[Senate Hearing 109-598]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 109-598
 
       VA RESEARCH: INVESTING TODAY TO GUIDE TOMORROW'S TREATMENT

=======================================================================

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                       ONE HUNDRED NINTH CONGRESS

                             SECOND SESSION

                               __________

                             APRIL 27, 2006

                               __________

       Printed for the use of the Committee on Veterans' Affairs


 Available via the World Wide Web: http://www.access.gpo.gov/congress/
                                 senate




                    U.S. GOVERNMENT PRINTING OFFICE

28-559 PDF                  WASHINGTON : 2007
------------------------------------------------------------------
For sale by Superintendent of Documents, U.S. Government Printing 
Office Internet: bookstore.gpo.gov  Phone: toll free (866) 512-1800;
DC area (202) 512-1800 Fax:  (202) 512-2250. Mail:  Stop SSOP, 
Washington, DC 20402-0001



                     COMMITTEE ON VETERANS' AFFAIRS

                      Larry Craig, Idaho, Chairman
Arlen Specter, Pennsylvania          Daniel K. Akaka, Hawaii, Ranking 
Kay Bailey Hutchison, Texas              Member,
Lindsey O. Graham, South Carolina    John D. Rockefeller IV, West 
Richard Burr, North Carolina             Virginia
John Ensign, Nevada                  James M. Jeffords, (I) Vermont
John Thune, South Dakota             Patty Murray, Washington
Johnny Isakson, Georgia              Barack Obama, Illinois
                                     Ken Salazar, Colorado
                  Lupe Wissel, Majority Staff Director
               D. Noelani Kalipi, Minority Staff Director


                            C O N T E N T S

                              ----------                              

                             April 27, 2006
                                SENATORS

                                                                   Page
Craig, Hon. Larry E., Chairman, U.S. Senator from Idaho..........     1
Akaka, Hon. Daniel K., Ranking Member, U.S. Senator from Hawaii..     3
Thune, Hon. John, U.S. Senator from South Dakota.................     4
Burr, Hon. Richard, U.S. Senator from North Carolina.............     4
Salazar, Hon. Ken, U.S. Senator from Colorado....................     5
Jeffords, Hon. James M., U.S. Senator from Vermont...............     6

                               WITNESSES

Perlin, Jonathan B., M.D., Ph.D., Under Secretary for Health, 
  Department of Veterans Affairs; accompanied by Richard F. Weir, 
  Ph.D., Research Scientist, Prosthetics Research Laboratory, 
  Jesse Brown VA Medical Center, Chicago, Illinois, Department of 
  Veterans Affairs, and Joel Kupersmith, M.D., Chief Research and 
  Development Officer (CRADO), Department of Veterans Affairs....     6
    Prepared statement...........................................     8
Wright, Fred S., M.D., Associate Chief of Staff for Research, VA 
  Connecticut Healthcare System, Department of Veterans Affairs..    24
    Prepared statement...........................................    25
Stevens, Dennis L., M.D., Ph.D., Associate Chief of Staff for 
  Research, Veterans Affairs Medical Center, Boise, Idaho, 
  Department of Veterans Affairs.................................    26
    Prepared statement...........................................    28
Feussner, John R., M.D., M.P.H., Professor and Chairman, 
  Department of Medicine, Birmingham, Alabama; Medical University 
  of South Carolina, Charleston, South Carolina..................    28
    Prepared statement...........................................    30
    Responses to written questions submitted by Hon. Larry E. 
      Craig......................................................    33
Kennedy, John I., Jr., M.D., Professor, Department of Medicine, 
  University of Alabama at Birmingham, Birmingham VA Medical 
  Center, Birmingham, Alabama; on behalf of The Alliance for 
  Academic Internal Medicine.....................................    34
    Prepared statement...........................................    36

                                APPENDIX

Letter to Hon. Kay Bailey Hutchison and Hon. Dianne Feinstein 
  from the Department of Veterans Affairs Medical and Research 
  Prosthetics Research Program...................................    45
Friends of VA Medical Care and Health Research, prepared 
  statement......................................................    46


       VA RESEARCH: INVESTING TODAY TO GUIDE TOMORROW'S TREATMENT

                              ----------                              


                        THURSDAY, APRIL 27, 2006

                               U.S. Senate,
                    Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 10 a.m., in room 
SR-418, Russell Senate Office Building, Hon. Larry E. Craig, 
Chairman of the Committee, presiding.
    Present: Senators Craig, Burr, Thune, Isakson, Akaka, 
Jeffords, Obama, and Salazar.

   OPENING STATEMENT OF HON. LARRY E. CRAIG, CHAIRMAN, U.S. 
                       SENATOR FROM IDAHO

    Chairman Craig. Good morning, ladies and gentlemen. The 
Committee on Veterans' Affairs will now be in order.
    We have entitled this hearing today ``VA Research: 
Investing Today to Guide Tomorrow's Treatment.'' Today's 
hearing will focus on an aspect of the VA Health Administration 
that often goes without the full measure of recognition that, I 
believe and I think most who know about it believe it, is due. 
The Medical and Prosthetic Research Program, VA's research 
program, encompasses bench science, clinical research, health 
service research, and rehabilitation research. Today these 
research activities have vastly contributed to the scientific 
knowledge base, led to the development of new technologies and 
improved the delivery of health services at VA medical 
facilities across the country.
    VA research has played a major role in a number of historic 
breakthroughs: the first successful liver transplant, the 
development of the first cardiac pacemaker, and the technology 
that led to the development of the CT scan, just to name a few. 
Impressively, VA has accomplished all of this on a limited 
budget. Each year, direct appropriations for VA R&D are 
leveraged with the NIH grant funding and resources from VA-
affiliated nonprofits. Due in part to this maximization of 
research funds, the roughly $400 million of annual 
appropriations for VA research brings about improvements from a 
$34 billion health system.
    As you know, this year's budget proposed a $13 million 
reduction in VA research funding. With servicemembers returning 
from Iraq and Afghanistan with traumatic injuries and in need 
of innovative medical care, now is not a time to cut research 
funding. I would like to thank the Members of our Committee for 
joining both with me and Senator Akaka, I believe some 
additional Members joined, in writing a letter to the 
appropriators urging them to overturn this reduction. We 
proposed that VA research be funded at $432 million, a modest 
increase over last year's budget, to keep pace with inflation 
and ensure that critical initiatives involving traumatic brain 
injury, spinal cord injury and prostheses are able to move 
forward.
    Beyond addressing this year's budget, we must look ahead to 
the future of VA research. Many of the research facilities are 
in great need of repair and modernization. Researchers carry 
out their day-to-day activities while under serious space 
constraints and in outdated buildings, many of which are 
approaching a 100-year-old mark. For example, in one site that 
is not fully equipped with modern air conditioning and 
ventilation systems, researchers opt to work at night so that 
extreme temperatures will not interfere with their results. 
There are limits to how long we can rely on early 20th century 
research facilities to yield cutting-edge 21st century research 
discoveries.
    However, there are also limits to the amount of funds the 
Congress can provide. As part of our focus on the 
infrastructure needs, it is important that we look for 
innovative ways for VA to enhance its existing relationships 
with universities. I am especially interested in exploring VA-
university collaboration in the form of jointly operating 
research space. Modern facilities are not just about attractive 
work space for academics.
    One of the myriad ways that research benefits the VA health 
care system is through recruitment of physician researchers. We 
will hear from our witnesses here today about how the shortage 
of modern research is hindering recruitment of new physicians.
    I want to be clear that this hearing is not about pointing 
out our shortcomings or our failures. It is about assessing our 
challenges for the future. In fact, I commend VA for its 
remarkable record of research accomplishments in spite of some 
serious obstacles. This exciting work will be highlighted 
during VA Research Week which will be held the second week of 
May. As one of the outcomes of this hearing, I hope that 
Members of this Committee will make a point of touring the 
research bases when making visits to their local VA facilities.
    We are joined today with VA Under Secretary of Health, Dr. 
Jonathan Perlin, who happens to be an academically trained 
researcher. He is accompanied by Dr. Joel Kupersmith, VA's 
Chief Research and Development Officer, and Richard Weir, who 
is a researcher at VA's Prosthetic Research Laboratory in 
Chicago.
    Following their testimony, we will hear from four 
distinguished witnesses who are involved in VA research 
throughout the country. Dr. Fred Wright comes to us from the 
West Haven, Connecticut VA, and Dr. Dennis Stevens is from the 
Boise, Idaho VA. We will also hear from Dr. Feussner, who is a 
former head of VA Research and currently chairs the Department 
of Medicine at the Medical University in South Carolina, and 
Dr. John Kennedy, from the University of Alabama, in 
Birmingham's School of Medicine, who will testify on behalf of 
the Alliance for Academic Internal Medicine. So we have some 
very distinguished and talented people before us.
    Before we go further, let me turn to my colleague and 
Ranking Member, Senator Akaka, for any opening comments he may 
have.
    Danny.

STATEMENT OF HON. DANIEL K. AKAKA, RANKING MEMBER, U.S. SENATOR 
                          FROM HAWAII

    Senator Akaka. Mr. Chairman, thank you so much. As always, 
Mr. Chairman, I appreciate the work of Chairman Craig in 
crystallizing the most pressing issues before the Committee, 
and as always, I enjoy working with him and with the Committee 
as well.
    Today we will assess the tremendous value of VA's research 
program, and I want to associate myself with the comments that 
were made by the Chairman. I welcome our witnesses to the 
hearing, including Dr. Perlin, good to see you again, and to 
the other witnesses that were already introduced by the 
Chairman.
    I thank you all for being here today. We are all without 
question immensely proud of VA research. The traditional 
research model, which stems from the peer-review process, has 
yielded an impressive list of accomplishments for the VA. VA's 
research strengths have spanned large clinical trials and more 
narrow looks into the fundamental parts of biology, what some 
call bench research. However, the value of VA's research 
enterprises do not lie solely in its results. The VA Medical 
Research has been instrumental in allowing recruitment and 
retention of physicians in the VA Health Care System. 
Adequately funding VA research helps to ensure that VA remains 
an attractive option to our best and brightest in medicine.
    VA cannot compete with the nongovernmental health care 
sector to attract highly paid physicians. But if VA can 
continue to attract some of our Nation's best doctors, veterans 
will receive the care they deserve, and I give some of this 
credit to Dr. Perlin and what you are doing here. Some of VA's 
researchers' greatest achievements have not been in the arena 
of new treatments for war wounds or for service-connected 
disabilities per se, but for illnesses affecting the populace. 
It is my view that young or old, combat veteran or peacekeeper, 
all of our Nation's veterans can and should be the recipients 
of a vibrant VA research program.
    Funding for the research program is obviously quite 
critical as well. I am extremely grateful that we all came 
together and agreed on the importance of fully funding VA 
research. The $399 million proposed by the VA and the 
Administration is simply not sufficient. I am confident that we 
will more appropriately fund the research program and that we 
will protect peer review research.
    With that, Mr. Chairman, I look forward to this hearing. 
Thank you very much for having it. Thank you very much.
    Chairman Craig. Senator Akaka, thank you very much. Before 
I turn to the rest of our colleagues on the Committee for any 
opening statements, we do have a markup, that is when we get a 
quorum of eight here.
    We now have that magic number in front of us.
    [Whereupon, at 10:10 a.m., the Committee proceeded to a 
markup nominations hearing.]
    [Whereupon, at 10:12 a.m., the Committee reconvened.]
    Chairman Craig. Now let me move on to anyone who would wish 
to make a comment before we move to our panelists. Senator 
Isakson, you are here next in order.
    Senator Isakson. I will yield to Senator Thune.
    Chairman Craig. And that is the appropriate yield, because 
that is the order involved.
    John.

  STATEMENT OF HON. JOHN THUNE, U.S. SENATOR FROM SOUTH DAKOTA

    Senator Thune. Thank you, Mr. Chairman. I want to thank you 
for holding this important hearing to examine the VA's Medical 
and Prosthetic Research Program. I also would like to extend a 
warm welcome to our panelists today. I am pleased to see Dr. 
Perlin again testifying before the Committee.
    The VA's researchers have the noble task of finding ways to 
more effectively address the unique medical problems that our 
veterans tend to suffer due to their service to our country. I 
applaud the efforts of the researchers testifying today who 
have dedicated their lives to improving the health conditions 
of our veterans. You and the 3,000 VA researchers across the 
country who work every day on behalf of our veterans are truly 
great Americans, and I would like to thank you all for your 
service to our country.
    Mr. Chairman, I was pleased to join with you and with 
Ranking Member Akaka, as well as with many other Members of the 
Senate, to send a letter to the Appropriations Committee this 
year expressing support for increased funding for the VA's 
medical research programs. While the Administration's fiscal 
year 2007 proposal for VA funding overall was quite generous, 
medical research funding required some improvement. I am glad 
to see that we are working in a bipartisan way to provide that 
improvement by increasing funding for medical research by $20 
million over last year's level.
    As we continue with the process of developing the VA's 
budget for fiscal year 2007, I am confident that we will 
continue as well to find ways to improve funding for the VA 
while not spending beyond our means. So, Mr. Chairman, I 
applaud your efforts to increase funding for VA medical 
research. I appreciate the opportunity to join you in that 
effort, and again want to thank you for holding this hearing, 
and thank our panelists for sharing their testimony. Thank you, 
Mr. Chairman.
    Chairman Craig. Senator Thune, thank you very much. Senator 
Burr, do you have any opening comments you wish to add?

         STATEMENT OF HON. RICHARD BURR, U.S. SENATOR 
                      FROM NORTH CAROLINA

    Senator Burr. I can ditto to what Senator Thune said, thank 
you to you and the Ranking Member. More importantly, I cannot 
think of a more important hearing for this Committee to have at 
this what I think is a very pivotal time where the signal that 
we send about the investment that we make and the tools that 
the VA has should be very clear. I think this is a statement, 
and I thank the Chair.
    Chairman Craig. Senator Burr, thank you. Senator Salazar.

          STATEMENT OF HON. KEN SALAZAR, U.S. SENATOR 
                         FROM COLORADO

    Senator Salazar. Thank you very much, Chairman Craig and 
Senator Akaka, for your leadership on this Committee and on 
veterans' issues, and thank you, Dr. Perlin, as well for your 
leadership of the VA.
    We all know how important the Veterans' Health 
Administration is to all of our veterans in our country, but 
something that I think we often overlook is how important VHA 
is to our Nation's health care system as a whole. Our veterans' 
health care system is often on the cutting edge of critical 
advances in prevention, diagnosis and treatment, and VA's 
medical research programs are a driving force behind its 
ability to serve this important capacity for our veterans and 
for our Nation. Because the core mission of the VHA is to 
address the prevention and treatment needs of our Nation's 
veterans, the services it provides and the research it conducts 
are patient-oriented. Six out of every ten VA researchers treat 
veterans. As a result, VA researchers do not operate in a 
vacuum. They deal with the very real and very serious health 
problems resulting from combat and from the sacrifices of our 
men and women in uniform. For the 5 million veterans enrolled 
in the VA health care system, they also have unique access to a 
clinical setting in which to put the results of their research 
into practice every day. For these reasons, VA medial research 
has been responsible for significant breakthroughs in the 
fields of prosthetics, diabetes, spinal cord injury, substance 
abuse, mental illness, heart disease, and cancer, all of which 
are prevalent among America's veteran population.
    I understand today's hearing will focus on some of the 
infrastructure challenges that VA's medical research programs 
currently face. Challenges ranging from extremely old 
facilities, to poor heating and ventilation, to outdated 
equipment. There is no question we need to work to address 
these needs if VA's research programs are to continue to be a 
leader in health care innovations, and I look forward to the 
testimony of today's panelists. However, we must be careful not 
to overlook the need to provide adequate resources to the many 
important research initiatives that are currently underway in 
VA facilities across the Nation.
    Despite the progress that research programs across the 
country have made, this year's budget request proposed cutting 
funding for research by $13 million. If anything, we should be 
increasing funding for these important programs so that the VA 
can continue to be a leader in innovation. I am proud to have 
joined my colleagues including Senator Craig and Senator Akaka 
in urging $432 million in funding for VA medical research.
    Thank you again, Chairman Craig and Senator Akaka, for 
holding today's hearing, and I look forward to hearing from the 
witnesses.
    Chairman Craig. Thank you very much, Senator Salazar.
    Senator Jeffords.

       STATEMENT OF HON. JAMES M. JEFFORDS, U.S. SENATOR 
                          FROM VERMONT

    Senator Jeffords. Mr. Chairman, thank you for holding this 
hearing on the VA research funding. I think we all agree that 
the cutting-edge research being conducted by the VA is one of 
the most important functions of the Veterans Administration. 
The VA is responsible for significant advances in medical 
treatment, specialty care, prosthetics, and development in 
outcomes research. The VA's research activities are one of the 
big attractions for top-quality doctors who want to explore 
advancements in medicine as they treat patients. I am concerned 
by the proposal in the President's budget to cut $13 million 
from the VA research budget. I joined many of my colleagues 
here in signing a letter to the Appropriations Committee urging 
the VA Subcommittee to increase the funding for VA research by 
$33 million. I look forward to hearing from you, Dr. Perlin, on 
this important topic.
    Chairman Craig. Jim, thank you very much. Now we turn to 
our panel. I have introduced them, but Dr. Perlin, once again 
let me introduce you, the Under Secretary for Health, United 
States Veterans Administration. So we welcome you and those who 
you have brought with you not only to tell us what you are 
doing, but to show us some of what you are doing. Welcome 
before the Committee.

 STATEMENT OF JONATHAN B. PERLIN, M.D., Ph.D., UNDER SECRETARY 
              FOR HEALTH, DEPARTMENT OF VETERANS 
        AFFAIRS; ACCOMPANIED BY RICHARD F. WEIR, Ph.D., 
  RESEARCH SCIENTIST, PROSTHETICS RESEARCH LABORATORY, JESSE 
               BROWN VA MEDICAL CENTER, CHICAGO, 
ILLINOIS, DEPARTMENT OF VETERANS AFFAIRS, AND JOEL KUPERSMITH, 
     M.D., CHIEF RESEARCH AND DEVELOPMENT OFFICER (CRADO), 
                 DEPARTMENT OF VETERANS AFFAIRS

    Dr. Perlin. Thank you very much, Chairman Craig, Ranking 
Member Akaka, Members of the Committee, good morning. It is a 
delight to be here with you, and we thank you for your support 
of VA research and the recognition that VA research is indeed a 
crown jewel among the Veterans Health Administration's 
resources to serve our Nation's heroes. I am pleased to have 
the opportunity to discuss our Medical and Prosthetics Research 
Program with you today.
    As mentioned, Dr. Joel Kupersmith is the Chief Research and 
Development Officer, and I am also honored to be joined by Dr. 
Richard Weir, a research scientist from the VA Chicago Health 
Care System who, indeed, will demonstrate a cutting-edge 
prosthetic device.
    Mr. Chairman, our research program has a proud history of 
accomplishments that have resulted in marked improvements in 
the health not only of veterans, but of all Americans. VA 
researchers developed the first effective therapies for 
tuberculosis, the implantable cardiac pacemaker, the Seattle 
Foot, and other prosthetic devices. Researchers made incredible 
contributions to such things as the development of the CT scan 
and the MRI, and just last year we announced the results of a 
clinical trial finding that will make a new shingles prevention 
vaccine the standard of care. Today, VA researchers are 
developing artificial retinas, biohybrid limbs and other 
futuristic prosthetic devices, including those designed for 
high-performance athletes who ski, play basketball, and other 
competitive sports.
    We are also evaluating and improving the care that VA now 
provides to veterans suffering from multiple injuries, or 
polytrauma, and those who use prosthetic devices. This year we 
are beginning a series of research projects on traumatic brain 
injury and spinal cord injuries. These projects will directly 
benefit veterans from Operations Enduring Freedom and Iraqi 
Freedom, as well as all veterans of other eras.
    Last week, Mr. Chairman, we established new collaboration 
with the University of Texas Southwestern Medical Center to 
launch a Center of Excellence for the research of Gulf War 
illnesses. This collaboration will help expand our research 
programs to help Gulf War veterans who continue to suffer from 
unexplained illnesses.
    We are collaborating with the Department of Defense and the 
National Institute of Mental Health to look at the incidence of 
PTSD among veterans of the Global War on Terror, and we will 
also be looking at our ability to improve treatment of burn 
injuries, long-term care issues involved with recovery from 
traumatic brain injury as well.
    Improving our ability to treat veterans is at the very core 
of VA research. VA clinicians who treat veterans are also the 
researchers who investigate the questions that they form at the 
bedside. No other health system can match VA's strong 
connection between clinical care and research, especially 
coupled with our exceptional electronic health record.
    Our unique position also enhances our ability to provide 
long-term care and to use genomic medicines as a means to move 
from preventive medicine to predictive medicine. In fact, we 
recently established a Genomic Medicine Advisory Committee 
composed of renowned scientists who will advise us on policy 
and process, and their first meeting will be later this year.
    For us to continue to build on the successes of both the 
past and the present, there are four things that we need to do. 
First, we need to continue our support to recruitment, 
retention, and training programs for clinical investigators; 
Career development awards bring tomorrow's stars to the care of 
today's veterans. In particular, we must continue to nurture 
our affiliations with medical schools which, as General Omar 
Bradley recognized 60 years ago, were vital to providing 
veterans with top-notch care.
    Second, we must maintain a modern, safe, and appropriate 
research infrastructure. This year we have already funded 
approximately $2 million to provide new or replacement research 
equipment and facility environment upgrades. We are currently 
surveying facilities, identifying deficiencies and ensuring our 
highly specialized needs are met. We will report the results of 
the survey to Congress early next year.
    Third, we must continue to lead the nationwide effort to 
improve protection for human research subjects. VA is a 
recognized leader in accrediting research facilities and 
training staff. We are working with other Federal agencies, 
medical school affiliates, and others to develop new 
institutional review board structures. These structures will 
allow us to maintain strict standards for subject protection, 
yet provide flexibility to expedite the review process, 
especially useful for smaller research facilities.
    We are in the process of developing a Central Institutional 
Review Board to facilitate consistent expertise and greater 
efficiency, and this will particularly enfranchise and help our 
smaller and rural research programs, allowing rural veterans 
greater access to research protocols that may offer new 
treatments for infections, heart disease, cancer, or other 
illnesses under investigation.
    Finally, we must support VA research. Appropriated funds 
are VA researchers' core funding. We can leverage these funds 
with money from industry, nonprofits and other Federal 
agencies, as well as continue our partnerships and 
collaborations, use our research programs to recruit and retain 
investigators and clinicians who in fact treat patients and 
help to find new solutions, treatments, devices, and 
discoveries to benefit both veterans and our Nation.
    Mr. Chairman, I thank you and all of the Senators who have 
asked for additional funding for VA research. We are grateful 
for your confidence in our program and in the work of our 
researchers, in our basic science research to advance the 
understanding of life and disease, who in our clinical research 
and cooperative studies help to bring new medications, devices, 
and treatments to the care of veterans and all Americans, who 
in our rehabilitation research help make injured veterans 
whole, and who in our Health Services Research Program in the 
words of Dr. Jonathan Lomas in the British Medical Journal, 
``Focus the light of health services research on our health 
care delivery, helping make VA one of the leading health care 
systems in the world.'' This concludes my statement, sir. Thank 
you.
    [The prepared statement of Dr. Perlin follows:]
Prepared Statement of Jonathan B. Perlin, M.D., Ph.D., Under Secretary 
               for Health, Department of Veterans Affairs
    Mr. Chairman and Members of the Committee,
    Thank you for the opportunity to appear before you today to discuss 
the Department of Veterans Affairs (VA) medical and prosthetic research 
program. I am pleased to have Dr. Joel Kupersmith, Chief, Research and 
Development Officer (CRADO), accompany me today.
    Also, Dr. Richard Weir, a VA Research Scientist from the VA Chicago 
Healthcare System working in the Prosthetic Research Laboratory, is 
here to describe the work he is doing. Dr. Weir will explain the 
efforts to develop a new hand/wrist prosthetic. I am proud to say that 
over three thousand researchers have the same commitment to their work 
as Dr. Weir does.
                              introduction
    The original design for the Veterans Health Administration (VHA) 
Office of Research and Development (ORD) was clear: VA shall carry out 
a program of medical research to provide health care more effectively 
and contribute to the Nation's knowledge about disease and disability 
with emphasis on injuries and illnesses particularly related to 
service. We hold to that same purpose today.
    A year ago in my confirmation hearing before you, I highlighted 
several accomplishments of VA's research program. Today, I would like 
to reiterate these and describe their importance to veterans and the 
Nation as a whole.
     VA pioneered the first effective therapies for 
tuberculosis in the 1940s; veterans returning from the Pacific theater 
and POW camps in World War II were some of the first to receive these 
treatments.
     From the 1940s to the present, VA researchers have led the 
development of better fitting, lighter, more functional artificial 
limbs. In the late 1970s and early 1980s the Veterans Administration, 
as it was called then, supported research that led to the Seattle Foot, 
a prosthetic device for lower limb amputees. This revolutionary device 
has allowed thousands of amputees from the Vietnam War to return to an 
active life and participate in activities like basketball, skiing, or 
running, all of which were impossible with traditional artificial 
limbs. By 1991, more than 70,000 Seattle feet were in use in the United 
States. Later, I will describe the exciting work VA research is doing 
today in the area of robotics and other cutting edge prosthetics.
     VA was instrumental in the invention and use of the first 
implantable cardiac pacemaker. William C. Chardack, chief of surgery at 
Buffalo's Veterans Administration Hospital, collaborated with Wilson 
Greatbatch in a partnership to develop the device and surgical 
techniques that have helped millions of Americans, including our aging 
veterans.
     VA research contributed significantly to the development 
of the CT scanner and MRI machine. VA's basic science research in 1960 
and 1961 contributed to the development of the computerized axial 
tomography (CAT scan) in the early 1970s and modern radioimmunoassay 
diagnostic techniques in the mid-1980s. This illustrates that the 
progress of discovery is not an overnight task. Sometimes, scientists 
must work for decades to find solutions to complex problems. Today, 
veterans and all of us benefit from the basics discovered by VA 
investigators.
     Smoking and military service have coincided for many 
years, so VA has a longstanding history of investigating treatments for 
nicotine dependence. VA's investigator, Jed Rose at the Durham VA 
Medical Center (VAMC), worked with others to invent the nicotine patch. 
Today, VA continues to support a strong portfolio of research about the 
effects of nicotine and its relationship with substance abuse, a major 
concern for many veterans.
    But, the history of VA research extends well beyond what we 
discussed last year:
     In the 1950s and 1960s, the VA cooperative studies program 
developed the essentials of the multi-site randomized controlled 
clinical trial that is the standard for testing the safety and efficacy 
of new treatments today. VA cooperative studies in the 1960s, 70s, and 
80s proved the value of such widely used therapies as coronary artery 
bypass, the use of lithium in bipolar disorders, and aspirin's ability 
to ward off heart attacks. More recent VA clinical trials have led to 
non-surgical treatments for gastro-esophageal reflux disease and 
prostate enlargement, demonstrated the value of advanced cochlear 
implants in veterans with profound hearing loss, and established 
effective treatments for post-traumatic stress disorder (PTSD). Such 
results have extended life and improved the quality of life for 
veterans and non-veterans alike.
     In the 1960s, the VA invented the radioimmunoassay, a 
procedure that is now a mainstay of clinical laboratory testing through 
the world for detecting biological markers associated with health and 
disease such as prostate-specific antigen (PSA).
     More recently in 2005, VA showed that an experimental 
vaccine for shingles cuts its incidence in half and dramatically 
reduces severity and complications in those that develop the disease.
     Also, researchers from VHA, Stanford University, and Duke 
University reported in the October 2005 New England Journal of Medicine 
that the implantable cardioverter defibrillator, although a costly 
device, is a relatively cost effective way to help prevent sudden 
cardiac deaths for some high risk patients. This is a good example of 
collaboration involving our academic partners with funding from another 
Federal agency (the Agency for Healthcare Research and Quality) as well 
as industry (Blue Cross Blue Shield Technology Evaluation Center).
    But, past success is not enough. Research must be future oriented. 
We must look at how we practice health care today and ask: how can we 
do better? Our research program builds on its past by identifying and 
confronting the important questions and challenges of today and then 
doing the hard work to find solutions for the future.
                   va research as a unique laboratory
    A special advantage of the VA research program is that it is nested 
within a health care system that serves more than 5 million veterans. 
This creates a unique national laboratory for the discovery and 
application of new medical knowledge. Translating research into 
clinical practice is talked about throughout the medical community, but 
VA is one place where we apply research every day. VA research has made 
direct contributions to current clinical practices for hypertension, 
PTSD, diabetes, and other chronic diseases. VA clinicians who have 
responsibility for providing care for patients and for training future 
health care providers are the same scientists who initiate our research 
projects; nurture the proposal through VA's rigorous scientific merit 
review; identify and secure additional funding from other Federal 
agencies, non-Federal sources, and industry; conduct the research; 
publish the results in prestigious medical journals; and then complete 
the circle back to the bedside. VA research truly brings scientific 
discovery from bedside to bench and then back to the bedside.
    In fact, the chance to conduct research has been a strong tool for 
VA to recruit and retain high quality physicians and other clinicians. 
Other health care systems rarely provide physicians and other 
clinicians with the opportunity to research questions that are most 
relevant to patient care. VA's healthcare system allows that we promote 
the idea of research within our unique research setting with tools such 
as the computerized patient record system and protected time for 
research. Allowing researchers to identify or ``protect'' time within 
their work week is part of VA's strong Career Development Program that 
allows investigators to nurture a research career in the VA system.
    The opportunity to conduct research has been one of our most 
effective tools to improve the quality of our care, as well as to 
recruit and retain top-notch clinicians. It also creates a culture of 
continuous learning and innovation that helps us maintain our position 
of leadership among health systems. Studies by the Institute of 
Medicine, RAND, and others have highlighted the delays that occur from 
the time of scientific discovery to the time an evidence-based practice 
becomes routine--in US healthcare, on average, the likelihood of 
receiving a treatment based on credible scientific evidence is only 
about 50 percent. VA far exceeds that level of performance on virtually 
every evidence-based indicator. Furthermore, VA has established a 
unique program, the Quality Enhancement Research Initiative (QUERI), 
whose mission is to bring researchers into partnership with health 
system leaders and managers in order to ensure the care we provide to 
veterans is based on the most current scientific evidence.
                   emerging priorities of va research
    Although in any given year the bulk of VA's research budget is 
committed to on-going investigation, each year we re-evaluate our 
priorities based on the changing needs of the veterans we serve, and 
attempt to fund high quality science that meets those priorities. I 
would like to highlight our current areas of focus for VA research.
    Operation Iraqi Freedom and Enduring Freedom (OIF/OEF). In order to 
better serve military personnel injured during OIF/OEF, VA has 
implemented a new research agenda which brings all parts of ORD 
together to develop new treatments and tools for clinicians to use to 
ease the physical and psychological pain of the men and women returning 
from conflicts, to improve access to VHA services, and to accelerate 
discoveries and applications, especially for PTSD diagnosis and 
treatment, state-of-the art amputation and prosthetics methods, and 
polytrauma.
    Neurotrauma (including traumatic brain injury and spinal cord 
injury). Traumatic Brain Injury (TBI) and Spinal Cord Injury (SCI) 
account for almost 25 percent of combat casualties suffered in OIF/OEF 
by US Forces. In November 2005, VA issued a program announcement to 
stimulate research in the area of combat casualty neurotrauma. This 
research initiative seeks to advance treatment and rehabilitation for 
veterans who suffer multiple traumas from improvised explosive devices 
and other blasts. Eighty-five letters of intent to submit a research 
proposal were received, indicating a high level of interest among our 
investigators, and we hope to fund as many high quality projects from 
this initiative as our budget will allow.
    Polytrauma and Blast-Related Injuries. Improvements in body armor 
and battlefield medicine have resulted in higher survival among wounded 
soldiers but also new combinations of critical injuries, including head 
injuries, vision and hearing loss, nerve damage, infections, emotional 
problems, and in some cases amputation or severed spinal cords. This is 
a new challenge for VA, and we need to develop the knowledge base to 
manage these conditions over the remaining lifetime of the veteran. VA 
has devoted its newest QUERI center to polytrauma and blast-related 
injuries with a focus on using the results of research to promote the 
successful rehabilitation, psychological adjustment, and community 
reintegration of these veterans. Other VA scientific studies are 
currently underway to characterize these injuries and delineate their 
outcomes and costs, and to identify geographic areas where the need for 
rehabilitation is greatest. Such information is critically important in 
helping VA redesign its care delivery system to meet the needs of these 
veterans.
    Amputation and Prosthetic Research. VHA ORD currently supports a 
broad research portfolio pertaining to amputation and prosthetics, and 
more research in this area is planned. Areas of interest include:
     Nanofabrication, microelectronics and robotics to create 
lighter, more functional prostheses. ORD is funding two new Prosthetics 
Rehabilitation Engineering and Platform Technology Centers that are 
national resources to develop computerized state-of-the art prosthetic 
limbs with the goal of using the latest advances in orthopedic surgery, 
tissue engineering, nanotechnology, and microelectronics to create 
prosthetics that look, feel, and act more like one's own limb.
     The Providence VA Medical Center, in collaboration with 
Brown University and the Massachusetts Institute of Technology, is 
working to develop a ``biohybrid'' limb that will use regenerated 
tissue, lengthened bone, internal and external implants and sensors to 
allow amputees to use brain signals and residual limb musculature to 
have better control of their limbs and reduce the discomfort and 
secondary complications associated with current prostheses. These 
researchers are already publishing and presenting about their work.
     The Advanced Platform Technology (APT) Center at the 
Cleveland VA Medical Center focuses on sensory and implanted control of 
prosthetic limbs, accelerated wound healing, and biological sensors for 
the detection of health and function to accelerate the use of new 
materials and innovative micro-mechanical or nanotechnologies to 
provide more independence to veterans with disabilities.
     ORD is starting a study to gather information about how 
prosthetic devices are used, costs, amputee satisfaction, comparisons 
selected prosthetic devices, and various prosthetic procurement 
alternatives to help VA match technology to the needs of an individual 
veteran.
     ORD is partnering with the Department of Defense (DoD), 
Walter Reed Army Medical Center, the Defense Advanced Research Projects 
Agency and Brooks Army Medical Center to compare prosthetic designs; 
define standards of function; evaluate psychological issues faced by 
returning service personnel; determine psychosocial issues that 
challenge successful reintegration; and initiate longitudinal studies 
to study veterans care over time.
     VA investigators are examining rehabilitation for the 
visually impaired including artificial retinas, especially for 
polytrauma victims; new treatments for burn victims; restoration of 
hearing and maximizing function for those with hearing loss, especially 
for polytrauma victims; and natural mechanisms of neural regeneration 
to return function to paralyzed veterans and those with brain injuries. 
VA investigators also plan to study advanced tissue engineering and the 
manufacturing of artificial skin to accelerate wound healing.
    Mental Health and PTSD Research. Studies about PTSD and other 
mental health issues are an important part of the VHA ORD research 
portfolio, and special attention is being paid to the circumstances of 
the returning OIF/OEF veteran.
    Interagency Collaboration regarding OIF/OEF Mental Health. VA, the 
National Institutes of Health (NIH) and DoD jointly issued a Request 
for Applications (RFA) in late 2005, to enhance and accelerate research 
on the identification, prevention and treatment of combat related post-
traumatic psychopathology and similar adjustment problems. The goal is 
to encourage studies involving active-duty or recently separated 
National Guard and Reserve troops involved in current and recent 
military operations (e.g., Iraq and Afghanistan). This RFA specifically 
encouraged participation of clinicians and researchers who screen, 
assess or provide direct care to at-risk, combat exposed troops, and 
emphasized interventions focusing on building resilience for veterans 
suffering from mental health problems, including PTSD, and developing 
new modes of treatment that can be sustained in community-based 
settings. Among the approaches being considered are novel 
pharmacological, psychosocial and combination treatments as well as the 
use of new technologies (e.g., World Wide Web, DVD, Virtual Reality, 
Tele-health) to extend the reach of VA's health care delivery system. 
Fifty-five proposals were received earlier this year in response to 
this RFA, and those proposals deemed to have scientific merit and 
relevance to veterans will start October 1, 2006.
    Women and PTSD. Because of women's new roles in the military and 
subsequent combat experiences, VA and DoD are studying the use of 
psychotherapy for treatment of PTSD in female veterans and active duty 
personnel. A randomized clinical trial, part of VA's Cooperative 
Studies Program, has recently been completed and results are currently 
being analyzed, with a report expected in 2007. Those results will 
inform additional research and implementation activities across VHA.
    Depression. Several approaches have been developed and tested by VA 
investigators to improve the assessment and treatment of mental health 
disorders. For example, implementation of an evidence-based 
collaborative care model for depression called ``TIDES'' (or 
Translating Initiatives in Depression into Effective Solutions) has 
demonstrated significant improvements in depression symptomatology 
among patients referred by their primary care providers. This study 
plus two companion evaluations of the processes, outcomes, and costs of 
implementation (called WAVES or Well-Being among Veterans Enhancement 
Study and COVES or Cost and Value of Evidence-based Solutions for 
Depression) are part of national VA strategic planning and rollout for 
improving the quality of depression care. Future research projects are 
planned to develop and test collaborative care models for PTSD and 
other anxiety disorders.
    Other projects. ORD is currently conducting and planning projects 
that address the long-term care needs of veterans with TBI, and assess 
(in collaboration with DoD) the long-term changes in health status 
resulting from combat deployment. We are studying the role of smoking 
and nicotine dependence among veterans with PTSD, and will begin this 
fall a multi-site clinical trial to study the effects of risiperidone 
on PTSD. ORD will continue to support other studies that test the 
effectiveness of virtual reality therapy and other new treatments for 
PTSD. It is important to note that this research will also have direct 
applications for all veterans and not simply those involved in OIF/OEF.
    Genomic Medicine Program. VHA, as a large healthcare system with an 
integrated research network and an unrivaled electronic medical record 
system, is uniquely positioned to develop a national Genomic Research 
Program. The goal of this program is to expand VA's ongoing genomic 
medicine effort. Research efforts will be developed to: understand the 
role of genetics in the prevention and cause of disease; use genetic 
information to improve how clinicians prescribe medications and to 
prevent adverse reactions; develop computer systems to manage genetic 
data and identify genetic predispositions; develop laboratory 
capability to do genetic and pharmacogenomic profiling within VA; and 
learn how to use genetic information effectively in everyday practice. 
The ultimate goal of these efforts is to predict and prevent disease 
and to treat more effectively and at lower costs through the 
customization of clinical interventions.
    In the March 22, 2006 Federal Register, VA announced the 
establishment of the Genomic Medicine Program Advisory Board. The 
Committee is composed of nationally renowned medical experts in genomic 
research, bioethics, and disease management. The purpose of the 
Committee is to provide advice to the Secretary of Veterans Affairs on 
the scientific and ethical issues related to the establishment, 
development, and operation of a genomic medicine program. Specifically, 
the Committee will assess the potential impact of a VA genomic medicine 
program on existing VA patient care services; recommend policies and 
procedures for tissue collection, storage and analysis; and develop a 
research agenda and approaches to incorporate research results into 
routine medical care.
    Gulf War Veterans' Illnesses. VA research places a high priority on 
scientific research aimed at improving the quality of life for veterans 
of the 1990-1991 Gulf War affected by chronic multisymptom illnesses 
commonly referred to as Gulf War Veterans' Illnesses (GWVI). Some 
veterans who participated in Operations Desert Shield and Desert Storm 
have reported conditions and chronic symptoms such as fatigue, 
weakness, gastrointestinal difficulties, cognitive dysfunction, sleep 
disturbances, persistent headaches, skin rashes, respiratory problems, 
and mood changes at rates that significantly exceed those reported by 
comparison groups. VA research continues to expand its efforts to 
understand and treat GWVI. The core objective is to improve the health 
of ill Gulf War veterans. It is important to note that Gulf War 
veterans with chronic unexplained symptoms are eligible for disability 
benefits even when the cause of their illness cannot be determined.
    VA has committed $15 Million in fiscal year 2006 for collaboration 
with the University of Texas Southwestern Medical Center and has also 
funded VHA ORD investigators for on-going projects. These ongoing 
studies address areas of interest that include: chronic multisymptom 
illnesses (CMI) affecting GW veterans; conditions and/or symptoms 
frequently reported by GW veterans; long-term health effects of 
potentially hazardous substances, alone and in combination, to which GW 
veterans may have been exposed during deployment; and any of the 21 
Research Topics forming the framework for the Annual Report to Congress 
of federally Sponsored Research on GWVI.
    Chronic Disease. According to a study of 1999 VA health care 
expenditures, VA health care users have more chronic diseases than the 
general population. This study also indicated that 72 percent of VA 
patients had at least 1 of 29 chronic diseases such as diabetes, 
Parkinson's disease, HIV/AIDS, Alzheimer's disease and substance abuse, 
and the care for these veterans accounted for 96 percent of health care 
expenditures provided at VA facilities. The following are examples of 
efforts by VA researchers to discover how to prevent and treat chronic 
disease.
    Diabetes. According to the National Institute of Diabetes and 
Digestive and Kidney Diseases at the National Institutes of Health, 
20.8 million people--7 percent of the population--have diabetes. An 
estimated 4.6 million people are diagnosed and 6.2 million people are 
undiagnosed. In 2005, 1.5 million new cases of diabetes were diagnosed 
in people aged 20 years or older. Diabetes affects nearly 20 percent of 
veterans receiving health care from VA: 1 million veteran users. An 
estimated 2 million veterans without diabetes have metabolic syndrome, 
which places them at high risk for diabetes. The cost is tremendous: 30 
percent of VA health care costs (in- and out-patient and pharmacy) are 
attributable to patients with diabetes. This includes 1.7 million days 
of hospital care. VA investigators have completed the first study to 
compare the quality of diabetes care among patients in VA and 
commercial managed care organizations. Quality of care measures were 
compared for seven diabetes processes of care, three diabetes 
intermediate outcomes, and four dimensions of satisfaction. Results 
from this study showed that VA patients had better scores than 
commercially managed care patients on all assessed quality of care 
measures. VA patients also had better low-density lipoprotein control 
and were slightly more satisfied with the overall quality of diabetes 
care at VA.
    Identifying the most effective treatment methods is crucial to 
reducing the incidence of diabetes among veterans. Although more 
patients are accessing medical information on the Internet, few studies 
have examined the effects of web-based interventions that incorporate 
an interactive component requiring feedback from patients. A VA study 
tested diabetes care management using a web-based system for veterans 
with poorly controlled diabetes. Results showed that web-based care 
management improves poorly controlled diabetes in veterans. Veterans 
participating in the web-based management program had significant 
improvements in HbA1c over 1 year compared to usual care, and 
persistent website users had even greater improvements compared to 
intermittent users.
    ORD has also initiated the VA Diabetes Trial to determine whether 
intensive control of blood sugar, compared to standard methods, can 
reduce other blood vessel damage and other complications. Smaller 
trials to determine the value of the interventions will come first, 
with more research to follow.
    Obesity. Results from the 2003-2004 National Health and Nutrition 
Examination Survey (NHANES) indicate that an estimated 66 percent of 
U.S. adults are either overweight or obese. The problem is similar or 
worse among VA's patient population, with 73 percent of veteran 
patients overweight or obese. Obesity contributes to increased heart 
disease, diabetes, and sleep apnea, and an estimated 300,000 Americans 
die annually from illnesses related to overweight and obesity.
    Findings from VA studies to assess the efficacy and safety of 
weight loss medications, as well as the effectiveness and adverse 
events associated with the surgical treatment of obesity, demonstrated 
that surgical treatment is more effective than non-surgical treatment 
for weight loss in severely obese patients; weight loss was maintained 
for up to 10 years and longer and was accompanied by significant 
improvements in several comorbid conditions.
    Other examples of VA research include studies on traditional and 
new approaches to prevent and treat obesity, such as a comparison of 
lower extremity functional electrical stimulation on obesity and 
associated co-morbidities in comparison to upper extremity aerobic 
exercise for persons with paraplegia; an assessment of the impact of 
walking aides on quality of life and physical activity in overweight 
and obese veterans with osteoarthritis; and explorations of drug 
therapies.
    Alzheimer's Disease. Alzheimer's Disease (AD) and related dementias 
affect 7.3 percent of veterans over age 65. VA research is helping to 
discover new facts about AD and other diseases and conditions that 
affect older veterans. For instance, researchers at the Bronx VA 
medical center have reported that diet-induced insulin resistance, a 
cause of type II diabetes, promoted beta-amyloid production concurrent 
with decreased insulin-degrading enzyme (IDE) activity in an animal 
model of AD. Beta-amyloid is the major component of amyloid plaques, 
the hallmark of AD pathology. IDE has been proposed to be responsible 
for the degradation and clearance of beta-amyloid in the brain. Such 
research is needed to form the basis of future interventions to prevent 
or reverse this devastating condition.
    Influenza. VA health services researchers have been instrumental in 
improving vaccination rates for veterans with chronic diseases that 
place them at high risk for complications from influenza, as well as 
enhancing vaccination among health care workers and veteran groups that 
historically have had low vaccination rates, such as minorities, 
smokers, and those with spinal cord injuries and disorders.
    Pandemic influenza infection has the potential for causing 
significant morbidity and mortality in the United States and elsewhere. 
ORD is responding, along with other Federal agencies, to this 
unprecedented public health threat by initiating studies that examine 
optimal dosing strategies for the antiviral agent oseltamivir (Tamiflu) 
in the event of an emerging pandemic of human infection with an avian 
or other influenza strain for which an effective vaccine is lacking.
    HIV/AIDS. AIDS (acquired immunodeficiency syndrome) is caused by 
HIV (human immunodeficiency virus). The virus kills or damages the 
body's immune system, which lowers the body's ability to fight 
infections and certain cancers. According to the Centers for Disease 
Control, at the end of 2003, an estimated one million persons in the 
United States were living with HIV/AIDS, with 24-27 percent undiagnosed 
and unaware of their HIV infection. VHA is the largest single provider 
of HIV care in the US, with nearly 20,000 patients seen annually with 
the disorder. Accordingly, ORD funds a full range of studies from bench 
research aimed at elucidating the underlying mechanisms of HIV to 
implementation projects that improve VHA's effectiveness in caring for 
this population.
    Researchers at the VA South Texas Health Care System and the 
University of Texas Health Science Center recently showed that people 
who have a below-average number of copies of a particular immune-
response gene have a greater likelihood of acquiring HIV and, once 
infected, of progressing to full-blown AIDS. These findings, cited as 
one of the top articles published in the eminent journal Science, have 
important implications for the treatment and prevention strategies for 
HIV/AIDS and possibly other infectious diseases as well.
    Women's Health. According to information from the VA's Center for 
Women Veterans, in 1973, women in the active duty military accounted 
for 2.5 percent of the armed forces. By fiscal year 2001, however, the 
number of women significantly increased making up 15 percent of the 
armed forces and those numbers are expected to increase. To respond to 
this demographic change and develop a more comprehensive VA women's 
health research agenda, a VA Women's Health Research Planning Group 
recently identified the needs of women veterans and a corresponding 
research agenda. VA researchers currently are investigating optimal 
strategies for conducting preventive health and disease screening 
activities among women veterans (e.g., cervical cancer screening) and 
developing and evaluating computerized, interactive educational 
programs to enhance VA staff awareness of women veterans and their 
health-care needs.
                             infrastructure
    It is crucial that VA investigators have the equipment and 
facilities necessary to conduct cutting-edge research in the twenty-
first century. To identify where improvements may be needed, ORD has 
initiated a comprehensive review of VA's research facilities to 
identify deficiencies and corrective actions. The objectives of the 
Research Infrastructure Evaluation and Improvement Project are to 
review the overall adequacy and utilization of research space and 
infrastructure (including animal research facilities); to develop a 
plan to update and maintain facilities; to ensure compliance with 
biosafety and research laboratory security requirements; to enhance 
collaborations between the local VA Medical Center and its academic 
affiliate; and to ensure that the needs for highly specialized research 
programs (e.g., Rehabilitation Research and Development (RR&D) and 
Health Services R&D (HSR&D) Centers of Excellence) are met.
    Survey teams including VA research administrators and scientists, 
as well as other VA employees and engineering contractors, will review 
documentation and visit facilities to evaluate the physical 
infrastructure (including the animal facility, research laboratories 
and common equipment rooms); operational infrastructure (capability to 
conduct research while meeting requirements for compliance with safety, 
animal welfare, and human subjects protection regulations); and 
equipment (major items of equipment used for the conduct of research) 
of VA facilities with active research programs. The data collected from 
the surveys will be used to develop financial needs and an asset 
management plan. We expect to have a report to Congress early in fiscal 
year 2007.
    In addition, ORD recently funded proposals as part of the Shared 
Equipment Evaluation Program that is managed by the Biomedical 
Laboratory and Clinical Science Research and Development Services. The 
purpose of this program is to fund new or replacement research and 
animal facility equipment. The program requires that facilities 
identify dollar-for-dollar matches in order to leverage the VA 
contributions. As a result of a December 2005 request for applications, 
a total of $2,086,173 for facility projects and research equipment has 
been funded for the following sites: Decatur, GA; Chicago, IL; 
Cleveland, OH; Miami, FL; Loma Linda, CA; Memphis, TN; Nashville, TN; 
New Orleans, LA; Omaha, NE; Palo Alto, CA; Philadelphia, PA; Portland, 
OR; Richmond, VA; San Francisco, CA; Seattle, WA; San Diego, CA; San 
Antonio, TX; and Los Angeles, CA.
    Other proposals for research equipment are pending funding with 
decisions expected later this fiscal year. This program was suspended 
for a number of years, but plans are to begin funding proposals on an 
annual basis after a review to determine merit and priorities.
                               conclusion
    As an academically trained researcher, I understand the 
complexities of the research process, and I am fascinated by the 
results. I fully support this program and advocate to you that its 
value, both to veterans as well as the Nation, far exceeds the costs. 
The history of VA research is impressive, and the future promises even 
more important advances. Can we prevent infections that hamper the use 
of biohybrid limbs? Can we develop artificial retinas so that wounded 
OIF/OEF soldiers and our aging veterans can regain their sight? Can we 
use our computerized medical record system and genetic samples to 
individualize drug and clinical treatments, or identify those veterans 
who may have a predisposition for a particular disease and prevent the 
onset of, rather than treat, the symptoms? Can we continue to examine 
ourselves to find out how to deliver patient care more effectively? The 
answers to these questions must be ``yes'', as no other health system 
is better positioned than VHA to make these discoveries, and no other 
group of patients is as deserving as America's veterans to receive the 
benefit of such innovation.

    Chairman Craig. Thank you very much, Dr. Perlin. You have 
been accompanied by Dr. Joel Kupersmith, Chief Research and 
Development Officer for the VA, and Dr. Richard Weir, VA 
Prosthetics Research Laboratory, in Chicago. Before we get into 
dialog and questions, obviously Dr. Weir has brought a unique 
device along, and I think it is time our Committee Members see 
it. I had the privilege of trying it on, fellow Senators, 
before you arrived and before we convened the Committee, and so 
I think it is important that we see some of this cutting-edge 
technology firsthand, may I say? Dr. Weir, if you would, 
please.
    Dr. Perlin. Mr. Chairman, if I might introduce Dr. Weir as 
he gets assembled there.
    Chairman Craig. Please do.
    Dr. Perlin. It is my privilege to introduce Dr. Richard F. 
Weir, in fact, a former Career Development Awardee, and now a 
research scientist, with the VA Prosthetics Research 
Laboratory, at the Jesse Brown VA Medical Center in Chicago. As 
with many, the Career Development Program nurtures the work of 
young investigators so that they can mature in their career and 
bring exciting new technology to the care of America's 
veterans. Dr. Weir will demonstrate the work that the VA and 
their partners are doing on hand and wrist prostheses. Too many 
servicemembers who have served in the Global War on Terror or 
in military careers experience trauma resulting in loss of 
their hands, and Dr. Weir and his fellow scientists are doing 
vital work that will significantly help these heroes. It is my 
pleasure to introduce Dr. Weir, and one of the most futuristic 
devices for restoring function to injured veterans.
    Mr. Weir. Good morning, and thank you, Mr. Chairman. It is 
an honor to be here today to have a chance to present on some 
of the work that I have been doing for the VA.
    We have been working on a new prosthetic for people who 
have lost all fingers and the thumb.
    Chairman Craig. Dr. Weir, we haven't made you sweat yet, so 
as to your connection with your sensors, I'm sorry. Go ahead. 
You need that moisture connection there.
    Mr. Weir. I need some more moisture. It dried out in the 
interval here.
    This is a new prosthetic device for a particular level of 
amputation that had not actually been addressed in the past, 
and it was for those individuals who had lost all fingers and 
thumb but still had a wrist. The wrist is a very important 
joint to maintain if you want to give somebody some function if 
you have lost all your fingers and thumb. So the challenge from 
our perspective in this project was actually to be able to 
develop a mechanism and a fitting technique that would allow 
any residual motion in the wrist to be maintained, and to allow 
an individual to regain as much function as possible.
    From an engineering design point of view, the challenge is 
where to put everything if you have only got the volume of the 
fingers, because someone who has a wrist still has this portion 
of their hand left, and then so the challenge is to get 
everything into just the fingers and the thumb.
    This was the little device that we came up with as an 
armature. Then we have little sensors that sit in the 
prosthetic socket it is called, or prosthetic interface, and 
this pushes onto the residual limb and these sensors sit over 
the residual muscles in the hand. The person will then think 
about closing their hand to close the hand like this, and then 
opening the hand to open the hand.
    The other thing is to develop a prosthetic socket, though, 
that keeps that motion going, and so this is the device we have 
come up with. We are in the process of fitting this to some 
patients at the moment, and we are in the process of developing 
this prosthetic interface so that it can be freely suspended 
without restricting wrist motion. Ironically enough or 
unfortunately, this project was started before Operation Iraqi 
Freedom just because the VA has a long-term view on prosthetics 
and the development of orphaned products, and the problem is 
that we are seeing injuries now coming from Operation Iraqi 
Freedom where soldiers are incurring burns and some of these 
burn injuries are resulting in amputation or loss of all digits 
and thumb. So now this little mechanism has particular 
relevance to fitting that level of amputation. That is pretty 
much all I have to say.
    Chairman Craig. Thank you very much, Dr. Weir, for that 
demonstration. I think it is a phenomenal example of the kind 
of work that is going on. Dr. Perlin, as you said, while the 
work is going on at VA and collaboratively with university 
settings, NIH and others, it is not exclusively for veterans. 
Once this is done, it goes to the market, and that is what 
becomes increasingly exciting, that the research going on for 
veterans really gets spread across the world scene ultimately, 
and that makes it all the more meaningful.
    In your testimony you stated that VA has begun a 
comprehensive review of its research infrastructure, and I am 
glad to hear that. We look forward to that report, as you are 
projecting its completion early next fiscal year?
    Dr. Perlin. Yes, sir.
    Chairman Craig. Meanwhile, can you elaborate, or possibly 
Dr. Kupersmith could, on the kind of information you expect to 
find from this report?
    Dr. Perlin. Thank you, first, Mr. Chairman, Ranking Member 
and Committee Members for your support of VA research. I think 
what you have seen today is truly extraordinary.
    Mr. Chairman, in particular you have really focused in on 
an area that helps not only veterans, but all Americans, and 
you have worked with us in grappling with serving veteran in an 
infrastructure that is aging. Nationally, the CARES process 
reviews some of the infrastructure, and the mean age of our 
buildings is about 58 years. The research facilities are 
equally aged. Let me ask Dr. Joel Kupersmith to describe some 
of the findings that suggest that we need to invest to improve 
and bring veterans and all Americans the sort of cutting-edge 
research that you saw this morning.
    Dr. Kupersmith.
    Dr. Kupersmith. Thank you very much. I want to also echo my 
thanks for your comments earlier. Much of the research space is 
inadequate for very simple reasons, there is not enough space, 
the ventilation in some places is not quite what it should be, 
and the basic structure of the space is also not necessarily 
easily adaptable to modern equipment. So I think those rather 
simple factors are why it becomes difficult to work in some of 
these areas.
    Chairman Craig. I presume that a substantial portion of the 
fiscal year 2007 research budget will be going toward projects 
VA has already committed to fund. If Congress were to provide 
additional funds for research above the President's request, 
can you give Members of this Committee an idea of where the 
additional funds would be allocated? And without asking you to 
commit on any level of research funding for a particular area, 
can you please explain if it would include research directly 
related to OIF or OEF veterans at this time?
    Dr. Perlin. Mr. Chairman, thank you for that question. Of 
course, we have an obligation to do the sort of research that 
helps assist our servicemembers in any injuries or illnesses 
that they might experience, especially in combat, as that is 
increasingly a focus, and the President's budget itself 
increases the funding these areas of acute trauma, spinal cord 
injury, brain injury, mental illness.
    Of course, any additional funds that were to be provided 
would be greatly appreciated and would be focused not only on 
the issues of America's combat veterans, but the issue of 
America's veterans broadly which, as you described, include not 
only those things that occur as a result of service, but those 
things that are part of the challenges of life, of aging, 
ranging from heart disease to cancer, especially diabetes, a 
challenge in our environment, and mental-illness research. Let 
me ask Dr. Kupersmith to speak more, perhaps, on some of the 
areas of strategic investment such as the Career Development 
Awards that also bring new investigators, new clinician/
researchers, top-notch individuals, to the care of veterans.
    Dr. Kupersmith. Yes, certainly I think Dr. Weir exemplifies 
this because he is the product of a Research Career Development 
Award as are many of the people who work in rehabilitation 
medicine.
    I think some of the programs that we are specifically doing 
in regard to veterans of the Afghani and Iraqi Wars have to do 
with neurotrauma, cervical spine injury, traumatic brain injury 
which is very common, and looking at this at all levels, both 
at the laboratory level as well as the clinical level, and how 
to approach long-term care in a younger patient. So many of our 
efforts in the past have been long-term care in the older 
individual and there are different needs, obviously, as there 
are different needs in prosthetics in younger and older 
individuals. In addition, in the wide range of prosthetics 
research, we are developing artificial retinas and some others.
    But I think we do make an investment in people, and we have 
an extensive Research Career Development Award program. That 
is, I think, one of the best there is to create investigators 
for the future. We like to keep all of these investigators, but 
we do not. They go on to other things, and they go on to help 
the country as a whole. Most of them stay with us and work in 
these areas, and that is a very important investment we make.
    The other important investment we make, as was mentioned, 
is collaboration with the universities. Again, Dr. Weir's work 
is an example of extensive collaboration on a number of 
prostheses between Northwestern and the Research Institute of 
Chicago and us. So these are the kinds of things we are doing.
    Chairman Craig. Gentlemen, thank you. Let me turn to 
Senator Akaka.
    Danny.
    Senator Akaka. Thank you very much, Mr. Chairman.
    Dr. Perlin, in the fiscal year 2007 budget, I read funding 
cuts are slated for research projects focusing on cancer, on 
diabetes, and heart disease. We all understand the pressing 
need and desire for the state of prosthetics and new treatments 
for service-connected disabilities, but these projects should 
not come, I believe, at the expense of peer-reviewed projects 
which address all kinds of health care needs. Can you please 
explain the rationale behind reducing funding for disease-
related research? Is there not enough room for all kinds of 
research?
    Dr. Perlin. Thank you, Senator Akaka, and thank you for the 
support you have expressed for VA research in your introductory 
comments and with the recognition that all of the areas of 
research conducted are of significant value.
    In the current environment with our troops deployed, we 
felt the commitment to increase the focus on areas that are 
related to injury or illness to which troops may be exposed, so 
we did prioritize in that direction. We always do hope to 
leverage and have had tremendous success in leveraging the 
investment that you make in the direct appropriation through 
recruiting additional grants in areas such as cancer or other 
illnesses from other funding entities such as the National 
Institutes of Health. In fact, the current support from the 
National Institutes of Health and other Federal Agencies is 
about $662 million, and so your investment in VA research is 
significantly amplified. But you are correct that when we focus 
on one area, it does push on project capacity in other areas 
which is why we are particularly appreciative of the support 
that you have endorsed.
    Senator Akaka. As I am pointing out here, somehow we need 
to continue the tradition of research that VA has in all of 
these areas.
    Dr. Perlin, the fiscal year 2008 construction list includes 
a $7 million project for a research facility located at Tripler 
Army Medical Center in Honolulu. This facility would be, as I 
understand it, the first of its kind, a joint center of 
cooperation and collaboration between VA and DOD. Do you see 
this concept of joint research facilities as a future avenue 
for success and innovation?
    Dr. Perlin. Senator Akaka, let me endorse the general 
concept of collaboration with our partners in the Department of 
Defense. In fact, throughout the country there are over 450 
separate sharing arrangements ranging from clinical activities, 
to shared infrastructure, to shared capital equipment. So there 
is no reason that should not extend to shared support of the 
research environment. I would note that the sharing of a 
physical space may have some unique aspects, and that is 
certainly a part of the culture sharing in terms of research 
activity.
    In terms of mental-health care, mentioned in my opening 
comments, there is collaboration with the Department of Defense 
on mental health and PTSD which also includes a third partner, 
the National Institute of Mental Health. We have collaborated 
on physical illnesses research as well, and look forward to, 
where we have the capacity to, be synergistic in sharing 
physical infrastructure as well.
    Senator Akaka. Dr. Perlin, I would like to ask you how much 
VHA spends on the indirect costs for conducting NIH grants. I 
ask that because NIH has refused to reimburse VA for the 
indirect costs of conducting research grants, and, therefore, 
those costs come out of health care dollars. Are you working 
with NIH on this?
    Dr. Perlin. Thank you, Senator. This has been an area of 
ongoing discussion with the National Institutes of Health. When 
NIH funds come directly to a VA medical center, they do not pay 
an indirect research cost as would occur were those funds to be 
conferred to any other institution. When funds come through a 
university, the university actually receives the indirects, and 
if there are space costs, some of those supports come through. 
Certainly, when NIH funds through our not-for-profit research 
corporations, the dollars come through. I would ask Dr. Joel 
Kupersmith to elaborate on the actual dollar amounts or provide 
for the record the complete figure.
    Dr. Kupersmith. Our estimate in the budget submission for 
2006 was $353 million coming from VERA dollars. The NIH issue 
has been a subject of ongoing discussion for several years and 
is pretty much in the same area. As Dr. Perlin mentioned, the 
essential way that the overhead dollars can be recovered is 
through the nonprofits. We have not been able to recover them 
in other ways. And may I add only in certain places have they 
been recovered. This is not uniform nationally by any means.
    Senator Akaka. Thank you. Mr. Chairman, my time has 
expired.
    Chairman Craig. Danny, thank you very much. Senator Burr, 
any questions of the panel?
    Senator Burr. Thank you, Mr. Chairman. Again let me 
reiterate my thanks to you and Senator Akaka for your 
persistence on this.
    Dr. Perlin, let me ask you, Durham, North Carolina, does a 
sizable amount of research for the VA, and it is unique in its 
location to Duke University, and the relationship that Duke 
University has with the VA is an incredible one. Are you able 
to work with academic institutions and with the private sector 
often enough on the research directions to make sure that there 
is little to no duplication in what our efforts are?
    Dr. Perlin. Senator, first, thank you very much for your 
question. Indeed, the relationship with Duke University and the 
Durham VA is a terrific one that has produced very important 
and cutting-edge research as, frankly, have many of the 
relationships with other universities in the State of North 
Carolina.
    That said, nationally I would say whether it be VA or 
elsewhere, there is not a program to effectively assure that 
research activities are not reduplicated. I do know that 
sometimes the advances are made in areas where there is 
competition, as in industry as well, but in VA at least we try 
to coordinate our portfolio to assure that we get the most 
product for the investment. I don't know, Dr. Kupersmith, if 
you would like to elaborate.
    Dr. Kupersmith. There is no national strategic plan among 
universities or for our collaboration with universities. I 
would point out that there is a certain amount of duplication 
that is appropriate because it is scientifically checking what 
happens, and so a certain amount of that is appropriate.
    I think that our collaborations, generally when grants are 
applied for, one has to give the uniqueness of the grant 
whether it is for us or NIH, and that guards against 
duplication in many ways.
    Senator Burr. The VA is faced with an increasing population 
as is the rest of the country of type 2 diabetes. I think by 
any historical standard, one might call this an epidemic, and 
that I am not sure that we as a Nation yet have accepted like 
we should. In North Carolina we are working on building a 
public-private partnership that is a research institution 
specifically focused on health science nutrition. You are aware 
of this and we have talked. It is extremely close to the 
Salisbury VA facility. It would probably be an ideal 
partnership for ongoing research that the VA is currently 
conducting in the area of diabetes.
    Dr. Perlin, what do you see as the VA's role not only in 
the North Carolina entity that we have talked about, but in 
replicating something like that elsewhere in the country? I 
just truly believe that public-private partnerships offer us an 
opportunity to leverage Federal dollars in a way that produce 
much more from the standpoint of the research bench and that 
means the Government and the private sector have to find these 
common points.
    Dr. Perlin. Senator Burr, thank you for both parts of your 
question, first, the public-private partnerships, and, second, 
the epidemic of obesity, overweight, and diabetes.
    I join the Secretary in being a fan of public-private 
partnerships. In fact, this terrific demonstration that we saw 
today has spawned a patent, and as Chairman Craig indicated, 
will not only benefit the immediate and obvious needs for 
veterans, but will benefit our country. It also will go into 
the marketplace and help to provide an economic engine for 
America's leadership in advanced biotechnology.
    The areas of diabetes is, sadly, not only an American 
epidemic, it is a worldwide epidemic. Our Secretary has 
championed a program called HealthierUS Veterans. The toll of 
overweight, obesity, and diabetes is affecting not only our 
military personnel, a large population, but especially our VA 
population, and this is one of the areas where if we can 
partner strategically with the private sector to improve 
exercise. In our HealthierUS Veterans program, you actually get 
a prescription for health, a ``prescription for life,'' arming 
veterans with pedometers now and new treatments. We offer care 
for something that is, in the words of Surgeon General Carmona, 
the number one threat to public health in the country, the 
complications of obesity and diabetes, and that in the VA 
population approaches nearly 1 in 4 veterans under our care.
    Senator Burr. Thank you. Thank you, Mr. Chairman.
    Chairman Craig. Senator Burr, thank you. Senator Jeffords, 
questions?
    Senator Jeffords. Dr. Perlin, the VA Medical Center at 
White River Junction, Vermont, together with Dartmouth Medical 
Center is doing a significant amount of cutting-edge research. 
It is one of the programs that draws talented medical 
professionals to our VA. A critical component of the medical 
research is infrastructure and facilities, laboratories, and 
access to patients. You mentioned that a study of the VA's 
infrastructure needs is underway. Shouldn't we be funding some 
of the needs that have already been identified?
    Dr. Perlin. Thank you, Senator Jeffords, for your comments. 
Indeed, the relationship of White River Junction and Dartmouth 
is a terrific example of the academic affiliation. It produces 
not only the basic science research that you have indicated, 
but leading health services research, improving the quality of 
health service delivery in many areas including to rural 
Americans.
    It is absolutely a necessity that we invest in our research 
infrastructure. There has been a phased approach thus far. 
There have been some issues related to improving the hardening 
and security of research areas that was one of the first areas 
of concentration and funding, and I would ask Dr. Kupersmith to 
elaborate on some of the areas for infrastructural improvement 
now and in the future, particularly as guided by the report 
that will be forthcoming to Congress.
    Dr. Kupersmith. As I said, I think the space issue is very 
important, and in many areas there is a need for space. I think 
some of these scientific appurtenances that older space have do 
not come up to what the newer spaces have, so these are the 
kinds of things that we are going to be interested in. This 
survey is beginning, will be complete by the end of the fiscal 
year and will be reported at the beginning of next year. We 
will have very detailed information on each site and what it 
needs, and I think it will incorporate all of these things.
    Senator Jeffords. I am pleased to hear that. Your 
demonstration of the hand was fascinating. Thank you for 
bringing it, Dr. Weir. I note that you said that you began your 
research work on this hand before the Iraq War. Dr. Perlin, has 
the Iraq War demanded more from the VA? And how is the VA 
redirecting its future research as a result of the war injuries 
coming to the VA?
    Dr. Perlin. Thank you, Senator Jeffords for the comment. 
About 505,000 Americans have separated after having served in 
combat, and in sheer numbers, the number of individuals who 
have experienced amputation to date is about 424. But whatever 
the number, our goal, our mission, is to restore function, and 
this is in part the very central reason for VA. The promise of 
doing what we can to make veterans whole, particularly, if they 
have experienced a loss in service to our country is so core to 
our mission that this really reminds us to refocus on the 
rehabilitation. So both preceding the war, but certainly in the 
context of combat, we are increasing our commitment to not only 
prosthetic advances, but advances in brain injury, spinal cord 
trauma such as occurs with the Improvised Explosive Devices, in 
areas of amputation, of course, blindness, hearing loss, and of 
course, the mental-health concerns that are important not only 
in their own right, but also would accompany the physical loss 
of function.
    Dr. Kupersmith has put together a very exciting and 
important portfolio for improving the care of injured veterans 
ranging from combat casualty, neurotrauma, blast injury, a 
program research on quality enhancement in care delivery, to 
the long-term care management of complex injury, limb loss, 
performance and an advanced platform technology development 
program at Cleveland that produced such things as the 
Functional Electrical Stimulator which actually gave 
Christopher Reeve, Superman, the ability to breathe without a 
ventilator, and artificial retina research. I believe in your 
package you will find a picture of a device that can be 
implanted in the back of the eye and work with a camera on a 
pair of eyeglasses. In the same way that we now take for 
granted that we can restore hearing with the cochlear implant, 
we have the ability now and in the future to begin to restore 
vision to veterans with physical injury, of trauma perhaps, or 
macular degeneration, retinitis pigmentosa, or diabetes, 
through these cutting-edge advances. Program projects with the 
Department of Defense, NIH, and longitudinal studies just as 
some examples.
    Dr. Kupersmith.
    Dr. Kupersmith. I just want to add that last study is a 
deployment health study in which we are examining soldiers and 
other military before they go to these wars, and then we will 
be examining them after. It is the first study to look at the 
genesis of PTSD and other mental difficulties in this way. I 
think this will add a tremendous amount to our information in 
gaining data on who is more likely to get PTSD and how it 
happens.
    Chairman Craig. Interesting.
    Senator Jeffords. I have another question.
    Chairman Craig. Please proceed.
    Senator Jeffords. The aging of our veteran population 
presents special challenges to the VA in treatment of veterans. 
Can you discuss in more detail the specific research the VA is 
doing to assist the Nation in understanding how to provide 
better care to the elderly and better understand the unique 
challenges of the diseases that disproportionately affect the 
elderly?
    Dr. Perlin. Again, Senator, a great question and a great 
area. In VA's portfolio, there is work directed specifically at 
improving the quality of life for aging veterans. Of course, 
this will provide insight for the aging of all Americans.
    In a sense, much of the disease-focused research that we 
undertake has implications for aging. Cancer or heart disease, 
stroke, as examples, are all areas where there are components 
specifically directed at the disease of interest, but there is 
another element of that that is focused on the complexity of 
that disease in an aging population such as much of the veteran 
population.
    VA has been making particular focus on improving quality of 
life at end of life as in palliative care. I recently came 
across a statistic yesterday: Asking about pain at each visit 
actually exceeds recording of any other vital sign, which is 
really quite a testament. The usual four vital signs are pulse, 
respiration, temperature, and blood pressure, and VA has a 
program to record pain as the fifth vital sign, and it is now 
the number one vital sign in VA. Improving the quality of 
palliative care is particularly important not only in illness 
in general, but at end of living in improving end-of-life care, 
and hospice programs have been an area of focus and leadership 
as well. Understanding the basis of dementia and Alzheimer's is 
one example, but also vascular dementias that are caused by the 
same sort of plaque buildup that lead to heart attacks is 
another. These are not only of interest in terms of treatment, 
but with our genomic medicine, it is very exciting, not only 
about getting to good prevention, controlling the cholesterol 
and the blood pressure, but getting to an era where we can 
actually predict who is at risk, and even before the 
cholesterol gets high, develop treatments and start treatments 
that prevent things from deteriorating even before they would 
be obvious to the clinician, and that is the promise of some of 
the genomic medicine, the genetics-based therapy, that we hope 
and the Secretary commits, to bring as the state-of-the-art 
care for veterans. Dr. Kupersmith?
    Dr. Kupersmith. I think the main point is that so much of 
our research is relevant to the aging individual, and kidney 
disease, lung disease, and particularly cancer, because as our 
population ages, the incidence of cancer will rise. But the 
other point is that many of our programs are related to 
implementation of research and actually translation of research 
to the beside have to do with aging individuals, and our so-
called QUERI program has a number of topics that are very 
directly related to aging individuals so that we actually 
assure that the care that the research is informing is provided 
to the veteran.
    Senator Jeffords. Thank you very much.
    Chairman Craig. Jim, thank you. We could spend all day with 
you, but we do not have all day, and neither do you. Thank you, 
gentlemen, very much. Dr. Perlin, Dr. Kupersmith, Dr. Weir, the 
work you are doing is going to make some people a good deal 
more capable than they otherwise might be in the future because 
of their injuries, and thank you for that work. Gentlemen, 
thank you for your testimony.
    Chairman Craig. We have a second panel, and we would like 
you to come forward, please. If we could get our panelists 
seated, we will proceed. Thank you. I guess the expression of 
the next panel is where the rubber hits the road or where the 
funding dollars make it to the bench or to the laboratory 
facility. We are pleased to have with us Dr. Fred Wright, 
Associate Chief of Staff, Research and Development, West Haven, 
Connecticut, VA Medical Center; Dr. Dennis Stevens, Associate 
Chief of Staff for Research Development, Boise, Idaho Medical 
Center; Dr. John Feussner, Chairman, Department of Medicine, 
Medical University of South Carolina. and Dr. John Kennedy, 
Professor, Department of Medicine, University of Alabama, in 
Birmingham, Alabama, VA Medical Center, representing the 
Alliance for Academic Internal Medicine. Dr. Wright, we will 
start with you.

STATEMENT OF FRED S. WRIGHT, M.D., ASSOCIATE CHIEF OF STAFF FOR 
   RESEARCH, VA CONNECTICUT HEALTHCARE SYSTEM, DEPARTMENT OF 
                        VETERANS AFFAIRS

    Dr. Wright. Mr. Chairman and Ranking Member, thank you for 
the opportunity to discuss the importance of the VA research 
program in general, and the research program and the facility 
infrastructure at the VA Connecticut Healthcare System.
    Our program has more than 350 active projects led by more 
than 100 principal investigators. The majority of our 
investigators are clinicians who also provide patient care in 
internal medicine, surgery, mental health, or neurology. The 
topics of VA Connecticut research include basic science 
(including molecular biology, cell biology, and genetics) and 
clinical research (clinical trials, health services, 
epidemiology and rehabilitation). Approximately two-thirds of 
the projects are clinical research studies involving human 
subjects. Of the remainder, about half are investigations using 
animal subjects, and the other half involve data analysis or 
cell lines. Last year, the competitively awarded funding for 
these projects exceeded $40 million. Most of this research 
activity is concentrated at our West Haven campus.
    The program centers on research to improve the health of 
and the health care for veterans, including our newest 
returning veterans. For example, our investigators at the 
National Center for PTSD seek ways to improve treatment for 
combat-related post-traumatic stress disorder and the 
associated depression. A current project in that program, in 
collaboration with the Department of Defense, is studying PTSD 
in soldiers returning from Iraq to correlate specific genetic 
information with response to a newly developed treatment.
    Another group of investigators in our Neuroscience Research 
Center is combining efforts in basic molecular biology, 
clinical trials, and clinical rehabilitation to treat spinal 
cord injury. Current work in that program is using tissue 
transplant procedures to insert healthy myelin-producing cells 
into damaged spinal cords in order to restore function.
    Attracting, hiring, and retaining outstanding clinician 
investigators is crucial to our ability to deliver high-quality 
primary and specialty care to veterans. These clinicians are 
individuals who are committed to academic medicine and are 
attracted to work in VA by the combination of providing care to 
veterans, teaching trainees, and conducting research in an 
environment enhanced by the resources of the nearby medical 
school. Without a robust research program, we would not be able 
to recruit the nationally recognized clinician investigators 
who also serve as attending physicians, clinical leaders, and 
specialist consultants to whom our primary care physicians 
refer patients.
    Our affiliations with Connecticut's two medical schools are 
also important to the success of VA Connecticut research. 
Nearly all members of our medical staff have dual appointments, 
as both VA physicians and medical school faculty members. Our 
ability to recruit physicians to VA Connecticut medical staff 
is greatly enhanced by the associated appointment to the Yale 
facility, the opportunity to serve as a teacher for Yale 
medical students and residents, and the expectation to carry 
independent research in an environment enriched by the 
proximity of the medical school.
    Funding: Approximately one-third of the direct-cost funding 
for VA Connecticut research comes from the VA research 
appropriation, while nearly one-half of our funding is provided 
by grants from the National Institutes of Health. VA research 
funds provide the necessary core support for veteran-centric 
research. However, we are able to supplement this funding by 
competing successfully for funds from NIH and other non-VA 
sources. This allows us to leverage what we are doing to 
increase VA research.
    Facilities: In the non-VA research world of public and 
private universities and medical schools, facilities for 
research, whether laboratories, offices, or patient care 
settings, are maintained, replaced, or expanded by a 
combination of funds from State governments, private 
philanthropy, and Federal Agencies such as NIH. These sources 
of funds are not generally available to VA medical centers, and 
in my experience, have not been available at VA Connecticut to 
support our needs for major infrastructure improvements. To 
ensure that VA investigators are able to conduct cutting-edge 
research in the 21st century, we will need appropriate 
facilities and proper research infrastructure that will enable 
us to attract clinician investigators to our medical staff. 
Thank you again for this opportunity to describe our research 
program at VA Connecticut.
    [The prepared statement of Dr. Wright follows:]
 Prepared Statement of Fred Wright, M.D., Associate Chief of Staff for 
  Research, VA Connecticut Healthcare System, Department of Veterans 
                                Affairs
    Thank you for the opportunity to discuss the importance of the VA 
research program in general, the research program at VA Connecticut 
Healthcare System (VACHS), and the facility infrastructure. Our program 
has more than 350 active projects led by more than 100 principal 
investigators. The majority of our investigators are clinicians who 
also provide patient care in Internal Medicine, Surgery, Mental Health, 
or Neurology. The topics of VACHS research include basic science 
(including molecular biology, cell biology, and genetics) and clinical 
research (clinical trials, health services, epidemiology, and 
rehabilitation). Approximately two thirds of the projects are clinical 
research studies involving human subjects. Of the remainder, about half 
are investigations using animal subjects, and half involve data 
analysis or cell lines. Last year the competitively awarded funding for 
these projects exceeded $40 million. Most of this research activity is 
concentrated at the West Haven campus.
    The program centers on research to improve the health of and 
healthcare for veterans, including our newest returning veterans from 
Operation Iraqi Freedom and Operation Enduring Freedom (OIF/OEF). For 
example, our investigators in the National Center for PTSD seek ways to 
improve treatment for post-traumatic stress disorder and associated 
depression. A current project, in collaboration with Department of 
Defense, is studying PTSD in soldiers returning from Iraq to correlate 
specific genetic information with response to a newly developed 
treatment. Another group of investigators, in our Neuroscience Research 
Center, are combining efforts in basic molecular biology, clinical 
trials and clinical rehabilitation to treat spinal cord injury. Current 
work is using tissue transplant procedures to insert healthy myelin 
producing cells into damaged spinal cords in order to restore function.
    Attracting, hiring, and retaining high quality clinical researchers 
are crucial to advance the research agenda. These are individuals, who 
are committed to academic medicine, and are attracted to work in VA by 
the combination of providing care for veterans, teaching trainees, and 
conducting research in an environment enhanced by the resources of the 
nearby medical school. Without a robust research program, we would not 
be able to recruit the nationally recognized clinician investigators 
who also serve as attending physicians, clinical leaders, and 
specialist-consultants to whom our primary care physicians refer 
patients.
    Our affiliations with Connecticut's two medical schools--the 
Newington campus with the University of Connecticut Health Center and 
the West Haven campus with the Yale University School of Medicine--are 
also important to the success of VACHS research. Nearly all members of 
the VACHS medical staff have dual appointments as both VA physicians 
and medical school faculty members. In addition to their VA patient 
care activities, VACHS physicians have responsibilities in teaching and 
research. For example, the VA's West Haven campus is an important site 
for clinical rotations by Yale medical students, residents, and fellows 
in specialty training programs. They contribute to the care of VA 
patients and are taught by Yale faculty who are based at the VA medical 
center. VA's ability to recruit physicians to the VACHS medical staff 
is greatly enhanced by the associated appointment to the Yale faculty, 
the opportunity to serve as a teacher for Yale medical students and 
residents, and the chance to carry out independent research in an 
environment enriched by the proximity of the medical school.
    Approximately one third of the direct cost funding for VACHS 
research comes from the VA Research appropriation while nearly one-half 
of our funding is provided by grants from the National Institutes of 
Health (NIH). VA research funds provide the necessary core support for 
veteran-centric research. However, we are able to supplement this 
funding by competing successfully for funds from NIH and other non-VA 
sources. This allows us to leverage what we are doing to increase VA 
research.
    In the non-VA research world of public and private universities and 
medical schools, facilities for research (whether in laboratories, 
offices, or patient care settings) are maintained, replaced or expanded 
by a combination of funds from state governments, private philanthropy, 
and Federal agencies such as the NIH. These sources of funds are not 
generally available to VA medical centers.
    To ensure that VA investigators have the equipment and facilities 
necessary to conduct cutting-edge research in the twenty-first century, 
the Office of Research and Development has initiated a review of VA's 
research facilities. We believe that maintaining the proper research 
infrastructure is necessary in facilitating cutting edge research, and 
will enable us to attract outstanding clinician-investigators to our 
medical staff.
    Thank you again for the chance to describe our research program at 
VACHS. I am ready to respond to any questions that you may have.

    Chairman Craig. Doctor, not only did you do well, but your 
timing was amazing.
    Dr. Wright. Thank you.
    Chairman Craig. Now we turn to Dr. Dennis Stevens.
    Dr. Stevens.

STATEMENT OF DENNIS L. STEVENS, M.D., Ph.D., ASSOCIATE CHIEF OF 
  STAFF FOR RESEARCH, VETERANS AFFAIRS MEDICAL CENTER, BOISE, 
             IDAHO, DEPARTMENT OF VETERANS AFFAIRS

    Dr. Stevens. Senator Craig, Members of the Senate Veterans' 
Affairs Committee, and colleagues from the Department of 
Veterans Affairs, it is with great pride that I come before you 
as a veteran myself, and as Associate Chief of Staff for 
Research at a small VA medical center in Boise, Idaho. As a 
current member of the VA Career Development Review Board, and 
as a science investigator who has enjoyed 26 years of funding 
through the Department of Veterans Affairs Merit Review 
Program, I want to say that at all VA medical centers of all 
size, the important of research cannot be separated from the 
quality of care that we provide for veterans.
    Most VAs with research programs are affiliated with medical 
schools. Having none in Idaho, we have had to be very creative 
in establishing affiliations, both academic and research. 
Specifically, we have a strong academic affiliation with the 
University of Washington as part of the WAMI Program and have a 
residency training program in collaboration with the University 
of Washington in Boise.
    While those relationships are very strong and have been 
very productive in generating high-quality education, they 
really have not improved the research capabilities of the Boise 
VA. The topic that we have today is the infrastructure 
mechanisms and costs, and clearly, building is one of those. 
The space that we have I am not going to into in great detail, 
but it is essentially one large room with two or three small 
laboratories. We have a very excellent animal care facility, 
and we have a very small clinical research unit.
    At the local level of VA operations, most investigators in 
small places wear many hats. We have about 30 percent of our 
time, if we do have a merit review grant, to conduct research. 
The rest of the time we are seeing patients, we are taking care 
of Committees and various other things. So I think we have 
special problems at small VAs just because of a lack of depth.
    There are many things that we should talk about in terms of 
VA infrastructure, but I think, clearly, buildings is one, 
renovation projects is another. Equipment, and not only 
equipment, but service contracts. Probably the VA's central 
office could play a major role in addressing ways that we could 
creatively reduce the cost of service contracts in dealing with 
large corporations that make such equipment.
    One of the major problems we have had at our small VA is 
recruitment of new physician investigators, and that is 
currently at an all-time low. I think the reasons for this are 
multiple, but, first, the population of Boise has grown and 
therefore the number of patients that we care for has 
increased. For example, in 1995, we had 10,000 veterans that we 
took care of, in 10 years this increased to 19,000. We have 
conscientiously hired clinically oriented physicians to take 
care of these patients to reduce the waiting list, but we 
really have not actively recruited physician investigators, and 
that is currently a high priority.
    Lacking a medical school, it is also necessary to develop a 
critical mass of researchers at the Boise VA, and that has 
required very innovative relationships with the other 
universities throughout the State. Specifically, I have been 
able to develop collaborations with Boise State University, 
Idaho State University, and the University of Idaho. I have met 
with the research and development heads of all those 
universities, and we have a plan together to develop a critical 
mass of researchers at the Boise VA, and they are committed to 
provide graduate student stipends, postdoctoral stipends, as 
well as salaries for several faculty members, and I think this 
is really going to help us. We have also coordinated these 
efforts with the State legislature and the Governor's office 
and so on.
    The only thing that we really require is building space to 
accomplish these goals, and we plan this fall to submit a small 
research proposal for minor construction of a building for 
research and education on the grounds of the Boise VA.
    Thank you.
    [The prepared statement of Dr. Stevens follows:]
 Prepared Statement of Dennis L. Stevens, M.D., Ph.D., Associate Chief 
 of Staff for Research, Veterans Affairs Medical Center, Boise, Idaho, 
                     Department of Veterans Affairs
    Senator Craig, Members of the Senate Veterans Affairs Committee, 
and Colleagues from the Department of Veterans Affairs.
    It is with great pride that I come before you as a veteran, as 
Associate Chief of Staff (ACOS) for Research at a VA Medical Center 
(VAMC), a current member of the VA Career Development Review Board, and 
as a basic science research investigator who has enjoyed 26 years of 
continuous funding through the Department of Veterans Affairs (VA) 
Merit Review Research Program.
    Clinical investigators have successfully conducted basic science 
research for more than 25 years at the VAMC in the areas of cardiology, 
oncology, pharmacology, immunology and infectious diseases. Patient 
related research has been conducted through outcomes research projects 
involving clinical pharmacology, pulmonary medicine and the modern 
mechanisms of clinical teaching. Investigators have also participated 
or served as Principal Investigators in clinical trials involving 
treatment of hepatitis C, HIV, pneumonia, bronchitis, skin and soft 
tissue infections, septic shock, exacerbations of asthma and urinary 
tract infections. These clinical studies have been in FDA phase II and 
III clinical studies using novel new antibiotics and anti-viral agents. 
All have been on the cutting edge of new clinical treatments. Boise 
VAMC is currently participating in a clinical trial to compare 
treatments for clinically localized prostate cancer. Prostate cancer 
therapy is a topic of considerable discussion in the medical community, 
and this study could provide significant value to that discussion.
    At all VAMCs, the importance of research cannot be separated from 
quality medical care for veterans. The VA's model of patient care, 
teaching and research attracts the best, brightest and most hard 
working of physicians. While translational research defined as ``from 
the bench to the bedside'' has been newly discovered by other 
healthcare systems, this is exactly what the VA Merit Review Program at 
Boise VAMC and elsewhere has been doing for over 25 years. 
Historically, within the VA system, we have learned to make clinical 
observations, ask research questions, design experiments to answer 
these questions and then move our results to clinical trials to improve 
the care of veterans. As a consequence of the VA model for research, 
there is currently a remarkable cadre of ``clinical investigators'' who 
enjoy national and international acclaim. The title of this hearing, 
``VA Research: Investing Today to Guide Tomorrow's Treatment'' is in 
keeping with the historical theme of the VA Office of Research and 
Development.
    For example, a Boise researcher is currently studying how the heart 
reacts when anthracyclines are used to treat cancer or infections. 
Another researcher is working on what may be causing the increasing 
number of streptococcal infections.
    At small VA research operations, we must continuously identify 
opportunities to improve our program, while balancing the 
responsibilities and work loads of investigators and administrative 
staff. As we develop plans to improve our program, it is also crucial 
that we continue to identify funding sources to support our facility 
infrastructure needs. Our goal is to improve patient care by finding 
solutions through research projects that meet the needs of veterans in 
Idaho as well as the Nation as a whole. Your support and interest in 
our needs is appreciated.

    Chairman Craig. Dr. Stevens, thank you very much. Now we 
turn to John Feussner.
    Dr. Feussner.

  STATEMENT OF JOHN R. FEUSSNER, M.D., M.P.H., PROFESSOR AND 
           CHAIRMAN, DEPARTMENT OF MEDICINE, MEDICAL 
    UNIVERSITY OF SOUTH CAROLINA, CHARLESTON, SOUTH CAROLINA

    Dr. Feussner. Mr. Chairman and Senator Akaka, good morning. 
After listening to your opening statements, it appears to me 
that the best my testimony can do is merely reinforce what you 
already seem to know. Nonetheless, I appreciate the opportunity 
to share my perspective on the importance and value of the 
Veterans Affairs research program as it relates to academic 
affiliations between VA and academic medical centers. In 
addition to my role as professor and chairman of the Department 
of Medicine at the Medical University in Charleston, South 
Carolina, I also serve as a volunteer staff physician at the 
Ralph H. Johnson VA Medical Center.
    You already know about the extensive collaboration that 
exists between the VA and the large majority of schools of 
medicine and their academic centers. The affiliated VA Medical 
Centers share key features in common with their academic 
affiliates. The shared academic missions include superior 
patient care, innovative and path-breaking medical research, 
and broad-based medical education efforts. As a physician 
researcher who has worked within university and VA medical 
centers throughout my career, I provide a personal testimonial 
to the importance and value of that affiliation, not just to 
our Department of Medicine in Charleston, but for similar 
affiliated Departments of Medicine throughout the country.
    Clearly, the VA research program is superb in its own 
right. You already know that. The presence of VA's research 
activities coupled with excellent collaboration with academic 
medical centers creates a culture of inquiry and innovation 
that has the additional effect of attracting the best 
practicing physicians. To be sure, the presence of the VA 
Research Program raises the standard of medical care and 
improves the quality of care delivered to our veteran patients.
    Mr. Chairman, one of the key features of the growth and 
success enjoyed by our two affiliated medical centers in 
Charleston was the joint construction in 1996 of a new state-
of-the-art laboratory research facility named the Strom 
Thurmond and Peter Gazes Biomedical Research Center. This 
excellent research facility, now operating in its tenth year, 
provides nearly 120,000 square feet of state-of-the-art 
research space. The initial cost of this research building in 
1996 was $31 million.
    In addition, and historically, the VA has focused efforts 
on training future physician researchers, and in this regard it 
serves its clinical research and education missions 
simultaneously. The VA's research career development program 
provides excellent and stable support for new physician 
researchers during the most vulnerable period of their careers, 
the initial startup phase.
    Given such a superb track record of achievement, the 
current Administration budget recommendation is especially 
disappointing in that it would result in an actual reduction of 
$13 million in the VA research appropriation. Clearly, this 
will have a deleterious effect for VA-supported physician 
researchers and a loss of many new initiatives. And this 
deleterious funding climate will also do harm to the VA/
academic affiliations, as opportunities will be reduced for 
both. If the budget for research decreases, the competition for 
grants of necessity will escalate, so meritorious proposals 
will not be funded. And the newest physician researchers will 
be especially disadvantaged and could be lost from the research 
pool permanently.
    Mr. Chairman, with regard to this Committee's activities, I 
was gratified to note in your major views and estimates report 
to the Budget Committee earlier this year that you recommended 
VA research be augmented for fiscal year 2007 by an additional 
$30 million. I believe Senator Akaka made a similar 
recommendation. This type of bipartisan support by the Senate 
Veterans' Affairs Committee for research is deeply appreciated, 
sir, by those of us who are engaged in these pursuits. I know I 
speak for the entire academic medical community in thanking you 
and urging you to persuade the Senate and the House 
appropriators to follow your lead.
    Finally, Mr. Chairman, at some point in time--maybe this 
point in time--somebody has to make the decision to make an 
investment in the VA's future by repairing the VA's 
deteriorating research infrastructure. VA, in conjunction with 
its academic partners, operates dozens of substantial research 
laboratories. It saddens me to say that most of them need major 
renovations and some need complete replacement, as was the case 
in Charleston nearly a decade ago.
    Please remember that an investment in VA's research 
program, whether in direct funding or infrastructure 
improvement, preferably for both, counts twice in a way, as it 
strengthens VA research and simultaneously enhances the half-
century of excellent affiliation and partnership between the VA 
and some of the country's finest academic institutions.
    Mr. Chairman, thank you. I am pleased to answer your 
questions.
    [The prepared statement of Dr. Feussner follows:]
  Prepared Statement of John R. Feussner, M.D., M.P.H., Professor and 
Chairman, Department of Medicine, Medical University of South Carolina, 
                       Charleston, South Carolina
    Mr. Chairman and Members of the Committee, good morning. I 
appreciate the opportunity to share my perspective on the importance 
and value of the Veterans Affairs research program as it relates to 
academic affiliations between Department of Veterans Affairs Medical 
Centers and Academic Medical Centers. My name is Jack Feussner, and I 
am Professor and Chairman of the Department of Medicine at the Medical 
University of South Carolina in Charleston. I am also a WOC (without 
compensation, volunteer) staff physician at the Ralph H. Johnson VA 
Medical Center. I have spent my entire academic career in a University-
based Academic Medical Center setting with a strong and effective 
University and VA affiliation. I first became a funded VA physician 
researcher in 1982, and I maintained that funding until I moved to VA 
Central Office nearly 10 years ago to serve as the VA's Chief Research 
Officer.
    I am sure you already know about the extensive collaboration that 
exists between the VA and the large majority of Schools of Medicine and 
their Academic Medical Centers who are closely affiliated with the VA. 
These affiliated Department of Veterans Affairs Medical Centers share 
key features in common with their academic affiliates. The shared 
academic missions include superior patient care, innovative and path 
breaking medical research, and broad based medical education efforts. 
As a Professor of Medicine, and as a physician researcher who has 
worked within University and VA medical centers throughout my career, I 
provide a personal testimonial to the importance and value of that 
affiliation, not just to our Department of Medicine in Charleston, but 
for similar affiliated Departments of Medicine throughout the country.
    Clearly, the VA research program is superb in its own right. VA 
research focuses on health issues that are common to or unique among 
veteran patients. The VA research program is not just focused on 
medical discoveries, or the generation of new medical knowledge, 
treatment options, or diagnostic strategies. VA research focuses also 
on translating this knowledge into improved patient care. The VA 
Research Program is a potent enabler for VA and Academic Medical 
Centers in facilitating recruitment of superior physician clinical 
researchers. The VA Research Program, being completely intramural and 
available only to VA employed staff, provides a special and incremental 
source of funding that allows VA investigators additional options for 
successful funding, especially in the current budgetary milieux, where 
even non-VA research dollars are somewhat scarce. VA Research, in 
collaboration with its academic affiliates, generates a halo effect 
facilitating recruitment of outstanding physicians who themselves do 
not do research. The presence of VA's superb research activities, and 
excellent collaboration with Academic Medical Centers, creates a 
culture of inquiry and innovation that has the additional effect of 
attracting the best practicing physicians. With this academic 
affiliation, VA is able to recruit scarce subspecialties to work in VA 
Medical Centers, such as physicians who are expert in cardiology, GI 
and liver disease, and medical oncology. Stability in VA research, and 
until recently, reasonable annual growth in the VA Research Program 
have also contributed to the retention of a cadre of superb VA 
physicians and physician researchers. To be clear, the presence of VA's 
research program raises the standard of medical care and improves the 
quality of care delivered to our veteran patients.
    In our own community, the Department of Medicine at MUSC and the 
Charleston VA Medical Center collaboration has produced tremendous 
success in acquiring NIH research funding, in addition to VA research 
support, for illnesses important to veterans. Sustained funding in the 
area of cardiovascular disease, kidney disease, diabetes, and 
psychiatric illness has helped us address many medical problems that 
are common in veterans and non-veterans alike. For example, in the area 
of cardiovascular diseases, heart failure is one of the most frequent 
causes of hospitalization and premature death among veterans. A VA/MUSC 
based research program focused on understanding heart muscle 
dysfunction and heart muscle disease was initially awarded to VA and 
Medical University based investigators in 1993. This major NIH program 
project grant has been continuously funded since then and will continue 
through 2008. The grant is the second longest continuously funded major 
heart research project funded by the National Heart Lung and Blood 
Institute, and the principle researchers are faculty and staff at the 
Medical University and VA, respectively. The research is conducted in a 
shared VA MUSC state-of-the-art research facility. This research 
opportunity has permitted the tripling of cardiology physicians, over 
the grant period of time. While there is a national shortage of highly 
qualified heart specialists, the Medical University and Charleston VA 
Medical Center have not experienced such a shortage. The research 
funding available to these collaborating investigators exceeds $3 
million per year, and nearly $18 million in total funding over all 
years of the current grant cycle. This collaborative research effort 
between the Medical University and VA has led to significant research 
success for a major clinical problem. The research has also facilitated 
the recruitment, retention and stabilization of a group of medical 
specialists that is currently in short supply nationally. As I said 
earlier, the collaboration between the VA and the University, and the 
availability of VA research funding, have permitted both institutions 
to achieve success out of proportion to what either could have achieved 
alone. In my opinion, the other key beneficiaries of such a successful 
affiliation are veteran patients who receive excellent medical care 
from superb doctors who care for their illnesses, and in addition, 
these investigators conduct research that promises new therapies in the 
future.
    One of the key features of this growth and success between our two 
affiliated medical centers was the joint construction in 1996 of new, 
state-of-the-art clinical and laboratory research facilities, named the 
Strom Thurmond and Peter Gazes Biomedical Research Center. This 
excellent research facility, now in its tenth year, provides nearly 
120,000 square feet of state-of-the-art research space. The initial 
cost of this research building was $31 million with subsequent 
renovations costing $12 million over the past decade. Because of the 
close and productive affiliation between our state supported medical 
school and the federally supported Department of Veterans Affairs 
Medical Center, we were able to create a state and Federal partnership 
which facilitated the building of modern research facilities, which 
improved the infrastructure for both partners and greatly facilitated 
additional high quality faculty recruitment. Unfortunately, few such 
examples of successful partnering and planning between state and 
Federal institutions exist, especially now when resources are scarce!
    There are other examples of tremendous success within the context 
of this one academic partnership between the Charleston VA and the 
Medical University of South Carolina. Kidney disease, infectious 
diseases, cancer, diabetes, and other medial illnesses benefit greatly 
from the affiliation between an Academic Medical Center and a VA 
Medical Center. The affiliation arrangement results in improved faculty 
recruitment, improved research opportunities and infrastructure, and as 
mentioned previously, improved retention of excellent physicians and 
scarce specialists.
    In addition, and historically, the VA has focused efforts on 
training future physician researchers, and in this regard serves its 
clinical, research and education missions simultaneously. The VA 
research program offers a strong attractant for recruitment of young 
physician researchers. The VA's research career development program 
provides excellent and stable support for new physician researchers 
during the most vulnerable period of their careers, the initial startup 
phase. In the mean time, these VA Research Career Development awards 
winners provide superb medical care to veterans, and often bring the 
interest and expertise of their Academic/University mentors to an 
engagement with other VA programs.
    Given such a superb track record of achievement, and with all the 
opportunities created by the affiliation between VA and the Academic 
Health Centers, the current Administration budget recommendation is 
especially disappointing in that it would result in an actual reduction 
of $13 million in the VA research appropriation, from the current level 
of $412 million to $399 million. This will have a deleterious effect 
for VA supported physician researchers and a loss of many new 
initiatives. And this deleterious funding climate will also do harm to 
the VA/Academic affiliations, as opportunities will be reduced for 
both! While the research infrastructure in Charleston, which culminates 
in an excellent partnership between a state supported institution and a 
Federal entity, is adequate now, such is not the case nationally. Much 
like the VA's hospital facilities are aging and deteriorating, the same 
applies for its research infrastructure. Furthermore, the difficulties 
with the VA research infrastructure extend beyond buildings, 
laboratories, and the customary bricks and mortar. VA needs resources 
to update expensive research equipment. The VA also is suffering from a 
lack of non-facility infrastructure. VA is having increasing difficulty 
supporting its network of clinical trials centers, and may also have 
difficulty supporting its outstanding centers in Outcomes (or Health 
Services) and Rehabilitation Research. With a decrementing budget, the 
VA will have difficulty sustaining its excellence in translational 
research, which focuses on the transfer of research knowledge into 
clinical practice to improve patient care. The current research budget 
does not permit even secure support of ongoing studies. If the budget 
for research decreases, the competition for grants will escalate, so 
meritorious proposals will not be funded, and the newest physician 
researchers will be especially disadvantaged and could be lost from the 
research pool permanently. The research training that is so critical to 
the VA and the academic community would also be diminished as VA loses 
research resources--VA would lose the ability to fund research career 
development awards.
    The VA is an attractive partner with the academic community because 
the missions of patient care, medical research and medical education 
are shared and mutually supported. If VA must choose to retreat from 
its commitment to excellence in research, decrement its training 
opportunities, or continue to have its infrastructure deteriorate it 
will become more problematic to achieve future success together. If VA 
investment in these critical missions is diminished, another casualty 
of that diminution in research resources will be the highly successful 
Academic and VA affiliation.
    Other groups such as the Friends of VA Medical Care and Health 
Research (FOVA) have made recommendations for both research funding and 
for separate funding for the VA research infrastructure. In the context 
of the overall budget for the Department of Veterans Affairs, 
additional funding for research seems like a necessary and valid 
additional investment given the tremendous downstream returns, and 
given VA's important role as a partner with Academic Medical Centers. 
Mr. Chairman, with regard to this Committee's responsibilities, I was 
gratified to note in your Majority Views and Estimates report to the 
Budget Committee earlier this year that you recommended VA research be 
augmented for fiscal year 2007 by an additional $30 million, bringing 
its total to $429 million. Senator Akaka made a similar recommendation. 
This bipartisan support by the Veterans' Affairs Committee for VA 
research is deeply appreciated by those of us who are engaged in these 
pursuits. I hope I can speak for the entire Academic/VA research 
community in thanking you and urging you to persuade Senate and House 
Appropriators to follow your lead.
    Mr. Chairman, at some point, someone has to decide to make an 
investment in the VA's future by repairing VA's deteriorating research 
infrastructure. VA, in conjunction with its Academic partners, operates 
dozens of substantial research laboratories. It saddens me to say that 
most of them need major renovations and some need complete replacement. 
But year in, year out these laboratories' needs do not draw any 
significant funds from VA's major or minor construction accounts. Those 
accounts are exclusively reserved for VA patient care and other 
projects. To complicate matters further, since 1989 NIH has refused to 
fund any facility-related costs in its VA-based grants. Some of the 
VA's research and education foundations have supported the VA research 
laboratories, but frankly, with very few exceptions, they do not have 
the depth of funding resources to continue doing this in general. 
Please remember that an investment in VA's research program, whether in 
direct funding or infrastructure improvement, counts twice, in a way, 
as it both strengthens VA research and also enhances the half-century 
of excellent affiliation and partnership between the VA and some of the 
country's finest academic institutions. While the dollars are 
difficult, I am sure, and recognizing there are many competing needs, 
this one is an especially good investment that the Congress can make in 
support of veterans' health for today, and into the future.
    Thank you, Mr. Chairman. I would be pleased to answer any questions 
you or other Committee Members wish to ask.
                                 ______
                                 
    Responses to Written Questions Submitted by Hon. Larry E. Craig 
                    to John R. Feussner, M.D. M.P.H.
    Question. ``As past director of the national VA research program, 
what were the unmet needs in VA's laboratories, how did you try to 
address them, and what is your assessment of those needs today? Do you 
have any recommendations for the Committee in dealing with those 
needs?''
    Answer. The intramural research program in the Department of 
Veterans Affairs is conducted in laboratories in VA Medical Centers 
nationwide. These laboratories must be equipped and maintained to meet 
standards for physical and operational infrastructure in order to 
ensure the efficient operation of laboratories and animal facilities, 
and to maximize the protection of personnel, experimental animals, the 
public and the environment. Many VA Medical Centers do not provide 
sufficient or appropriate space to investigators because of either a 
shortage of laboratory space or deficiencies in the quality of space. 
There is a serious risk that an aging and inadequately maintained 
research infrastructure will become an impediment to recruitment of the 
``best and brightest'' clinician scientists to VA facilities.
    In 2001-2002 the VA research program compiled a list of thirty (30) 
priority sites requiring research infrastructure improvements. These 
needed improvements ranged from minor construction or renovation of 
``wet'' laboratories, construction of new research structures and other 
capital improvements. The list of thirty sites is contained in an 
official VA report filed in the Office of Research and Development. An 
important observation of this process was that research space in the 
majority of the minority sites could be adequately renovated as ``minor 
renovation,'' or for approximately $4 million/site. The VA's medical 
research appropriation cannot be expended for capital improvements, 
therefore available support from the research office alone has been 
limited. VA has no other designated funding stream for improving, 
renovating, or updating research facilities.
    In addition to these construction costs, the second unmet need that 
VA research has is a sustainable source of funding for equipment 
purchases or modernization. Again, any funding for research equipment, 
especially expensive, technologically sophisticated equipment must come 
from the same funds that support individual research grants.
    As there is no current mechanism for supporting research 
infrastructure needs, I was unable to address the issue of remodeling 
wet lab facilities or building new facilities. In the summer of 2001, 
we initiated discussions with the House Veterans Affairs Committee and 
had reached a mutual agreement that the only strategy for improving VA 
research infrastructure, and addressing this problem systematically 
through time, was to create a new line appropriation for research 
construction similar to the line for construction of medical care 
facilities in the medical care appropriation. The chairman of the House 
Committee at the time was Congressman Christopher Smith, but our plans 
and recommendations were hi-jacked by events occurring on September 11, 
2001.
    Fundamentally, the VA study that was done and discussed with the 
House Veterans Affairs Committee was comprehensive and robust. This was 
done with the intention that Congress might to address these serious 
shortcomings on an incremental basis over a multi-year period. Our 
initial request in 2001 was for approximately $40-45 million/year as a 
new line item appropriation. As I reported in my congressional 
testimony, ``at some point in time somebody has to make a decision to 
make an investment in the VA's future by repairing the VA's 
deteriorating research infrastructure.'' Given that this matter has 
garnered little attention over the past 5 years, I am sure that the 
situation has deteriorated further.
    I do have several recommendations for the Committee in dealing with 
these needs. First, the Committee could charge the Office of Research 
and Development in VA to update the previous VA research report 
cataloging the unmet needs for research construction and facilities 
modernization. I would estimate that such an activity should take no 
more than 90 to 120 days. The Committee could compare the original 
report and the new report, where VA would again prioritize its 
facilities needs in terms of minor construction or new facility 
construction. I would estimate that if the Congress would create a new 
line item for VA research facilities construction of approximately $40-
50 million per year, VA would be able to refurbish and upgrade its 
thirty (30) most pressing infrastructure problems in as little as 2 
years.
    In addition, the Committee could direct that any construction funds 
not allocated for renovation and remodeling of existing facilities 
should be applied to modernization with replacement of state-of-the-art 
research equipment.
    Finally research facility construction is a separate and serious 
challenge. And as you recall, the joint facility built in Charleston in 
1996 cost $31 million a decade ago. Individual research buildings 
constructed in multiple locations would probably cost upwards of $50 
million per building with 2006 dollars. I would recommend that if the 
Congress wishes to fund selected new construction, that the VA could 
request matching monies in a joint venture effort with the affiliated 
research universities. Several areas in need of serious research 
construction in 2002 were the Pittsburgh VA (affiliated with the 
University of Pittsburgh); the Los Angeles VA (affiliated with UCLA); 
the VA Puget Sound (affiliated with the University of Washington); the 
Philadelphia VA (affiliated with the University of Pennsylvania); the 
Iowa City VA (affiliated with the University of Iowa) and the Nashville 
VA (affiliated with Vanderbilt University) as several examples. New 
construction is fundamentally more expensive and challenging than 
renovations, and I would recommend the renovations proceed first.
    As you already know Mr. Chairman, the VA research is superb in its 
own right. The affiliation between Department of Veterans Affairs and 
research universities benefits VA in ways that are numerous and 
recognizable to VA leadership. As the VA's research infrastructure 
continues to deteriorate, the VA will become a less viable and less 
attractive site for new physician specialists who wish to develop a 
research career. Any progress that this Committee can make in this 
critically important area of medical care and biomedical research will 
greatly benefit current and future generations of veterans. Given the 
stellar performance of VA research in the past, this investment will 
inevitably return superior dividends to all Americans. Mr. Chairman, I 
can not thank you enough for your persistent interest in this important 
issue and your unflagging support for veterans' needs.

    Chairman Craig. Doctor, thank you very much.
    Now we turn to Dr. John Kennedy. Welcome.

      STATEMENT OF JOHN I. KENNEDY, JR., M.D., PROFESSOR, 
 DEPARTMENT OF MEDICINE, UNIVERSITY OF ALABAMA AT BIRMINGHAM, 
                 BIRMINGHAM VA MEDICAL CENTER, 
  BIRMINGHAM, ALABAMA; ON BEHALF OF THE ALLIANCE FOR ACADEMIC 
                       INTERNAL MEDICINE

    Dr. Kennedy. Good morning, Mr. Chairman and Senator Akaka. 
I am honored to be here today. As you know, I am a professor of 
medicine at the University of Alabama at Birmingham. I am proud 
to tell you that I spend the majority of my professional time 
at the Birmingham VA where I hold the positions of Associate 
Chief of Staff for Acute and Subspecialty Care and Chief of the 
Medical Service there. I am also a funded investigator, and I 
take care of patients. I am testifying today, however, on 
behalf of the Alliance for Academic Internal Medicine, so I 
want to thank you again for providing me the opportunity to 
testify about VA research.
    I am here today to tell you that the VA research program 
works, but as you know, it also faces important challenges. My 
examples of its success will come from my local experience in 
Birmingham, but the Nation is replete with similar stories.
    We have many successful research programs in our center. I 
want to highlight two of the large multi-investigator programs. 
The first is VA's Birmingham Atlanta Geriatrics Research unit, 
or GRECC. In their research, 22 GRECC investigators focus on 
genitourinary disorders, mobility in older patients, and 
palliative care. Work of these GRECC investigators has led to 
the development of a new palliative care program with an 
inpatient unit in Birmingham where veterans nearing the end of 
life receive compassionate care from specially trained, 
multidisciplinary teams. The VA's research support of the GRECC 
has also leveraged funds from other sources. In fiscal year 
2005, two-thirds of the GRECC's total research funding came 
from sources outside of VA. However, without the VA's initial 
investment in the GRECC, none of this would have materialized.
    The Deep South Center on Effectiveness at the Birmingham VA 
is another excellent example of VA's research successes. This 
center's mission is to improve health care for veterans and the 
Nation through partnerships in effectiveness research. Some 
highlights of this center's success include a joint effort with 
UAB to develop programs to educate providers about 
bioterrorism; examining new approaches for the treatment of 
PTSD, as you know an important concern both for current and 
newly returning veterans; and innovative uses of the electronic 
health record combined with Internet to support providers in 
community-based outpatient clinics as they care for patients 
after heart attacks.
    Now, despite these successes of the VA research program, 
AAIM has concerns for its future. The lack of growth in program 
funding, as you have heard, is particularly troubling to us 
all. A flat budget sends messages to young clinician-scientists 
that hard times are ahead and that research may not be the 
career for them. Over the past 4 years, a time of level funding 
in our center, the number of funded investigators has decreased 
by 30 percent and the entry of new investigators has dropped 
dramatically. Senior researchers with a history of sustained 
funding have found it increasingly difficult to obtain 
continued funding in VA. Gaps in support lead to losses of 
technicians and other key personnel and seriously erode the 
momentum of the research effort. Faced with these ongoing 
problems, some physicians from our center have left VA. As a 
result, our ability to recruit and retain the highly skilled 
specialists needed to care for our complex patient population 
is seriously compromised.
    AAIM thanks the Committee and its leadership for its 
ongoing support of the research programs. As a member of FOVA, 
AAIM supports the $460 million appropriation for the VA 
research program in fiscal year 2007. I cannot overstate how 
important growth to the program will be given the likely 
difficulties in increasing the overall Federal support for 
research in the coming year, despite your best efforts.
    AAIM's second specific concern is VA's research 
infrastructure. As you have heard, modern scientists need 
modern facilities in which to conduct their research. I have 
heard countless stories from all across the country about 
difficulties in upgrading ventilation and electrical systems. 
These basic needs are absolutely critical. More investment in 
core facilities to house essential research tools will be 
required for VA to move into the future of research where it 
most deservedly belongs. AAIM encourages you to consider the 
development of a designated authority for funding VA research 
infrastructure.
    The Alliance's final concern pertains to the distribution 
of VA's scarce research resources. The successes I have 
reported to you inherently result from the intramural structure 
of the research program, which assures that these investigators 
are also available as clinicians and educators. The other 
inherent element of the program is peer review, the process 
through which the very best research can be identified and 
priorities for funding can be determined. AAIM encourages this 
Committee to lead efforts to retain these valuable aspects of 
the program and to strengthen VA research as it serves today's 
and tomorrow's veterans.
    Again, thank you for the opportunity to appear today. I 
look forward to your questions.
    [The prepared statement of Dr. Kennedy follows:]
Prepared Statement of John I. Kennedy, Jr., M.D., Professor, Department 
of Medicine, University of Alabama at Birmingham, Birmingham VA Medical 
  Center, Birmingham, Alabama; on Behalf of the Alliance for Academic 
                           Internal Medicine
    Good morning Mr. Chairman and Members of the Committee. My name is 
John Kennedy, and I am a Professor of Internal Medicine and Residency 
Site Director at the University of Alabama at Birmingham. I spend the 
majority of my professional time at the Birmingham VA Medical Center 
where I hold the positions of Associate Chief of Staff for Acute and 
Subspecialty Care and Chief of the Medical Service. I am testifying 
today, however, in my role as a leader of the Association of Program 
Directors in Internal Medicine and on behalf of the Alliance for 
Academic Internal Medicine.
    Thank you for providing me the opportunity to testify about the 
successes of and challenges to the VA medical and prosthetics research 
program. Internists represent roughly 50 percent of all VA researchers 
and conduct bench research, clinical research, and health services 
research in all the specialties of internal medicine. These specialties 
range from the primary care field of general internal medicine to 
rheumatology, gastroenterology, and cardiac electrophysiology--as well 
as my own field of pulmonary and critical care medicine--to name a few. 
Internists have also been at the forefront of providing excellent 
leadership to the VA research program, and I must take this opportunity 
to thank my fellow internists here today, Drs. Feussner, Perlin, and 
Kupersmith, for their vision and management of the program.
    I am here today to tell you that the VA research program works but 
faces challenges. My examples of this success will come from my local 
experience, but the Nation is replete with similar stories.
    My first example of the success of the program is VA's Birmingham/
Atlanta Geriatrics Research, Education, and Clinical Center, or GRECC. 
The GRECC employees 22 core VA personnel at the two VA medical centers. 
In their research, the GRECC investigators focus on genitourinary 
disorders, mobility, and palliative care, studying such topics ranging 
from sarcopenia, or loss of muscle, to driving issues among older 
veterans. Among the results reported by investigators from the GRECC in 
2005 were studies showing that daytime exercise and bladder control 
strategies were more effective than medication in controlling the need 
to urinate at night and studies documenting the important aspects of 
team functioning that yielded functional improvements for stroke 
patients.
    Of course, the GRECC investigators are also clinicians and 
educators in the two facilities. Notable among their clinical 
accomplishments has been the development of a palliative care program 
at the facility in Birmingham, well-recognized among the best in the 
Nation if not the world. Approximately 25 percent of all patients 
hospitalized at the Birmingham VA Medical Center are seen by palliative 
care consultants who address their needs for relief of suffering of all 
types and assist with development and implementation of directives for 
future care and at the end of life. This work has ultimately led to the 
opening of a new 10-bed inpatient palliative care unit in our medical 
center where veterans nearing the end of life can receive compassionate 
care from a multidisciplinary team trained to address their particular 
needs and those of their families.
    On the education front, GRECC educators have been successful in 
raising over $2 million in the last year alone to improve the training 
medical practitioners receive in caring for elderly patients, a 
critical area for education given America's aging population. The GRECC 
has also reached out to the community with its VA Teacher Ambassador 
Training Program, a VISN recognized effort to honor veterans.
    In addition to these programmatic accomplishments, VA research 
support has worked in this case by leveraging funds from other sources. 
In fiscal year 2005, the GRECC had a total of more than $35 million in 
research funding. Of this total, $9.9 million came from VA while $25.8 
million came from outside funding sources. This group of researchers 
has proven to be highly productive and able to successfully compete for 
funding in every sphere. However, without VA's investment in the GRECC, 
it is hard to see how any of these results would have materialized.
    The Deep South Center on Effectiveness at the Birmingham VA Medical 
Center is another excellent example of VA's research successes. The 
Center is funded as a VA Research Enhancement Award Program, or REAP. 
The Center's mission is to improve healthcare for veterans and the 
Nation through partnerships in effectiveness research. The Center 
develops strategies to change provider practice patterns using 
evidence-based interventions to improve the quality of care for 
veterans, and it uses VA's extensive data bases to promote improved 
care by establishing links between direct patient care and population-
based analyses. The Center includes 35 investigators and 14 FTE support 
staff.
    One of the reasons this Center is a success for VA research is 
because it has forged strong liaisons with the University of Alabama at 
Birmingham. In one linkage, the Center has undertaken a research 
project to assess the effectiveness of bioterrorism preparedness 
education among health care practitioners. This project directly ties 
in with the work of the UAB Center for Biodefense and Emerging 
Infections. Through the affiliation with UAB, several VA researchers 
also participate in major national research initiatives such as 
Coronary Artery Risk Development in Young Adults, or CARDIA. Utilizing 
the CARDIA data base, these VA researchers recently published their 
important new findings identifying a link between second-hand smoke 
exposure and glucose intolerance, a precursor of diabetes. This 
function of the academic affiliation strengthens both the VA and UAB, 
improving their research efforts and the care provided to veterans and 
other patients.
    The Center is also a success in that it is a platform for research 
efforts with possible effects on both the Nation's current veteran 
population as well as the veterans returning from Afghanistan and Iraq. 
For instance, the Center is planning a study of atypical antipsychotic 
medications in post-traumatic stress disorder, while at the same time 
studying best practices for hernia repair and improving intermediate 
outcomes in veterans with diabetes.
    Finally, the Center is a success in utilizing VA as an excellent 
laboratory for projects that aim to improve care for veterans. The 
Center's recently funded VA MI+ study seeks to understand and increase 
provider adherence to clinical practice guidelines for post-heart 
attack patients. The study integrates the VA electronic health record 
system and its community based outpatient clinics, or CBOCs, to achieve 
this goal. No other health system in the United States could serve as 
well as VA as a setting for this study.
    Despite the successes of the VA research program, AAIM has concerns 
for its future.
    The lack of growth in program funding, particularly the 
Administration's long standing reluctance to incorporate increases for 
the program in its budget proposal, is particularly troubling. A flat 
budget sends messages to young clinician-scientists, as well as 
established investigators, that hard times are ahead and that research 
may not be the career for them. Over the past 4 years, during which 
overall research funding to our VA medical center has remained 
relatively flat, the number of funded investigators has decreased by 30 
percent and the entry of new investigators has dropped dramatically. 
Mid-level and senior researchers with a prior history of sustained 
funding, and active funding from NIH and other sources, have found it 
increasingly difficult to obtain research funding in VA. Several of our 
physician-investigators have had to resubmit grant proposals up to four 
times before obtaining funding. During such gaps in support, the 
momentum of the research effort is seriously eroded. One investigator 
working in HIV reported that 60 percent of the lab's personnel departed 
during such a gap. Faced with these ongoing problems, physicians from 
our medical center in the specialties of nephrology, gastroenterology, 
and pulmonary diseases have abandoned efforts to obtain future research 
funding from VA. As a result, our ability to recruit and retain the 
highly skilled specialists needed to care for our complex patient 
population is compromised.
    AAIM thanks the Committee for its support of the program in your 
views and estimates letters. The Alliance also thanks Senator Craig and 
Senator Akaka for their sponsorship of the Dear Colleague letter to 
appropriators. As a member of the Friends of VA Medical Care and Health 
Research coalition, or FOVA, AAIM supports a $460 million appropriation 
for the VA research program in fiscal year 2007. I cannot overstate how 
important growth to the program will be given the likely difficulties 
in increasing overall Federal support for research in the coming year, 
despite your best efforts.
    AAIM's second specific concern for the future of the program is 
VA's research infrastructure. Modern scientists need modern facilities 
in which to conduct research. I have heard countless stories from AAIM 
members across the country about difficulties in upgrading ventilation 
and electrical systems. These basic needs are critical. The precision 
equipment required for modern research programs, such as genomics, will 
require precise control of the laboratory environment. The advanced 
computer systems and high-tech equipment that will support this work 
will absolutely demand consistent, uninterrupted supply of electrical 
power. More investment in core facilities to house essential research 
tools, such as mass and NMR spectrometers, advanced microscopy, 
robotics and computer equipment, will be required for VA to move into 
the future of research where it most deservedly belongs. AAIM 
encourages you to consider the development of a designated authority 
for funding VA research infrastructure.
    The alliance's final concern pertains to the distribution of VA's 
scarce research resources. The successes outlined in my statement 
inherently result from the intramural structure of the research 
program. In most cases, VA funded investigators must have at least a 5/
8ths appointment. This structure assures these same investigators are 
available as clinicians and educators in the VA, vital roles for caring 
for the veteran population. The other inherent element of the program 
is peer review, the process through which the best research can be 
identified and prioritized for funding. AAIM encourages this Committee 
to lead efforts to retain these valuable aspects of the program and 
strengthen VA research as it serves today's and tomorrow's veterans.
    Again, thank you for the opportunity to appear today. I look 
forward to your questions.

    Chairman Craig. Dr. Kennedy, thank you very much, and to 
all of our panelists, thank you.
    Let me ask a question specific of you, Dr. Stevens, because 
of the size of the facility in Boise compared with, I think, 
your peers who are here and are dealing with probably 
university settings and a larger type of research setting. And 
then I want to ask a series of questions that I think all of 
you might want to react to.
    Dr. Stevens, I understand that you specialize in the area 
of infectious diseases. Can you briefly describe the range of 
research activities that are underway at your facility?
    Dr. Stevens. Yes, sir. We have done basic science research 
in gram-positive bacteria, such as Group A strep, Staph. 
aureus, Clostridium perfringens, gas gangrene, and we have 
investigated how these toxins really cause destruction of 
limbs, and how they cause shock, in an effort to try to explain 
why with battlefield injuries, for example, people lose arms 
and legs in a matter of hours. And so we have defined the 
important toxins for many of these organisms and have actually, 
in collaboration with Porton Down in great Britain, developed a 
vaccine to prevent gas gangrene, at least in animal models.
    We also have done clinical studies with hepatitis C, and I 
am happy to say that for genotype II and III, we have been able 
to cure 95 percent of veterans that have hepatitis C that are 
non-genotype I.
    We have also done clinical studies with HIV, and we have 
investigated mechanisms of actions of antibiotics and defined 
some better ways to treat gram-positive infections that are 
associated with toxins, like toxic shock syndrome.
    Chairman Craig. What strategies have been effective in 
maximizing the research funds for your relatively small-scale 
type program?
    Dr. Stevens. Well, I think collaborations. You know, we 
don't have a critical mass of people there to collaborate with, 
but we have been able to collaborate with people from all over 
the world that have similar interests. So I think collaboration 
is one. Partnerships with pharmaceutical companies in terms of 
clinical trials as well as investigation-initiated research 
projects are also important. We have worked with the various 
universities that I mentioned to try to improve collaboration 
and to try to develop joint graduate school programs. And I 
think those are the things that are kind of in their infancy 
but we are very excited about and moving forward and I think 
trying to develop a critical mass there in Boise.
    Chairman Craig. Gentlemen, to all of you, you bring with 
you a wide range of perspectives from regionally diverse VAs, 
major medical schools, and from academic clinical experiences. 
If we are to move forward toward enhancing VA's university 
collaboration in the area of research, your views would 
certainly be welcome in all of these discussions.
    Can any of you comment, or would you, on the degree of 
opportunity you see in the joint operation of a VA university 
research space? Do you foresee certain obstacles that the 
Committee should be aware of in these kinds of relationships?
    Dr. Feussner. Well, Senator, I would be happy to take that 
question since we currently operate a joint research facility 
between the VA and the medical university.
    I think the obstacle, the operative obstacle is finding the 
original startup capital to create the facilities. In our case, 
it was a joint venture not between public and private partners 
but between Government partners. The Federal Government 
contributed dollars, the State of South Carolina contributed 
dollars, and the medical university financed the rest.
    We share 120,000 square feet of research space. The 
investigators experience no barriers. The VA administrative 
office is actually housed in the research building. If 
anything, the sharing, in my opinion, facilitates 
collaboration. It gets the researchers out of their silos and 
gets them to collaborate with one another. In our case, two 
major program project grants initially seeded by VA research 
dollars, funded to our investigators, one in cardiovascular 
disease, continuously funded now for almost 15 years, and 
another one in diabetes, a program project funded by the NIH. 
And both those major grants, the investigators for the most 
part are both VA and university faculty.
    So I think the real barrier, the operative barrier, is 
getting the initial startup capital to make the investment 
happen.
    Dr. Wright. I could provide a slightly different 
perspective on that in southern Connecticut. We are very 
fortunate to be in a community with a large research-oriented 
medical school. The challenge that we face is that our facility 
is 4 miles away from Yale, and so it is difficult to co-occupy 
a single facility. In the efforts that we have made in working 
with the school we have found that the school, with its view on 
its own concerns, is most interested in facilities that are 
immediately on the campus.
    As Dr. Kennedy said, that the VA-appropriated funds provide 
the core support or the initiating support, is either in 
projects or in capital funding, that then enable the VA to make 
other funds materialize. In our experience, without adequate 
appropriated funding support directed at the VA, the VA has 
great difficulty in attracting the additional funds, which in 
our case is two-thirds of our funding.
    Chairman Craig. Dr. Kennedy.
    Dr. Kennedy. Mr. Chairman, I would just agree with my 
colleague Dr. Feussner that I think the major obstacle is the 
capital to fund these buildings. But sort of going at a 
different perspective from Dr. Wright, I think there is a 
tremendous opportunity in those settings, as in Birmingham, 
where the VA and the university are in very close proximity, 
immediately adjacent to one another, and there are other such 
arrangements where the proximity is not an issue, and these are 
tremendous opportunities for joint efforts for space and other 
activities.
    So, again, on a positive note, seeking out opportunities, I 
think this is one.
    Chairman Craig. Thank you very much.
    Senator Akaka.
    Senator Akaka. Thank you very much, Mr. Chairman.
    Dr. Stevens, you detailed the success researchers have in 
areas such as cardiology, oncology, and infectious diseases. 
However, these are programs that are facing the real funding 
cuts. Is it not possible for VA researchers to work on service-
connected research and concurrently on diseases facing all 
Americans?
    Dr. Stevens. Well, thank you for that question, Senator 
Akaka. I agree with you. I think that there are many priorities 
for research within the veteran population, and I think that 
there should be basic research and clinical research and 
outcomes research in the areas of cardiovascular disease, 
oncology, et cetera. Those things all affect veterans as well. 
I don't think it should just be limited to war-type injuries, 
although in my own case we have spent a lot of time trying to 
solve some of the infectious disease problems from some of 
those cases.
    So I do not want to cutoff my nose to spite my face here, 
but, on the other hand, I think that it should be a broad base.
    Senator Akaka. You also mentioned in your testimony about 
the growth of need for services in Idaho, and in 10 years you 
went from 10,000 to almost double, which is 19,000, and also 
the problem of recruiting for new positions because of this 
kind of growth, which make it so important that we got some of 
these shifts in emphasis.
    Dr. Kennedy, your testimony discusses the fact that in some 
cases, VA research is funded more from outside sources than 
from Federal funding. For example, the GRECC, or Geriatrics 
Research, Education Clinical Center, received a total of $35 
million last year; only $9.9 million was from VA funds. Outside 
funding then is vital in the program's success.
    You have cited the lack of growth in program funding as a 
concern. Can you, Dr. Kennedy, describe how continued lack of 
funding will impact recruitment and retention of new clinician 
scientists? And would more VA funding for programs such as 
GRECC perhaps minimize attrition of researchers and continue to 
encourage outside funding?
    Dr. Kennedy. Thank you, Senator Akaka. That is a wonderful 
question.
    As you point out, this investment that you make in VA 
research, as all the testimony has alluded to today, is a 
tremendous bargain and the yield is phenomenal. So I do not 
know any other investment where you get a two-for-one return on 
investment in the short term. And this is in the grand scheme 
of the Federal budget not a huge amount of money.
    That said, I can tell you specific examples in Birmingham 
where we have lost physicians. We were the only facility in our 
network to employ a full-time neurosurgeon, who was a basic 
science investigator, who lost funding and left VA. We have 
senior faculty, as I have mentioned already, who have become 
very discouraged. Some have gone through four cycles of repeat 
submissions in order to gain continued funding after long 
periods of successful funding. They have become very 
discouraged, and some have left the VA, gone back solely into 
the university. This is a major impact for me as the Chair of 
Medicine trying to staff the wards and the clinics to provide 
the specialists that we need there.
    This research avenue is the critical one to help us recruit 
such people. Even as the pay bill, we hope, brings the pay up 
to competitive levels, that alone will not be sufficient, in my 
opinion, to keep this steady supply of highly trained 
specialists in VA.
    Senator Akaka. Well, thank you, Mr. Chairman. If I may 
proceed to another question?
    Chairman Craig. Please.
    Senator Akaka. Because of the shift of emphasis, I would 
like to hear what your feelings about this. My question goes to 
each of you. As experienced researchers, I do not have to tell 
you about the value of maintaining a vital peer review process. 
From my vantage point, we have seen an increase in earmarks in 
the case of sending VA dollars outside of VA to other entities. 
Now, my question to you is: Is the peer review process as vital 
as we need it to be?
    Dr. Stevens. Thank you, Senator Akaka. I would to take a 
shot at that, if I may.
    I think the peer review process is absolutely vital to a 
healthy competitive research program, and I think the VA's 
central office has just done a marvelous job in the peer review 
program over the years. And I think it is impartial. I think it 
gives money to the best grants, the best people. And I think 
they do a wonderful job in that respect.
    I think as you have pointed out, as you have both pointed 
out, the research money that is allocated is, in my opinion, 
inadequate and it has been inadequate for a long time. The peer 
review process is excellent, but when the funding level gets 
down, it is devastating. And it takes an awfully good 
researcher to be able to compete with everyone else in the 
world when the funding level is 10 percent or even 15 percent. 
That is a destructive level. The funding level of grants' 
approval rate has got to be higher than that.
    You know, you would not want to just allow 20 percent to 
the VAs throughout the Nation to have research programs. That 
is what it boils down to.
    So I think that the peer review process is excellent. It is 
necessary. But, believe me, it weeds out very good people when 
the funding level gets too low.
    The other thing that is, I think, related to the question 
of funding in the VA system is the amount of the award. And 10 
or 15 years ago, I think the maximum was $150,000 per year for 
a merit review. It is now $125,000 a year maximum. And so, you 
know, within inflation and the cost of equipment and salaries, 
that is not a lot of money. I mean, we are very grateful. We 
are very grateful for it. But everything else in the world has 
grown. The awards for a merit review have actually decreased in 
total amount for those people that are successful. And I think 
at a small VA like I am, I think this is devastating. But I 
think it is equally devastating for large programs such as in 
our VISN, the University of Oregon, Portland VA, the Seattle 
VA. It is devastating for them as well.
    Senator Akaka. Dr. Wright.
    Dr. Wright. Senator, if I may, extend that briefly with our 
experience: I have heard people compare the peer review system 
to democracy. I think people have said about democracy that it 
is painful and it can be messy and it is difficult. The peer 
review system is like that also, but like democracy, we think 
it is the best way to do it.
    I can give an example from our recent experience this year. 
When the funding level of available funds to divide up by peer 
review is in this 10- to 15-percent range, that does not 
necessarily mean that 85 or 90 percent of the applications are 
not worthwhile. In fact, I was very disappointed this year when 
one of our new potential recruits, a woman who I taught as a 
medical student sometime ago, and who has now been through 
residency and fellowship training and graduate training and is 
ready to embark on her own research career did not receive VA 
funding. My understanding is she came in about fifth out of 25 
applicants in the last round and will have to reapply for 
funding. So she will be treading water with us and trying to 
conduct her research. She wants very much to stay at the VA and 
be a clinician and an investigator.
    Senator Akaka. Dr. Feussner.
    Dr. Feussner. Yes, Senator. I do not think the power of 
your question can be understated, and if we start by saying 
what my colleagues have already said, that the start point is a 
situation where research resources are precious and scarce, the 
peer review process promotes very strong very rigorous science, 
very rigorous research methods, and it provides an opportunity 
for accountability of how the research dollars are spent.
    You might say that bypassing that process in a period of 
scarce resources cheats hard-working scientists who are 
participating in the research process, who go through this 
rigorous review with perhaps a front-end opportunity of being 
succeeded one in five, or 20 percent. So I think activities 
that bypass this process are--I should not say reprehensible, 
but are unfortunate. And I would commend the VA. The VA has a 
rigorous peer review process. It has for decades. It emulates 
the peer review process of other major biomedical Federal 
funders like the National Institutes of Health, to a degree the 
NSF.
    Senator Akaka. Dr. Kennedy.
    Dr. Kennedy. I would just echo those comments from my 
colleagues and point out that in this time of scarcity, any 
constraint, any further constraint on funding does indeed 
discourage particularly young investigators, and that 
interrupts severely the pipeline as we send those people away 
from VA and perhaps away from research careers altogether, then 
we face a gap, a significant gap in time before replacements 
will be available, people trained and able to begin to initiate 
new research initiatives.
    So that is a key element. This is really a vital 
investment. This program cannot be sustained without steady and 
predictable funding.
    Senator Akaka. Thank you, Dr. Kennedy.
    Thank you for the time, Mr. Chairman.
    Chairman Craig. Well, gentlemen, we will end on that note. 
I think that was an excellent wrap-up, Senator Akaka, that 
question, and all of your responses to it. I think it 
demonstrates obviously the value of the research dollar, and we 
have certainly known over the years, as we brought money into 
NIH and other areas and bumped those up, the level of research, 
the types of research programs underway and the findings that 
are now pouring out as it relates to human health and human 
health-related problems. And certainly VA has played and will 
continue to play a role in that, and I think that is why 62 of 
us joined together to express our concern as to a bump-up in 
these research dollars and at least sustaining a progressive 
level of increase instead of cuts. It remains critical, and we 
will continue to push to assure that happens.
    So, gentlemen, again, thank you for coming. Thank you for 
your time and your insight. As we continue to work on these 
issues, we will be back to you to question you and to ask for 
your advice as we move along.
    Thank you very much. The Committee will stand adjourned.
    [Whereupon, at 11:47 a.m., the Committee was adjourned.]
                            A P P E N D I X

                              ----------                              

               Department of Veterans Affairs' Medical and 
                     Research Prosthetics Research Program.
                                                                   
Hon. Kay Bailey Hutchison, Chairman,
Hon. Dianne Feinstein, Ranking Member,
Subcommittee on Military Construction and Veterans
  Affairs Committee on Appropriations,
U.S. Senate,
Washington, DC.
    Dear Chairman Hutchison and Ranking Member Feinstein: We strongly 
urge the Appropriations Subcommittee on Military Construction and 
Veterans Affairs to demonstrate this Nation's commitment to its 
veterans for the Department of Veterans Affairs' Medical and 
Prosthetics Research program.
    The Administration's proposed fiscal year 2007 budget for the 
direct costs of VA research is $399 million, a $13 million cut from the 
current year's level of $412 million. The proposed level of direct 
funds does not keep pace with inflation and will compel VA to cut 
numerous projects. Therefore, we support a fiscal year 2007 funding 
level of $432 million, in order to cover inflation, sustain current VA 
research and development commitments, and allow critical new research 
initiatives to move forward.
    If enacted, the proposed cuts to the VA research budget will result 
in the loss of 96 research projects in valuable areas such as diabetes, 
cancer, aging, heart disease, and 286 full-time. employees (FTE) are 
projected to lose their jobs. Further, given that participation in VA's 
top-notch research program is a major factor in recruiting physicians 
to VA, the research program must be provided the necessary funds to 
attract and retain quality clinical staff.
    Another point to take into account is that the nature of modem 
warfare and battlefield medicine has resulted in servicemembers coming 
home with wounds that would have been fatal in previous wars. Many 
wounded servicemen d women are in need of prosthetic limbs, extensive 
physical therapy, or have endured traumatic brain injuries. With 
thousands of military personnel engaged in service overseas, it is 
vital that Congress invest in research that could have a direct impact 
on their post-deployment quality of life.
    VA research programs have been instrumental in developing 
innovative and effective methods of treatment since World War II, 
making landmark contributions to the welfare of veterans and the 
entirety of the Nation. Past VA research projects have resulted in the 
first successful liver transplant performed in the U.S., development of 
the cardiac pacemaker, and pioneering the concepts that led to the CT 
scan. VA research also has played a vital role in treating 
tuberculosis, rehabilitating blind veterans, and more recently, in 
launching the largest-ever clinical trial of psychotherapy to at PTSD. 
For the last 60 years, VA research has been extremely competitive with 
its private sector counterparts.
    Today, VA's research program continues to remain appropriately 
focused. In 2004, VA research took on leadership of a $60 million 
nationwide study- funded by the Nation& Institute on Aging and other 
partners--to identify brain changes linked with Alzheimer's disease. VA 
research, in partnership with Brown University and MIT, established a 
major center of excellence to develop state-of-the-art prosthetics for 
veteran amputees. In June 2005, US. News & World Report called VA 
hospital care ``the best around.'' The important role VA research 
played in this transformation of the VA medical care system cannot go 
overlooked; its innovations improved the overall quality and delivery 
of VA health care for years to come.
    Keeping this distinguished record of success in mind, we ask you to 
further support VA research by ensuring that an appropriate level of 
funding continues for this program. These funds must be at a level that 
accounts for inflation, new and daunting challenges, and most 
importantly, enables VA to remain attractive option to our best and 
brightest in medicine. Adequately funding VA's Medical and Prosthetics 
Research Program is vital to maintaining our commitment to veterans.

            Signed by,

    Senators Craig, Akaka, Salazar, Johnson, Rockefeller, Kennedy, 
Burns, Jeffords, Specter, Leahy, Murray, Levin, Lautenburg, Baucus, 
     Bingaman, Obama, Ensign, Stabenow, Clinton, DeWine, Mikulski, 
Allen, Conrad, Inouye, Dorgan, Bond, Boxer, Sarbanes, Pryor, Dodd, 
  Santorum, Kohl, Durbin, Snowe, Kerry, Isakson, Roberts, Coleman, 
 Nelson, Graham, Menendez, Lott, Hagel, Dayton, Biden Jr., Talent, 
Cantwell, Landrieu, Schumer, Carper, Lieberman, Lincoln, Feingold, 
     Crapo, Thune, Wyden, Dole, Burr, Harkin, Reed, Murkowski, and 
                                                            Nelson.
                                 ______
                                 
  Prepared Statement of Friends of VA Medical Care and Health Research
    The Friends of VA Medical Care and Health Research (FOVA) member 
organizations thank both the House and Senate Committees on Veterans 
Affairs for their views and estimates with regard to fiscal year 2007 
funding for the VA Medical and Prosthetic Research program. Their 
recommended increases, ranging from least $28 million up to $51.5 
million over the Administration's budget request for the VA research 
program, affirm their ongoing support for our Nation's veterans. We 
also thank the many Senators that co-signed Chairman Larry Craig's and 
Ranking Member Daniel Akaka's Dear Colleague letter to Senators Kay 
Bailey Hutchison and Diane Feinstein, the Chair and Ranking Member of 
the Military Construction and Veterans Affairs Appropriations 
Subcommittee, urging an fiscal year 2007 appropriation of $432 million 
for the VA Medical and Prosthetic Research program.
    FOVA is a diverse coalition of 86 national academic, medical, and 
scientific societies; voluntary health and patient advocacy groups; and 
veterans service organizations, all committed to high quality health 
care for veterans. We appreciate the opportunity to submit a statement 
today regarding the role of the VA Medical Research and Prosthetics 
Research program in attracting and retaining physicians, and we urge 
your support for an fiscal year 2007 appropriation of $460 million so 
that this success may continue.
 the role of va research in the recruitment and retention of physicians
VA Medical Care
    The mission of the Veterans Healthcare System is ``to serve the 
needs of America's veterans by providing primary care, specialized 
care, and related medical and social support services.'' The Veterans 
Health Administration (VHA) operates one of the largest comprehensive, 
integrated health care delivery systems in the United States. Organized 
around 21 Veterans Integrated Service Networks (VISNs), VA's health 
care system includes 154 medical centers and operates more than 1,300 
sites of care, including 875 ambulatory care and community-based 
outpatient clinics, 136 nursing homes, 43 residential rehabilitation 
treatment programs, 206 Veterans Centers, and 88 comprehensive home-
care programs.
    More than 5.3 million unique patients received care in VA health 
care facilities in 2005. That same year, VA inpatient facilities 
treated 587,000 patients and VA's outpatient clinics registered nearly 
57.5 million visits. VHA has experienced unprecedented growth in the 
medical system workload over the past few years. The number of patients 
treated increased by 29 percent from 4.1 million in 2001. In fiscal 
year 2007, VHA estimates it will care for almost 5.5 million veterans.
    The VA health care system had 7.7 million veterans enrolled to 
receive VA health care benefits as of October 2005. To help VA manage 
health care services within budgetary constraints, enrolled veterans 
are placed in priority groups or categories. Unfortunately, with 
limited resources, VA has had to restrict the number of priority 8 
veterans--higher-income veterans suffering from conditions not related 
to their service--who can receive VA care.
    Despite limiting access of enrolled veterans, a significant backlog 
of delayed appointments has resulted from an inadequate supply of 
clinical physicians. While the VHA has made commendable improvements in 
quality and efficiency, the Independent Budget veterans service 
organizations cite excessive waiting times and delays as the primary 
problem in veterans' health care. Without increases in clinical staff, 
veterans' demand for health care will continue to outpace the V's 
ability to supply timely health-care services and will erode the world-
renowned quality of VA medical care.
Physician Shortage
    The Council on Graduate Medical Education (COGME), a national 
advisory body that makes policy recommendations regarding the adequacy 
of the supply and distribution of physicians, predicts that if current 
trends continue, demand for physicians will significantly outweigh 
supply by 2020. With the VA already struggling to meet the needs of our 
Nation's sick and disabled veterans, the looming physician shortage 
poses a serious threat to VA's ability to competitively recruit and 
retain the physicians who wi11 be critical to its future success.
VA Medical and Prosthetic Research Program
    To accomplish its aforementioned mission, VHA acknowledges that it 
needs to provide ``excellence in research,'' and must be an 
organization characterized as an ``employer of choice.'' The VA Medical 
and Prosthetic Research program is one of the Nation's premier research 
endeavors and attracts high-caliber clinicians to deliver care and 
conduct research in VA health care facilities. The VA research program 
is exclusively intramural; that is, only VA employees holding at least 
a five-eighths salaried appointment are eligible to receive VA awards. 
Unlike other Federal research agencies, VA does not make grants to 
colleges and universities, or to any other non-VA entity. As such, the 
program offers a dedicated funding source to attract and retain high-
quality physicians and clinical investigators to the VA health care 
system. This in turn ensures that our Nation's veterans receive state-
of-the-art health care.
    VA currently supports 5,143 researchers, of which nearly 83 percent 
are practicing physicians who provide direct patient care to veteran 
patients. As a result, the VHA has a unique ability to translate 
progress in medical science directly to improvements in clinical care.
Academic Affiliations
    The affiliations between VA medical centers and the Nation's 
medical schools have provided a critical link that brings expert 
clinicians and researchers to the VA health system. As stated in 
seminal VA Policy Memorandum No. 2 published in 1946, the affiliations 
allow VA to provide veterans ``a much higher standard of medical care 
than could be given [them] with a wholly full-time medical service.'' 
At present, 130 VA medical centers have such agreements with 107 of the 
126 allopathic medical schools. This represents 84 percent of the 154 
VA medical centers. These long standing affiliations with the academic 
health care community are a major factor in ensuring quality care for 
U.S. veterans and represent a model partnership between the Federal 
Government and non Federal institutions.
    Over six decades, these affiliations have proven to be mutually 
beneficial by affording each party access to resources that would 
otherwise be unavailable. It would be difficult for VA to deliver its 
high quality patient care without the physician faculty and residents 
that are available through these affiliations. In return, the medical 
schools gain access to invaluable undergraduate and graduate medical 
education opportunities through medical student rotations and residency 
positions at the VA hospitals. Faculty with joint VA appointments are 
afforded opportunities for research funding that are restricted to 
individuals designated as VA employees.
    These faculty physicians represent the full spectrum of generalists 
and specialists required to provide high quality medical care to 
veterans, and, importantly, they include accomplished sub-specialists 
who would be very difficult and expensive, if not impossible, for the 
VA to obtain regularly and dependably in the absence of the 
affiliations. According to a 1996 VA OIG report, about 70 percent of VA 
physicians hold joint medical school faculty positions. These jointly 
appointed clinician-investigators are typically attracted to the 
affiliated VA Medical Center both by the challenges of providing care 
to the veteran population and by the opportunity to conduct disease-
related research under VA auspices.
   fiscal year 2007 appropriations for the va medical and prosthetic 
                                research
    FOVA recommends an fiscal year 2007 direct research appropriation 
of $460 million for VA medical and prosthetic research and development. 
Investments in investigator-initiated research projects at VA have led 
to an explosion of knowledge that is advancing the understanding of 
disease and unlocking strategies for prevention, treatment, and cures. 
The complexity of research, combined with biomedical research 
inflation, has increased the cost of research. Biomedical research 
inflation alone, estimated at 5.5 percent for fiscal year 2005 and 
projected at 4.1 percent for fiscal year 2006, has reduced the 
purchasing power of the VA Research appropriation by $22.7 million and 
$16.5 million respectively for a total impact of $39.2 million over 
just 2 years. In the absence of commensurate increases, VA is unable to 
sustain important research on diabetes, hepatitis C, heart diseases, 
stroke and substance abuse while also addressing emerging needs for 
more research on post traumatic stress disorder and long-term treatment 
and rehabilitation of veterans with polytraumatic blast injures. 
Additional funding is needed to take advantage of burgeoning research 
opportunities within the VA to improve quality of life for our veterans 
and the Nation as a whole.
Administration's Budget Recommendation
    The Administration's fiscal year 2007 budget request includes $399 
million for the VA Medical and Prosthetic Research program, a $13 
million (3.2 percent) reduction from the final fiscal year 2006 
appropriation of $412 million. These VA research funds provide direct 
support for research projects as well as the salaries of non-clinician 
investigators.
    FOVA members are deeply disappointed with the Administration's 
budget request and note that if enacted, it will have significant 
adverse consequences for the VA research program. In its budget 
summary, the VA anticipates that this $13 million reduction will result 
in the elimination of 82 investigator-initiated programs, 15 special 
research initiatives, and 7 multi-site research projects. Furthermore, 
the department would reduce the number of VA's direct research 
employees by 286.
    In fiscal year 2007, VA expects to increase funding for studies of 
acute and traumatic injury as well as central nervous system injury and 
related disorders. However, to fund these new studies with a shrinking 
budget, VA projects cuts to research in aging, cancer, infectious 
diseases, kidney diseases, diabetes, lung disorders, and heart 
diseases, among others. In other words, VA is proposing to rob Peter to 
pay Paul.
    As in prior years, the Administration's fiscal year 2007 budget 
includes projections for VA research spending from the VA medical 
services appropriation. This ``medical care support'' is slated for a 
$13 million increase, from $353 million in fiscal year 2006 to $366 
million in fiscal year 2007. While this increase might seem to offset 
the proposed cut to direct research funding, the medical care support 
allocation does not directly support research projects. As the budget 
submission indicates, this allocation funds ``facility costs of heat, 
light, telephone, and other utilities associated with laboratory space; 
the administrative cost of human resource support, fiscal service, and 
supply service attributable to research; research's portion of a 
medical center's hazardous waste disposal and nuclear medicine 
licenses; and, most importantly, the time clinicians devote to their 
research activities.''
    The VA budget also includes non-VA funding sources among the lines 
of support for VA research. The budget optimistically projects a $13.24 
million increase (from $662 million in FY 2006 to $675 million in 
fiscal year 2007) in other federally funded research conducted at VA, 
funds that have primarily come from the National Institutes of Health 
(NIH).
    However, the Administration's fiscal year 2007 budget for the NIH 
is flat, making it highly unlikely that VA will enjoy significant 
growth in NIH-funded research grants.
    Though the Administration's projections of private contributions 
for VA research have been inflated in previous years, the VA budget 
anticipates a reasonable $4 million increase for fiscal year 2007 (from 
$204 million in fiscal year 2006 to $208 million in fiscal year 2007). 
This funding comes from industry for support clinical trials as well as 
foundations and other non-profit entities to support a variety of 
research projects.
    Programmatically, the VA research budget includes plans for two 
special research projects to begin in fiscal year 2007. The first 
project focuses on the special needs of service personnel returning 
from Operation Iraqi Freedom and Operation Enduring Freedom. The 
project envisions wide ranging research efforts, including post-
traumatic stress disorder and other mental health issues; amputation 
and prosthetics research; and returning personnel reentry and 
reintegration. A second special project would focus on genomic 
medicine. The thrust of this project is to link veterans' genetic 
information with the VA electronic health record. According to the 
budget submission, ``The goal is to develop genetic assessments that 
will potentially enable `mass customization' of medical treatment.'' 
These new projects necessitate additional funding over FY 2006 levels 
plus an accommodation for biomedical research inflation if VA is to 
continue pre-existing endeavors as well implementing these new 
initiatives.
    The coalition wholeheartedly supports the vision to expand the VA 
research program to encompass the needs of service personnel returning 
from current conflicts, whether they include polytrauma, massive burn 
injury, or mental conditions. Such expansion of the program requires 
new resources so VA's other research areas, which are equally important 
to the care of large numbers of veterans, do not languish in the 
meantime.
Earmarks and Designation of VA Research Funds
    The members of FOVA oppose earmarking the VA research appropriation 
because they jeopardize the strengths of the VA Research program. VA 
has well-established and highly refined policies and procedures for 
peer review and national management of the entire VA research 
portfolio. Peer review of proposals ensures that VA's limited resources 
support the most meritorious research. Additionally, centralized VA 
administration provides coordination of VA's national research 
priorities, aids in moving new discoveries into clinical practice, and 
instills confidence in overall oversight of VA research, including 
human subject protections, while preventing costly duplication of 
effort and infrastructure.
    VA research encompasses a wide range of types of research. 
Designated amounts for specific areas of research compromise VA's 
ability to fund ongoing programs in other areas and force VA to delay 
or even cancel plans for new initiatives. While Congress certainly 
should provide direction to assist VA in setting its research 
priorities, earmarked funding exacerbates resource allocation problems. 
FOVA urges Congress to preserve the integrity of the VA research 
program as an intramural program firmly grounded in scientific peer 
review. These are principles under which it has functioned so 
successfully and with such positive benefits to veterans and the Nation 
since its inception.
VA Research Infrastructure
    State-of-the-art research requires state-of-the-art technology, 
equipment, and facilities. Such an environment promotes excellence in 
teaching and patient care as well as research. It also helps VA recruit 
and retain the best and brightest clinician scientists. In recent 
years, funding for the VA medical and prosthetics research program has 
failed to provide the resources needed to maintain, upgrade, and 
replace aging research facilities. Many VA facilities have run out of 
adequate research space, and ventilation, electrical supply, and 
plumbing appear frequently on lists of needed upgrades along with space 
reconfiguration. Under the current system, research must compete with 
other facility needs for basic infrastructure and physical plant 
improvements which are funded through the minor construction 
appropriation.
    FOVA appreciates the attention the Appropriations Committee gave to 
this problem in the House Report accompanying the fiscal year 2006 
appropriations bill (P.L. 109-114), which expresses concern that 
equipment and facilities to support the research program may be lacking 
and that some mechanism is necessary to ensure the Department's 
research facilities remain competitive. It noted that more resources 
may be required to ensure that research facilities are properly 
maintained to support the Department's research mission.
    To ensure that funding is adequate to meet both immediate and long 
term needs, FOVA recommends an annual appropriation of $45 million in 
the minor construction budget dedicated to renovating existing research 
facilities and additional major construction funding sufficient to 
replace at least one outdated facility per year until the backlog is 
addressed.
    Again, FOVA appreciates the opportunity to present our views to the 
Committee. While research challenges facing our Nation's veterans are 
significant, if given the resources, we are confident the expertise and 
commitment of the physician-scientists working in the VA system will 
meet the challenge.
Administrators of Internal Medicine
    Alliance for Academic Internal Medicine Alliance for Aging Research
    American Academy of Child and Adolescent Psychiatry
    American Academy of Neurology
    American Academy of Orthopaedic Surgeons
    American Association for the Study of Liver Diseases
    American Association of Anatomists
    American Association of Colleges of Nursing
    American Association of Colleges of Osteopathic Medicine
    American Association of Colleges of Pharmacy American
    Association of Spinal Cord Injury Nurses
    American Association of Spinal Cord Injury Psychologists and Social 
Workers
    American College of Chest Physicians
    American College of Clinical Pharmacology
    American College of Physicians
    American College of Rheumatology
    American Dental Education Association
    American Federation for Medical Research
    American Gastroenterological Association
    American Geriatrics Society
    American Heart Association
    American Hospital Association
    American Lung Association
    American Military Retirees Association
    American Occupational Therapy Association
    American Optometric Association
    American Osteopathic Association
    American Paraplegia Society
    American Physiological Society
    American Podiatric Medical Association
    American Psychiatric Association
    American Psychological Association
    American Society for Bone and Mineral Research
    American Society for Pharmacology and Experimental Therapeutics
    American Society of Hematology
    American Society of Nephrology
    American Thoracic Society
    Association for Assessment and Accreditation of Laboratory Animal 
Care
      International
    Association for Research in Vision and Ophthalmology
    Association of Academic Health Centers
    Association of American Medical Colleges
     Association of Professors of Medicine
    Association of Program Directors in Internal Medicine
    Association of Schools and Colleges of Optometry
    Association of Specialty Professors
    Association of VA Chiefs of Medicine
    Association of VA Nurse Anesthetists
    Blinded Veterans Association
    Blue Star Mothers of America
    Clerkship Directors in Internal Medicine
    Coalition for Heath Services Research
    Digestive Disease National Coalition
    Federation of American Societies for Experimental Biology
    Gerontological Society of America
    Gold Star Wives
    Hepatitis Foundation International
    International Foundation for Functional Gastroenterological 
Disorders
    Juvenile Diabetes Research Foundation International
    Legion of Valor of the USA, Inc.
    Medical Device Manufacturers Association
    Medicine-Pediatrics Program Directors Association
    Military Officers Association of America
    National Alliance on Mental Illness
    National Association for the Advancement of Orthotics and 
Prosthetics
    National Association for Uniformed Services
    National Association of VA Dermatologists
    National Association of VA Physicians and Dentists
    National Association of Veterans' Research and Education 
Foundations
    National Mental Health Association
    Nurses Organization of Veterans Affairs
    Osteogenesis Imperfecta Foundation
    Paralyzed Veterans of America
    Paralyzed Veterans of America Spinal Cord Research Foundation
    Partnership Foundation for Optometric Education
    Society for Investigative Dermatology
    Society for Neuroscience
    Society for Women's Health Research
    Society of General Internal Medicine
    Spinal Cord Research Foundation
    The Endocrine Society
    United Spinal Association
    Veterans Affairs Physician Assistant Association
    Veterans of the Vietnam War and the Veterans Coalition
    Vietnam Veterans of America
  

                                  
