of who  
has the resources.  The VA research budget overall is decimal dust,  
I repeat, sir, decimal dust in comparison to the size of the research  
budget at the National Institutes of Health.  If it is, in fact, in  
the national interest, and we believe it is, NIH should fund it in  
whole.
 

Similarly there are a number of things in our written statement that  
I would draw your attention to having to do with NIH refusing to pay  
admin overhead, et cetera, that we would hope that the Commission  
would address with your counterparts on the appropriate authorizing  
Committee.
 

Last, and I want to focus the remaining time here on the National  
Vietnam Veterans Longitudinal Study, the unfortunate  
mischaracterization of the GAO report this morning or this  
afternoon is something that we cannot let rest.  GAO does not  
tell the Executive Branch what to do in any instance.  It is, of  
course, an arm of the Congress.
 

It was an administrative decision to stop the NVVLS originally taken 
 by the previous Under Secretary who stopped it arguing that $17  
million was too much to spend on this study.  This is the same  
incidentally Under Secretary who was removed for throwing $374  
million down the toilet on hardware and software that did not  
work at Bay Pines, Florida.
 

But 17 million was too much money to spend on a longitudinal study.   
We have difficulty with that, sir.  The excuse that is given now  
for not continuing and completing the replication as required by  
Public Law 106-4119 of the National Vietnam Veterans Readjustment  
Study, otherwise known as the National Vietnam Veterans Longitudinal  
Study, is that they can only find 300 veterans left alive of the  
2,500, 2,500 who were sampled.
 

We would suggest to you, Mr. Chairman, that if only 300 of the  
original 2,500 are alive, then that would merit a press release and  
if indeed not a press conference by this Committee to ask what in  
the world is going on that a statistically valid, random sample of  
Vietnam veterans, 85 percent of them have died since 1985.  There  
is no reason in our view for any further delay in moving forward  
on completing the NVVLS.
 

Two quick comments on a couple of other studies that Dr. Friedman so  
ably commented on.  The Twin Study does not include any African  
Americans.  It does not include any or virtually no Latinos and it  
includes no women whatsoever, whereas, in fact, the database for the  
National Vietnam Veterans Longitudinal Study has over-sampled for all  
three of those groups and would allow us to make statements about it.
 

Last but not least on the Twin Study is the Twin Study is really  
right on the borderline of being too small to allow us to make  
judgments about the overall veterans' population within the country.
 

The brain injury work, we certainly applaud and would encourage all  
of that ancillary research to go on, but that does not substitute  
for the NVVLS.
 

Last but by no means least, I would like to just briefly comment that  
there are a heck of a lot of very curious studies that have been  
funded instead of the NVVLS over the last three years.  Let me just  
cite three examples that we can supply to the Committee to be part  
of the record.
 

First is PTSD plus electroconvulsive shock treatment with them  
claiming that people were faking symptoms.  This came out of the  
Topeka, Kansas VA Medical Center, but was funded by R&D.  The claim  
there was that because reportedly symptomatology went down after  
they informed the veteran that we are going to admit him inpatient  
and for two weeks we are twice a day going to run current through  
his body and put him into electroconvulsive, electrically induced  
convulsions, that suddenly his reported symptoms went down.
 

I would suggest to you, Mr. Chairman, that a veteran with chronic  
PTSD, acute PTSD, if you and I informed him that twice a day if he  
reported any more symptoms we were going to take him out in the  
parking lot and beat the bejeebers out of him, then he would stop  
reporting symptomatology.  I mean, this is not the kind of research,  
quote, unquote, that we should be reporting.
 

Additionally, also at that same medical center, there was a study  
that came to the conclusion that smoking increases your risk of  
PTSD.  This struck us as very odd when, in fact, of course, it is  
the other way around.  There are other factors that cause and  
increase your risk of getting posttraumatic stress disorder.  And  
smoking is elevated among people who have PTSD, but does not  
increase the risk, at least from any reasonable point of view that  
we can see nor have we ever seen any literature whatsoever  
supporting either of those theses.
 

Mr. Chairman, we would be glad to answer any questions.  We thank  
you once again for your leadership in pushing to make the few dollars  
that VA has on for research and development most relevant to America's 
 veterans and to our service men and women who are serving today.
 

Thank you very much, sir.
 

The Chairman.  Thank you very much.
 

Sir.
 

[The statement of Richard Weidman appears on p.  ]
 


**********INSERT**********


STATEMENT OF DENNIS E. NIEWOEHNER

 

Dr. Niewoehner.  I am respiratory disease specialist at the  
Minneapolis VA Medical Center and a Professor of Medicine at the  
University of Minnesota.  While I am a VA employee, I am today  
testifying as a private citizen on behalf of the Friends of VA  
Healthcare and Medical Research, better known as FOVA.
 

FOVA is a coalition of over 80 veterans service voluntary health  
and medical professional organizations that support funding for  
veterans' health programs.  FOVA is especially committed to ensuring  
a strong VA Medical and Prosthetic Research Program.
 

So why support VA Research Program?  I will give you three  
reasons.  Good science, good physicians, and good care for veterans.
 

The VA Research Program produces good science whether it is  
hepatitis, heart disease, Parkinson's disease, diabetes, or  
rehabilitation medication.  The VA Research Program is producing 
 new approaches and new treatments that are published in the  
leading medical journals.
 

VA research is peer reviewed.  Like our colleagues at the NIH and  
other federal funding agencies, all VA research proposals go through 
 a vigorous peer review process to ensure that only the best  
scientific proposals are funded.
 

The VA Research Program excels in clinical research.  And by  
clinical research, I mean testing therapies in patients, not in  
test tubes.  Our laboratory colleagues do an excellent job of  
generating novel ideas from basic research, but somebody has to  
translate these research ideas into treatments for patients.  And  
the VA Research Program is very good at that task.
 

Allow me to provide just one example from my own experience.   
Chronic obstructive pulmonary disease, which is also called COPD or  
emphysema, is a prevalent disease among our veterans and relevant to  
the Chairman's previous comments, I think, can be viewed as being  
veteran centric and is one of the most common reasons for hospital  
admission.  Hospital admissions account for more than one-half of  
the total medical costs of treating this terrible disease.
 

In a trial sponsored by the VA Cooperative Studies Program, we  
demonstrated giving cortisone-like drugs significantly reduced  
length of hospital stay.  So by using this treatment, patients get  
better sooner and the VA medical system saves money.
 

These findings were published in the New England Journal of Medicine  
and these findings have been widely incorporated into clinical practice 
 both within and without the VA medical system.
 

The VA Research Program helps attract highly-qualified physicians to  
serve our nation's veterans because it provides a unique opportunity  
to combine a career in clinical medicine with opportunities to do  
research.
 

For me personally, the research program was a major reason that I  
joined the VA and equally important it is also the reason that I have 
 remained in the VA medical system for nearly 30 years.
 

Lastly, and I emphasize this point most strongly, the VA Research  
Program is good for veterans.  It focuses resources on diseases of  
high prevalence among veterans and evaluates new treatments in a  
highly scientific manner.
 

The VA Research Program fosters a culture of inquiry where the  
veterans' care needs drive the research program and in turn findings  
from the research program drive improvements in veterans' care.  In  
addition, new research findings can be quickly and broadly  
implemented across the entire VA medical system.
 

One dark spot on the shining achievements of the VA Research Program  
is its aging facilities.  The subpar research facilities are making  
it increasingly hard to recruit and retain top-flight physician  
researchers in the VA medical system.
 

FOVA greatly appreciates the recent congressional efforts to address  
this issue in the military quality of life, VA appropriations bills.   
However, the problem persists.  VA has identified a priority of lists  
of VA labs that are in need of renovation and is committed to  
executing these renovation projects provided Congress provides the 
 funding.
 

FOVA strongly recommends that $45 million be provided to rehabilitate  
the existing VA data lab space.
 

Mr. Chairman, I think it is clear that the VA research uses its  
resources wisely and efficiently to the betterment of veterans'  
healthcare.  Thank you for listening to the views and recommendations  
of FOVA, and I would be happy to answer any questions.
 

[The statement of Dennis Niewoehner appears on p.  ]
 


*********INSERT**********
 

The Chairman.  Thank you very much to all of you for your testimony.
 

Mr. Blake, in your testimony, you talked about PVA supporting the  
building of these Centers of Excellence.  So let me go specifically  
to the one VA currently operates, the Center for Limb Loss and  
Prosthetic Engineering in Puget Sound, Washington where investigators  
study amputation prevention, lower limb prosthetic improvement, and  
patient outcome measurements.
 

So with that in mind, why should we create a new center which will  
require additional real dollars instead of just perhaps even beefing  
up what we presently have?
 

Mr. Blake.  Well, Mr. Chairman, I think the point that I was trying  
to make is that one single center across the VA spectrum given what  
seems to be a fairly significant problem among the newer veterans  
returning is probably not enough to meet the demand for that growing  
service within the VA system.
 

We recognize the importance of that one particular center in  
providing service and the research it is conducting.  But if you  
spread that wealth out a little more, instead of having it in one  
general area, and even though it kind of operates within that hub  
and spoke approach that I spoke about, you can spread out the  
different activities that are being done to more than one center so  
that you meet this growing population of veterans who are dealing  
with these particular problems.
 

The Chairman.  Have you been to this center?
 

Mr. Blake.  I have not, sir.
 

The Chairman.  Have you, Mr. Stripling?
 

Mr. Stripling.  [Shakes head negatively.]
 

The Chairman.  Do not worry.  I have not either.
 

Dr. Ruff, have you been there to this center in Puget Sound?
 

Dr. Ruff.  Yes.
 

The Chairman.  I know this is a little out of ordinary.  Dr. Ruff,  
can you come forward just a second.  Can you tell us about this  
center in Puget Sound.  I mean, if the Senate has a proposal over  
there and we have limited dollars, should we really be building  
more centers around the country or beefing up what exists at an  
existing facility?
 

Dr. Ruff.  The Puget Sound center is a center in rehab research.  It  
is one of 15 centers in rehab research.  Its mission is shared  
somewhat by a new center that has been developed in Providence in  
terms of Providence is looking at ways of enhancing prosthetic  
design, reducing the deficits that people with amputations have.
 

The Center in Seattle is focusing a little bit more on prevention  
of limb loss and they are coordinating their research activities  
with a podiatry service, clinical podiatry service which leads a  
program called PACT, which is Prevention of Amputation Care Team,  
which is a national program within the VA.  That focuses on  
reducing the risk of amputation primarily for older veterans who  
are at risk due to diabetes and peripheral vascular disease.
 

The center in Seattle is a research center that coordinates with  
clinical centers, but I think they are talking about a different  
type of center.  I think that they were talking about a clinical  
center for prosthetics care maybe to link with the center in  
Seattle.  But I do not want to speak -- 
 

The Chairman.  Well, wait a minute.  Let me ask Mr. Blake because  
I am confused.
 

What are you asking for, Mr. Blake?
 

Mr. Blake.  I would say it would be a broad-based center that has  
both clinical aspects to it as well as research aspects.  And we  
also make recommendations so that these centers put a great deal of  
emphasis on research in terms of performance standards and improving  
the equipment that is being placed out there.
 

Although we recognize that many of the servicemembers who are coming  
back through places like Walter Reed in particular but Bethesda or  
Brook are receiving high-quality prosthetics, that is being done  
through a program supported with DoD.
 

And the VA needs to get in line with that as well, and these centers  
could kind of align their own prosthetics program with what the DoD  
is doing in a very small location to ensure that there is continuity  
of those types of services once those servicemembers are out into the  
VA and receiving their care there and not directly from DoD.
 

The Chairman.  All right.  Thank you.
 

Thank you, Mr. Weidman.
 

Thank you, Dr. Ruff.
 

Mr. Michaud, you are recognized.
 

Mr. Michaud.  Thank you very much, Mr. Chairman.
 

Mr. Weidman, thank you for your comments about the NVVLS study and  
the importance of completing the study.  I know in the past, you  
have talked about having a separate line item to complete the  
study.  I believe it was $25 million to complete the study.
 

Should that money come out of the $412 million for research or should  
that be additional resources to complete the study?
 

Mr. Weidman.  First of all, with the indulgence of the Chair, I  
misspoke earlier.  It was not a GAO report.  It was an Inspector  
General's report that was issued September 30th, 2005, but the 
point still holds.  The IG has no line authority to cancel or 
to start anything.
 

The 25 million, up to 25 million because, frankly, we do not think  
it would take 25 million to complete the study.  When the study was  
cancelled in early October of 2003 by Dr. Roswell, they were just  
on the cusp of delivering their first set of deliverables to the  
VA.  It was mismanagement incidentally.  The IG hit the  
mismanagement of VHA, not Research Triangle Institute.
 

Were there some people who did not act all that well at RTI?   
Sure.  But that was not the issue.  The issue was that VA failed to  
manage the contract.
 

When we testified, if you recall, Mr. Michaud, we were asking for  
a ten percent raise to the R&D budget.  That would bring it up to  
roughly $443 million and we had intended for it to come out of R&D 
 and not out of patient care dollars.
 

Mr. Michaud.  Thank you.
 

Doctor, if we look at the funding for VA research, it is a mix of  
appropriated dollars plus non-VA dollars.
 

How should the mix be envisioned for the future?  Is there an  
ideal percentage?  Are these dollars fungible or are there ideal  
uses for the VA dollars that non-VA dollars are not appropriated  
or vice versa?
 

Dr. Niewoehner.  Is this -- 
 

Mr. Michaud.  Yes.
 

Dr. Niewoehner.   -- directed towards me?  I am afraid I did not  
quite understand the question.
 

Mr. Michaud.  When you look at VA research, there is a mix of dollars  
that is appropriated, that Congress appropriates to VA, but also 
 non-VA dollars, such as NIH.
 

Is there a certain percentage that should be VA specific and, if so,  
what is that percentage between VA dollars and non-VA dollars?
 

Dr. Niewoehner.  Well, the diseases that we are addressing are  
certainly common.  Many of the diseases that we are addressing  
certainly are common to both VA and non-VA patients.  I mentioned  
COPD as being a veteran centric disease, but there is obviously a  
huge amount of this disease in the non-VA community as well.
 

So I think it is very appropriate that the VA devotes additional 
money towards research into the treatment and prevention of COPD, 
but recognizing that from a broader societal standpoint that 
everybody will benefit from this.
 

And I am not sure that I am prepared to put any specific -- I am 
not knowledgeable enough to put a specific number on that.
 

Mr. Michaud.  Thank you.
 

Mr. Blake, dealing with the spinal cord injury research, your  
organization is definitely in the forefront in that particular arena.
 

Do you think the VA is doing enough in this area and, if not, what  
do you think the VA should be doing?
 

Mr. Blake.  I think I would like to defer to Mr. Stripling because  
he is intimately involved with that particular program.
 

Mr. Michaud.  Thank you.
 

Mr. Stripling.  Thank you very much for the question, sir.  I am  
not sure we ever get to the point where enough has been done on a  
lifetime disease or a lifetime disability.
 

I think the issue becomes one of being able in the VA system to  
track the kinds of the things that are a repeat problem.  So we  
are never going to cure, if you would, as quickly an injury that  
happens in a split second.
 

But when we see urinary infections continuing to be a problem, we  
see respiratory problems continuing, we see pressure ulcers  
continuing, we see diabetes continuing, we know we are not doing  
enough in those areas.  We need to isolate them as the VA has in  
various initiatives whether it is QUERI, whether it is rehab R&D,  
or whether it is in their Clinical Affairs Division to see whether  
we can make some progress in those things.
 

We may not be able to settle the issue of diabetes forever, but we  
make it a manageable condition.  We may not be able to completely  
take care of emphysema, but we make it a manageable condition.
 

Bringing more information into the process, we get better clinical  
outcomes, we get better clinical practice, and we get reduced  
incidences of those in our area, you know, in our tracking system  
and we know we are making progress.
 

So I think that when you have a lifetime condition, there may never  
be enough that can be ever done because the condition is a lifetime.  
But there are management issues that any of us would expect and any  
of us would accept as ways of living with that condition, that move  
us from the process of catastrophicness, if you would, to  
manageability.
 

And I think those are what we see now in the outcome studies that  
are being performed across the healthcare system whether in the VA  
population, in the SCI population, or in the civilian populations.
 

We have a life expectancy now that we can be proud that we have 
 created.  We have gone from a condition that was not manageable  
to a condition that is survivable to an extent, if you would.
 

So I think that we continue to monitor ourselves.  We continue to 
see that we get progress in what we are doing.  I am not really 
sure we will ever get to the point where we have done enough.
 

Mr. Michaud.  Thank you.
 

And once again, Mr. Chairman, I want to thank you for having this  
hearing.
 

And the reason why I asked Dr. Perlin for information on all of  
what they are doing in research and development, because I think  
there is an important aspect of what the VA is doing in R&D as  
well as with DoD, and I was interested in that because I think it  
is important that they are focused and working together.
 

But also as equally as important, I know there is a lot of research  
going out there in the private sector working in different areas.   
And a good example is the University of Maine, which is doing some  
research which affects the Navy, the Coast Guard and fishermen on  
boats and the speed of the boat and the pounding of the boat on  
the water, as to the impact on the spinal cord.
 

So there is a lot of research going out there, and I think it is  
important with the finite amount of R&D dollars that we have as  
much collaboration not only interagency but also with the private  
sector to try to get the most bang for the buck.
 

Thank you.  I yield back my time, Mr. Chairman.
 

The Chairman.  Thank you very much for the gentleman's contribution.
 

Mr. Blake, I know that PVA have been very active in your work to  
establish the two Centers of Excellence for MS, Baltimore and the 
 Seattle/Portland facility.  And Mr. Brown and Mr. Michaud are  
considering making that a permanent authorization.
 

And I would like to know what do you think that would do?  Is  
that something they should be doing or not?
 

Mr. Blake.  Absolutely, sir.  I think we make that recommendation.   
We have made it numerous times.  I think the reason we make the  
recommendation is the VA is clearly doing great work there.
 

And the point is, by permanently authorizing, we ensure that due  
to some kind of budgetary whim or some other problem that may arise  
as we talk about here, limitations of dollars, that these centers do  
not become victim to cuts that might be necessary just through the  
fact that there is no money available.  And by permanently  
authorizing them, we can protect them in that manner.
 

The Chairman.  To the Friends of the VA, let me thank you for  
the written testimony.  Please express my appreciation to whoever  
put all this together.  If it was you, congratulations.  You did  
good work.
 

One of our challenges, when you come in with your testimony and say,  
well, you should upgrade your research by $45 million, it is not how  
the budgets get broken out.  You know, Dr. Perlin sends over their  
medical construction and there is not a specific break-out column.   
We do not get one from you, Doc, that says, okay, this is the medical  
research construction budget.
 

I mean, we give dollars to them.  Then you have that internal fight  
with regard to how those dollars are spent.  And we have not had a  
specific break-out with regard to how we do our budgets.  I think  
you know that.  So it is hard for us when you go, okay, you tell us  
there should be a specific $45 million.  It is not all aligned that  
way.  I just want you to know that.
 

Dr. Perlin.  I know.
 

The Chairman.  Okay.  We do recognize and are cognizant that based  
off the site visits, he has given his testimony that upgrades need  
to be made.  Dr. Perlin is sitting right next to him.  I think given  
Dr. Perlin, he would have preferred for him to be here himself.  But  
we like Dr. Perlin to bring his team here so he can also hear from  
his team.  And I think it is important as he hears from his team we  
are also listening to it too.
 

And so I appreciate the time you put in and please extend that to  
your team.
 

Mr. Weidman, thank you.
 

Mr. Blake, congratulations.  You are figuring this place out.
 

Mr. Blake.  Thank you, sir.
 

Mr. Chairman, could I made one other point real quick -- 
 

The Chairman.  Sure.
 

Mr. Blake.   -- just to clarify on the question about the amputation  
centers?  Senator Craig's proposal, I think, just kind of envisioned  
clinical service centers for veterans who have amputations and their  
needs for prosthetics.
 

And in our recommendation both before the Senate and in our  
statement that we brought here to you today, we take that a step 
 further by introducing the research component into it because we  
recognize through all the Centers of Excellence and just like  
through SCI centers the importance of the research aspect and the  
clinical research that goes on as this care is provided.
 

The Chairman.  I have not seen Chairman Craig's legislation.  I do  
not know a lot about it.  I have learned more just today.  If that  
is what it is, I am a little more attentive.  I do not want to  
create more research facilities out there and take away from  
existing facilities.
 

Mr. Weidman, you have a closing comment?
 

Mr. Weidman.  No.  Just a question, Mr. Chairman.  If you would 
entertain at least a link to the Inspector General's report in 
question.  Those reading the record in the future will be confused 
who is correct about the right reading of the Inspector General's 
report of September 30th, 2005.  If that could be included in the 
record or at least to link it from the House of Veterans' Affairs 
web site to the IG's office?  I do not know if I am making any 
sense on that, sir.
 

The Chairman.  Try it one more -- 
 

Mr. Weidman.  Okay.
 

The Chairman.  Come at it one more time.
 

Mr. Weidman.  The Inspector General's report -- 
 

The Chairman.  Yes.
 

Mr. Weidman.   -- of September 30th, 2005, in regard to the National 
Vietnam Veterans Longitudinal Study -- 
 

The Chairman.  Yes.
 

Mr. Weidman.   -- there was obviously a difference of opinion as to 
what that report said.
 

The Chairman.  Yes.
 

Mr. Weidman.  My question to you, sir, is would you entertain  
considering having a link from the record of this hearing to that  
Inspector General's report so that those reading the record, either  
other members of their staff or the public, in the future have  
access to it.
 

The Chairman.  Yes.  I think the fact, Mr. Weidman, that you have  
now referred to that report, individuals could find it.  I prefer  
not to have that part of our hearing record.  But the fact that you  
have mentioned it, those who may read it now know how to refer to it.
 

Mr. Weidman.  Thank you, sir.
 

The Chairman.  Okay?  Thank you very much.
 

This hearing is now concluded.
 

[Whereupon, at 3:06 p.m., the Committee was adjourned.]




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