[Senate Hearing 112-]
[From the U.S. Government Publishing Office]



 
       DEPARTMENT OF DEFENSE APPROPRIATIONS FOR FISCAL YEAR 2013

                              ----------                              


                        WEDNESDAY, JUNE 6, 2012

                                       U.S. Senate,
                               Committee on Appropriations,
                                                    Washington, DC.
    The subcommittee met at 10:03 a.m., in room SD-192, Dirksen 
Senate Office Building, Hon. Daniel K. Inouye (chairman) 
presiding.
    Present: Senators Inouye and Cochran.

                       NONDEPARTMENTAL WITNESSES


             OPENING STATEMENT OF CHAIRMAN DANIEL K. INOUYE

    Chairman Inouye. I would like to welcome our witnesses this 
morning to the Department of Defense subcommittee to receive 
public testimony pertaining to various issues related to the 
fiscal year 2013 Department of Defense (DOD) appropriations 
request. Due to the number of witnesses who wish to present 
testimony this morning, I'd like to remind each witness that 
they will be limited to no more than 4 minutes. However, your 
full statements will be made part of the official record, and I 
look forward to hearing from each of you today on the many 
important and serious subjects that you will address.
    But before I do, I'd like to recognize the Vice Chairman of 
the Committee, Senator Cochran, for any comments he may wish to 
make.

                   STATEMENT OF SENATOR THAD COCHRAN

    Senator Cochran. Mr. Chairman, I'm pleased to join you in 
welcoming our witnesses to the hearing today reviewing the 
fiscal year 2013 DOD request for appropriations. We appreciate 
the witnesses' interest in the subject and we look forward to 
hearing your testimony and hearing from each one of you.
    Thank you.
    Chairman Inouye. Our first witness represents the Air Force 
Sergeants Association (AFSA), former Command Master Sergeant 
John R. ``Doc'' McCauslin.
STATEMENT OF CHIEF MASTER SERGEANT JOHN R. ``DOC'' 
            McCAUSLIN, U.S. AIR FORCE (RETIRED), CHIEF 
            EXECUTIVE OFFICER, AIR FORCE SERGEANTS 
            ASSOCIATION
    Sergeant McCauslin. Chairman Inouye, Ranking Member 
Cochran, and distinguished members of the Department of Defense 
subcommittee: On behalf of the 110,000 members of the Air Force 
Sergeants Association, thank you for this opportunity to 
present the views of our members on the military personnel 
programs that affect those serving and who have served our 
Nation. Your continuing efforts toward improving the quality of 
lives have certainly made a real difference.
    In the interest of time, I will briefly touch on four 
specific funding goals for this subcommittee. Those goals are: 
military pay; healthcare; Survivor Benefit Plan (SBP) 
Dependency and Indemnity Compensation (DIC); and Guard and 
Reserve GI Bill. Three others of great importance to us--
tuition assistance, final pay, and sequestration-were covered 
in my written testimony to you.
    Thanks to the great work of your subcommittee, the Congress 
has made significant strides to restore military pay 
comparability over these past 12 years, including a statutory 
change that explicitly ties military pay raises to the 
Employment Cost Index growth. Past history has regularly and 
consistently demonstrated that significant problems occur when 
those pay and benefits are reduced or eliminated.
    The very top of all discussion about earned benefits is 
TRICARE. Healthcare and the immediate receipt of retirement pay 
are the only incentives that DOD can offer to entice someone to 
volunteer 20 or more years of their youth to our Nation just to 
be eligible. Despite acknowledging this long-term commitment, 
DOD again re-introduced plans, rejected by the Congress in the 
past, to force military dependents and retirees to either pay 
more for their healthcare coverage or to opt out of TRICARE 
entirely.
    AFSA considers it a supreme breach of faith to force those 
who serve to sacrifice even more. It denigrates the years of 
up-front service and the unlimited liability required of career 
military and their families. And if breaking faith with those 
currently serving is wrong, so is imposing a major bait-and-
switch change on those who already completed a 20- or 30-year 
career induced by promises of current benefits.
    Recent public statements speak to the conundrum we 
presently think of. President Obama has said, ``As a Nation, 
we're facing tough choices as we put our fiscal house in order. 
But I want to be absolutely clear: We cannot and we must not 
balance the budget on the backs of our veterans.'' All of our 
military retirees are those veterans.
    An appropriate quote by Senator Jim Webb recently was, 
``You can't renegotiate the front end once the back end is 
done. This is an obligation that has been made to people whose 
military careers are now done.'' Senator Webb understands that 
very few join the military intent on making it a career.
    I am pleased to note that the 2013 National Defense 
Authorization Act approved by the Senate Armed Services 
Committee 2 weeks ago rejects many of those planned increases 
and the bill now awaits action on your Senate floor. I urge you 
to support their efforts with the necessary appropriation.
    AFSA endorses the view that surviving spouses with military 
survivor benefit plan annuities should be able to concurrently 
receive earned SBP benefits and DIC payments related to their 
sponsor's service-connected death. We would like to thank 
Senator Bill Nelson for introducing S. 260 and the 50 Senators 
who have co-sponsored this important repeal legislation.
    Arguably, the best piece of legislation ever passed by the 
Congress, and thanks to the efforts of many of you here, the 
Post-9/11 GI Bill, is providing unprecedented educational 
opportunities for thousands of men and women who served in 
uniform since 9/11. Regrettably, benefits for joining the 
Selective Reserve were not included in that bill. AFSA strongly 
recommends the Congress work to restore basic Reserve 
Montgomery GI Bill benefits to the historic benchmark of 47 to 
50 percent of active-duty benefits. In conclusion, on behalf of 
all AFSA members, we appreciate your efforts and, as always, 
we're ready to support you in matters of mutual concern.

                           PREPARED STATEMENT

    AFSA contends that it is of paramount importance for a 
Nation to provide quality healthcare and top-notch benefits in 
exchange for the devotion, sacrifice, and service of our 
military members. To quote Bob Woodward from his book ``The War 
Within'', ``Those who serve and their families are the 
surrogates of all Americans. They bear the risk and strain of a 
year or more in a foreign land. So many have spent their youth 
and spilled their blood in a fight far from home. What do we 
owe them? Everything. And what do we give them? Much less than 
they deserve.''
    [The statement follows:]
 Prepared Statement of Chief Master Sergeant John R. ``Doc'' McCauslin
    Chairman Inouye, Ranking Member Cochran, and distinguished members 
of the Department of Defense subcommittee: On behalf of the 110,000 
members of the Air Force Sergeants Association (AFSA), thank you for 
this opportunity to present the views of our members on the military 
personnel programs that affect those serving (and who have served) our 
Nation. This hearing will address issues critical to those serving and 
who have served our Nation.
    Your continuing efforts toward improving the quality of their lives 
have made a real difference, and our members are grateful. In this 
statement, I have identified specific funding goals we hope this 
subcommittee will consider for fiscal year 2013 on behalf of current 
and past enlisted members and their families. AFSA represents Active 
Duty, Guard, Reserve, retired, and veteran enlisted Air Force members 
and their families. The content of this statement reflects the views of 
our members as they have communicated them to us. As always, we are 
prepared to present more details and to discuss these issues with your 
staffs.
                   proposed fiscal year 2013 funding
    The administration requested $525.4 billion for Department of 
Defense (DOD) base budget for fiscal year 2013, a $5.2 billion or 1-
percent reduction from this year's spending level. We understand a plan 
recently approved by the House Appropriations Committee provides an 
increase of $1.1 billion more than the fiscal year 2012 level and $3.1 
billion more than the President's request. AFSA encourages you to 
follow their lead to ensure the Department has sufficient funds to meet 
the needs of our Nation's defense.
                          military pay raises
    Thanks to the great work of this subcommittee. The Congress has 
made great strides to restore military pay comparability over the past 
12 years, including a statutory change that explicitly ties military 
pay raises to Employment Cost Index (ECI) growth. The current formula 
provides military servicemembers with a 1.7-percent pay raise in fiscal 
year 2013, and we urge you to set aside the necessary funding to make 
certain this is so. That said, we are very concerned that the 
administration plans break the tie to civilian pay growth in future 
years by limiting military raises to 0.5 percent, 1 percent, and 1.5 
percent for 2015, 2016, and 2017, respectively. Past history has 
clearly shown that significant retention problems will occur when pay 
and benefits are reduced or eliminated. Recent calls to cut back on 
military raises, create a new comparability standard or substitute more 
bonuses for pay raises in the interests of deficit reduction are 
exceptionally short-sighted in view of the extensive negative 
experience with military pay raise caps. AFSA urges the subcommittee to 
fully fund these important pay increases not just this year, but in 
future years, based on the ECI as specified in current law.
                             sequestration
    Our members are deeply concerned with the prospect of sequestration 
and how it could undermine proper defense funding in the coming years. 
As a result of the Budget Control Act of 2011, DOD now faces the 
specter of another $500 billion in defense cuts beyond $490 billion in 
reductions previously agreed to. That is, of course, unless the 
Congress intervenes. Military leaders from the top down have made it 
quite clear that an additional $500 billion of cuts would do 
catastrophic damage to our military, hollow out the force, and degrade 
its ability to protect the country. America's military strength exists 
to secure the blessings of ordered liberty for the American people. We 
sincerely hope Members of Congress can find an alternative to punitive 
reductions mandated by sequestration which would force across-the-board 
cuts to defense programs including pay and benefits which would 
threaten the future viability of the all-volunteer force. Less than 1 
percent of the population is shouldering 100 percent of the burden of 
maintaining our national security, and we hope you will act soon so 
they won't be left wondering when, or if, the rug will be pulled out 
from underneath them.
                          retirement benefits
    The administration's proposed fiscal year 2013 budget called for 
the creation of a base realignment and closure-like panel that will 
review current military compensation and recommend changes (most likely 
reductions) for the Congress to consider. The commission is to be 
formulated on the premise that the groups agreed upon plan must save 
DOD money. Instead of approaching the subject with discussion on what 
is the Nation's obligation to those who serve, the administration plans 
to use a formula that lays out a predetermined result. We believe those 
who serve and have served in uniform deserve better. Senior military 
leaders often speak of the importance of ``Keeping the faith'' with 
military members, particularly where earned benefits are concerned--
benefits like retired pay and healthcare. Right now, airmen are asking, 
``Where is the faith?'' And they are looking to you, the Members of 
Congress, to provide that answer. ``Passing the buck'' to 
servicemembers instead fulfilling promised benefits will only serve to 
undermine long-term retention and readiness. Much of the success of the 
all-volunteer force can be directly attributed to the benefits we 
provide military members in return for their service and sacrifice. Not 
just them, but their families, too. Do we want to risk this? I urge you 
to resist any plan that reduces pay and benefits and fully fund the 
existing systems that have directly contributed to the extraordinary 
success of the all-volunteer force for nearly four decades.
                                tricare
    No military personnel issues is more sacrosanct than pay and 
benefits, which is why healthcare is such a sensitive subject. It and 
the immediate receipt of retirement pay are the only incentives DOD can 
offer to entice someone to first volunteer 20 or more years of their 
youth to the Nation just to be eligible. Yet, despite acknowledging 
this long-term commitment, DOD again reintroduced plans--rejected by 
the Congress in the past--to force military dependents and retirees to 
either pay more for their healthcare coverage or to opt out of TRICARE 
entirely. Specifically, the department proposes to raise beneficiary 
costs by:
  --raising annual fees by as much as $2,000 or more for retired 
        families younger than age 65;
  --establishing new annual enrollment fees of up to $950 for retired 
        couples older than age 65;
  --imposing ``means testing'' of military retiree health benefits 
        based on their retired income--something no other Federal 
        program does;
  --dramatically increasing pharmacy co-pays to approach or surpass the 
        median of current civilian plans; and
  --tying future annual increases to an unspecified health cost index 
        estimated to average more than 6 percent each year.
    In announcing these so-called ``modest'' proposals, DOD leaders 
stressed their intent to ``keep faith with currently serving troops'' 
by avoiding any retirement changes that would affect the current force. 
But their concept of ``keeping faith on retirement'' apparently doesn't 
extend to retirement healthcare benefits, as the proposed changes would 
affect any currently serving member who retires the day after they were 
implemented. Further, the proposed pharmacy changes would affect 
hundreds of thousands of currently serving Guard/Reserve members and 
families, as well as the family members of currently serving personnel 
who don't have access to military pharmacies.
    Modest increases? How could raising out-of pocket healthcare costs 
$2,000 annually or increasing pharmacy copays up to 375 percent be 
considered modest? And I remind the members of this panel that our more 
senior retirees, those in TRICARE for Life, are already required to 
participate in Medicare Part B in order to retain their earned 
healthcare coverage.
    AFSA regards all efforts to force those who serve and sacrifice the 
most, to sacrifice even more, as a supreme breach of faith. It 
denigrates the years of upfront service and sacrifice required of 
career military and their families, plus these anti-people proposals 
will be perceived very negatively by future generations, who may 
consider civilian employment far more rewarding and safer than military 
service. And if breaking faith with the currently serving is wrong, so 
is imposing a major ``bait and switch'' change on those who already 
completed 20-30 year careers, induced by promises of current benefits.
    At a recent hearing to examine the administration's proposed fee 
hike, Senator Jim Webb (D-VA) accurately observed, ``You can't 
renegotiate the front end once the back end is done. This is an 
obligation that has been made to people whose military careers are now 
done.'' Senator Webb understands few join the military intent on making 
it a career which involves multiple moves and hazardous deployments, 
their children constantly uprooted from schools and spouses from career 
opportunities, virtually zero in home ownership equity, and upon 
military retirement, potential age discrimination entering the civilian 
marketplace. In fact, only 8.5 percent of those who serve in the 
military ever reach retirement, a percentage derived by dividing DOD's 
1.9 million retirees by the Department of Veterans Affairs' (VA) 22.2 
million veterans--a percentage that is even less if medical retirees 
are excluded.
    Like Senator Webb, our greatest concern is that the continued 
erosion of pay and benefits could lead to the end of a professionally 
led, all-volunteer military that for 39 years and more than a decade of 
nonstop war has served the American public extremely well. We hope you 
believe likewise, and will fully fund the military healthcare system.
    Other healthcare issues included in our priorities are listed 
below. Funding for each of these issues is encouraged, and we would be 
happy to provide additional information if requested:
  --exempt those military retirees who entered service prior to 
        December 7, 1956, from the obligation of Medicare Part B 
        payments;
  --oppose the various recommendations for retirees aged 38-64 to seek 
        healthcare coverage from somewhere else besides TRICARE;
  --include Applied Behavior Analysis (ABA) therapy as part of regular 
        TRICARE coverage; and
  --establish a full optometry benefit for military retirees.
                           tuition assistance
    The discretionary Air Force Tuition Assistance program is an 
important quality of life program that provides tuition and fees for 
courses taken by Active-Duty personnel. The program is one of the most 
frequent reasons given for enlisting and re-enlisting in the Air Force, 
and we urge full funding for this program.
                      family readiness and support
    A fully funded, robust family readiness program is crucial to 
military readiness, and especially appropriate given the continuing 
demands of deployments and the uncertainty of the legacy of the effects 
11 years of war have had on servicemembers and their families. AFSA 
urges the subcommittee to continue much-needed supplemental funding 
authority to schools impacted by large populations of military students 
(Impact Aid), fully fund effective family readiness programs, and 
support the child care needs of our highly deployable force.
                         military resale system
    AFSA strongly believes military commissary, exchange and Morale 
Welfare and Recreation programs contribute significantly to a strong 
national defense by sustaining morale and quality of life for military 
beneficiaries both within the United States and around the globe. In 
surveys looking at the benefits of service, military servicemembers 
often cite access to the commissary and exchange as one of their top 
five benefits. With this in mind, we urge this subcommittee to resist 
initiatives to civilianize or consolidate DOD resale systems in any way 
that would reduce their value to patrons. AFSA instead urges a thorough 
review of the findings of an extensive and costly ($17 million) 
multiyear study that found consolidation is not a cost-effective 
approach to running these important systems.
                        retiree/survivor issues
    Concurrent Receipt.--AFSA continues its advocacy for legislation 
that provides concurrent receipt of military retired pay and veterans' 
disability compensation for all disabled retirees without offset. Under 
current statues, retirees with 50 percent or greater disabilities will 
receive their full-retired pay and VA disability in fiscal year 2014. 
The Congress should now focus on eliminating this unjust offset for 
veterans with lesser disabilities and in particular, individuals who 
were medically retired with less than 20 years of service due to a 
service-connected illness or injury. They are not treated equally.
    Age-57 Dependency and Indemnity Compensation (DIC) Remarriage.--
AFSA commends Members of Congress for previous legislation, which 
allowed retention of DIC, burial entitlements, and VA home loan 
eligibility for surviving spouses who remarry after age 57. However, we 
strongly recommend the age-57 DIC remarriage provision be reduced to 
age 55 to make it consistent with all other Federal survivor benefit 
programs.
    Repeal Survivor Benefit Plan (SBP)/DIC Offset.--We endorse the view 
that surviving spouses with military SBP annuities should be able to 
concurrently receive earned SBP benefits and DIC payments related to 
their sponsor's service-connected death. We would like to thank Senator 
Bill Nelson (D-FL) for introducing S. 260 and the 50 Senators who have 
co-sponsored this important legislation to repeal the SBP-DIC offset. 
Despite budgetary difficulties, we sincerely hope the Congress will 
find the funding to eliminate this unfair offset.
    Retention of Final Paycheck.--Current regulations require survivors 
of deceased military retirees to return any retirement payment received 
in the month the retiree passes away or any subsequent month 
thereafter. Once a retirees passes, the Defense Finance and Accounting 
Service stops payment on the retirement account, recalculates the final 
payment to cover only the days in the month the retiree was alive, and 
then forwards a check for those days to the surviving spouse.
    Understandably, this practice can have an adverse impact on the 
surviving spouse. When the retirement pay is deposited, they use those 
funds to make payment on items such as mortgages, medical expenses, or 
other living expenses. Automatically withdrawing those funds can 
inadvertently cause essential payments to bounce and places great 
financial strain on a beneficiary already faced with the prospect of 
additional costs associated with their loved one's death. AFSA strongly 
encourages this subcommittee to appropriate the funds necessary to 
bring an end to this abhorrent practice.
                        guard and reserve issues
    Reduce the Earliest Guard and Reserve Retirement Compensation Age 
From 60 to 55.--Legislation was introduced during the last Congress to 
provide a more equitable retirement for the men and women serving in 
the Guard and Reserves. The proposed legislation would have reduced the 
age for receipt of retirement pay for Guard and Reserve retirees from 
60 to 55. Active-Duty members draw retirement pay the day after they 
retire. Yet, Guard and Reserve retirees currently have to wait until 
they reach age 60 before they can draw retirement pay. Although 
legislation addressing this issue does not exist in the 112th Congress, 
we urge the members of this subcommittee to support it when and if it 
is reintroduced.
    Reduction of Retirement Age Due to Title 10 Service.--A provision 
in the fiscal year 2008 National Defense Authorization Act reduces the 
Reserve component retirement age requirement by 3 months for each 
cumulative 90 days ordered to Active Duty. However, this provision only 
credits active service since January 28, 2008, so it disenfranchises 
and devalues the service of hundreds of thousands of Guard and Reserve 
members who served combat tours (multiple tours, in thousands of cases) 
between 2001 and 2008. These contributions to national security are 
further demeaned by language that specifies eligible service must fall 
within a given fiscal year (e.g., a reservist receives no credit for a 
90-day tour that began in August and ended in November because the 
period of service spanned 2 fiscal years).
    AFSA supports full funding of initiatives that eliminate the fiscal 
year limitation and authorizes early retirement credit for all Guard 
and Reserve members who have served on Active-Duty tours of at least 90 
days retroactive to September 11, 2001.
    Provide Concurrent Retirement and Disability Pay (CRDP) for Service 
Incurred Disabilities.--National Guard and Reserve with 20 or more good 
years are currently able to receive CRDP; however, they must wait until 
they are 60 years of age and begin to receive their retirement check. 
This policy must be changed, and along with the reduction in retirement 
age eligibility, is a benefit our Guard and Reserve deserve. They have 
incurred a service-connected disability, and we must provide concurrent 
retirement and disability pay to them.
    Many Guard/Reserve retirees have spent more time in a combat zone 
than their Active Duty counterparts. DOD has not supported legislation 
to provide Guard/Reserve men and women more equitable retirement pay in 
the past. Additional requirements and reliance has been placed on the 
Guard and Reserve in recent years. It is time to recognize our men and 
women in uniform serving in the Reserve components and provide them a 
more equitable retirement system.
    Award Full Veterans Benefit Status to Guard and Reserve Members.--
It is long overdue that we recognize those servicemembers in the Guard 
and Reserve who have sustained a commitment to readiness as veterans 
after 20 years of honorable service to our country. Certain Guard and 
Reserve members that complete 20 years of qualifying service for a 
reserve (nonregular) retirement have never been called to active-duty 
service during their careers. At age 60, they are entitled to start 
receiving their Reserve military retired pay, Government healthcare, 
and other benefits of service including some veterans' benefits. But, 
current statutes deny them full standing as a ``veteran'' of the Armed 
Forces. S. 491, the ``Honor America's Guard-Reserve Retirees Act of 
2011'' introduced by Senator Mark Pryor (D-AR) and a House-approved 
bill, H.R. 1025 by Representative Tim Walz (D-MN) would change current 
statues to include in the definition(s) of ``veteran'' retirees of the 
Guard and Reserve components who have completed 20 years or more of 
qualifying service. There is little or no cost associated with this 
change, it's simply the right thing to do, and I encourage the members 
of this subcommittee to support Senator Pryor's bill.
    Guard/Reserve GI Bill.--Arguably the best piece of legislation ever 
passed by the Congress, and thanks to the efforts of many of you here, 
the Post-9/11 GI Bill is providing unprecedented educational 
opportunities for the thousands of men and women who served in uniform 
since 9/11 and for many of their family members. Regrettably, many 
volunteers who join the Selected Reserve were left behind in this 
legislation because Selected Reserve Montgomery GI Bill (MGIB) Benefits 
were not upgraded or integrated in the Post-9/11 GI Bill as AFSA 
previously recommended.
    AFSA supports funding of legislation that restores basic Reserve 
MGIB benefits for initially joining the Selected Reserve to the 
historic benchmark of 47-50 percent of active-duty benefits; integrates 
Reserve and Active Duty MGIB laws in title 38, and enacts academic 
protections for mobilized Guard and Reserve students, including refund 
guarantees and exemption of Federal student loan payments during 
activation.
            uniformed services former spouses protection act
    AFSA urges this subcommittee to support some fairness provisions 
for the Uniformed Services Former Spouses Protection Act (USFSPA) 
(Public Law 97-252). While this law was passed with good intentions in 
the mid-1980s, the demographics of military service and their families 
have changed. As a result, military members are now the only U.S. 
citizens who are put at a significant disadvantage in divorce 
proceedings. Because of the USFSPA, the following situations now exist:
  --A military member is subject to giving part of his/her military 
        retirement pay (for the rest of his/her life) to anyone who was 
        married to him/her during the military career regardless of the 
        duration of the marriage.
  --The divorce retirement pay separation is based on the military 
        member's retirement pay--not what the member's pay was at the 
        time of divorce (often many years later).
  --A military retiree can be paying this ``award'' to multiple former 
        spouses.
  --It takes a military member 20 years to earn a retirement; it takes 
        a former spouse only having been married to the member (for any 
        duration, no matter how brief) to get a portion of the member's 
        retirement pay.
  --Under this law, in practice judges award part of the member's 
        retirement pay regardless of fault or circumstances.
  --There is no statute of limitations on this law; i.e., unless the 
        original divorce decree explicitly waived separation of future 
        retirement earnings, a former spouse who the military member 
        has not seen for many years can have the original divorce 
        decree amended and ``highjack'' part of the military member's 
        retirement pay.
  --The former spouse's ``award'' does not terminate upon remarriage of 
        the former spouse.
  --The ``award'' to a former spouse under this law is above and beyond 
        child support and alimony.
  --The law is unfair, illogical, and inconsistent. The member's 
        military retired pay which the Government refers to as 
        ``deferred compensation'' is, under this law, treated as 
        property rather than compensation. Additionally, the law is 
        applied inconsistently from State to State.
  --In most cases, the military retiree has no claim to part of the 
        former spouse's retirement pay.
  --Of all U.S. citizens, it is unconscionable that military members 
        who put their lives on the line are uniquely subjected to such 
        an unfair and discriminatory law.
  --While there may be unique cases (which can be dealt with by the 
        court on a case-by-case basis) where a long-term, very 
        supported former spouse is the victim, in the vast majority of 
        the cases we are talking about divorces that arise which are 
        the fault of either or both parties--at least one-half of the 
        time not the military member. In fact, with the current levels 
        of military deployments, more and more military members are 
        receiving ``Dear John'' and ``Dear Jane'' letters while they 
        serve.
  --This is not a male-versus-female issue. More and more female 
        military members are falling victim to this law. These are just 
        a few of the inequities of this law. We believe this law needs 
        to be repealed or, at the least, greatly modified to be fairer 
        to military members. We urge the subcommittee to support any 
        funding requirement that may be necessary to take action on 
        this unfair law--for the benefit of those men and women who are 
        currently defending the interests of this Nation and its 
        freedom.
                               conclusion
    Chairman Inouye, Ranking Member Cochran, in conclusion, I want to 
thank you again for this opportunity to express the views of our 
members on these important issues as you consider fiscal year 2013 
appropriations. We realize that those charged as caretakers of the 
taxpayers' money must budget wisely and make decisions based on many 
factors. As tax dollars dwindle, the degree of difficulty deciding what 
can be addressed, and what cannot, grows significantly.
    AFSA contends that it is of paramount importance for a nation to 
provide quality healthcare and top-notch benefits in exchange for the 
devotion, sacrifice, and service of military members. So, too, must 
those making the decisions take into consideration the decisions of the 
past, the trust of those who are impacted, and the negative 
consequences upon those who have based their trust in our Government. 
We sincerely believe that the work done by your committees is among the 
most important on the Hill. On behalf of all AFSA members, we 
appreciate your efforts and, as always, are ready to support you in 
matters of mutual concern.

    Chairman Inouye. I thank you very much, Sergeant. May I 
just assure you that we'll never forget anyone who is willing 
to stand in harm's way on our behalf.
    Sergeant McCauslin. Thank you, Sir.
    Chairman Inouye. Our next witness, Ms. Elizabeth Vink, 
represents the International Foundation for Functional 
Gastrointestinal Disorders.
STATEMENT OF ELISABETH VINK, PROGRAM ASSISTANT, 
            INTERNATIONAL FOUNDATION FOR FUNCTIONAL 
            GASTROINTESTINAL DISORDERS
    Ms. Vink. Chairman Inouye, Vice Chairman Cochran: Thank you 
for the opportunity to present testimony regarding functional 
gastrointestinal disorders (FGIDs) among service personnel and 
veterans. My name is Elisabeth Vink, and I am testifying on 
behalf of the International Foundation for Functional 
Gastrointestinal Disorders (IFFGD). IFFGD is a nonprofit 
organization dedicated to supporting individuals affected by 
functional gastrointestinal and motility disorders through 
education and research. I am also a proud member of a military 
family, with my father having served 23 years in the U.S. Air 
Force, and I appreciate the opportunity to present testimony in 
support of veterans like my dad.
    FGIDs are disorders in which the movement of the 
intestines, the sensitivity of the nerves of the intestines, or 
the way in which the brain controls intestinal function is 
impaired. The result is multiple, persistent, and often painful 
symptoms ranging from nausea and vomiting to altered bowel 
habit.
    More than two dozen different FGIDs have been identified, 
ranging in severity from bothersome to disabling. One thing 
these conditions have in common is that little is understood 
about their underlying mechanisms, making them difficult to 
treat effectively. The onset of a functional gastrointestinal 
(GI) disorder can be triggered by severe stress and infections 
of the digestive system.
    Deployed military personnel face an elevated chance of 
experiencing these risk factors and developing FGIDs as a 
result of their service. For this reason, continued research 
through the Department of Defense (DOD) Gulf War Illness 
Research Program (GWIRP) is critical in fiscal year 2013.
    In 2010, the Institute of Medicine (IOM) published a report 
titled ``Gulf War and Health, Volume 8; Update on the Health 
Effects of Serving in the Gulf War'', which determined that 
there is sufficient evidence to associate deployment to the 
gulf war and FGIDs. According to the report, there have been a 
large number of FGID cases among gulf war veterans and their 
symptoms have continued in the years since the war. Based on 
the report from IOM, the Department of Veterans Affairs (VA) 
adopted a final rule in August 2011 stating that there is a 
presumptive service connection between FGIDs and service in the 
Southwest Asia theater of operations during the Persian Gulf 
war.
    Our military personnel are taught to put duty first, and we 
have noticed that by the time they reach out to us their 
condition is incredibly painful or highly disruptive to their 
life. Not only are these disorders hard to treat, but, in the 
words of one retired sergeant, these sometimes very 
embarrassing GI disorders are just as hard to talk about.
    In order to better articulate the suffering associated with 
FGIDs, I would like to share with you the voices of veterans 
affected by these disorders. This is from Steven in North 
Carolina, who served in the Persian Gulf theater of operations. 
``While there and since my return, I have been plagued with a 
multitude of GI problems, including irritable bowel syndrome 
(IBS). I suffered nearly constant diarrhea for over 10 years 
before the IBS was ever diagnosed. None of my GI problems 
existed prior to my deployment and they simply do not seem to 
go away afterwards.''
    Another veteran, Jason, mentioned the prevalence of these 
conditions. ``While speaking with several of my former 
soldiers, I came to realize that they are experiencing the same 
signs and symptoms. I am the first one of a group of friends 
and veterans that is doing research to find out that we are not 
alone.''

                           PREPARED STATEMENT

    The DOD Gulf War Illness Research Program conducts 
important research on the complex set of chronic symptoms that 
impact gulf war veterans. Given the conclusions of the IOM 
report and the report's recommendations for further research on 
the length between FGIDs and exposures experienced by veterans 
in the gulf war, we ask that you continue to support the Gulf 
War Illness Research Program and encourage research into FGIDs 
through this program, so that important research on FGIDs among 
veterans can be conducted.
    Thank you for your time and your consideration of this 
request.
    [The statement follows:]
Prepared Statement of Elisabeth Vink, Program Assistant, International 
          Foundation for Functional Gastrointestinal Disorders
    Thank you for the opportunity to present the views of the 
International Foundation for Functional Gastrointestinal Disorders 
(IFFGD) regarding functional gastrointestinal disorders (FGIDs) among 
service personnel and veterans. FGIDs are recognized by the Department 
of Veterans Affairs (VA) as disabling and connected to military service 
as a part of gulf war illness, and we request that the subcommittee 
continue support the Department of Defense (DOD) Gulf War Illness 
Research Program (GWIRP) through the Congressionally Directed Medical 
Research Program. I am a proud member of a military family, with my 
father having served 23 years in the U.S. Air Force, and I appreciate 
the opportunity to present testimony in support of veterans like my 
dad.
    Established in 1991, IFFGD is a patient-driven nonprofit 
organization dedicated to assisting individuals affected by FGIDs, and 
providing education and support for patients, healthcare providers, and 
the public at large. Our mission is to inform and support people 
affected by painful and debilitating digestive conditions, about which 
little is understood and few (if any) treatment options exist. The 
IFFGD also works to advance critical research on functional 
gastrointestinal (GI) and motility disorders, in order to provide 
patients with better treatment options, and to eventually find a cure.
    FGIDs are disorders in which the movement of the intestines, the 
sensitivity of the nerves of the intestines, or the way in which the 
brain controls intestinal function is impaired. People who suffer from 
FGIDs have no structural abnormality, which makes it difficult to 
identify their condition using xrays, blood tests, or endoscopies. 
Instead, FGIDs are typically identified and defined by the collection 
of symptoms experienced by the patient. For this reason, it is not 
uncommon for FGID suffers to have unnecessary surgery, medication, and 
medical devices before receiving a proper diagnosis.
    More than two dozen different FGIDs have been identified. Severity 
ranges from bothersome to disabling and life-altering. The conditions 
may strike anywhere along the gastrointestinal tract, from nausea and 
vomiting to altered bowel habit. Examples of FGIDs include irritable 
bowel syndrome (IBS) and functional dyspepsia. IBS is characterized by 
abdominal pain and discomfort associated with a change in bowel 
pattern, such as diarrhea and/or constipation. Symptoms of functional 
dyspepsia usually include an upset stomach, pain in the belly, and 
bloating.
    FGIDs can be emotionally and physically debilitating. Due to 
persistent pain and bowel unpredictability, individuals who suffer from 
these disorders may distance themselves from social events, work, and 
even may fear leaving their home. Stigma surrounding bowel habits may 
act as barrier to treatment, as patients are not comfortable discussing 
their symptoms with doctors.
    The onset of a functional GI disorder can be triggered by severe 
stress and infections of the digestive system. Deployed military 
personnel face an elevated chance of experiencing these risk factors 
and developing FGIDs as a result of their service. In April 2010, the 
Institute of Medicine (IOM) published a report titled ``Gulf War and 
Health, Volume 8: Update on the Health Effects of Serving in the Gulf 
War'', which determined that there is sufficient evidence to associate 
deployment to the gulf war and FGIDs. According to the report, there 
have been a large number of FGID cases among gulf war veterans, and 
their symptoms have continued to be persistent in the years since the 
war. The IOM report focused on the incidence of GI disorders among 
veterans and did not attempt to determine causality. However, the 
report provides compelling evidence linking exposure to enteric 
pathogens during deployment and the development of FGIDs. The IOM 
recommended that further research be conducted on this association.
    Based on the report from IOM, Department of Veterans Affairs 
adopted a final rule on August 15, 2011, stating that there is a 
presumptive service connection between FGIDs and service in the 
Southwest Asia theater of operations during the Persian Gulf war. This 
includes conditions like IBS and functional dyspepsia.
    At IFFGD we hear from numerous veterans about their difficulties 
with FGIDs, including conditions such as IBS and cyclic vomiting 
syndrome. Our military personnel are taught to put duty first, and at 
IFFGD we have noticed that by the time they reach out to us, their 
situation is usually pretty bad. Not only are these disorders hard to 
treat, but in the words of one retired Sergeant, these ``sometimes very 
embarrassing GI disorders'' are just as hard to talk about. In order to 
better articulate the suffering associated with FGIDs, I would like to 
share with you the voices of veterans affected by these disorders. This 
is from Stephen in North Carolina:

    ``I am a Desert Shield/Desert Storm veteran that served in the 
Persian Gulf theater of operations from August 1990 to March 1991, as 
the G2 Sergeant Major for the 24th Infantry Division. While there, and 
since my return, I have been plagued with a multitude of GI problems 
including IBS, a functional GI problem. I suffered nearly constant 
diarrhea for over 10 years before the IBS was ever diagnosed. None of 
my GI problems existed prior to my deployment and they simply do not 
seem to go away afterwards.''

    This is from Jason, who contacted us earlier this year:

    ``I am a disabled Iraq veteran that was deployed during 2003-2005 
timeframe with a National Guard unit attached to Active Duty. Since 
returning from Iraq, I have had issues with my gastrointestinal tract. 
I have made a few attempts to try to pinpoint the cause of this change 
in my bodily function to no avail . . . While speaking with several of 
my former soldiers I came to realize that they are experiencing the 
same signs and symptoms. I am the first one of a group of friends/vets 
that is doing research to find out that we are not alone.''

    The DOD Gulf War Illness Research Program conducts important 
research on the complex set of chronic symptoms that impact Gulf War 
Veterans. Given the conclusions of the IOM report and the report's 
recommendations for further research on the link between FGIDs and 
exposures experienced by veterans in the Gulf War, we ask that you 
continue to support the Gulf War Illness Research Program and encourage 
research into FGIDs through this program so that important research on 
FGIDs among veterans can be conducted.
    Thank you again for the opportunity to address the subcommittee.

    Chairman Inouye. Thank you very much. If this matter is 
service-connected, I can assure you we're morally bound to do 
something about it.
    Thank you.
    Ms. Vink. Thank you, Chairman.
    Chairman Inouye. Our next witness is Mr. Anthony Castaldo, 
representing the United States Hereditary Angiodema 
Association.
STATEMENT OF ANTHONY CASTALDO, PRESIDENT, U.S. 
            HEREDITARY ANGIOEDEMA ASSOCIATION
    Mr. Castaldo. Chairman Inouye and Vice Chairman Cochran: 
I'm delighted to present testimony today on hereditary 
angioedema (HAE). I am Anthony Castaldo, president of the 
United States HAE Association, a Honolulu-based nonprofit 
patient services, research, and advocacy organization that 
represents more than 4,500 HAE patients.
    Now, HAE is a rare, debilitating, and potentially life-
threatening genetic condition that occurs in about 1 in 50,000 
people. HAE patients experience frequent attacks of intense 
swelling of various body parts, including the hands, face, 
feet, throat, and abdomen. Abdominal attacks involve 
excruciating abdominal pain, nausea, and vomiting. Attacks 
involving the throat are particularly dangerous because the 
swelling can progress to the point where the airway closes and 
causes death by suffocation.
    The historical mortality rate for HAE sufferers is well 
over 30 percent and, tragically, even today HAE patients 
continue to die from swelling attacks that close the airway. 
Unfortunately, according to a recent study HAE patients suffer 
for almost a decade before obtaining an accurate diagnosis, and 
are therefore often subject to unnecessary exploratory surgery 
and ineffective medical procedures.
    Now, the swelling experienced by many HAE patients is 
actually caused by a genetic defect that results in deficient 
levels of a key blood protein. However, there are still 
patients in the HAE Association community who do not yet know 
what causes their swelling. Despite a family history of 
debilitating and life-threatening swelling attacks, these 
patients have normal levels of the protein that I mentioned 
earlier. This important subset of HAE sufferers represent a 
significant unmet medical need and research is required to 
identify the genetic and biochemical markers for this form of 
HAE.
    Mr. Chairman and Vice Chairman Cochran, I'd like to share 
some examples of how HAE has a significant impact on the 
ability to serve in our country's armed services. Today, right 
on the island, Hawaiian island of Oahu, there was a remarkable 
young man, Christian Davis, whose dreams of following his 
father's footsteps and becoming an Air Force pilot have been 
dashed because his HAE symptoms prevent him from military 
service.
    Christian, who bravely endures frequent HAE attacks 
involving his abdomen and throat, loved to visit Hickham Air 
Force Base and proudly watch his father, Lieutenant Colonel 
Milton Davis, take off and land Hawaii Air National Guard C-17 
cargo planes. With visions of one day serving America by 
grasping the controls and piloting a C-17, Christian eagerly 
began the process of applying for military service. It did not 
take long, however, for this young man's aspirations to be 
dowsed by the reality that HEA would cause him to be rejected 
for military service.
    My father, who experienced severe swelling attacks, yet 
served with distinction in the Korean war, chose to endure his 
excruciating swelling without seeking treatment, so he could 
continue to serve his country. Of course, in those days HAE had 
not yet been identified as a discrete disease. Indeed, my dad 
was so proud to serve as a U.S. military police officer that 
while in Korea he stopped reporting to the field hospital 
during swelling attacks, in an attempt to avoid a medical 
discharge.

                           PREPARED STATEMENT

    Mr. Chairman and Mr. Vice Chairman, on behalf of HEA 
patients in the United States, including those like Christian 
Davis who would like to serve his country, and veterans like my 
dad, who remained on active duty despite suffering from 
debilitating HAE swelling attacks, I would like to request that 
the subcommittee continue--that HAE continue to be eligible for 
the Peer-Reviewed Medical Research Program for fiscal year 
2013. There is a critical need for research in understanding 
all causes of HAE, including currently available treatments, 
and ultimately finding a cure.
    Thank you for inviting me to appear today.
    [The statement follows:]
                 Prepared Statement of Anthony Castaldo
    Chairman Inouye, Vice Chairman Cochran, and distinguished members 
of the Defense subcommittee: Thank you for the opportunity to present 
testimony on Hereditary Angioedema (HAE). I am Anthony Castaldo, 
president of the United States Hereditary Angeioedema Association 
(USHAEA) and an HAE patient. USHAEA is a nonprofit patient advocacy 
organization founded to provide patient support, educate patients and 
their families, advance HAE research, and find a cure. Our efforts 
include providing research funding to scientific investigators to 
increase the HAE knowledge base and maintaining a patient registry to 
support groundbreaking research efforts. Today, we would like to 
request the continued inclusion of HAE in the fiscal year 2013 Peer-
Reviewed Medical Research Program (PRMRP) within the Department of 
Defense (DOD) appropriations bill.
    My family has a long history of military service, my grandfather 
served in the Great War and my father and uncle in Korea; I grew up 
understanding the sacrifices and dedication of our servicemen and 
women. I, however, was and am unable to serve my country in the same 
way because of my condition. There are also a number of other men and 
women who were prevented from serving in the military due to an HAE 
diagnosis.
    HAE is a rare and potentially life-threatening inherited disease 
with symptoms of severe, recurring, debilitating attacks of edema 
(swelling). HAE patients have a defect in the gene that controls a 
blood protein called C1-inhibitor, so it is also more specifically 
referred to as C1-inhibitor deficiency. This genetic defect results in 
production of either inadequate or nonfunctioning C1-inhibitor protein. 
Because the defective C1-inhibitor does not adequately perform its 
regulatory function, a biochemical imbalance can occur and produce an 
unwanted peptide--called bradykinin--that induces the capillaries to 
release fluids into surrounding tissues, thereby causing swelling.
    People with HAE experience attacks of severe swelling that affect 
various body parts including the hands, feet, face, airway (throat), 
and intestinal wall. Swelling of the throat is the most life-
threatening aspect of HAE, because the airway can close and cause death 
by suffocation. Studies reveal that more than 50 percent of patients 
will experience at least one throat attack in their lifetime.
    HAE swelling is disfiguring, extremely painful, and debilitating. 
Attacks of abdominal swelling involve severe and excruciating pain, 
vomiting, and diarrhea. Because abdominal attacks mimic a surgical 
emergency, approximately one-third of patients with undiagnosed HAE 
undergo unnecessary surgery. Untreated, an average HAE attack lasts 
between 24 and 72 hours, but some attacks may last longer and be 
accompanied by prolonged fatigue.
    The majority of HAE patients experience their first attack during 
childhood or adolescence. Most attacks occur spontaneously with no 
apparent reason, but anxiety, stress, minor trauma, medical, surgical, 
and dental procedures, and illnesses such as colds and flu have been 
cited as common triggers. ACE inhibitors (a blood pressure control 
medication) and estrogen-derived medications (birth control pills and 
hormone replacement drugs) have also been shown to exacerbate HAE 
attacks.
    HAE's genetic defect can be passed on in families. A child has a 
50-percent chance of inheriting the disease from a parent with HAE. 
However, the absence of family history does not rule out the HAE 
diagnosis; scientists report that as many as 25 percent of HAE cases 
today result from patients who had a spontaneous mutation of the C1-
inhibitor gene at conception. These patients can also pass the 
defective gene to their offspring. Worldwide, it is estimated that this 
condition affects between 1 in 10,000 and 1 in 30,000 people.
                 peer-reviewed medical research program
    On behalf of the HAE community, including our military families, I 
would like to thank the subcommittee for recognizing HAE as a condition 
eligible for study through Peer-Reviewed Medical Research Program 
(PRMRP) in the committee reports accompanying the fiscal year 2012 DOD 
appropriations bill. The scientific community showed great interest in 
the program, responding to the grant announcements with an immense 
outpouring of proposals. We urge the Congress to maintain HAE's 
eligibility in the PRMRP in committee reports accompanying the fiscal 
year 2013 DOD appropriations bill, to help find a cure so the men and 
women born with HAE can serve their country in the Armed Forces and 
help their families with the very challenging condition.
    Thank you for the opportunity to present the views of the HAE 
community.

    Chairman Inouye. I thank you very much, Mr. Castaldo. I 
assure you that we'll look into this matter.
    Mr. Castaldo. Thank you, Sir.
    Chairman Inouye. Thank you.
    Our next witness is Lieutenant Colonel Carl Hicks, 
representing the Pulmonary Hypertension Association.
STATEMENT OF LIEUTENANT COLONEL CARL HICKS, U.S. ARMY 
            (RETIRED), PULMONARY HYPERTENSION 
            ASSOCIATION
    Colonel Hicks. Mr. Chairman, first I'd like to acknowledge 
you as a personal hero. Your actions long ago set an example 
for bravery and sacrifice, inspiring so many young Americans 
who would later follow as infantrymen and earn the combat 
infantryman's badge. Sir, I was one of them, and I'm especially 
humbled to be in your presence, as any American would be. Thank 
you.
    And thank you for having me here today to speak on behalf 
of hundreds of thousands of Americans impacted by pulmonary 
hypertension (PH). On behalf of the PH community, I am here to 
request that you once again include pulmonary hypertension as a 
condition eligible for study through the Department of Defense 
(DOD) Peer-Reviewed Medical Research Program.
    I volunteer for a grassroots, patient-centric organization 
called the Pulmonary Hypertension Association (PHA). With more 
than 20,000 members and supporters, including more than 250 
support groups across the country, PHA now is recognized 
worldwide. We are dedicated to improving treatment options and 
finding cures for PH and supporting affected individuals 
through coordinated research, education, and advocacy 
activities.
    PH is a debilitating and usually fatal condition where 
blood pressure in the lungs rises to dangerously high levels. 
In PH patients, the walls of the arteries that take the blood 
from the side of the heart to the lungs thicken, scar, and 
constrict, and as a result the right side of the heart has to 
pump harder to move blood into the lungs, causing it to enlarge 
and ultimately fail.
    Symptoms of PH include shortness of breath, fatigue, chest 
pain, dizziness, and fainting. The stricken feel, even at rest, 
as though they are suffocating, because they are. The only way 
to ultimately survive being stricken with PH is to undergo a 
lung or a heart-lung transplant.
    August 16, 1981, was one of the happiest days of my life. I 
was a young airborne Ranger infantry captain who had worked his 
way up from private. I felt pretty tough. Holding my first-born 
Meaghan in my arms moments after she was born, I looked down 
into her beautiful little face and vowed these arms would 
protect her from everything, and there was no doubt that I 
could.
    Fast-forward 13 happy years and our little happy family had 
grown to three healthy, beautiful Army brats. I had been 
promoted rapidly, and we were on our way back from Germany to 
assume the command of the 10th Mountain Division. Life could 
not have been better.
    Days away from leaving, Meaghan, who was a fit, healthy 
young gymnast of 13, fainted and complained of shortness of 
breath. Initially misdiagnosed, we were soon at Walter Reed, 
where I was confident they could solve the problem. After 3 
days of testing, an Army doctor asked me to join him around the 
corner, where he said: ``Colonel Hicks, I regret to inform you, 
but your daughter, Meaghan, has a terminal illness. She has 
less than a year to live and there is nothing we can do for 
her.''
    I was not such a tough warrior any more. Little did they 
know that Meaghan was a tough warrior, though, and with the 
combined help and prayers of many she lived another 12 years 
before declining precipitously. Finally, the only hope for 
Meaghan was a dangerous heart and lung transplant, which she 
fearlessly endured. But there were serious complications. 
Undaunted, she fought on, never quitting or giving up.
    As she once again began to decline, helpless to find ways 
to comfort her, I offered her an old Ranger tee shirt to wear 
as she lay in bed. She was so proud that she rallied briefly. 
Yet, 48 hours later we lost her. I had failed my most important 
mission, that promise to protect her from everything. She was 
the bravest person I have ever known.

                           PREPARED STATEMENT

    Distinguished members, while new treatment options have 
been developed for PH in recent years, they are limited and 
there remains no cure. For the members of our military and 
their families who are struggling with PH, the hope for a 
better quality of life depends on advancements made through 
biomedical research. It is important to note that research in 
this area has a potential to yield additional benefits toward 
the study of America's number one killer, heart disease, as 
well as other lung illnesses.
    Pulmonary hypertension was included as a condition eligible 
for study through DOD Peer-Reviewed Medical Research Program in 
2009. I respectfully request once again that we renew that 
commitment toward a better tomorrow made through this important 
research by including pulmonary hypertension as a condition 
eligible for fiscal year 2013.
    Thank you.
    [The statement follows:]
          Prepared Statement of Lieutenant Colonel Carl Hicks
    Chairman Inouye, Ranking Member Cochran, and distinguished members 
of the subcommittee: Thank you for having me here today to speak on 
behalf of the hundreds of thousands of Americans impacted by pulmonary 
hypertension (PH). As a military veteran and as a veteran of the 
ongoing battle against PH, it is my honor to appear before you as a 
representative of the Pulmonary Hypertension Association (PHA). On 
behalf of the PH community, I am here to request that you once again 
include PH as a condition eligible for study through the Department of 
Defense (DOD) Peer-Reviewed Medical Research Program (PRMRP) as you 
work to complete fiscal year 2013 Defense appropriations.
    PHA has served the PH community for more than 20 years. In 1990, 
three PH patients found each other with the help of the National 
Organization for Rare Disorders and shortly thereafter founded PHA. At 
that time, the condition was largely unknown amongst the general public 
and within the medical community; there were fewer than 200 diagnosed 
cases of the disease. Since then, PHA has grown into a nationwide 
network of more than 20,000 members and supporters, including more than 
250 support groups across the country. PHA is dedicated to improving 
treatment options and finding cures for PH, and supporting affected 
individuals through coordinated research, education, and advocacy 
activities. We now have an international presence and reputation around 
the world for which I am deeply proud.
    PH is a debilitating and often fatal condition where the blood 
pressure in the lungs rises to dangerously high levels. In PH patients, 
the walls of the arteries that take blood from the right side of the 
heart to the lungs thicken and constrict. As a result, the right side 
of the heart has to pump harder to move blood into the lungs, causing 
it to enlarge and ultimately fail. Symptoms of PH include shortness of 
breath, fatigue, chest pain, dizziness, and fainting. The only way to 
ultimately survive being stricken with PH is a lung or heart-lung 
transplant.
    On August 16, 1981, I was a young Airborne Ranger Infantry captain 
who'd worked his way up from private and felt pretty tough. As I held 
my firstborn child, Meaghan, in my arms moments after she was born, I 
looked down into her beautiful little face and knew these arms could 
protect her from anything, and I lovingly told her so in front of her 
beaming mother. Fast forward 13 happy years and our little family had 
grown to three happy, healthy, beautiful Army brats. I had been 
promoted multiple times below the zone, and we were on our way back 
from Europe so I could assume a new command in the 10th Mountain 
Division. Life couldn't have been better, or so I thought.
    Days away from leaving, Meaghan, a super fit healthy gymnast of 13, 
fainted and complained of shortness of breath. Initially misdiagnosed 
as are almost all, we eventually ended up at Walter Reed. Two days 
later a young Army doctor asked me to join him around the corner where 
he said, ``Colonel Hicks, I regret to inform you that your daughter, 
Meaghan, has a terminal illness, and there is nothing we can do for 
her. She has less than a year to live at best.'' I was no longer the 
tough battle-hardened Ranger that moments before I was.
    Little did they know that Meaghan was tough, and combined with the 
help of a civilian physician, she lived another 12 years before 
declining precipitously. Finally the only hope was a dangerous heart-
lung transplant which she fearlessly endured. But there were 
complications. Undaunted, she fought on, never quitting or giving up. 
As she again began to decline and she asked for my Ranger t-shirt to 
wear. Forty-eight hours later, with all of us around her, she lost her 
last fight. I had failed my mission and didn't keep that promise to 
protect from everything, but Meaghan, she never gave up. Rangers both 
retired and Active Duty came from around the world for her celebration 
of life, and we did a Ranger ``roll-call'' for her and stood to salute 
when she didn't respond. She was the bravest person I ever knew, and 
she never, ever quit.
    Gentlemen, while new treatment options have been developed for PH 
in recent years, these treatment options are limited and there remains 
no cure. For the members of our military and their families who are 
struggling with PH, the hope for a better quality of life depends on 
advancements made through biomedical research. It is important to note 
that research in this area has the potential to yield additional 
benefits towards the study of America's number one killer, heart 
disease. PH was included as a condition eligible for study through the 
DOD's Peer-Reviewed Medical Research Program as recently as 2009. I ask 
that this subcommittee renew the commitment towards a better tomorrow 
made through this important research by including pulmonary 
hypertension as a condition eligible for study through the Peer-
Reviewed Medical Research Program in fiscal year 2013.
PHA Fiscal Year 2013 DOD Appropriations Recommendations
    Peer-Reviewed Medical Research Program (PRMRP):
  --Please, once again, include pulmonary hypertension (PH) on the list 
        of conditions deemed eligible for study through the DOD PRMRP 
        as you continue your important work on the fiscal year 2013 
        Defense appropriations bill.
  --In addition, please provide $50 million for PRMRP, which is housed 
        within the DOD Congressionally Directed Medical Research 
        Program, so that this program may continue to advance important 
        research activities focused on a number of conditions.
    Thank you for your time and your consideration of this request.

    Chairman Inouye. I thank you very much and thank you for 
your kind words. We will make certain that this matter is 
continued.
    Colonel Hicks. Thank you, Sir.
    Chairman Inouye. Thank you.
    The next group of witnesses: Mr. Neal Thompson of the 
Interstitial Cystitis Association; Mr. Danny Smith of the 
Scleroderma Foundation; Ms. Dee Linde, the Dystonia Medical 
Research Foundation; and Ms. Joy Simha, National Breast Cancer 
Coalition.
    I call upon Mr. Thompson.
STATEMENT OF F. NEAL THOMPSON, TREASURER, BOARD OF 
            DIRECTORS, INTERSTITIAL CYSTITIS 
            ASSOCIATION
    Mr. Thompson. Thank you. Chairman Inouye, Vice Chairman 
Cochran, distinguished members of the subcommittee: Thank you 
for the opportunity to present testimony before you today. My 
name is Neal Thompson. I'm speaking on behalf of the 
Interstitial Cystitis Association (ICA). The ICA advocates for 
interstitial cystitis (IC) research, raises awareness, and 
serves as a center hub for healthcare providers, researchers, 
and millions of patients with IC.
    I'm also a lieutenant colonel in the Virginia Defense 
Force, which is a voluntary military organization set up to 
provide support for the Department of Military Affairs, which 
is the Virginia National Guard and Army Guard.
    I was a high-level insurance executive, but my life came to 
a screeching halt when I got this IC base. I couldn't travel. I 
couldn't sleep. Fortunately, I was able to get a diagnosis from 
the Medical College of Virginia, from a doctor there who was 
also working at the Department of Veterans Affairs (VA) 
hospital. So that changed my life and I was able to get some 
treatment.
    IC is a chronic condition characterized by recurring pain, 
pressure, and discomfort of the bladder and pelvic region. It's 
often associated with urinary frequency and urgency. The cause 
of IC is still unknown and the diagnosis is made only after 
excluding other urinary and bladder conditions.
    Misdiagnosis is very common, and when healthcare providers 
are not properly educated about IC patients may suffer for 
years before receiving an accurate diagnosis, often as long as 
5 years. IC is often considered a woman's disease, but, while 
it is more common in women, scientific evidence shows that all 
demographic groups are affected by IC. It is estimated that 12 
million Americans have IC symptoms.
    The effects of IC are damaging to work life, psychological 
well-being, personal relationships, and general health. The 
impact on IC quality of life is equally as severe as rheumatoid 
arthritis and end stage renal disease. IC can cause patients to 
suffer from sleep dysfunction, high rates of depression, 
anxiety, sexual dysfunction, and in some cases, suicide.
    The burden of IC on our military, the Nation's military 
members and veterans, is significant. The Urological Disease of 
America Project conducted between 1999 and 2002 found that 
approximately 1.4 of all veterans who utilized the Veterans 
Health Administration (VHA) have been treated for IC. This 
study also showed a 14-percent increase in IC patients within 
the VHA over the same period.
    The ICA has also heard from many service men and women 
about their struggles with IC, including a woman who is just 
currently in field training, who experienced severe pain every 
time she fired her weapon. Several individuals, such as former 
Navy Captain Gary Monray, were forced to retire from their 
military career due to pain and limitations imposed by IC.
    IC research through the Department of Defense Peer-Reviewed 
Medical Research Program remains essential for expanding our 
knowledge of this painful condition. This program is an 
indispensable resource for studying emerging areas of IC 
research, such as prevalence in men, the role of environmental 
conditions, and development and diagnosis and various 
treatments.

                           PREPARED STATEMENT

    Senator, I've read your Medal of Honor designation in 1945 
and I read the actions taken in Northern Italy. It's chilling 
just to read that, but at the time I'm sure you knew what was 
happening and you knew the cause and you knew what the 
treatment. What is so insidious about IC is you don't see it 
externally and we still need more research to find the cure.
    On behalf of IC patients, including many veterans, we 
request IC continue to be eligible for the Peer-Reviewed 
Medical Research Program for fiscal year 2013.
    Thank you for your time and consideration.
    [The statement follows:]
                 Prepared Statement of F. Neal Thompson
    Chairman Inouye, Vice Chairman Cochran, and distinguished members 
of the subcommittee: Thank you for the opportunity to present 
information on interstitial cystitis (IC). I am Neal Thompson, 
treasurer of the board of directors of the Interstitial Cystitis 
Association (ICA). ICA provides advocacy, research funding, and 
education to ensure early diagnosis and optimal care with dignity for 
people affected by IC. Until the biomedical research community 
discovers a cure for IC, our primary goal remains the discovery of more 
efficient and effective treatments to help patients live with the 
disease.
    I am a member of the Virginia Defense Forces, a volunteer military 
reserve set up to provide back up for the Virginia National Guard. This 
group, when called to active duty, is trained to secure any Federal and 
State property left in place in the event of the mobilization of the 
Virginia National Guard. I was a high-level financial executive, but my 
life came to a complete stop because of IC. I struggled for many years 
to get a diagnosis while trying to keep an active travel schedule and 
meet the demands of a high-level position. The challenges of being 
diagnosed and finding an effective treatment eventually forced me to 
leave work due to disability.
    IC is a chronic condition characterized by recurring pain, 
pressure, and discomfort in the bladder and pelvic region. The 
condition is often associated with urinary frequency and urgency, 
although this is not a universal symptom. The cause of IC is unknown. 
Diagnosis is made only after excluding other urinary and bladder 
conditions, possibly causing 1 or more years of delay between the onset 
of symptoms and treatment. Men suffering from IC are often misdiagnosed 
with bladder infections and chronic prostatitis. Women are frequently 
misdiagnosed with endometriosis, inflammatory bowel disease (IBD), 
irritable bowel syndrome (IBS), vulvodynia, and fibromyalgia, which 
commonly co-occur with IC. When healthcare providers are not properly 
educated about IC, patients may suffer for years before receiving an 
accurate diagnosis and appropriate treatment.
    Although IC is considered a ``women's disease'', scientific 
evidence shows that all demographic groups are affected by IC. Women, 
men, and children of all ages, ethnicities, and socioeconomic 
backgrounds develop IC, although it is most commonly found in women. It 
is estimated that as many as 12 million Americans have IC symptoms, 
more people than Alzheimer's, breast cancer, and autism combined.
    The effects of IC are pervasive and insidious, damaging work life, 
psychological well-being, personal relationships, and general health. 
The impact of IC on quality of life is equally as severe as rheumatoid 
arthritis and end-stage renal disease. Health-related quality of life 
in individuals with IC is worse than in individuals with endometriosis, 
vulvodynia, and overactive bladder. IC patients have significantly more 
sleep dysfunction, higher rates of depression, anxiety, and sexual 
dysfunction.
    The burden of IC among our Nation's servicemembers and veterans is 
significant. The Urologic Diseases in America Project, conducted 
between 1999 and 2002, found that approximately 1.4 percent of all 
veterans utilizing the Veterans Health Administration (VHA) had been 
treated for IC. This study also showed a 14-percent increase in IC 
patients within VHA over the same period.
    Navy Captain Gary Mowrey (Retired) was forced to cut his naval 
career short as a result of IC. Captain Mowrey was in the Navy for 25 
years and has served as commander of the VAQ133 Squadron, operations 
officer on the USS Dwight D. Eisenhower, chief of the Enlisted 
Performance Division in the Bureau of Naval Personnel, and earned a 
Southwest Asia service medal with two stars for his service in 
Operation Desert Storm. In 1994, he began to experience significant 
pain, could not always make it to the restroom, and was not even able 
to sit through normal meetings. After months of unsuccessful antibiotic 
treatments for urinary tract infections, Captain Mowrey was diagnosed 
with IC, and retired due to the pain and limitations imposed by IC. He 
then attempted to teach high school math, but had to retire from this 
position as well due to the pain and frequent urination associated with 
his IC.
    Although IC research is currently conducted through a number of 
Federal entities, including the National Institutes of Health and the 
Centers for Disease Control and Prevention (CDC), the DOD's Peer-
Reviewed Medical Research Program (PRMRP) remains essential. The PRMRP 
is an indispensable resource for studying emerging areas in IC 
research, such as prevalence in men, the role of environmental 
conditions such as diet in development and diagnosis, barriers to 
treatment, and IC awareness within the medical military community. 
Specifically, IC education and awareness among military medical 
professionals takes on heightened importance, as the President's fiscal 
year 2013 budget request did not include renewed funding for the CDC's 
IC Education and Awareness Program.
    On behalf of the IC community, including our veterans, I would like 
to thank the subcommittee for recognizing IC as a condition eligible 
for study through the DOD's PRMRP in the committee reports accompanying 
the fiscal years 2010, 2011, and 2012 DOD appropriations bills. The 
scientific community showed great interest in IC research through this 
program. We urge the Congress to maintain IC's eligibility in the PRMRP 
in committee report accompanying the fiscal year 2013 DOD 
appropriations bill, as the number of current military members, family 
members, and veterans affected by IC is increasing.

    Chairman Inouye. Sir, I can assure you that we'll do our 
best to maintain the eligibility of IC patients. Thank you very 
much.
    Now may I call upon Mr. Danny L. Smith.
STATEMENT OF DANNY L. SMITH, U.S. ARMY (RETIRED), 
            SCLERODERMA FOUNDATION
    Mr. Smith. Chairman Inouye, Ranking Member Cochran, and 
distinguished members of the Defense subcommittee: Thank you 
for the opportunity to talk to you today about scleroderma. I'm 
Danny Smith from Saginaw, Michigan. I have been a scleroderma 
patient since 1999. Before my battle with scleroderma started, 
I was in the U.S. Army--Hawaii 1965 and Vietnam 1966.
    The word ``scleroderma'' literally means ``hard skin'', 
which is one of the most manifestations of the disease. The 
cause of scleroderma is unknown, although it involves an 
overproduction of collagen. This can cause the hardening of the 
internal organs. Serious complications of the disease include 
pain, skin ulcers, pulmonary hypertension, disorders of the 
digestive system, and others.
    For me, it began with my hands. They turned blue, stiffened 
up. I could not move my fingers. I went to my doctor. She sent 
me to a rheumatologist. They sent me to a rheumatologist. He 
diagnosed me with scleroderma eventually. I had just gotten a 
new job working for the United Auto Workers (UAW), and I didn't 
get to sit in that chair because they put me on disability 
right away and I never got there.
    But as time went on, the skin on my arms and my hands got 
tighter. I could not even close my hands. A few months later, I 
began an experimental treatment called cytoxin infusion for 
scleroderma, taken once a month for 2 years. My scleroderma 
began impacting my right lung. Breathing became difficult. I 
was losing weight and coloration of my skin was changing.
    The rheumatologist referred me to a lung specialist at the 
University of Michigan. The lung specialist said that my right 
lung was not fluctuating. It was beginning to harden and turn 
to stone, which is a term used in scleroderma. After many 
tests, counseling on risk, I decided to go ahead with the lung 
transplant. On September 20, 2004, at 11 p.m., I got a phone 
call that a lung was available. I was on the operating table 
the next morning at 7:30 a.m.

                           PREPARED STATEMENT

    As I said before, the exact cause of scleroderma is not 
known. However, it is suspected that an unknown inciting event 
can trigger autoimmune reactions. Additionally, toxic agents 
soldiers may be exposed to on a battlefield have often proved 
to cause lung injury and fibrosis. The successful completion of 
studies being done by DOD will bring us much closer to being 
able to treat scleroderma, lung disease, and other diseases 
involving lung injury and fibrosis to human patients. This is 
very important because there are currently no effective FDA-
approved treatments for these diseases.
    On behalf of scleroderma patients, we request scleroderma 
continue to be eligible for the Peer-Reviewed Medical Research 
Program for fiscal year 2013.
    Thank you very much.
    [The statement follows:]
                  Prepared Statement of Danny L. Smith
    Chairman Inouye, Ranking Member Cochran, and distinguished members 
of the subcommittee: As a military veteran, it is my honor to appear 
before you as a representative of the Scleroderma Foundation and on 
behalf of those living with scleroderma. My name is Danny L. Smith. I 
live in Saginaw, Michigan and I was in the U.S. Army from September 
1964 until September 1967. I was discharged at Fort Lewis, Washington 
and was stationed in Hawaii in 1965 and Vietnam in 1966 at Cu Chi. I 
was diagnosed with scleroderma in 1999. I also have had lupus since the 
mid-1970s. I am here to request that you continue to include 
scleroderma as a condition eligible for study through the Department of 
Defense's (DOD) Peer-Reviewed Medical Research Program (PRMRP) as you 
work to complete fiscal year 2013 Defense appropriations.
    The Scleroderma Foundation is a national organization for people 
with scleroderma and their families and friends. The Foundation's 
mission is threefold:
  --support to help patients and their families cope with scleroderma 
        through mutual support programs, peer counseling, physician 
        referrals, and educational information;
  --education to promote public awareness and education through patient 
        and health professional seminars, literature, and publicity 
        campaigns; and
  --research to stimulate and support research to improve treatment and 
        ultimately find the cause of and cure for scleroderma and 
        related diseases.
    Systemic sclerosis (scleroderma) is a chronic autoimmune disorder 
marked by early skin lesions and the progressive tissue fibrosis. More 
than skin deep, this thickening and hardening of connective tissue 
affects the blood capillaries, the gastrointestinal tract, the lungs, 
and the heart. In scleroderma patients, fibrosis frequently leads to 
organ dysfunction, serious illness, and death. Researchers have yet to 
determine the underlying cause of this disfiguring, debilitating 
condition or find an effective antifibrotic remedy. Scleroderma impacts 
approximately 300,000 Americans; 80 percent of whom are women diagnosed 
during their child-bearing years. Scleroderma also has a highly 
disproportionate impact on Native American, African-American, and 
Hispanic populations. These groups tend to exhibit more rapidly 
progressing and severe cases of the disease. Scleroderma lung disease 
is categorized as an interstitial lung disease (ILD). ILD refers to a 
broad category of lung diseases, of which scleroderma is one among 
nearly 150 conditions, marked by fibrosis or scarring of the lungs. The 
net result of the fibrosis is ineffective respiration or difficulty 
breathing. Lung fibrosis occurs in nearly all patients with systemic 
sclerosis and for reasons that are not clear, severe lung scarring is 
seen more frequently in men and in African-American scleroderma 
patients. I was one of these men. Lung disease is the number one cause 
of death in scleroderma patients.
    It began with trouble with my hands at work. They were turning blue 
and I could not flex them. I went to my family doctor and she referred 
me to a rheumatologist who subsequently diagnosed me with Raynaud's 
(the blue color) and scleroderma. As time went on the skin was getting 
tighter on my arms and so tight on my hands that I could not even close 
them. The doctor started me on an exercise program for my arms and 
hands. A few months later I began an experimental treatment, Cytoxin 
Infusion, for the scleroderma, taken once a month. I was on it for 2 
years. After 2 years, my scleroderma began impacting my right lung. 
Breathing became difficult, I was losing weight, and the coloration of 
my skin was changing. The rheumatologist then referred me to a lung 
specialist at the University of Michigan. The lung specialist said that 
my right lung was not fluctuating and was beginning to harden or turn 
to stone--a term used with scleroderma.
    When I inquired about a transplant I was tested and counseled by 
multiple doctors because the operation would be experimental. There 
were considerable risks. I was finally put on the transplant list. On 
September 20, 2004, I got a phone call at 11 p.m. that a lung was 
available. They said I needed to get to Ann Arbor as quickly as 
possible. When I got there they checked to make sure I was healthy 
enough for the operation and ran tests for infection. I was on the 
operating table the next morning, September 21, at 7:30 a.m. I was in 
the hospital for a week. Having become so weak being on oxygen for 2 
years, I also required extensive physical therapy. Since the operation 
I have been doing well. The lung is still functioning as well today as 
the day I received it.
    Since my operation I have joined a Scleroderma Foundation support 
group and found out there is so much we don't know about scleroderma. 
We all differ in our degrees of the illness. I have learned that none 
of us are the same or have the same outcomes. For example, I knew a 
young lady, 17 years old, who had scleroderma. Her one wish was to go 
to Disney World. A trip was arranged for her and her family. She was 
not doing well but wanted to go anyway. She made it to Florida and to 
the hotel but then needed to go to the hospital. She passed away the 
next day without getting to see Disney World. The doctors here in 
Saginaw used some of the treatments on her that were used on me. The 
treatments worked for me but not for her.
    As I stated before, I am a veteran of the United States Army and a 
Vietnam Vet. Scleroderma research is of utmost importance to the 
military. The exact cause of scleroderma is not known; however, it is 
suspected that an unknown inciting event triggers injury, probably to 
cells lining the blood vessels. There are also changes in the body's 
immune system that cause the immune cells to react to body components 
including the connective tissue. A major consequence of these so-called 
``autoimmune reactions'' is stimulation of fibroblasts (cells that make 
collagen and other connective tissue components). The net result is 
excessive accumulation of collagen and other connective tissue 
components in parts of the body such as skin, lungs, and walls of the 
arteries. A veteran's immune system disability may be related to his 
in-service chemical exposure. Systemic sclerosis and systemic lupus 
have been reported in patients exposed to TCE.
    Additionally, toxic agents soldiers may be exposed to on the 
battlefield have also proved to cause lung injury/fibrosis. The 
successful completion of studies will bring us much closer to being 
able to treat scleroderma lung disease and other diseases involving 
lung injury/fibrosis in human patients. This is of the utmost urgency 
because there are currently no effective, U.S. Food and Drug 
Administration-approved treatments for these diseases.
    On behalf of the scleroderma community, including our veterans, I 
would like to thank the subcommittee for recognizing scleroderma as a 
condition eligible for study through the DOD's PRMRP in the committee 
reports accompanying the fiscal years 2010, 2011, and 2012 DOD 
appropriations bills. The scientific community showed great interest in 
the program, responding to the grant announcements with an immense 
outpouring of proposals. We urge the Congress to maintain scleroderma's 
eligibility in the PRMRP.

    Chairman Inouye. We'll do our best to make certain that 
it's eligible for research.
    Thank you very much, Sir.
    Our next witness is Ms. Dee Linde, representing the 
Dystonia Medical Research Foundation.
STATEMENT OF DEE LINDE, PATIENT ADVOCATE, DYSTONIA 
            ADVOCACY NETWORK
    Ms. Linde. Mr. Chairman, Mr. Vice Chairman: Thank you for 
the opportunity to testify here today. My name is Dee Linde and 
I'm a dystonia patient and volunteer with the Dystonia Advocacy 
Network (DAN). As a veteran and former Navy petty officer, I am 
honored to testify before this subcommittee.
    The DAN is comprised of five dystonia patient groups and 
works to advance dystonia research, increase dystonia 
awareness, and provide support for dystonia patients. Dystonia 
is a rare neurological movement disorder that causes muscles to 
contract and spasm involuntarily. Dystonia is a chronic 
disorder whose symptoms vary in degrees of frequency, 
intensity, disability, and pain. Dystonia can be generalized or 
focal. Generalized dystonia affects all major muscle groups, 
resulting in twisting, repetitive movements, and abnormal 
postures. Focal dystonia affects a specific part of the body, 
such as the legs, arms, eyelids, or vocal cords.
    Dystonia can be hereditary or caused by trauma, and it 
affects approximately 300,000 persons in the United States. At 
this time there is no cure for dystonia and treatment is highly 
individualized. Patients frequently rely on invasive therapies.
    In 1995, after my Navy career, I started feeling symptoms 
from what would later be diagnosed as tardive dystonia, which 
is medication-induced dystonia. The symptoms started as an 
uncontrollable shivering sensation. Over the next 2 years, the 
symptoms continued to worsen and I started feeling like I was 
being squeezed in a vise. My diaphragm was constricted and I 
couldn't breathe. I also had blepharospasm, a form of dystonia 
that forcibly shut my eyes, leaving me functionally blind even 
though there was nothing wrong with my vision.
    My dystonia affected my entire upper body and for years my 
spasms didn't allow me to sit in a chair or sleep safely in bed 
with my husband. I spent those years having to sleep and even 
eat on the floor. I was also forced to give up my private 
practice as a psychotherapist.
    In 2000, I underwent surgery to receive deep brain 
stimulation (DBS). The neurosurgeon implanted leads into my 
brain that emit constant electrical pulses which interrupt the 
bad signals and help control my symptoms. Thanks to DBS, I have 
gone from being completely nonfunctional to having the ability 
to walk and to move like a healthy individual and I am now 
almost completely symptom-free. But DBS is not a cure.
    The Dystonia Medical Research Foundation (DMRF) has 
received reports that the incidence of dystonia in the United 
States has noticeably increased since our military forces were 
deployed to Iraq and Afghanistan. An article in Military 
Medicine titled ``Post-Traumatic Shoulder Dystonia in an Active 
Duty Soldier'' stated that, ``Dystonia after minor trauma can 
be as crippling as a penetrating wound, with disability that 
renders the soldier unable to perform his duties.''
    Awareness of this disorder is essential to avoid 
mislabeling and possibly mistreating a true neurological 
disease.
    In addition, a study published this month in ``Science 
Translational Medicine'' found that blast exposures can cause 
structural problems in the brain. We believe these structural 
problems will lead to increased dystonia.
    The Department of Defense Peer-Reviewed Medical Research 
Program is critical to developing a better understanding of the 
mechanisms connecting trauma and dystonia.

                           PREPARED STATEMENT

    The dystonia community would like to thank the subcommittee 
for adding dystonia to the list of conditions eligible for 
study under this program since fiscal year 2010. We're excited 
to report that dystonia researchers have competed successfully 
within the peer-reviewed system every year thus far. We urge 
the subcommittee to maintain dystonia as an eligible condition 
in the Defense Peer-Reviewed Medical Research Program in fiscal 
year 2013.
    Thank you again for your time and interest.
    [The statement follows:]
                    Prepared Statement of Dee Linde
    Mr. Chairman and members of the Senate Department of Defense 
Appropriations subcommittee, thank you for the opportunity to testify 
today. My name is Dee Linde, and I am a dystonia patient and volunteer 
with the Dystonia Advocacy Network (DAN). I am also a former Navy 
servicemember, and I am honored to testify before this subcommittee. 
The DAN is comprised of five dystonia patient groups working 
collaboratively to meet the needs of those affected:
  --the Benign Essential Blepharospasm Research Foundation (BEBRF);
  --the Dystonia Medical Research Foundation (DMRF);
  --the National Spasmodic Dysphonia Association (NSDA);
  --the National Spasmodic Torticollis Association (NSTA); and
  --ST/Dystonia, Inc.
    The DAN works to advance dystonia research, increase dystonia 
awareness, and provide support for those living with the disorder. On 
behalf of the dystonia community, I am here to request that you include 
dystonia as a condition eligible for study through the Peer-Reviewed 
Medical Research Program as you work to complete fiscal year 2013 
Department of Defense appropriations.
    Dystonia is a rare neurological movement disorder that causes 
muscles to contract and spasm involuntarily. It is a chronic disorder 
whose symptoms vary in degrees of frequency, intensity, disability, and 
pain. Dystonia can be generalized or focal. Generalized dystonia 
affects all major muscle groups, resulting in twisting repetitive 
movements and abnormal postures. Focal dystonia affects a specific part 
of the body such as the legs, arms, hands, eyelids, or vocal chords. 
Dystonia can be hereditary or caused by trauma such as a car crash or a 
blast exposure as experienced by military personnel. At this time, 
there is no cure for dystonia and treatment is highly individualized. 
Patients frequently rely on invasive therapies like botulinum toxin 
injections or deep brain stimulation (DBS) to help manage their 
symptoms.
    In 1995, after my Navy career, I started feeling symptoms for what 
would later be diagnosed as tardive dystonia, which is medication-
induced dystonia. The symptoms started as an uncontrollable shivering 
sensation that often prompted people to ask me if I was cold. Over the 
next 2 years, the symptoms continued to worsen, and I started feeling 
like I was being squeezed: my diaphragm was constricted and I couldn't 
breathe. I also had belpharospasm which meant that my eyes would shut 
forcibly and uncontrollably, leaving me functionally blind even though 
there was nothing wrong with my vision.
    The tardive dystonia affected my entire upper body and for years my 
spasms didn't allow me to sit in a chair, or sleep safely in the bed 
with my husband. As a family joke, my mother made my husband a nose 
guard to wear because I kept hitting him during the night. We made 
light of the situation when we could, but I was facing much hardship 
and loneliness. I spent those years having to sleep and even eat on the 
floor. Before I developed dystonia, I had my own private practice as a 
licensed psychotherapist which I had to give up as a result of my 
spasms.
    Because I have other service-connected disabilities and am 
considered 100-percent unemployable, I receive care at the Veterans 
hospital in Portland, Oregon. In 2000, I underwent surgery to receive 
DBS. The surgeons implanted leads into my basil ganglia, the part of 
the brain that controls movement. The DBS therapy delivers constant 
electrical stimulation that interrupts the bad signals and helps 
control the involuntary movements. Thanks to DBS, I have gone from 
being completely nonfunctional, to having the ability to walk and to 
move like a healthy individual. I am happy to say that I am now almost 
completely symptom free. Many dystonia patients who undergo DBS do not 
experience the positive results on the scale that I have, and some 
undergo brain surgery only to find that the DBS has no effect. 
Moreover, DBS is a treatment--not a cure.
    The DAN has received reports that the incidence of dystonia in the 
United States has noticeably increased since our military forces were 
deployed to Iraq and Afghanistan. This recent increase is widely 
considered to be the result of a well-documented link between traumatic 
injuries and the onset of dystonia. A June 2006 article in ``Military 
Medicine'' entitled ``Post-Traumatic Shoulder Dystonia in an Active 
Duty Soldier'' reported on dystonia experienced by military personnel 
and concluded the following:

    ``Dystonia after minor trauma can be as crippling as a penetrating 
wound, with disability that renders the soldier unable to perform his 
duties . . . awareness of this disorder [dystonia] is essential to 
avoid mislabeling, and possibly mistreating, a true neurological 
disease.''

    More recently, a study published in the May 16, 2012 issue of 
``Science Translational Medicine'' led by Dr. Lee E. Goldstein of 
Boston University's School of Medicine found that blast exposures can 
cause structural problems in the brain that we believe will lead to 
increased dystonia. As military personnel remain deployed for longer 
periods, we can expect dystonia prevalence in military and veterans 
populations to continue to rise.
    Although Federal dystonia research is conducted through a number of 
medical and scientific agencies, the Department of Defense (DOD) Peer-
Reviewed Medical Research Program remains the most essential program 
studying dystonia in military and veteran populations. This program is 
critical to developing a better understanding of the mechanisms 
connecting trauma and dystonia. For the past 2 years, I have been a 
consumer reviewer on this panel. The DAN would like to thank the 
subcommittee for adding dystonia to the list of conditions eligible for 
study under the DOD Peer-Reviewed Medical Research Program in the 
fiscal year 2010, fiscal year 2011, and fiscal year 2012 Defense 
Appropriation bills. The DAN is excited to report that dystonia 
researchers have competed successfully within the peer-reviewed system 
every year which underscores the important nature of their work. We 
urge the subcommittee to maintain dystonia as a condition eligible for 
study through the Peer-Reviewed Medical Research Program in fiscal year 
2013.
    Thank you again for allowing me the opportunity to address the 
subcommittee today. I hope you will continue to include dystonia as a 
condition eligible for study under the DOD Peer-Reviewed Medical 
Research Program.
DAN Fiscal Year 2013 Defense Appropriations Recommendations
    Peer-Reviewed Medical Research Program (PRMRP):
  --Include ``dystonia'' as a condition eligible for study through the 
        PRMRP.
  --Provide $50 million for PRMRP, which is housed within the 
        Congressionally Directed Medical Research Program.

    Chairman Inouye. If this matter is service-connected, I can 
assure you that we'll do our best to make certain your 
organization continues its research.
    Ms. Linde. Thank you.
    Chairman Inouye. Thank you.
    Our next witness is Ms. Joy Simha, representing the 
National Breast Cancer Coalition.
STATEMENT OF JOY SIMHA, MEMBER, BOARD OF DIRECTORS, 
            NATIONAL BREAST CANCER COALITION
    Ms. Simha. Thank you very much. I am Joy Simha, an 18-year 
breast cancer survivor, co-founder of the Young Survival 
Coalition and a member of the board of directors of the 
National Breast Cancer Coalition, which is an organization made 
up of hundreds of grassroots organizations from across the 
country.
    Chairman Inouye, Ranking Member Cochran, members of the 
subcommittee: We thank you for your longstanding support for 
the Department of Defense Peer-Reviewed Breast Cancer Research 
Program (BCRP). You know the importance of this program to 
women and their families both within and outside the military 
across the country, to the scientific and healthcare 
communities, and to the Department of Defense, because much of 
the progress that has been made in the fight against breast 
cancer is due to your investment in this important program.
    The vision of the Department of Defense Peer-Reviewed BCRP 
is to eradicate breast cancer by funding innovative, high-
impact research through the unique partnership of the Congress, 
the Army, scientists, and consumers.
    The Department of the Army must be applauded for overseeing 
this unique program. It's established itself as a model medical 
research program, respected throughout the cancer and broader 
medical communities for its innovative, transparent, and 
accountable approach. This program is incredibly streamlined. 
The flexibility of the program has allowed the Army to 
administer it with unparalleled efficiency and effectiveness. 
It is lauded worldwide and others try to emulate the program.
    Its specific focus on breast cancer allows it to rapidly 
support innovative proposals that reflect the most recent 
discoveries in the field. It is responsive not just to the 
scientific community, but also to the public. The pioneering 
research performed through the program and the unique vision it 
maintains have the potential to benefit not just breast cancer, 
but all cancers, as well as other diseases. Biomedical research 
is literally being transformed by the Department of Defense 
BCRP, 90 percent of the funds appropriated go to research.
    Advocates bring a necessary perspective to the table, 
ensuring that the science funded by the program is not only 
meritorious, but also relevant to the women whose lives are 
affected by this disease.
    You may remember Karen Moss, a retired Air Force Lieutenant 
Colonel who served almost 21 years on active duty and she 
chaired the integration panel. Karen passed away in September 
2008. She was committed to making a difference and ensuring 
that the voices of consumer advocates were heard by the 
scientific community, challenging scientists to always think 
differently.
    Her legacy reminds us that breast cancer is not just a 
struggle for scientists; it's a disease of the people. She 
chaired the integration panel the year that she died. The 
consumers who sit alongside the scientists at the vision-
setting peer review and programmatic review stages of the BCRP 
are there to ensure that no one forgets the women who have died 
from this disease and to keep the program focused on its 
vision.

                           PREPARED STATEMENT

    This is research that will help us win a very real and 
devastating war against a very vicious enemy. You and your 
subcommittee have shown great determination and leadership in 
funding the DOD Peer-Reviewed BCRP at a level that has brought 
us closer to ending this disease. I am hopeful that you will 
continue that determination and leadership.
    Thank you again for the opportunity to submit testimony and 
represent all the people across this country who care about 
ending this disease. Thank you.
    [The statement follows:]
                    Prepared Statement of Joy Simha
    Thank you, Mr. Chairman and members of the Appropriations 
Subcommittee on the Department of Defense, for the opportunity to 
submit testimony today about a program that has made a significant 
difference in the lives of women and their families.
    I am Joy Simha, an 18-year breast cancer survivor, communications 
consultant, a wife and mother, co-founder of The Young Survival 
Coalition, and a member of the board of directors of the National 
Breast Cancer Coalition (NBCC). I am also a member of the Integration 
Panel of the Department of Defense (DOD) Breast Cancer Research Program 
(BCRP). My testimony represents the hundreds of member organizations 
and thousands of individual members of the NBCC. NBCC is a grassroots 
organization dedicated to ending breast cancer through action and 
advocacy. Since its founding in 1991, NBCC has been guided by three 
primary goals:
  --to increase Federal funding for breast cancer research and 
        collaborate with the scientific community to implement new 
        models of research;
  --improve access to high-quality healthcare and breast cancer 
        clinical trials for all women; and
  --expand the influence of breast cancer advocates wherever breast 
        cancer decisions are made.
    In September 2010, in order to change the conversation about breast 
cancer and restore the sense of urgency in the fight to end the 
disease, NBCC launched Breast Cancer Deadline 2020--a deadline to end 
breast cancer by January 1, 2020.
    Chairman Inouye and Ranking Member Cochran, we appreciate your 
longstanding support for the Department of Defense (DOD) Peer-Reviewed 
Breast Cancer Research Program. As you know, this program was born from 
a powerful grassroots effort led by NBCC, and has become a unique 
partnership among consumers, scientists, Members of Congress and the 
military. You and your subcommittee have shown great determination and 
leadership in funding DOD Peer-Reviewed BCRP at a level that has 
brought us closer to ending this disease. I am hopeful that you and 
your subcommittee will continue that determination and leadership.
    I know you recognize the importance of this program to women and 
their families across the country, to the scientific and healthcare 
communities and to DOD. Much of the progress that has been made in the 
fight against breast cancer is due to the Appropriations Committee's 
investment in breast cancer research through the DOD BCRP. To support 
this progress moving forward, we ask that you support a $150 million 
appropriation for fiscal year 2013. In order to continue the success of 
the program, you must ensure that it maintains its integrity and 
separate identity, in addition to this funding. This is important not 
just for breast cancer, but for all biomedical research that has 
benefited from this incredible Government program.
                           vision and mission
    The vision of DOD Peer-Reviewed BCRP is to ``eradicate breast 
cancer by funding innovative, high-impact research through a 
partnership of scientists and consumers''. The meaningful and 
unprecedented partnership of scientists and consumers has been the 
foundation of this model program from the very beginning. It is 
important to understand this collaboration:
  --consumers and scientists working side-by-side;
  --asking the difficult questions;
  --bringing the vision of the program to life;
  --challenging researchers and the public to do what is needed; and
  --then overseeing the process every step of the way to make certain 
        it works.
    This unique collaboration is successful: every year researchers 
submit proposals that reach the highest level asked of them by the 
program and every year we make progress for women and men everywhere.
    And it owes its success to the dedication of the U.S. Army and 
their belief and support of this mission. And of course, to you. It is 
these integrated efforts that make this program unique.
    The Department of the Army must be applauded for overseeing the DOD 
BCRP which has established itself as a model medical research program, 
respected throughout the cancer and broader medical community for its 
innovative, transparent, and accountable approach. This program is 
incredibly streamlined. The flexibility of the program has allowed the 
Army to administer it with unparalleled efficiency and effectiveness. 
Because there is little bureaucracy, the program is able to respond 
quickly to what is currently happening in the research community. Its 
specific focus on breast cancer allows it to rapidly support innovative 
proposals that reflect the most recent discoveries in the field. It is 
responsive, not just to the scientific community, but also to the 
public. The pioneering research performed through the program and the 
unique vision it maintains have the potential to benefit not just 
breast cancer, but all cancers as well as other diseases. Biomedical 
research is literally being transformed by the DOD BCRP.
                         consumer participation
    Advocates bring a necessary perspective to the table, ensuring that 
the science funded by this program is not only meritorious, but that it 
is also meaningful and will make a difference in people's lives. The 
consumer advocates bring accountability and transparency to the 
process. They are trained in science and advocacy and work with 
scientists willing to challenge the status quo to ensure that the 
science funded by the program fills important gaps not already being 
addressed by other funding agencies. Since 1992, more than 700 breast 
cancer survivors have served on the BCRP review panels.
    Four years ago, Karin Noss, a retired Air Force Lieutenant Colonel 
who served almost 21 years on active duty as a missile launch officer 
and intelligence analyst, chaired the Integration Panel. Karin was 36 
years old when she discovered a lump that was misdiagnosed by 
mammography and clinical exam; just more than 1 year later, however, 
she was diagnosed with Stage II breast cancer. Her diagnosis inspired 
her to become knowledgeable about her disease, and as a trained 
consumer advocate she began participating as a consumer reviewer on 
BCRP scientific peer-review panels in 1997. Karin was committed to 
making a difference and ensuring that the voice of consumer advocates 
was heard by the scientific community, challenging scientists to think 
differently.
    Karin worked tirelessly in support of the BCRP through the pain and 
fatigue of metastatic breast cancer. She died of the disease in 
September 2008. Just a few weeks before her passing, Karin served what 
would be her final role for the BCRP when she chaired the fiscal year 
2008 Vision Setting Meeting, an important milestone at which the 
program determines which award mechanisms to offer in order to move 
research forward. She said that:

    ``Consumer involvement in all facets of the BCRP has proven crucial 
to ensuring not only that the best and most innovative science gets 
funded, but that the science will really make a difference to those of 
us living with the disease.''

    Karin demonstrated an amazing strength, determination, and 
commitment to eradicating breast cancer. She was an optimist, 
determined to make things better for women with breast cancer whose 
legacy reminds us that breast cancer is not just a struggle for 
scientists; it is a disease of the people. The consumers who sit 
alongside the scientists at the vision setting, peer review and 
programmatic review stages of the BCRP are there to ensure that no one 
forgets the women who have died from this disease and to keep the 
program focused on its vision.
    For many consumers, participation in the program is ``life 
changing'' because of their ability to be involved in the process of 
finding answers to this disease. In the words of one advocate:

    ``Participating in the peer review and programmatic review has been 
an incredible experience. Working side by side with the scientists, 
challenging the status quo and sharing excitement about new research 
ideas . . . it is a breast cancer survivor's opportunity to make a 
meaningful difference. I will be forever grateful to the advocates who 
imagined this novel paradigm for research and continue to develop new 
approaches to eradicate breast cancer in my granddaughters' 
lifetime.''----Marlene McCarthy, three-time breast cancer ``thriver'', 
Rhode Island Breast Cancer Coalition.

    Scientists who participate in the Program agree that working with 
the advocates has changed the way they do science. Let me quote Greg 
Hannon, the fiscal year 2010 DOD BCRP Integration Panel Chair:

    ``The most important aspect of being a part of the BCRP, for me, 
has been the interaction with consumer advocates. They have currently 
affected the way that I think about breast cancer, but they have also 
impacted the way that I do science more generally. They are a constant 
reminder that our goal should be to impact people's lives.''----Greg 
Hannon, Ph.D., Cold Spring Harbor Laboratory.
                            unique structure
    The DOD BCRP uses a two-tiered review process for proposal 
evaluation, with both steps including scientists as well as consumers. 
The first tier is scientific peer review in which proposals are weighed 
against established criteria for determining scientific merit. The 
second tier is programmatic review conducted by the Integration Panel 
(composed of scientists and consumers) that compares submissions across 
areas and recommends proposals for funding based on scientific merit, 
portfolio balance, and relevance to program goals.
    Scientific reviewers and other professionals participating in both 
the peer review and the programmatic review process are selected for 
their subject matter expertise. Consumer participants are recommended 
by an organization and chosen on the basis of their experience, 
training, and recommendations.
    The BCRP has the strictest conflict of interest policy of any 
research funding program or institute. This policy has served it well 
through the years. Its method for choosing peer and programmatic review 
panels has produced a model that has been replicated by funding 
entities around the world.
    It is important to note that the Integration Panel that designs 
this program has a strategic plan for how best to spend the funds 
appropriated. This plan is based on the state of the science--both what 
scientists and consumers know now and the gaps in our knowledge--as 
well as the needs of the public. While this plan is mission driven, and 
helps ensure that the science keeps to that mission of eradicating 
breast cancer in mind, it does not restrict scientific freedom, 
creativity, or innovation. The Integration Panel carefully allocates 
these resources, but it does not predetermine the specific research 
areas to be addressed.
                   distinctive funding opportunities
    The DOD BCRP research portfolio includes many different types of 
projects, including support for innovative individuals and ideas, 
impact on translating research from the bench to the bedside, and 
training of breast cancer researchers.
Innovation
    The Innovative Developmental and Exploratory Awards (IDEA) grants 
of the DOD program have been critical in the effort to respond to new 
discoveries and to encourage and support innovative, risk-taking 
research. Concept awards support funding even earlier in the process of 
discovery. These grants have been instrumental in the development of 
promising breast cancer research by allowing scientists to explore 
beyond the realm of traditional research and unleash incredible new 
ideas. For example, in fiscal year 2009, Dr. Seongbong Jo of the 
University of Mississippi was granted a concept award to develop a 
multifunctional nanoparticle that can selectively recognize breast 
cancer and specifically inhibit the growth of cancer cells, while 
minimally affecting normal cells. This has the potential to 
significantly improve the delivery of breast cancer chemotherapy, 
increase its efficiency, and contribute to the reduction of breast 
cancer mortality rates.
    IDEA and concept grants are uniquely designed to dramatically 
advance our knowledge in areas that offer the greatest potential. In 
fiscal year 2006, Dr. Gertraud Maskarinec of the University of Hawaii 
received a synergistic IDEA grant to study effectiveness of the Dual 
Energy Xray Absorptiometry (DXA) as a method to evaluate breast cancer 
risks in women and young girls. Such a method, which could possibly be 
used to prevent breast cancer during adulthood, is currently not 
available because the risk of xray-based mammograms is considered too 
high in that age group. Such grants are precisely the types that rarely 
receive funding through more traditional programs such as the National 
Institutes of Health and private research programs. They, therefore, 
complement and do not duplicate other Federal funding programs. This is 
true of other DOD award mechanisms as well.
    Innovator awards invest in world renowned, outstanding individuals 
rather than projects, by providing funding and freedom to pursue highly 
creative, potentially groundbreaking research that could ultimately 
accelerate the eradication of breast cancer. Dr. Dennis Slamon of the 
University of California, Los Angeles was granted an innovator award in 
fiscal year 2010 to develop new insights that will result in the 
development of novel treatment initiatives for all of the current 
therapeutic subtypes of breast cancer. This research builds upon the 
past gains in understanding of the molecular diversity of human breast 
cancer which has led treatment away from the ``one-size-fits-all'' 
therapeutic approaches, and the success of existing treatments of 
specific breast cancer subtypes.
    The Era of Hope Scholar Award supports the next generation of 
leaders in breast cancer research, by identifying the best and 
brightest scientists early in their careers and giving them the 
necessary resources to pursue a highly innovative vision of ending 
breast cancer. Dr. Stuart S. Martin of the University of Maryland, 
Baltimore received a fiscal year 2010 Era of Hope Scholar Award to 
build an international consortium to define a molecular framework that 
governs the mechanical properties of a certain type of tumor cell 
which, because of its shape, poses a greater metastatic risk than other 
cells.
    One of the most promising outcomes of research funded by the DOD 
BCRP was the development of the first monoclonal antibody targeted 
therapy that prolongs the lives of women with a particularly aggressive 
type of advanced breast cancer. Researchers found that over-expression 
of HER-2/neu in breast cancer cells results in very aggressive biologic 
behavior. The same researchers demonstrated that an antibody directed 
against HER-2/neu could slow the growth of the cancer cells that over-
expressed the gene. This research, which led to the development of the 
targeted therapy, Herceptin, was made possible in part by a DOD BCRP-
funded infrastructure grant. Other researchers funded by the DOD BCRP 
are identifying similar targets that are involved in the initiation and 
progression of cancer.
    These are just a few examples of innovative funding opportunities 
at the DOD BCRP that are filling gaps in breast cancer research.
Translational Research
    The DOD BCRP also focuses on moving research from the bench to the 
bedside. DOD BCRP awards are designed to fill niches that are not 
addressed by other Federal agencies. The BCRP considers translational 
research to be the process by which the application of well-founded 
laboratory or other pre-clinical insight results in a clinical trial. 
To enhance this critical area of research, several research 
opportunities have been offered. Clinical Translational Research Awards 
have been awarded for investigator-initiated projects that involve a 
clinical trial within the lifetime of the award. The BCRP has expanded 
its emphasis on translational research by also offering five different 
types of awards that support work at the critical juncture between 
laboratory research and bedside applications.
    The Multi Team Award mechanism brings together the world's most 
highly qualified individuals and institutions to address a major 
overarching question in breast cancer research that could make a 
significant contribution towards the eradication of breast cancer. Many 
of these Teams are working on questions that will translate into direct 
clinical applications. These Teams include the expertise of basic, 
epidemiology, and clinical researchers, as well as consumer advocates.
Training
    The DOD BCRP is also cognizant of the need to invest in tomorrow's 
breast cancer researchers. Erin McCoy of the University of Alabama, 
Birmingham received a fiscal year 2010 Predoctoral Traineeship Award 
for work on the potential role a certain protein, CD68, plays in breast 
cancer cells attaching themselves to bone which allows metastatic 
growth to take place. The bone is the most common site for breast 
cancer metastasis. In fiscal year 2011, Dr. Julie O'Neal of the 
University of Louisville received a Postdoctoral Fellowship Award to 
study breast cancer biology with an emphasis on identifying enzymes 
that are required for breast cancer growth.
    Dr. John Niederhuber, former Director of the National Cancer 
Institute (NCI), said the following about the program when he was 
Director of the University of Wisconsin Comprehensive Cancer Center in 
April, 1999:

    ``Research projects at our institution funded by the Department of 
Defense are searching for new knowledge in many different fields 
including: identification of risk factors, investigating new therapies 
and their mechanism of action, developing new imaging techniques and 
the development of new models to study [breast cancer] . . . Continued 
availability of this money is critical for continued progress in the 
nation's battle against this deadly disease.''

    Scientists and consumers agree that it is vital that these grants 
continue to support breast cancer research. To sustain the program's 
momentum, $150 million for peer-reviewed research is needed in fiscal 
year 2013.
    outcomes and reviews of the department of defense breast cancer 
                            research program
    The outcomes of the BCRP-funded research can be gauged, in part, by 
the number of publications, abstracts/presentations, and patents/
licensures reported by awardees. To date, there have been more than 
14,724 publications in scientific journals, more than 19,013 abstracts 
and nearly 643 patents/licensure applications. The American public can 
truly be proud of its investment in the DOD BCRP. Scientific 
achievements that are the direct result of the DOD BCRP grants are 
moving us closer to eradicating breast cancer.
    The success of the DOD Peer-Reviewed BCRP has been illustrated by 
several unique assessments of the program. The Institute of Medicine 
(IOM), which originally recommended the structure for the program, 
independently re-examined the program in a report published in 1997. 
They published another report on the program in 2004. Their findings 
overwhelmingly encouraged the continuation of the program and offered 
guidance for program implementation improvements.
    The 1997 IOM review of the DOD Peer-Reviewed BCRP commended the 
program, stating, ``the Program fills a unique niche among public and 
private funding sources for cancer research. It is not duplicative of 
other programs and is a promising vehicle for forging new ideas and 
scientific breakthroughs in the nation's fight against breast cancer.'' 
The 2004 report spoke to the importance of the program and the need for 
its continuation.
    The DOD Peer-Reviewed BCRP not only provides a funding mechanism 
for high-risk, high-return research, but also reports the results of 
this research to the American people every 2 to 3 years at a public 
meeting called the Era of Hope. The 1997 meeting was the first time a 
federally funded program reported back to the public in detail not only 
on the funds used, but also on the research undertaken, the knowledge 
gained from that research and future directions to be pursued.
    Sixteen hundred consumers and researchers met for the sixth Era of 
Hope meeting in August 2011. As MSNBC.com's Bob Bazell wrote, this 
meeting ``brings together many of the most committed breast cancer 
activists with some of the nation's top cancer scientists. The 
conference's directive is to push researchers to think `out of the box' 
for potential treatments, methods of detection and prevention . . .'' 
He went on to say ``the program . . . has racked up some impressive 
accomplishments in high-risk research projects . . .''
    During the 2011 Era of Hope, investigators presented work that 
challenged paradigms and pushed boundaries with innovative, high-impact 
approaches. Some of the research presented looked at new ways to treat 
the spread of breast cancer, including a vaccine for HER2+ breast 
cancer that has stopped responding to treatment, and an innovative 
treatment using nanoparticles of HDL cholesterol tied to chemotherapy 
drugs to more directly zero in on cancer cells.
    The DOD Peer-Reviewed BCRP has attracted scientists across a broad 
spectrum of disciplines, launched new mechanisms for research and 
facilitated new thinking in breast cancer research and research in 
general. A report on all research that has been funded through the DOD 
BCRP is available to the public. Individuals can go to the Department 
of Defense Web site and look at the abstracts for each proposal at 
http://cdmrp.army.mil/bcrp/.
           commitment of the national breast cancer coalition
    The National Breast Cancer Coalition is strongly committed to the 
DOD BCRP in every aspect, as we truly believe it is one of our best 
chances for reaching Breast Cancer Deadline 2020's goal of ending the 
disease by the end of the decade. The Coalition and its members are 
dedicated to working with you to ensure the continuation of funding for 
this program at a level that allows this research to forge ahead. From 
1992, with the launch of our ``300 Million More Campaign'' that formed 
the basis of this program, until now, NBCC advocates have appreciated 
your support.
    Over the years, our members have shown their continuing support for 
this program through petition campaigns, collecting more than 2.6 
million signatures, and through their advocacy on an almost daily basis 
around the country asking for support of the DOD BCRP.
    Consumer advocates have worked hard over the years to keep this 
program free of political influence. Often, specific institutions or 
disgruntled scientists try to change the program though legislation, 
pushing for funding for their specific research or institution, or try 
to change the program in other ways, because they did not receive 
funding through the process; one that is fair, transparent, and 
successful. The DOD BCRP has been successful for so many years because 
of the experience and expertise of consumer involvement, and because of 
the unique peer review and programmatic structure of the program. We 
urge this subcommittee to protect the integrity of the important model 
this program has become.
    There are nearly 3 million women living with breast cancer in this 
country today. This year, approximately 40,000 will die of the disease 
and more than 260,000 will be diagnosed. We still do not know how to 
prevent breast cancer, how to diagnose it in a way to make a real 
difference or how to end it. It is an incredibly complex disease. We 
simply cannot afford to walk away from this program.
    Since the very beginning of this program in 1992, the Congress has 
stood with us in support of this important approach in the fight 
against breast cancer. In the years since, Chairman Inouye and Ranking 
Member Cochran, you and this entire subcommittee have been leaders in 
the effort to continue this innovative investment in breast cancer 
research.
    NBCC asks you, the Department of Defense Appropriations 
subcommittee, to recognize the importance of what has been initiated by 
the Appropriations Committee. You have set in motion an innovative and 
highly efficient approach to fighting the breast cancer epidemic. We 
ask you now to continue your leadership and fund the program at $150 
million and maintain its integrity. This is research that will help us 
win this very real and devastating war against a cruel enemy.
    Thank you again for the opportunity to submit testimony and for 
giving hope to all women and their families, and especially to the 
nearly 3 million women in the United States living with breast cancer 
and all those who share in the mission to end breast cancer.

    Chairman Inouye. I thank you for your testimony and I can 
assure you that we'll do our very best to maintain the funding. 
Thank you.
    Next panel.
    Our next panel consists of: the Honorable Charles Curie, 
American Foundation for Suicide Prevention; Captain Charles D. 
Connor, United States Navy, Retired, representing the American 
Lung Association; Dr. William Strickland, representing the 
American Psychological Association; and Mr. Robert Ginyard, 
ZERO--the Project to End Prostate Cancer.
    May I call upon Mr. Curie.
STATEMENT OF HON. CHARLES CURIE, MEMBER, NATIONAL BOARD 
            OF DIRECTORS AND PUBLIC POLICY COUNCIL, 
            AMERICAN FOUNDATION FOR SUICIDE PREVENTION
    Mr. Curie. Chairman Inouye, Vice Chairman Cochran: Thank 
you for providing the American Foundation for Suicide 
Prevention (AFSP) with the opportunity to present testimony on 
the needs of programs within the Department of Defense (DOD) 
that play a critical role in suicide prevention efforts among 
our Nation's military personnel. I respectfully submit my 
written comments for the record.
    Chairman Inouye. Without objection.
    Mr. Curie. My name is Charles Curie. I'm a member of AFSP's 
Public Policy Council and I serve on its National Board of 
Directors. AFSP is the leading national not-for-profit 
grassroots organization exclusively dedicated to understanding 
and preventing suicide through research, education, and 
advocacy, and to reaching out to people with mental disorders 
and those impacted by suicide.
    My professional experience spans 30 years in the mental 
health and substance use services field. I was nominated by 
President George W. Bush and confirmed by the U.S. Senate from 
2001 to 2006 to head the Substance Abuse and Mental Health 
Services Administration (SAMHSA). As SAMHSA Administrator, I 
led the $3.4 billion agency responsible for improving the 
accountability, effectiveness, and capacity of the Nation's 
substance abuse prevention, addictions treatment, and mental 
health services, including the President's New Freedom 
Commission on Mental Health, the Strategic Prevention 
Framework, Access to Recovery, National Outcome Measures, and 
work with postconflict and war-torn countries' mental health 
service systems, including Iraq and Afghanistan.
    At the outset, I would like to thank the DOD and 
specifically the Department of the Army for the tremendous 
strides they have taken in recent years to not only understand 
suicide, but for the concrete steps they have taken to prevent 
suicide among their ranks. The DOD message that it's okay to 
seek help and that getting help is the courageous thing to do 
certainly saves lives and brings a new level of attention to 
the problem of suicide.
    Today, more than 1.9 million warriors have deployed for 
Operation Iraqi Freedom and Operation Enduring Freedom, two of 
our Nation's longest conflicts. The physical and psychological 
demands on both the deployed and nondeployed soldiers have been 
enormous. These demands are highlighted by the steady increases 
in suicides among Army personnel since 2005.
    Consider these facts: From 2005 to 2011, more than 927 
active-duty Army personnel took their own lives; in 2008, 
estimates of the rate of suicide among active-duty soldiers 
began to surpass the suicide rate among U.S. civilians; 278 
active-duty Army personnel, National Guard members, and Army 
reservists died by suicide in 2011; and year-to-date data 
indicates that so far 2012 is on track to be a record-high year 
for suicides in the Army.
    While access to affordable and quality treatment of mental 
disorders is critical in preventing suicide, public health 
efforts to get in front of suicide prevention are equally, if 
not more, important than healthcare efforts, because we know it 
is far more difficult to change behavior once someone has 
already attempted suicide or has received treatment in an 
inpatient treatment facility.
    Last year, the Congress appropriated an $8.1 million 
increase for the suicide prevention program under the Defense 
Health Program. While AFSP appreciates the Congress's 
commitment to preventing suicide among our Nation's military 
personnel, this funding sits largely unused because of 
restrictions on how those dollars must be spent. According to 
the Office of the Secretary of Defense, Defense Health Program 
dollars must be used for healthcare delivery programs and 
services, not for prevention, education and training, or 
research and development programs.

                           PREPARED STATEMENT

    Requiring additional funding to be spent on treatment is 
not going to help get in front of the problem. The services 
should have the authority to spend it on prevention efforts and 
not just healthcare delivery. Therefore, AFSP requests that 
this subcommittee add clarifying language to the fiscal year 
2013 Defense appropriations bill that would allow for these 
dollars to be spent on pre-medical related prevention, 
education, and outreach programs.
    Thank you, Mr. Chairman, Mr. Vice Chairman, for the 
opportunity.
    [The statement follows:]
                  Prepared Statement of Charles Curie
    Chairman Inouye, Ranking Member Cochran, and members of the 
subcommittee: Thank you for providing the American Foundation for 
Suicide Prevention (AFSP) with the opportunity to provide testimony on 
the needs of programs within the Department of Defense (DOD) that play 
a critical role in suicide prevention efforts among our Nation's 
military personnel.
    At the outset, I would like to thank the DOD, and specifically the 
Department of the Army, for the tremendous strides they have taken in 
recent years to not only understand suicide, but for the concrete steps 
they have taken to prevent suicide among their ranks. Military leaders 
are now more willing to openly talk about suicide within the military, 
as well as among veterans and the civilian population. The DOD message 
that it is okay to seek help, that getting help is the courageous thing 
to do, has certainly saved lives and brought a new level of attention 
to the problem of suicide. But we cannot wait for one minute, nor 
soften our collective resolve, inside and outside of Government, to 
help active duty military, veterans, and their families understand the 
warning signs of suicide, or where to get help.
    AFSP is the leading national not-for-profit, grassroots 
organization exclusively dedicated to understanding and preventing 
suicide through research, education, and advocacy, and to reaching out 
to people with mental disorders and those impacted by suicide. You can 
see more at www.afsp.org.
    My name is Charles Curie. I am member of AFSP's Public Policy 
Council, and I serve on the AFSP National Board of Directors. I am also 
the Principal and Founder of The Curie Group, LLC, a management and 
consulting firm specializing in working with leaders of the healthcare 
field, particularly the mental health services and substance use 
treatment and prevention arenas, to facilitate the transformation of 
services and to attain increasingly positive outcomes in the lives of 
people worldwide. I currently reside in Rockville, Maryland.
    My professional experience spans 30 years in the mental health and 
substance use services fields. I was nominated by President George W. 
Bush and confirmed by the U.S. Senate from 2001 to 2006 to head the 
Substance Abuse and Mental Health Services Administration (SAMHSA). As 
SAMHSA Administrator, I led the $3.4 billion agency responsible for 
improving the accountability, capacity, and effectiveness of the 
Nation's substance abuse prevention, addictions treatment, and mental 
health services, including The President's New Freedom Commission on 
Mental Health, the Strategic Prevention Framework for substance use 
prevention, Access to Recovery, National Outcome Measures and work with 
post-conflict and war-torn countries metal health and substance use 
treatment service systems, including Iraq and Afghanistan.
    More than 1.9 million warriors have deployed for Operation Iraqi 
Freedom (OIF) and Operation Enduring Freedom (OEF), two of our Nation's 
longest conflicts (IOM, 2010). The physical and psychological demands 
on both the deployed and nondeployed soldiers have been enormous. These 
demands are highlighted by the steady increase in suicides among Army 
personnel since 2005.
    Consider these facts:
  --From 2005 through 2011, more than 927 active duty Army personnel 
        took their own lives.
  --In 2008, estimates of the rate of suicide among active duty 
        soldiers in the regular Army, Army Reserve, and Army National 
        Guard began to surpass the suicide rate among U.S. 
        civilians.\1\
---------------------------------------------------------------------------
    \1\ Kuehn BM. Soldier suicide rates continue to rise: military, 
scientists work to stem the tide. JAMA 2009; 301: 1111-13.
---------------------------------------------------------------------------
  --Two hundred seventy-eight active duty Army personnel, National 
        Guard members, and Army reservists died by suicide in 2011.
  --Year-to-date data indicates that 2012 is on track to be a record-
        high year for suicides in the Army.
    In light of studies that have shown more than 90 percent of people 
who die from suicide have one or more psychiatric disorders at the time 
of their death; critical context for these alarming suicide numbers was 
provided in the April edition of the Medical Surveillance Monthly 
Report (MSMR).
    The MSMR showed that in 2011 mental disorders accounted for more 
hospital bed days than any other medical category, and substance abuse 
and mood disorder admissions accounted for 24 percent of the total DOD 
hospital bed days.
    This report also stated that outpatient behavioral health treatment 
was the third highest workload category, and that the largest 
percentage increase in workload between 2007 and 2011 was for mental 
disorders (99-percent increase or 943,924 additional medical 
encounters).
    While access to affordable and quality treatment of mental 
disorders is critical in preventing suicide, public health efforts to 
``get in front'' of suicide prevention are equally, if not more, 
important than healthcare efforts because we know that it is far more 
difficult to change behavior once someone has already attempted suicide 
or has received treatment in an inpatient treatment facility.
    Last year, the Congress appropriated an $8,158,156 program increase 
for suicide prevention under the Defense Health Program. While AFSP 
appreciates the Congress's commitment to preventing suicide among our 
Nation's military personnel, this funding sits largely unused because 
of restrictions on how those dollars must be spent.
    According to the Office of the Secretary of Defense, Defense Health 
Program dollars must be used for healthcare delivery programs and 
services and not for education and training or research and development 
programs.
    Requiring additional funding to be spent on treatment is not going 
help the services get in ``front'' of this problem. The services should 
have the authority to spend it on ``program evaluation'' and prevention 
efforts and not just on healthcare delivery.
    Therefore, AFSP requests that this subcommittee add clarifying 
language to the fiscal year 2013 Defense appropriations bill that would 
allow for these dollars to be spent on pre-medical related prevention, 
education, and outreach programs.
    Chairman Inouye, Ranking Member Cochran, and members of the 
subcommittee: AFSP once again thanks you for the opportunity to provide 
testimony on the funding needs of programs within the Department of 
Defense that play a critical role in suicide prevention efforts. With 
your help, we can assure those tasked with leading the Department of 
Defense's response to the unacceptably high rate of suicide among our 
military personnel will have the resources necessary to effectively 
prevent suicide.

    Chairman Inouye. I'm certain you're aware that this 
subcommittee is deeply concerned about the rising rate of 
suicides. We will make certain that these funds are used for 
research and prevention.
    Thank you very much.
    Mr. Curie. Thank you.
    Chairman Inouye. Our next witness is Captain Charles D. 
Connor, representing the American Lung Association.
STATEMENT OF CAPTAIN CHARLES D. CONNOR, U.S. NAVY 
            (RETIRED), PRESIDENT AND CHIEF EXECUTIVE 
            OFFICER, AMERICAN LUNG ASSOCIATION
    Captain Connor. Thank you very much, Mr. Chairman, Mr. Vice 
Chairman. It's an honor to be here before you today to discuss 
important matters such as the health of our Armed Forces. As a 
retired Navy captain myself, it's very important to me as well.
    The American Lung Association, as you know, was founded in 
1904 to fight tuberculosis. Today, our mission is to save lives 
by improving lung health and fighting lung disease. We 
accomplish this through three research, advocacy, and 
education.
    All of us here, of course, recognize the importance of 
keeping our military people healthy. Tobacco's adverse impact 
on health is well known and extensively documented. 
Accordingly, our view is that tobacco is an insidious enemy of 
combat readiness.
    Additionally, as this subcommittee well knows, healthcare 
costs for our troops and their families continue to rise, both 
for the Department of Defense (DOD) and the Veterans 
Administration (VA). More than a billion dollars of this 
healthcare bill is being driven by tobacco use annually. We owe 
it to our military people and their families and the taxpayers 
to prioritize the lung health of our troops.
    The American Lung Association wishes to invite your 
attention to three issues today for the DOD fiscal year 2013 
budget: Number one, the terrible burden on the military caused 
by tobacco use and the need for the Department to aggressively 
combat it; the importance of restoring funds for the Peer-
Reviewed Lung Cancer Research Program to $20 million; and 
finally, the health threat posed by soldiers' current and past 
exposure to toxic pollutants in Iraq and Afghanistan.
    The first subject is tobacco, briefly. Tobacco is a 
significant public health problem for the Defense Department, 
and it's not a problem that DOD simply inherited. More than 1 
in 7 active duty personnel begin smoking after joining the 
service.
    The American Lung Association recognizes the Department of 
the Navy's recent efforts to reduce tobacco use in their 
branch, such as the Navy's 21st Century Sailor and Marine 
Initiative announced just in the past few weeks. This 
initiative will help sailors and marines quit tobacco and 
promote tobacco-free environments. It also puts in place 
environmental changes that will reduce tobacco use throughout 
the Navy and Marine Corps.
    Likewise, the American Lung Association also recognizes the 
Air Force for its March 26 instruction on tobacco use. The 
instruction states that, ``The goal is a tobacco-free Air 
Force.'' It lays out strong policies on tobacco-free facilities 
and workplaces, tobacco use in formal training programs, and 
tobacco cessation programs. The document also establishes clear 
responsibilities within the Air Force chain of command to 
accomplish these goals and enforce their policies.
    So these steps are really the first signal from the 
military that tobacco use is disfavored. Both of these efforts, 
the Departments of the Navy and the Air Force, are 
unprecedented investments in the comprehensive health of 
sailors, marines, airmen, and their families. So the American 
Lung Association hopes these initiatives expand quickly to 
cover all military personnel.
    Also in 2011, DOD released a proposed rule implementing 
coverage of tobacco cessation treatment through TRICARE. When 
finalized, this new coverage will give soldiers and their 
families the help they need to quit tobacco.
    All of these actions follow recommendations in the 
Institute of Medicine's report ``Combatting Tobacco Use in 
Military and Veterans Populations'', which is now as of this 
month 3 years old. The American Lung Association urges the DOD 
and VA to fully implement all the recommendations in the report 
and, importantly, we urge the Congress to remove any 
legislative barriers that exist to implementing these 
recommendations.
    I'd like to leave for the record two articles from the 
American Journal of Public Health that fully document the 
extent to which the tobacco industry through their friends in 
the Congress over decades past have enshrined into law 
impediments that will impede the elimination of tobacco in the 
military.
    Just to wind up, we strongly support the Lung Cancer 
Research Program and Congressionally Directed Medical Research 
Program and its original intent to research the scope of lung 
cancer in our military. We urge the subcommittee to restore the 
funding level to $20 million and make sure the program is 
returned to its original intent as directed by the 2009 
program, which states, ``These funds shall be used for 
competitive research. Priority shall be given to the 
development of integrated components to identify, treat, and 
manage early curable lung cancer.''
    Last, respiratory item, the American Lung Association 
continues to be troubled by reports of soldiers and civilians 
returning from Iraq and Afghanistan with lung illness. Research 
is beginning to show that the air our troops breathe in the war 
theater can have high concentrations of particulate matter, 
which can cause or worsen lung disease.

                           PREPARED STATEMENT

    Data from a 2009 study of soldiers deployed in Iraq and 
Afghanistan found that 14 percent of them suffered new-onset 
respiratory symptoms. This is a much higher rate than their 
nondeployed colleagues. So we urge that immediate steps be 
taken to minimize troop exposure to pollutants and that DOD 
investigate pollutants in the air our troops breathe.
    Thank you very much for your time today.
    [The statement follows:]
            Prepared Statement of Captain Charles D. Connor
    The American Lung Association is pleased to present this testimony 
to the Senate Appropriations subcommittee on the Department of Defense 
(DOD). The American Lung Association was founded in 1904 to fight 
tuberculosis and today, our mission is to save lives by improving lung 
health and preventing lung disease. We accomplish this through 
research, advocacy, and education.
    I have no doubt you recognize the importance of keeping our 
soldiers' lungs healthy. A soldier who uses tobacco or has asthma or 
other lung disease is a soldier whose readiness for combat is 
potentially compromised. Additionally, healthcare costs for these 
troops continue to rise, both for DOD and for the Veteran's 
Administration (VA). We owe it to our soldiers, their families, and 
taxpayers to prioritize troops' lung health.
    The American Lung Association wishes to invite your attention to 
three issues for the DOD fiscal year 2013 budget:
  --the terrible burden on the military caused by tobacco use and the 
        need for the Department to aggressively combat it;
  --the importance of restoring funding for the Peer-Reviewed Lung 
        Cancer Research Program to $20 million; and
  --the health threat posed by soldiers' exposure to toxic pollutants 
        in Iraq and Afghanistan.
                      tobacco use in the military
    Tobacco use is a significant public health problem for DOD. And it 
is not a problem DOD has simply inherited. More than 1 in 7 
(approximately 15 percent) of active duty personnel begin smoking after 
joining the service.
    The American Lung Association recognizes the Department of the 
Navy's recent efforts to reduce tobacco use in the military, such as 
the Navy's 21st Century Sailor initiative. This initiative will help 
sailors and marines quit tobacco, promote tobacco-free environments, 
and put in place environmental changes that will reduce tobacco use 
throughout the Navy and Marine Corps.
    The American Lung Association also recognizes the Department of the 
Air Force for its March 26 Air Force Instruction (AFI 40-102) on 
Tobacco Use in the Air Force. The Instruction states that ``the goal is 
a tobacco-free Air Force,'' and lays out strong policies on tobacco-
free facilities and workplaces, tobacco use in formal training 
programs, and tobacco cessation programs. The document also establishes 
clear responsibilities within the Air Force chain of command to 
accomplish its goal and enforce the policies. Both of these efforts are 
unprecedented investments in the comprehensive health of sailors, 
marines, and airmen and their families. The American Lung Association 
hopes these initiatives expand to other military branches.
    In 2011, DOD released a proposed rule implementing coverage of 
tobacco cessation treatment through TRICARE. When finalized, this new 
coverage will give soldiers and their families the help they need to 
quit tobacco.
    All of these actions follow recommendations in the Institute of 
Medicine's report Combating Tobacco Use in Military and Veterans 
Populations. The American Lung Association urges DOD and VA to fully 
implement all recommendations included in the report.
                      lung cancer research program
    The American Lung Association strongly supports the Lung Cancer 
Research Program (LCRP) in the Congressionally Directed Medical 
Research Program (CDMRP), and its original intent to research the scope 
of lung cancer in our military. In fiscal year 2012, LCRP received 
$10.2 million. We urge this subcommittee to restore the funding level 
to $20 million and that the LCRP be returned to its original intent, as 
directed by the 2009 program: ``These funds shall be for competitive 
research . . . Priority shall be given to the development of the 
integrated components to identify, treat, and manage early curable lung 
cancer''.
    In August 2011, the National Cancer Institute released results from 
its National Lung Screening Trial (NLST), a randomized clinical trial 
that screened at-risk smokers with either low-dose computed tomography 
(CT) or standard chest xray. The study found that screening individuals 
with low-dose CT scans could reduce lung cancer mortality by 20 percent 
compared to chest xray. These are exciting results, but conclusions can 
only be drawn for the segment of the population tested by the NLST:
  --current or former smokers aged 55 to 74 years;
  --a smoking history of at least one pack a day for at least 30 years; 
        and
  --no history of lung cancer. As the report made clear, CT scans 
        should be recommended for this narrowly defined population of 
        patients--but evidence does not support recommending them for 
        everyone.
    The American Lung Association recently endorsed screening for this 
defined population.
    The Lung Cancer Research Program has the potential to further 
knowledge on the early detection of lung cancer. The program recently 
funded an exciting study at Boston University aimed at discovering 
biomarkers to improve the accuracy of lung cancer diagnoses. We 
encourage the DOD to continue its research into lung cancer.
                       respiratory health issues
    The American Lung Association is troubled by reports of soldiers 
and civilians returning from Iraq and Afghanistan with lung illnesses. 
Research is beginning to show that the air troops breathe in the war 
theater can have high concentrations of particulate matter, which can 
cause or worsen lung disease. Data from a 2009 study of soldiers 
deployed in Iraq and Afghanistan found that 14 percent of them suffered 
new-onset respiratory symptoms, a much higher rate than their 
nondeployed colleagues. The American Lung Association urges that 
immediate steps be taken to minimize troop exposure to pollutants and 
that the DOD investigate pollutants in the air our troops breathe.
                               conclusion
    In summary, this Nation's military is the best in the world, and we 
should do whatever necessary to ensure that the lung health needs of 
our armed services are fully met. Troops must be protected from tobacco 
and unsafe air pollution and the severe health consequences.
    Thank you.

    Chairman Inouye. The matter that you have discussed is very 
serious and we look upon it as very serious. I can assure you 
that we'll continue funding this.
    Thank you.
    Our next witness is Dr. William Strickland, representing 
the American Psychological Association.
STATEMENT OF WILLIAM J. STRICKLAND, Ph.D., AMERICAN 
            PSYCHOLOGICAL ASSOCIATION
    Dr. Strickland. Good morning, Mr. Chairman and Mr. Vice 
Chairman. I'm Dr. Bill Strickland from the Human Resources 
Research Organization (HumRRO). I'm submitting testimony today 
on behalf of the American Psychological Association (APA), 
which is a scientific and professional organization of more 
than 137,000 psychologists.
    For decades, psychologists have played vital roles within 
the Department of Defense (DOD) as providers of clinical 
services to military personnel and their families and as 
scientific researchers investigating mission-targeted issues 
ranging from airplane cockpit design to counterterrorism. My 
own military-oriented research and consulting focus on 
recruiting, selecting, and training enlisted members of the 
Army and the Air Force.
    My testimony this morning will focus on reversing 
administration-proposed cuts to the DOD science and technology 
(S&T) budget. In terms of the overall DOD S&T budget, the 
President's request for fiscal year 2013 represents another 
step backward for defense research. Defense S&T would fall from 
an enacted fiscal year 2012 level of $12.3 billion to $11.9 
billion.
    APA urges the subcommittee to reverse this cut to the 
critical Defense Science Program by providing a total of $12.5 
billion in Defense S&T funds in fiscal year 2013. APA also 
encourages the subcommittee to provide increased funding to 
reverse specific cuts to psychological research throughout the 
military research laboratories. This human-centered research is 
vital to sustaining warfighter superiority and both the 
national academies and the Defense Science Board recommend that 
DOD fund priority research in the behavioral sciences in 
support of national security.
    In the President's proposed fiscal year 2013 budget, the 
Army and Air Force basic and applied research accounts all 
would be reduced. The Air Force Research Laboratory's Human 
Effectiveness Directorate is an example of a vital DOD human-
centered research program slated for dramatic cuts. 
Headquartered at Wright-Paterson Air Force Base in Ohio, with 
additional research sites in Texas and Arizona, the Human 
Effectiveness Directorate's mission is to provide science and 
leading-edge technology to define human capabilities, 
vulnerabilities and effectiveness, to train warfighters, to 
integrate operators and weapons systems, and to protect Air 
Force personnel while sustaining aerospace operations.
    The directorate is the heart of human-centered science and 
technology in the Air Force as it integrates both biological 
and cognitive technologies to optimize and protect airmen's 
capabilities to fly, fight, and win in air, space, and 
cyberspace. Proposed cuts to this directorate would cripple the 
Air Force's to optimize the human elements of warfighting 
capability.

                           PREPARED STATEMENT

    We urge you to support the men and women on the front lines 
by reversing yet another round of cuts to the overall Defense 
S&T account, and specifically to the human-oriented research 
projects within the military laboratories.
    Thank you and I'd be happy to answer any questions.
    Chairman Inouye. We will most certainly look into these 
cuts. I've been told that you have some report language you'd 
like to recommend.
    Dr. Strickland. Yes, Sir, we do. It's in my written 
statement.
    Chairman Inouye. Will you submit that, Sir?
    Dr. Strickland. Yes, Sir.
    Chairman Inouye. I thank you very much, Doctor.
    [The statement follows:]
           Prepared Statement of William J. Strickland, Ph.D.
    The American Psychological Association (APA) is a scientific and 
professional organization of more than 137,000 psychologists and 
affiliates.
    For decades, psychologists have played vital roles within the 
Department of Defense (DOD), as providers of clinical services to 
military personnel and their families, and as scientific researchers 
investigating mission-targeted issues ranging from airplane cockpit 
design to counterterrorism. More than ever before, psychologists today 
bring unique and critical expertise to meeting the needs of our 
military and its personnel. APA's testimony will focus on reversing 
administration cuts to the overall DOD Science and Technology (S&T) 
budget and maintaining support for important behavioral sciences 
research within DOD.
     fiscal year 2013 department of defense appropriations summary
    The President's budget request for basic and applied research at 
DOD in fiscal year 2013 is $11.9 billion, a significant cut from the 
enacted fiscal year 2012 level of $12.3 billion. APA urges the 
subcommittee to reverse this cut to the critical Defense Science 
Program by providing a total of $12.5 billion for Defense S&T in fiscal 
year 2013.
    APA also encourages the subcommittee to provide increased funding 
to reverse specific cuts to psychological research through the military 
research laboratories. This human-centered research is vital to 
sustaining warfighter superiority.
                     department of defense research
    ``People are the heart of all military efforts. People operate the 
available weaponry and technology, and they constitute a complex 
military system composed of teams and groups at multiple levels. 
Scientific research on human behavior is crucial to the military 
because it provides knowledge about how people work together and use 
weapons and technology to extend and amplify their forces.''----Human 
Behavior in Military Contexts; Report of the National Research Council, 
2008.

    Just as a large number of psychologists provide high-quality 
clinical services to our military servicemembers stateside and abroad 
(and their families), psychological scientists within DOD conduct 
cutting-edge, mission-specific research critical to national defense.
behavioral research within the military service labs and department of 
                                defense
    Within DOD, the majority of behavioral, cognitive, and social 
science is funded through the Army Research Institute for the 
Behavioral and Social Sciences (ARI) and Army Research Laboratory 
(ARL); the Office of Naval Research (ONR); and the Air Force Research 
Laboratory (AFRL), with additional, smaller human systems research 
programs funded through the Office of the Secretary of Defense (OSD) 
and the Defense Advanced Research Projects Agency (DARPA).
    The military service laboratories provide a stable, mission-
oriented focus for science, conducting and sponsoring basic (6.1), 
applied/exploratory development (6.2), and advanced development (6.3) 
research. These three levels of research are roughly parallel to the 
military's need to win a current war (through products in advanced 
development, 6.3) while concurrently preparing for the next war (with 
technology ``in the works,'' 6.2) and the war after next (by taking 
advantage of ideas emerging from basic research, 6.1). All of the 
services fund human-related research in the broad categories of 
personnel, training, and leader development; warfighter protection, 
sustainment, and physical performance; and system interfaces and 
cognitive processing.
National Academies Report Calls for Doubling Behavioral Research
    A recent National Academies report on ``Human Behavior in Military 
Contexts'' recommended doubling the current budgets for basic and 
applied behavioral and social science research ``across the U.S. 
military research agencies.'' It specifically called for enhanced 
research in six areas:
  --intercultural competence;
  --teams in complex environments;
  --technology-based training;
  --nonverbal behavior;
  --emotion; and
  --behavioral neurophysiology.
    Behavioral and social science research programs eliminated from the 
mission labs due to cuts or flat funding are extremely unlikely to be 
picked up by industry, which focuses on short-term, profit-driven 
product development. Once the expertise is gone, there is absolutely no 
way to ``catch up'' when defense mission needs for critical human-
oriented research develop. As DOD noted in its own Report to the Senate 
Appropriations Committee:

    ``Military knowledge needs are not sufficiently like the needs of 
the private sector that retooling behavioral, cognitive and social 
science research carried out for other purposes can be expected to 
substitute for service-supported research, development, testing, and 
evaluation . . . our choice, therefore, is between paying for it 
ourselves and not having it.''
Defense Science Board Calls for Priority Research in Social and 
        Behavioral Sciences
    This emphasis on the importance of social and behavioral research 
within DOD is echoed by the Defense Science Board (DSB), an independent 
group of scientists and defense industry leaders whose charge is to 
advise the Secretary of Defense and the Chairman of the Joint Chiefs of 
Staff on ``scientific, technical, manufacturing, acquisition process, 
and other matters of special interest to the Department of Defense''.
    In its report on ``21st Century Strategic Technology Vectors'', the 
DSB identified a set of four operational capabilities and the 
``enabling technologies'' needed to accomplish major future military 
missions (analogous to winning the Cold War in previous decades). In 
identifying these capabilities, DSB specifically noted that ``the 
report defined technology broadly, to include tools enabled by the 
social sciences as well as the physical and life sciences.'' Of the 
four priority capabilities and corresponding areas of research 
identified by the DSB for priority funding from DOD, the first was 
defined as ``mapping the human terrain''--understanding the human side 
of warfare and national security.
     fiscal year 2013 department of defense budget for science and 
                               technology
Department of Defense
    In terms of the overall DOD S&T budget, the President's request for 
fiscal year 2013 again represents a step backward for defense research. 
Defense S&T would fall from an enacted fiscal year 2012 level of $12.3 
to $11.9 billion. The military service labs and Defense-wide research 
offices would see variable decreases, but also in some cases increases, 
to their accounts. The Army and Air Force 6.1, 6.2, and 6.3 accounts 
all would be reduced in the proposed budget. Navy's basic research 
account (6.1) would remain funded at the fiscal year 2012 level, but 
its 6.2 and 6.3 applied research portfolios each would see decreases. 
DOD's OSD Defense-wide account would get increased funding in fiscal 
year 2013 for both its basic 6.1 and advanced development 6.3 research, 
whereas its 6.2 applied research account would be cut.
    AFRL's Human Effectiveness Directorate is an example of a vital DOD 
human-centered research program slated for dramatic cuts in the 
President's fiscal year 2013 budget. Headquartered at Wright-Patterson 
Air Force Base in Ohio (with additional research sites in Texas and 
Arizona), the 711th Human Performance Wing's Human Effectiveness 
Directorate's mission is to provide ``science and leading-edge 
technology to define human capabilities, vulnerabilities and 
effectiveness; train warfighters; integrate operators and weapon 
systems; protect Air Force personnel; and sustain aerospace operations. 
The directorate is the heart of human-centered science and technology 
for the Air Force'', and integrates ``biological and cognitive 
technologies to optimize and protect the Airman's capabilities to fly, 
fight and win in air, space and cyberspace''. Proposed cuts to this 
Directorate would cripple the Air Force's ability to optimize the human 
elements of warfighting capability.
Defense Advanced Research Projects Agency
    Defense Advanced Research Projects Agency (DARPA) is slated for a 
slight agency-wide increase over its fiscal year 2012 level, increasing 
from $2.74 to $2.75 billion in fiscal year 2013.
                                summary
    The President's budget request for basic and applied research at 
DOD in fiscal year 2013 is $11.9 billion, a significant cut from the 
enacted fiscal year 2012 level of $12.3 billion. APA urges the 
subcommittee to reverse this cut to the critical Defense Science 
Program by providing a total of $12.5 billion for Defense S&T in fiscal 
year 2013.
    APA also encourages the subcommittee to provide increased funding 
to reverse specific cuts to psychological research through the military 
research laboratories. This human-centered research is vital to 
sustaining warfighter superiority.
    Within the S&T program, APA encourages the subcommittee to follow 
recommendations from the National Academies and the Defense Science 
Board to fund priority research in the behavioral sciences in support 
of national security. Clearly, psychological scientists address a broad 
range of important issues and problems vital to our national defense, 
with expertise in modeling behavior of individuals and groups, 
understanding and optimizing cognitive functioning, perceptual 
awareness, complex decisionmaking, stress resilience, recruitment and 
retention, and human-systems interactions. We urge you to support the 
men and women on the front lines by reversing another round of cuts to 
the overall Defense S&T account and the human-oriented research 
projects within the military laboratories.
    As our Nation continues to meet the challenges of current 
engagements, asymmetric threats, and increased demand for homeland 
defense and infrastructure protection, enhanced battlespace awareness 
and warfighter protection are absolutely critical. Our ability to both 
foresee and immediately adapt to changing security environments will 
only become more vital over the next several decades. Accordingly, DOD 
must support basic S&T research on both the near-term readiness and 
modernization needs of the Department and on the long-term future needs 
of the warfighter.
    Below is suggested appropriations report language for fiscal year 
2013 which would encourage the DOD to fully fund its behavioral 
research programs within the military laboratories and the Minerva 
Initiative:
                         department of defense
Research, Development, Test, and Evaluation
    Warfighter Research.--The subcommittee notes the increased demands 
on our military personnel, including high operational tempo, leadership 
and training challenges, new and ever-changing stresses on 
decisionmaking and cognitive readiness, and complex human-technology 
interactions. To help address these issues vital to our national 
security, the subcommittee has provided increased funding to reverse 
cuts to psychological research through the military research 
laboratories:
  --the Air Force Office of Scientific Research and Air Force Research 
        Laboratory;
  --the Army Research Institute for the Behavioral and Social Sciences 
        and Army Research Laboratory; and
  --the Office of Naval Research.
    The Committee also notes the critical contributions of behavioral 
science to combating counterinsurgencies and understanding extremist 
ideologies, and renews its strong support for the DOD Minerva 
Initiative.

    Chairman Inouye. Our next witness is Mr. Robert Ginyard, 
ZERO--the Project to End Prostate Cancer.
STATEMENT OF ROBERT GINYARD, MEMBER, BOARD OF 
            DIRECTORS, ZERO--THE PROJECT TO END 
            PROSTATE CANCER
    Mr. Ginyard. Good morning, Mr. Chairman. Good morning, Vice 
Chairman. Thank you for the opportunity to speak to you about 
the prostate cancer research program and the Congressionally 
Directed Medical Research Programs at the Department of 
Defense.
    My name is Robert Ginyard. I am a member of the Board of 
Directors of ZERO--The Project to End Prostate Cancer, but I'm 
also a prostate cancer survivor.
    ZERO is a patient advocacy organization that raises 
awareness and educates men and their families about prostate 
cancer. Of particular importance to us is the issue of early 
detection. It is a fact that early detection of prostate cancer 
increases the likelihood that a man will survive prostate 
cancer. In fact, if caught early the cancer--surviving cancer 
at least 5 years is nearly 100 percent. If the cancer spreads 
outside of the prostate into other organs, the chances drop to 
29 percent. This is why I'm here today.
    The recent actions taken by the United States Preventative 
Service Task Force (USPSTF) threaten men's access to care and 
makes it more important than ever for us to protect critical 
research dollars that will help doctors make better decisions 
about the diagnosis and treatment.
    Two years ago my life was changed forever when I heard the 
words: ``You have prostate cancer.'' Because my father also had 
prostate cancer, I began having my prostate checked at age 40. 
I am now 49. During my annual checkup, my doctor noticed that 
my prostate-specific antigen (PSA) level was high, and it had 
been rising in recent years. After the results of this PSA, 
however, my doctor suggested that I see a urologist.
    A few days after, I received a call that I would never want 
to wish on anyone else. The doctor said: You do have prostate 
cancer. I recall the doctor mentioning that he hated to give 
this news on a Monday morning and, quite frankly, it wouldn't 
have mattered what day he had given me this news.
    I remember crying in the stairwell outside of my office. 
The only thing I thought about was death, how long do I have to 
live, will I see my daughters go to their prom, will I see them 
go off to college, how will my beautiful wife and children make 
out without me if something happens to me?
    After getting over my diagnosis, it was time to take 
action. I elected to receive a radical prostatectomy in 2010, 
but because there were positive margins I had to undergo 4 
months of radiation treatment and 4 months of hormone 
treatment. Thirteen months afterwards, I'm proud to say, I'm 
happy to say, I'm blessed to say, I am cancer-free with a great 
quality of life.
    But one of the most important things that came out of my 
experiences things. During my daily treatments, most of the men 
that I was in treatment with would always talk about their 
wives. They would talk about them with hope in their voices. 
They talked about how they wanted to enjoy life rather than 
focus on death. It is my hope that we find a cure for prostate 
cancer so that every day will be a father's day, a son's day, a 
brother's day, a good friend's day.
    I'm here today because prostate cancer affects the family, 
not just the man. I am here today because I want the important 
research at the Congressionally Directed Medical Research 
Program, and particularly the Prostate Cancer Research Program.
    Prostate cancer is a disease that is diagnosed in more than 
240,000 American men each year and will kill 28,000 men in 
2012. It is the second leading cause of cancer deaths among 
men. One in six men--1 in 4 African-American men--will get 
prostate cancer. Some will only be in their 30s.
    The recent recommendation change by the USPSTF has 
highlighted the issue of early detection for prostate cancer. 
However, the issue is not whether we should be trying to detect 
prostate cancer early, but how we can do it most effectively 
and identify what cancers should be treated versus the ones 
that shouldn't. The only way that doctors will know the answer 
to this question is through advances that may be closer than we 
think.
    In 2010, research partially funded by the Prostate Cancer 
Research Program identified 24 types of prostate cancer. Each 
of these are aggressive forms of the disease. If we could 
identify what type of cancer a man has, we could more 
effectively determine if he needs treatment and how aggressive 
treatment should be. This would render moot the argument some 
make that the disease is overtreated and ultimately save men's 
lives.
    The Prostate Cancer Research Program is funding some of the 
most critical research in cancer today. I ask that the 
committee continue to fund this important, important research. 
Many men will count on you. Many women will count on you. Their 
family members will count on you.

                           PREPARED STATEMENT

    It is one day that I can always look back and say: Hey, 
look, I was there with you. I hope we get through this 
together. I just ask for your continued support in this 
initiative. There are many men who are really hoping that you 
make the right decision to allocate the proper resources for 
this research.
    I thank you for your time and I thank you for your efforts 
and all that you've done. Thank you.
    [The statement follows:]
                  Prepared Statement of Robert Ginyard
    Mr. Chairman and members of the subcommittee: Thank you for the 
opportunity to speak to you about the Prostate Cancer Research Program 
(PCRP) and the Congressionally Directed Medical Research Programs 
(CDMRP) at the Department of Defense. My name is Robert Ginyard--I am a 
member of the Board of Directors of ZERO--The Project to End Prostate 
Cancer. Many people can speak effectively about the research this 
program has done or is doing, about its history, funding levels, and 
accomplishments, but I want to tell you about my experience with 
prostate cancer and how you are having an impact on the lives of 
patients and will continue to impact the lives of men and their 
families through the research funded by the PCRP.
    ZERO is a patient advocacy organization that raises awareness and 
educates men and their families about prostate cancer. Of particular 
importance to us is the issue of early detection. It is a fact that 
early detection of prostate cancer increases the likelihood that a man 
will survive prostate cancer. In fact, if caught early, a man's chances 
of surviving cancer at least 5 years is nearly 100 percent--if the 
cancer spreads outside of the prostate into other organs those chances 
drop to 29 percent. This is why I am here today--recent actions by the 
United States Preventive Services Task Force (USPSTF) threaten men's 
access to care and makes it more important than ever for us to protect 
critical research dollars that will help doctors make better decisions 
about diagnosis and treatment.
    Two years ago, my life was changed forever by three words I thought 
I would never hear: ``You have cancer.'' Prior to receiving the news 
that I had prostate cancer, I was engaged in another sort of battle--
seeking investors to raise capital for my tote bag company. And then 
things came to an unexpected halt.
    Because my father also had prostate cancer, I began having my 
prostate checked at age 40; I am now 49. During my annual check up my 
doctor noticed that my prostate specific antigen (PSA) level was high--
it had been rising in recent years. After the results of this PSA, 
however, my doctor suggested I see a urologist for a biopsy. After a 
few days, I received a call that I thought I would never receive--we 
did find cancer in your prostate. I recall the doctor mentioning that 
he hated to deliver this type of news on a Monday morning. Quite 
frankly, with this type of news, it would not have made a difference 
what day I received it. I remember crying in a stairwell outside of my 
office. The only thing I thought of was death. How long do I have to 
live? Will this mean I won't get to see my beautiful daughters go to 
their high school prom, or graduate from college? How will my wife and 
daughters make it without me?
    After getting over the shock of my diagnosis, it was time to take 
action and research the treatment options that were available to me. I 
elected to have a radical prostatectomy in August 2010. Because there 
were positive margins after my surgery, I underwent 4 months of hormone 
therapy and 8 weeks of radiation treatments. Thirteen months after 
treatment, I am happy to be cancer-free with a great quality of life.
    One of the most interesting things that came out of my prostate 
cancer experience was the power of hope. During my daily radiation 
treatments, many of the men who I got to know on a very personal basis 
always had a look of hope in their eyes. Going through with their 
treatments they always talked about their wives. They talked about it 
with hope in their voices--hope that their treatment will cure them, or 
keep the cancer away long enough to be more engaged in living rather 
than focusing on dying. It is with this hope that we must continue to 
fund prostate cancer research so that everyday will be father's day, 
son's day, grandfather's day, uncle's day, brother's day, or simply a 
good friend's day.
    I am here today because prostate cancer affects the family, not 
just the man. I am here today because I want to stress the importance 
of research at the CDMRP and particularly the PCRP.
    Prostate cancer is a disease that is diagnosed in more than 240,000 
American men each year and will kill more than 28,000 men in 2012. It 
is the second-leading cause of cancer related deaths among men. One in 
six men--1 in 4 African-American men--will get prostate cancer and some 
will only be in their 30s. It's not just an old man's disease.
    The recent recommendation change by the USPSTF has highlighted the 
issue of early detection for prostate cancer. However, the issue is not 
whether we should be trying to detect prostate cancer early, but how 
can we do it most effectively and identify the cancers that should be 
treated versus the ones that shouldn't.
    The only way doctors will ever really know the answer to this 
question is through advances that may be closer than we think. In 2010, 
research partially funded by the PCRP identified 24 different types of 
prostate cancer. Eight of these are aggressive forms of the disease. If 
we could identify what type of prostate cancer a man has, we could more 
effectively determine if he needs treatment and how aggressive that 
treatment should be. This would render moot the argument some make that 
the disease is over-treated, and ultimately save men's lives.
    Another innovative funding mechanism of the PCRP is the Clinical 
Trials Consortium. To address the significant logistical challenges of 
multicenter clinical research, the clinical trials consortium was 
started to promote rapid Phase I and Phase II trials of promising new 
treatments for prostate cancer.
    Since 2005, nearly 90 trials with more than 2,600 patients have 
taken place, leading to potential treatments that will soon be 
available to patients. Two recently approved drugs, XGEVA and ZYTIGA, 
benefited from the consortium, accelerating their approval time by more 
than 2 years.
    The PCRP is funding some of the most critical work in cancer today. 
The program uses innovative approaches to funnel research dollars 
directly into the best research to accelerate discovery, translate 
discoveries into clinical practice, and improve the quality of care and 
quality of life of men with prostate cancer.
    It is the only federally funded program that focuses exclusively on 
prostate cancer, which enables them to identify and support research on 
the most critical issues facing prostate cancer patients today. The 
program funds innovative, high-impact studies--the type of research 
most likely to make a difference.
    I understand that the subcommittee is working under extremely tight 
budgetary constraints this year and that many tough decisions are 
ahead. This program is important to the millions of men who are living 
with the disease, those who have survived the disease and those who are 
at risk for the disease, including our veterans and active duty 
military personnel.
    Active duty males are twice as likely to develop prostate cancer as 
their civilian counterparts. While serving our country, the United 
States Armed Forces are exposed to deleterious contaminants such as 
Agent Orange and depleted uranium. These contaminants are proven to 
cause prostate cancer in American veterans. Unfortunately, the genomes 
of prostate cancer caused by Agent Orange are the more aggressive 
strands of the disease, and they also appear earlier in a man's life. 
In addition, a recent study showed that Air Force personnel were 
diagnosed with prostate cancer at an average age of just 48.
    There are many men that will be diagnosed with cancer this year. 
These men are placing their hope in this subcommittee that you will 
consider them as you make the decision to allocate the proper resources 
to help find a cure for this disease that not only affects men, but 
their families and other loved ones.
    Thank you very much for your time.

    Chairman Inouye. I thank you very much, Mr. Ginyard, and I 
can assure you we'll do our best to continue funding.
    Mr. Ginyard. Thank you, Sir.
    Chairman Inouye. I'd like to thank the panel.
    Our next panel consists of: Captain Marshall Hanson, U.S. 
Navy, Retired, representing Associations for America's Defense; 
Major General Andrew ``Drew'' Davis, United States Marine 
Corps, Retired, representing the Reserve Officers Association; 
Ms. Karen Goraleski, representing the American Society for 
Tropical Medicine and Hygiene; and Mr. John Davis, representing 
the Fleet Reserve Association.
    May I call upon Captain Hanson.
STATEMENT OF CAPTAIN MARSHALL A. HANSON, U.S. NAVY 
            (RETIRED), ACTING CHAIRMAN, ASSOCIATIONS 
            FOR AMERICA'S DEFENSE
    Captain Hanson. Thank you, Mr. Chairman, Senator Cochran. 
It's nice to be back in this seat after an absence before this 
subcommittee of a couple of years.
    The Associations for America's Defense (A4AD) is again 
honored to testify. A4AD represents 13 associations that share 
a concern for our national security.
    While the subcommittee is recognized for its stewardship on 
the defense issues, the challenges being faced this year seem 
almost insurmountable. The administration's new defense 
strategy guidance realigns national security with a tighter 
Federal budget. Scheduled personnel cuts that start in 2015 
will be used to pay for future investments in intelligence, 
surveillance, reconnaissance, cyberspace, and counterterrorism. 
The resulting reduction in force is supposed to be offset by 
building partner capacity and by employing the concept of 
reversibility.
    While this may look good on paper, one can question the 
substance. Not only is the Nation's security at risk of being 
hollowed out from underbudgeting, but with the incomplete 
strategy the United States might not be planning for a 
potential threat.
    The Pentagon will rely on traditional and new allies to 
complement the U.S. force structure. Yet, European defense 
plans will still rely on the United States. With military 
budgets being cut in nearly all North Atlantic Treaty 
Organization (NATO) countries, there is little promise that 
Europe is ready to pick up the slack.
    The defense guidance also states that the concept of 
reversibility is a key part of the U.S. decision calculus, 
placing emphasis on quickly restarting the industrial base and 
relying on the right Active-to-Reserve component balance. This 
is akin to building our defense foundation on quicksand. 
Reversibility will take time, which may not be available in a 
crisis.
    The Pentagon has warned the Congress that there is no room 
for modification of their budget or their strategy. This was 
emphasized by the lack of submission of unfunded priority 
lists. A4AD agrees with those Senators who wrote the service 
chiefs that, without the military's budgetary needs, the 
Congress cannot accurately determine the resources necessary 
for our Nation's defense.
    Normally, A4AD's testimony would include an unfunded list 
for both the active and Reserve components which were submitted 
by member associations. But the blackout of information has 
affected us as much as it has this subcommittee.
    When the Air Force suggested hasty cuts to its 
infrastructure, the Congress wisely questioned this 
hurriedness. The Senate Armed Services Committee has suggested 
a commission to study the makeup of the Air Force. A4AD shares 
the concern over the lack of analysis and justification and 
suggests that this type of study needs to be done for all of 
the services.
    The Armed Forces need a critical surge capacity for 
domestic and expeditionary support to national security in 
response to domestic disasters. A strategic surge construct 
needs to include manpower, airlift, and air refueling, sealift 
inventory, logistics, and communications to provide a surge-to-
demand operation. This capacity requires funding for training, 
equipment, and maintenance of a mission-ready strategic reserve 
composed of both active and Reserve units.

                           PREPARED STATEMENT

    This in itself is formidable, only complicated further by 
budget control. The specter of sequestration only multiplies 
the complexity of the puzzle that needs to be solved. The 
disastrous consequences of automatic cuts to defense have been 
documented in earlier hearings. A4AD asks this subcommittee to 
work toward resolving sequestration prior to a lame duck 
session, before the meat cleaver chops into the military and 
the defense industry.
    Thank you again for the opportunity to testify.
    [The statement follows:]
      Prepared Statement of Captain Marshall Hanson, USN (Retired)
                   associations for america's defense
    Founded in January 2002, the Associations for America's Defense 
(A4AD) is an ad hoc group of military and veteran service organizations 
that have concerns about National Security issues that are not normally 
addressed by The Military Coalition (TMC) and the National Military 
Veterans Alliance (NMVA), but participants are members from each. 
Members have developed expertise in the various branches of the Armed 
Forces and provide input on force policy and structure. Among the 
issues that are addressed are equipment, end strength, force structure, 
and defense policy. A4AD also cooperatively works with other 
associations, who provide input while not including their association 
name to the membership roster.
                       participating associations
American Military Society
Army and Navy Union
Association of the U.S. Navy
Enlisted Association of the National Guard of the United States
Hispanic War Veterans of America
Marine Corps Reserve Association
Military Order of World Wars
National Association for Uniformed Services
Naval Enlisted Reserve Association
Reserve Enlisted Association
Reserve Officers Association
The Flag and General Officers' Network
The Retired Enlisted Association
                              introduction
    Mr. Chairman and distinguished members of the subcommittee, A4AD is 
again very grateful for the invitation to testify before you about our 
views and suggestions concerning current and future issues facing the 
Department of Defense Subcommittee Appropriations.
    A4AD is an ad hoc group of 13 military and veteran associations 
that have concerns about national security issues. Collectively, we 
represent Armed Forces members and their families, who are serving our 
Nation, or who have done so in the past.
              current versus future: issues facing defense
    A4AD would like to thank this subcommittee for the on-going 
stewardship that it has demonstrated on issues of defense. While in a 
time of war, this subcommittee's pro-defense and nonpartisan leadership 
continues to set an example.
Force Structure: The Risk of Erosion in Capability
    Last January, the Obama administration announced a new Defense 
Strategy Guidance, which has been a driving force in current budget 
talks. The new strategy realigns national security with a tighter 
Federal budget. Not only is the Nation's security at risk of being 
hollowed out from being under budgeted, but with an incomplete strategy 
the United States might not be planning for a potential future threat.
    Not surprisingly, a lot of the aspects about this plan are not new. 
The new strategy for the United States has evolved from fighting and 
quickly winning two major wars simultaneously into winning one war 
while ``deterring'' or ``dismantling'' the designs of a second 
potential adversary.
    Part of the ``revolution'' in military thinking justifying a new 
strategy is a refocus from Europe to ``rebalance toward the Asia-
Pacific region''. It requires a shift of power to the Pacific, with 
military end-strength reductions in Europe. But rather than build up 
garrisoned forces in the Far East, this plan calls upon the mobility of 
the Navy and Air Force to project power.
    With a leaner defense strategy, the Pentagon will rely on 
traditional and new allies to complement U.S. force structure. With the 
U.S. planning to reduce its financial and military presence in Europe, 
the Department of Defense (DOD) will expect Europe to take the lead. 
Yet with military budgets being cut in nearly all North Atlantic Treaty 
Organization (NATO) countries, there is little promise that Europe is 
ready to pick up the slack.
    Six years ago, Admiral Mike Mullen, then Chief of Naval Operations, 
envisioned a thousand-ship Navy, where the U.S. and other navies 
worldwide would partner to improve maritime security and information 
sharing. ``For it to work, explicit and implicit references to U.S. 
security concerns have to go'', warned one unnamed, former military 
officer in an ``Armed Forces Journal'' article.
    The risk of basing a national security policy on foreign interests 
and good world citizenship is increasingly uncertain because their 
national objectives can differ from our own. Alliances should be viewed 
as a tool and a force multiplier, but not the foundation of National 
Security.
    In many ways, the new strategy is ``back to the future'', with DOD 
constructing a strategy on old tactics and untried concepts, in order 
to save money. This strategy is building a force structure on a shaky 
foundation. Rather than rushing into this unknown, the Congress needs 
to examine this plan closer.
                         budgetary constraints
    A4AD strongly disagrees with placing budgetary constraints on 
defense, especially in light of the fact that under the Budget Control 
Act of 2011 (BCA) defense will take 50 percent of the cuts despite 
being less than 20 percent of the overall budget. Member associations 
also question the current administration's spending priorities, which 
place more importance on the immediate future rather than a longer-term 
approach.
    DOD faces a trigger of an additional $500 billion in budget 
reduction starting on January 1, 2013, that is in addition to the $587 
billion already planned by DOD as cuts over the next 10 years, unless 
something is done by the Congress.
    ``Historically we've run about 20 percent reductions after these 
conflicts'', warned General James E. ``Hoss'' Cartwright, USMC 
(Retired), former Vice Chairman of the Joint Chiefs at the Joint 
Warfighting Conference. ``We are about halfway there . . . If you take 
another two hundred billion out of this budget, we're going to start to 
run into a problem if you don't start thinking about strategy.''
    At a time when strategy is being shaped by budget, election 
posturing, and an authority squabble between the Congress and the 
Secretary of Defense, national security is being held hostage.
              authority over force structure and strategy
    A conflict has arisen over who maintains force structure. Defense 
Secretary Leon Panetta has objected to additional defense funding in 
the House National Defense Authorization Act, emphasizing that every $1 
added to the defense authorization will come at the expense of other 
critical national security programs. House Armed Services Committee 
chairman Representative Buck McKeon responded that increases were 
offset while complying with the overall BCA budget targets, which 
specify $487 billion in cuts.
    This exchange reflects an ongoing tension between the Pentagon and 
the Congress over defense budgeting. The new Defense Strategy Guidance 
warns ``as a result of a thorough process that was guided by the 
strategy and that left no part of the budget unexamined, we have 
developed a well-rounded, balanced package. There is no room for 
modification if we are to preserve the force and capabilities that are 
needed to protect the country and fulfill the missions of the 
Department of Defense.'' The Pentagon is frustrated with any amount of 
control by the Congress over the department's business.
    A4AD understands that the Congress takes seriously their 
constitutional responsibility to raise and maintain the Armed Forces. 
This is interpreted as congressional authority to fund, equip, and 
train the military and give committees, such as this, oversight on the 
force structure, including nonfunded items.
                         risk of sequestration
    As sequestration automatically cuts the Federal budget, DOD faces a 
trigger of an additional $500 billion in budget reduction starting on 
January 1, 2013 unless the Congress finds an offset or agrees to 
reconciliation.
    Secretary of Defense Panetta has warned the Congress that if the 
automatic cuts of sequestration are allowed to take effect then the 
number of U.S. ground troops would fall to pre-1940 levels; the Navy 
would have the smallest number of ships since 1915; and the Air Force 
would be the smallest ever.
    If the President exempts personnel accounts, Secretary Panetta 
warns that sequestration could require a 23-percent cut across the 
military's budget for fiscal year 2013.
    Some are suggesting that reconciliation can wait until after the 
election, but the lame duck session schedule is already full. Among 
things needing to be considered by December 31, 2012, are reversing 
cuts to doctors' Medicare payments, Bush tax rates, 2-percent Social 
Security payroll-tax cut, increasing the debt-ceiling negotiations, 
expiration of the payroll tax cut, extending unemployment benefits, 
rises in the Alternative Minimum Tax and the estate tax rates, tax cuts 
from the 2009 economic-growth/stimulus law, the 100-percent write-off 
for business investment, transportation and farm bill reauthorizations, 
and 12 appropriations bills.
    A4AD takes a position that it is vital that reconciliation is 
reached prior to the national election. The House has already passed 
its version. A4AD hopes that the Senate develops and passes its own 
version of a balanced deficit reduction package, thus permitting the 
two chambers to conference.
                              end strength
    The administration already proposes cutting 100,000 troops. End-
strength cuts need to be made cautiously.
    The deployment of troops to Iraq and Afghanistan proved that the 
pre-9/11 end strengths left the Army and Marine Corps undermanned, 
which stressed the force. Sequestration would double the reductions for 
these two services.
    The goal for active duty dwell time is 1:3, and 1:5 for the Reserve 
component. After 10 years of war, this has yet to be achieved under 
current operations tempo, and end-strength cuts will only further 
impact dwell time.
    Trying to pay the defense bills by premature manpower reductions 
will have consequences.
                             reversibility?
    President Obama made the point that an important goal of his 
Defense strategy guidance was to avoid the mistakes made in previous 
downsizings. He suggested that this could be done by designing 
reversibility into the drawdown.
    ``The concept of `reversibility'--including the vectors on which we 
place our industrial base, our people, our Active-Reserve component 
balance, our posture and our partnership emphasis--is a key part of our 
decision calculus,'' states the new DOD strategy.
    This concept should be approached cautiously. If manpower is 
drawndown and industry production lines are shut down, either will take 
years to recover.
    Adequate training for an infantry warrior can take a year and more, 
and even then they lack the field experience. DOD's solution is to keep 
midgrade officers and enlisted that can mature into the next-generation 
leadership. Unfortunately, this is where shortages currently exist.
    If industry is shutdown, skilled labor is laid off, and without 
incentives tooling is destroyed. A restart is neither quick nor 
inexpensive. Even with equipment back online, the skilled labor has 
left for other work opportunities.
    Without question, DOD needs to plan how it can sustain basic 
proficiencies needed to battle emerging threats before relying on 
reversibility. A4AD questions this strategy.
                     maintaining a surge capability
    The Armed Forces need to provide critical surge capacity for 
homeland security, domestic, and expeditionary support to national 
security and defense, and response to domestic disasters, both natural 
and man-made that goes beyond operational forces. A strategic surge 
construct includes manpower, airlift and air refueling, sealift 
inventory, logistics, and communications to provide a surge-to-demand 
operation. This capability requires funding for training, equipping, 
and maintenance of a mission-ready strategic reserve composed of Active 
and Reserve units.
    The budget will drive changes to the Armed Forces structure. The 
National Guard and Reserve are in a position to fulfill many of the 
missions, while remaining an affordable alternative.
                  base closure or defense realignment?
    The President's budget recommends two more rounds of base closures. 
A4AD does not support such a base realignment and closure (BRAC) 
recommendation.
  --BRAC savings are faux savings as these savings are outside the 
        accounting cycle; with a lot of additional $1 expenses front-
        loaded into the DOD budget for infrastructure improvements to 
        support transferred personnel.
  --Too much base reduction eliminates facilities needed to support 
        surge capability. Some surplus is necessary.
    Instead, A4AD recommends that the Congress consider an independent 
Defense Realignment Commission that would examine the aggregate 
national security structure. The commission could examine:
  --Emerging threats;
  --Foreign defense treaties and alliance obligations;
  --Overseas and forward deployment requirements;
  --Foreign defense aid;
  --Defense partnerships with the State Department and other agencies, 
        as well as nongovernmental organizations;
  --Requisite missions and elimination of duplicity between the 
        services;
  --Current and future weapon procurement and development;
  --Critical industrial base;
  --Surge capability and contingency repository;
  --Best utilization and force structure of Active and Reserve 
        components;
  --Regional or centralized training, and dual-purpose equipment 
        availability; and
  --Compensation, recruiting and retention, trends, and solutions.
    In a time of war and force rebalancing, it is wrong to make cuts to 
the end strength of the Reserve components. We need to pause to permit 
force planning and strategy to take precedence over budget reductions.
                        compensation commission
    Another recommendation in the President's budget is a commission to 
review deferred compensation. As structured, A4AD does not support this 
proposal either, but if considered:
  --This should not be a BRAC-like commission. The Congress should not 
        give up its authority.
  --In one section of the President's budget, it suggests that the 
        President will appoint all of the members on the commission. 
        The Congress should share in appointments.
  --While alternatives to current military retirement should be 
        explored, A4AD does not support a two-tiered system where two 
        generations of warriors have different benefit packages.
  --An incentivized retirement option could be offered, rather than 
        making any new mandatory system.
  --Should a task force be appointed, A4AD recommends that individuals 
        with military experience in both the Active and Reserve 
        component compensation be among those appointed, as the 
        administration has suggested that both regular and nonregular 
        (Reserve) retirement should be the same.
                         unfunded requirements
    Earlier this year, the Joint Chiefs of Staff announced its decision 
to discontinue the practice of providing the Congress with formal lists 
of programs that were excluded from the President's budget request.
    A4AD concurs with those Senators who wrote to the Secretary of 
Defense that the military's budgetary needs cannot be determined 
without the lists, known formally as the Unfunded Priorities Lists. 
These lists, which have effectively been an extension of the Pentagon's 
annual spending request for more than a decade, provide insight that 
may otherwise be overlooked.
    In the past, A4AD has submitted unfunded recommendations for the 
service components of the Active and Reserve forces. Without such 
lists, it is difficult to make recommendations that provide the 
committee with additional information that spans even beyond the list.
           national guard and reserve equipment requirements
    A4AD asks this subcommittee to continue to provide appropriations 
for unfunded National Guard and Reserve Equipment Requirements. The 
National Guard's goal is to make at least one-half of Army and Air 
assets (personnel and equipment) available to the Governors and 
Adjutants General at any given time. To appropriate funds to Guard and 
Reserve equipment would provide Reserve Chiefs with a flexibility of 
prioritizing funding.
                        force structure funding
U.S. Army
    Much of the media attention has been on the manpower cuts which 
could be between 72,000-80,000 soldiers over the next 6 years, along 
with a minimum of eight brigade combat teams. If sequestration occurs 
reports are that another 100,000 personnel could be cut. The problem 
faced by the Army is balancing between end strength, readiness, and 
modernization.
    Examples of Army reductions in procurement are its M1A1 Abrams 
upgrade and Stryker vehicle program taking 84 percent and 57-percent 
cuts, respectively, in planned spending. Army cuts create strategic 
vulnerabilities.
    To ignore the risk of a protracted ground campaign is a security 
gamble. The Army has provided between 50 to 70 percent of the U.S. 
deployable forces over the last 10 years.
    Yet, 1 in 3 Active Army units do not have sufficient personnel to 
perform its missions, requiring personnel to be cross-assigned from one 
unit to another to accomplish missions. The Army Reserve and National 
Guard face similar challenges. Defense cuts will further impact the 
Army's ability to train and be ready. The Army needs $25 billion to 
reset its force.
    Air power and technology may be a critical part of a strategy, but 
America's enemies won't fight the way America expects them to. Boots on 
the ground will remain a critical part of this Nation's defense.
U.S. Marine Corps
    Proposed budget cuts and mission resets could clip USMC's 
triphibious flexibility. The USMC's capability to perform a combined 
mission of land, naval, and air attack could become unbalanced with the 
administration's plan to reset funding and missions to pre-war 
strategies, and build-down the Armed Forces.
    A change in strategy announced by Secretary of Defense Leon Panetta 
would cut the USMC further than the 20,000 announced by the 
administration. Under consideration is the elimination of another 
infantry battalion and reducing some light-armored reconnaissance 
capability.
    A4AD supports the House V-22 proposal to procure under a multiyear 
procurement contract that will save a proposed $852 million versus 
single-year contracts.
    The USMC is facing critical shortages of stockpiled equipment such 
as radios, small arms, and generators. It needs about $12 billion to 
reset its force.
    The past three Marine Commandants have emphasized that the USMC 
needs to get back to its naval roots as an amphibious force. The 
associations have concerns that the stated need for amphibious warships 
is a minimum of 33, and the likely cap is 30 ships.
U.S. Navy
    Proposed defense cuts could reduce the number of navy ships to the 
point that China will become dominant in the Western Pacific. This 
reduction undercuts the new Defense Strategy Guidance.
    Rather than growing the fleet to 330 ships, under sequestration 
analyst warns that the fleet could drop to as few than 230 ships. The 
Navy is tempted to retire ships early to reduce manpower requirements, 
but this reduction also will reduce capability.
    One in five ships when inspected is found not to be combat ready or 
is severely degraded. The combatant commanders ask for 16 attack 
submarines on a daily basis, but the USN can only provide 10. USN's 
repair backlog is $367 million.
    The Navy could lose some of its most important shipbuilding 
industry partners if it slows down construction schedules.
    A4AD applauds the House for reinstating 3 of the 4 cruisers 
scheduled to be retired. These are cruisers with the Aegis Combat 
System that is suitable for the at-sea missile defense mission. This 
provides a flexible option to a land-based site.
U.S. Air Force
    The U.S. Air Force's (USAF) fleet is now the oldest it has ever 
been, and sequestration cuts will either reduce the number of units 
sharply, or eliminate the USAF modernization. Defense cuts will affect 
more than 20 USAF acquisition programs. Sequestration will have a 
detrimental effect on all of the Air Force's procurements, including 
new refueling tankers, tactical fighter jets, remotely piloted 
aircraft, and long-range strike bombers.
    The average age of a strategic bomber is 34 years. Cutting funds 
for a new USAF bomber would seriously setback the progress of a 
replacement.
    The Air Force plans to drop 500 aircraft from its inventory in the 
near future. This is caused by retirement of airplanes, elimination of 
close combat missions, and delays in procuring replacements. The USAF 
is cutting F-15 and F-16 fighters by more than 200 aircraft before 
replacement F-35s are available.
    The majority of these cuts are from the Air National Guard and Air 
Force Reserve, affecting air sovereignty and surge capability.
    The ``Air Force Magazine'' reports that the USAF's end-strength is 
7-percent smaller than it was 7 years ago, yet the personnel costs for 
this smaller force have risen 16 percent. USAF would have to cut 47,000 
airmen out of its total force just to hold personnel spending at a 
constant rate between fiscal year 2011 and fiscal year 2017. The Air 
Force showed that a high percentage of the cuts would be taken out of 
its Reserve components.
    A4AD commends the House Armed Services Committee for delaying the 
proposed cuts to the Air Reserve Components until the Secretary of the 
Air Force provides supporting data, and details as to the affects of 
such cuts on National Security. A4AD hopes that Senate will provide 
similar direction to DOD.
    According to Pentagon reports, the proposed fiscal year 2013 budget 
calls for a 12-percent cut in aircraft programs. Aircraft procurement 
for the Air Force, Navy, and Marine Corps, and the Army decreased from 
$54.2 billion in fiscal year 2012 to a budget request of $47.6 billion 
in fiscal year 2013.
                               conclusion
    A4AD is a working group of military and veteran associations 
looking beyond personnel issues to the broader issues of National 
Defense. This testimony is an overview, and expanded data on 
information within this document can be provided upon request.
    Thank you for your ongoing support of the Nation, the Armed 
Services, and the fine young men and women who defend our country. 
Please contact us with any questions.

    Chairman Inouye. Thank you very much, Captain. I can assure 
you that we are doing our very best to avoid sequestration, 
because if that ever happens then this hearing is for naught, 
and in the process we may have to take some painful cuts, make 
some painful decisions. But I can assure you we'll do our best.
    Thank you very much.
    Now may I call upon Major General Andrew Davis.
STATEMENT OF MAJOR GENERAL ANDREW DAVIS, U.S. MARINE 
            CORPS (RETIRED), EXECUTIVE DIRECTOR, 
            RESERVE OFFICERS ASSOCIATION OF THE UNITED 
            STATES
    General Davis. Chairman Inouye and Senator Cochran: The 
Reserve Officers Association (ROA) thanks you for the 
invitation to appear and give testimony. I am retired Marine 
Major General Drew Davis, the Executive Director of Reserve 
Officers Association. I am speaking on behalf of the Reserve 
Enlisted Association (REA).
    ROA and REA are concerned about how the Congress and the 
Pentagon will meet the requirements set by the Budget Control 
Act of 2011 and the resulting cuts to the Defense budget. With 
the Pentagon looking to reduce the Defense budget, a risk is 
that the services will make disproportionate cuts to the 
Reserve component to protect active duty roles, missions, and 
end strengths.
    Army Vice Chief of Staff General Lloyd Austin told the 
Senate that with sequestration the Army would likely lose 
another 100,000 troops on top of the 72,000 cuts already 
planned. He said that one-half of these cuts would be in the 
National Guard and the Army Reserve.
    Cutting one reservist only provides 35 percent of the cost 
savings when compared to the reduction of an active duty 
rifleman, airman, or sailor.
    As they have shown after 10 years of war, Reserve and Guard 
perform their missions on par with active duty, at less 
overhead and infrastructure cost. They require no base housing 
and no medical care, and their retirement benefit is deferred 
to age 60. To ignore the cost efficiencies of the Reserve 
component is a disservice to the American taxpayer and violates 
the axioms of strategic planning for our Nation's defense.
    Additional further cost savings are found when civilian 
knowledge and proficiencies can be called upon at no training 
cost to the military.
    With the Pentagon and the Congress examining our Nation's 
security, it would be incorrect to discount the Reserve 
components' abilities and cost efficiencies. The Reserve 
strength of these part-time warriors provides a cost-saving 
solution and are an area to retain competencies for missions 
not directly embodied in the administration's new strategic 
guidance.
    For reversibility to succeed we will need a viable Reserve 
component. The Reserve and National Guard are no longer just a 
part-time strategic force, but contribute to our Nation's 
operational ability to defend itself, project power, and 
perform needed noncombat missions.
    Nearly 850,000 Reserve and Guard members have been 
activated and deployed since September 11, 2001, with more than 
275,000 having done so two times or more. By throwing away this 
required expertise and can-do attitude, we undermine the total 
force at the same time.
    Already, the Air Force and Navy are using their Reserve 
components as bill-payers. ROA and REA thank those members of 
this committee who delayed the recommended cuts by the Air 
Force of Reserve component aircraft and facilities. Experienced 
warriors are returning to their Reserve component training 
sites and are finding aging facilities and obsolete and battle-
damaged equipment. To remain robust and relevant, they need to 
have the same type of equipment or simulators for training that 
they used during overseas missions. If the Reserve component is 
simply put on the shelf, these volunteer young men and women 
will walk away.
    ROA and REA's written testimony includes lists of unfunded 
requirements that we hope this subcommittee will fund. But we 
also urge this subcommittee to specifically identify funding 
for both the services' Reserve forces and the National Guard 
exclusively to train and equip the Reserve components by 
providing funds for the National Guard and Reserve equipment 
appropriation. Just because the services did not submit a wish 
list does not mean there are no wishes or needs.

                           PREPARED STATEMENT

    In addition, we hope that the chairman reconsiders the 
military construction appropriations to the Reserve components, 
even though that subcommittee has marked up its bill. Our 
written testimony includes dollar recommendations.
    ROA and REA thank you again for your consideration of our 
testimony and we look forward to working with this committee.
    [The statement follows:]
            Prepared Statement of Major General Andrew Davis
    The Reserve Officers Association of the United States (ROA) is a 
professional association of commissioned and warrant officers of our 
Nation's seven uniformed services and their spouses. ROA was founded in 
1922 during the drawdown years following the end of World War I. It was 
formed as a permanent institution dedicated to national defense, with a 
goal to teach America about the dangers of unpreparedness. When 
chartered by the Congress in 1950, the act established the objective of 
ROA to: ``. . . support and promote the development and execution of a 
military policy for the United States that will provide adequate 
National Security''. The mission of ROA is to advocate strong Reserve 
components and national security and to support Reserve officers in 
their military and civilian lives.
    The Association's 58,000 members include Reserve and Guard 
soldiers, sailors, marines, airmen, and coastguardsmen, who frequently 
serve on active duty to meet critical needs of the uniformed services 
and their families. ROA's membership also includes officers from the 
U.S. Public Health Service and the National Oceanic and Atmospheric 
Administration, who often are first responders during national 
disasters and help prepare for homeland security. ROA is represented in 
each State with 54 departments plus departments in Latin America, the 
District of Columbia, Europe, the Far East, and Puerto Rico. Each 
department has several chapters throughout the State. ROA has more than 
450 chapters worldwide.
    ROA is a member of The Military Coalition, where it co-chairs the 
Guard and Reserve Committee. ROA is also a member of the National 
Military/Veterans Alliance. Overall, ROA works with 75 military, 
veterans, and family support organizations.
    The Reserve Enlisted Association (REA) is an advocate for the 
enlisted men and women of the United States Military Reserve Components 
in support of national security and homeland defense, with emphasis on 
the readiness, training, and quality-of-life issues affecting their 
welfare and that of their families and survivors. REA is the only joint 
reserve association representing enlisted reservists--all ranks from 
all five branches of the military.
                              introduction
    On behalf of the 1.1 million members of the Reserve and National 
Guard, the ROA and the REA thank the subcommittee for the opportunity 
to submit testimony on budgeting issues affecting serving members, 
retirees, their families, and survivors.
    The associations would like to further thank those Senators who 
have been working to postpone planned cuts to Reserve component (RC) 
aircraft by the Air Force. A proper analysis needs to be done before 
premature action is taken that could encumber our national security.
    The title 10 Reserve and National Guard are no longer just a part-
time strategic force but are an integral contributor to our Nation's 
operational ability to defend itself, assist other countries in 
maintaining global peace, and fight against overseas threats. They are 
an integrated part of the total force, yet remain a surge capability as 
well.
    At a time that the Pentagon and the Congress are examining our 
Nation's security, it would be incorrect to discount the RC abilities 
and cost efficiencies. Instead, these part-time warriors provide a 
cost-savings solution and an area to retain competencies for missions 
not directly embodied in the administration's new strategic policy, 
``Sustaining U.S. Global Leadership: Priorities for a 21st Century 
Defense''.
    ROA and REA are concerned that as the Pentagon strives to achieve 
the administration's goals for this new strategic policy, it is not 
seriously considering the available assets and cost efficiencies of the 
RC, and that it views the Reserve and National Guard as a bill payer 
instead.
    The Congress, starting with the leadership of this subcommittee, 
should insist on a methodical analysis of suggested reductions in 
missions and bases before budgeting for such changes. Haste creates 
mistakes.
           provide and execute an adequate national security
    The ROA is chartered by the Congress ``to support and promote the 
development and execution of a military policy for the United States 
that will provide adequate national security''.
    Requested action:
  --Hold congressional hearings on the new policy of ``Sustaining U.S. 
        Global Leadership: Priorities for the 21st Century Defense''.
  --Seek reconciliation to offset Defense sequestration budget cuts.
  --Study the impact of manpower cuts to Army and Marine Corps on 
        national security.
  --Avoid simple parity cuts of components without analyzing the best 
        Active-Reserve balance.
  --Maintain robust and versatile all-volunteer Armed Forces that can 
        accomplish its mission to defend the homeland and U.S. 
        interests overseas.
    ROA and REA question the current spending priorities that place 
more importance on the immediate future, rather than first doing a 
short- and long-term threat analysis. The result of such a budget-
centric policy could again lead to a hollow force whose readiness and 
effectiveness is degraded.
    ROA and REA share concerns about reductions in the Department of 
Defense, while proposed budgets for other Federal agencies increase. An 
example of this is the $13.4 billion budget increase for the Department 
of Veteran Affairs (VA). Of this, $10.6 billion is an increase in 
mandatory funding. When ROA asked the VA's Chief Financial Officer, 
Todd Grams, what offset is being made to allow this increase, his 
response was that no offset was needed as all but $1 billion were for 
existing programs.
    While some VA increase is obviously needed with the ever increasing 
number of service-connected veterans who are disabled, injured, or ill, 
every agency should be fiscally responsible to help balance the budget 
and reduce the ever-growing deficit.
    Serving members, retirees, families, and survivors are in effect 
being taxed by defense reductions to be the dollar offsets for other 
departments. Not only is this unfair, but by making cuts to national 
security, it puts future warriors at a greater risk.
                    reserve strength thru efficiency
    ``With roughly 1.4 [million] Active-Duty servicemembers, 1.2 
million Reserve-component members and likely future missions 
worldwide,'' Dennis McCarthy, then-Assistant Secretary of Defense for 
Reserve Affairs told ROA, ``the military will need to continue to rely 
on reserve strength.''
    The Reserve forces are no longer a part-time strategic force but 
are an integral contributor to our Nation's operational ability to 
defend our soil, assist other countries in maintaining global peace, 
and fight in overseas contingency operations, as demonstrated by the 
last 10 years of war. The Reserve and National Guard should not be 
arbitrarily cut from the defense strategy.
    Rather than be limited by historical thinking, and parochial 
protections, creative approaches should be explored. The RC needs to 
continue in an operational capacity because of cost efficiency and 
added value. The cost of the Reserve and National Guard should not be 
confused with their value, as their value to national defense is 
incalculable.
    The RCs remain a cost-efficient and valued force. It is just a 
small percentage of the total services budget:
  --Army Reserve: 7 percent of the Army budget; 18 percent of the 
        force.
  --Army National Guard: 14 percent of the Army budget; 32 percent of 
        the force.
  --Marine Forces Reserve: 6 percent of the United States Marine Corps 
        (USMC) budget; 16.5 percent of the force.
  --Navy Reserve: 7 percent of the United States Navy budget; 17 
        percent of the force.
  --Air Force Reserve: 4 percent of the Air Force (AF) budget, 14 
        percent of the force, and 20 percent of the capability.
  --Air National Guard: 6 percent of the AF budget and 21 percent of 
        the force.
    Value, on the other hand, is more intangible to calculate. The RC 
fills an ongoing need for a surge capability as an insurance policy 
against worse-case scenario's. Reserve and National Guard members give 
the armed forces access to civilian skills that would prove too 
expensive for the uniformed services to train and maintain. With less 
than 1 percent of the U.S. population serving in uniform, the RC also 
provides a critical link to American communities.
    The Reserve and National Guard should also be viewed as a 
repository for missions and equipment that aren't addressed in the 
administration's new strategic policy. They can sustain special 
capabilities not normally needed in peacetime.
    Part of the President's budget includes planned end-strength 
reductions for both the Army and Marine Corps, by 80,000 and 20,000, 
respectively. It should be remembered that individuals cannot be 
brought quickly on to active duty on a temporary basis, as it is an 
accumulation of experience and training that is acquired over years 
that becomes an asset for the military. The Reserve is also a 
repository for these skills.
    To maintain a strong, relevant, and responsive Reserve force, the 
Nation must commit the resources necessary to do so. Reserve strength 
is predicated on assuring the necessary resources--funding for 
personnel and training, equipment reconstitution, and horizontal 
fielding of new technology to the RC, coupled with defining roles and 
missions to achieve a strategic/operational Reserve balance.
           national guard and reserve equipment appropriation
    Once a strategic force, the RCs are now also being employed as an 
operational asset; stressing an ever greater need for procurement 
flexibility as provided by the National Guard and Reserve Equipment 
Appropriations (NGREA). Much-needed items not funded by the respective 
service budget are frequently purchased through NGREA. In some cases, 
it is used to procure unit equipment to match a state of modernizations 
that aligns with the battlefield.
    With the active component (AC) controlling procurement, a risk 
exists where Defense planners may be tempted to put the National Guard 
and title 10 Reserve on the shelf, by providing them ``hand me down'' 
outmoded equipment and by underfunding training. NGREA gives the 
Reserve chiefs some funding control.
    The Reserve and National Guard are faced with the ongoing 
challenges of how to replace worn out equipment, equipment lost due to 
combat operations, legacy equipment that is becoming irrelevant or 
obsolete, and, in general, replacing what is lost in combat, or aged 
through the abnormal wear and tear of deployment. The RCs benefit 
greatly from a National Military Resource Strategy that includes an 
NGREA.
    The Congress has provided funding for the NGREA for more than 30 
years. At times, this funding has made the difference in a unit's 
abilities to carry out vital missions.
    ROA thanks the Congress for approving $1 billion for NGREA for 
fiscal year 2012, but more dollars continue to be needed. ROA urges the 
Congress to appropriate into NGREA an amount that is proportional to 
the missions being performed, which will enable the RC to meet its 
readiness requirements.
                         military construction
    ROA and REA attempted to submit testimony to an earlier hearing on 
military construction by the Subcommittee on Military Construction and 
Veterans Affairs, and other related agencies, but the associations were 
told to submit this during the public witness hearing.
    Unfortunately, the Military Construction and Veterans Affairs, and 
other related agencies marked up their portion of the Senate version of 
the appropriations bill on May 15. It is hoped that the Chairman will 
include some of the following information in his Chairman's markup.
    Requested Action.--ROA and REA urge the Congress to continue 
appropriating funds for Military Construction budgets for the Reserve 
and National Guard.
    Military Construction funding has not generally kept pace with 
essential RC facility modernization, conversion, and replacement 
requirements. In fiscal year 2012, Military Construction for the RC was 
appropriated $1.2 billion, which was $223 million less then the fiscal 
year 2011 enacted level. The RCs indicated they need a higher level of 
Military Construction funding in fiscal year 2013.
    The RC's mission has changed from being primarily strategic 
reserves and ``weekend warriors'' to being an operational reserve. The 
RC now has a required high level of mission readiness which needs to be 
supported by functional training and facilities for current and future 
needs. They must train troops, maintain facilities and prepare troops 
postdeployments to return to civilian life. Additionally, families are 
supported throughout the force regeneration cycle phases. All of these 
initiatives require maintaining, renovating, and modernizing 
facilities.
    As morale and combat readiness can be significantly affected by 
inadequate facilities, it is prudent to sustain fiscal year 2011's 
level of improvement (except the Air Force) in funding and allocation 
of projects in fiscal year 2013.
    Five-year project backlog:
      Army National Guard.--Approximately $1.8 billion.
      Air National Guard.--Approximately $660 million.
      Army Reserve.--Approximately $1 billion.
      Air Force Reserves.--Approximately $170 million.
      Navy and Marine Corps.--Approximately $240 million.
    In 2011, the U.S. Senate found that National Guard Army Reserve 
facilities average more than 40 years in age. Other RCs suffer similar 
challenges with aging infrastructure. Military Construction requests 
fund the Reserve's most critical facilities and support total force 
transformation. The Reserve and National Guard will be realigning its 
forces to operational missions to provide increased combat service, 
while the active-duty end strengths are being reduced.
                base closure and realignment commission
    The President's budget recommends two more rounds of base closures. 
ROA and REA do not support such a base closure and realignment (BRAC) 
recommendation. If any action is taken, the emphasis should be placed 
on realignment rather than closure.
    The association concerns are:
  --BRAC savings are faux savings as these savings are beyond the 
        congressional budget accounting cycle; with a lot of additional 
        dollar expenses front loaded into the Defense budget for 
        infrastructure improvements to support transferred personnel.
  --Too much base reduction eliminates facilities needed to support 
        surge capability, some surplus is good.
  --Reserve and National Guard facilities should not be included, as 
        was the case in BRAC 2005 when RC facilities were closed to 
        reduce the risk of closure to active duty facilities.
                         association priorities
    Calendar year 2011 legislative priorities are:
  --Recapitalize the total force to include fully funding equipment and 
        training for the National Guard and Reserves.
  --Ensure that the Reserve and National Guard continue in a key 
        national defense role, both at home and abroad.
  --Provide adequate resources and authorities to support the current 
        recruiting and retention requirements of the Reserves and 
        National Guard.
  --Support citizen warriors, families and survivors.
Issues To Help Fund, Equip, and Train
    Advocate for adequate funding to maintain national defense during 
times of war and peace.
    Regenerate the RC with field compatible equipment.
    Improve and implement adequate tracking processes on National Guard 
and Reserve appropriations and borrowed RC equipment needing to be 
returned or replaced.
    Fully fund the military pay appropriation to guarantee a minimum of 
48 drills and 2 weeks of training.
    Sustain authorization and appropriation to NGREA to permit 
flexibility for Reserve chiefs in support of mission and readiness 
needs.
    Optimize funding for additional training, preparation and 
operational support.
    Keep Active and Reserve personnel and operation and maintenance 
funding separate.
Issues To Assist Recruiting and Retention
    Support continued incentives for affiliation, re-enlistment, 
retention, and continuation in the RC.
            Pay and Compensation
    Simplify the Reserve duty order system without compromising drill 
compensation.
    Offer professional pay for RC medical professionals, consistent 
with the AC's pay.
    Eliminate the 1/30th rule for Aviation Career Incentive Pay, Career 
Enlisted Flyers Incentive Pay, Diving Special Duty Pay, and Hazardous 
Duty Incentive Pay.
            Education
    Continue funding the GI bill for the 21st century.
            Healthcare
    Provide medical and dental readiness through subsidized preventive 
healthcare.
    Extend military coverage for restorative dental care for up to 90 
days following deployment.
    Provide funding for transitional TRICARE Reserve Select healthcare 
for those beneficiaries being released from drill status.
            Spouse Support
    Repeal the Survivor Benefits Plan--Dependency Indemnity Clause 
offset.
             national guard and reserve equipment accounts
    It is important to maintain separate equipment and personnel 
accounts to allow Reserve component chiefs the ability to direct 
dollars to vital needs.
    Key issues facing the Armed Forces concerning equipment:
  --Procuring new equipment for all U.S. forces.
  --Modernize by upgrading the equipment already in the inventory.
  --Replacing the equipment deployed from the homeland to the war.
  --Making sure new and renewed equipment gets into the right hands, 
        including the RC.
    Reserve component equipping sources:
  --Procurement.
  --Cascading of equipment from AC.
  --Cross-leveling.
  --Recapitalization and overhaul of legacy (old) equipment.
  --Congressional add-ons.
  --NGREA.
  --Supplemental appropriation, such as overseas contingency operations 
        funding.
End Strength
    The ROA would like to place a moratorium on any potential 
reductions to the National Guard and Reserve manning levels. Manpower 
numbers need to include not only deployable assets but individuals in 
the accession pipeline. ROA urges this subcommittee to fund the support 
of:
  --Army National Guard of the United States, 358,200.
  --Army Reserve, 206,000.
  --Navy Reserve, 66,200.
  --Marine Corps Reserve, 39,600.
  --Air National Guard of the United States, 106,700.
  --Air Force Reserve, 71,400.
  --Coast Guard Reserve, 10,000.
    In a time of war and force rebalancing, it is wrong to make cuts to 
the end strength of the RCs. We need to pause to permit force planning 
and strategy to catch-up with budget reductions.
                  unfunded reserve component equipment
    ROA and REA agree with the Senate leadership that the Congress 
should be provided with a unfunded list from both Active and Reserve 
components. The below charts shows that the ground forces have the 
greatest backlog of unfunded equipment.




 Chart 1.--Items of unfunded equipment reported in the National Guard 
 and Reserve Equipment Report published by the Office of the Assistant 
Secretary of Defense for Reserve Affairs. Fiscal year 2013 could be the 
  last year of publication if the Secretary of Defense insists on not 
                        further unfunded lists.

              army reserve components equipment priorities
Army Reserve Unfunded Requirements
    While the Army Reserve (USAR) has 91 percent of its equipment on-
hand, only 67 percent of it is modernized, a decline of 2 percent from 
last year. More new production and recapitalized equipment is needed to 
close the gap with the active and the Army Guard.
    An enduring operational force cannot be fully effective if it is 
underfunded. Theater-provided equipment has allowed the USAR to provide 
support during mobilization. The USAR rebuilt 70 percent of its 5-ton 
cargo trucks and 83 percent of its semitrailer tankers to meet its 
mission.
    Top USAR equipping challenges of an operational Reserve are:
  --Modernize and sustain equipment in a resource-constrained 
        environment.
  --Equip USAR as an operational force capable of overseas, homeland 
        defense, and natural disasters.
  --Modernize the tactical wheeled vehicle (TWV) fleet.
  --Achieve full transparency for equipment procurement and 
        distribution.
  --Expand the use of simulators to mitigate equipment shortfalls and 
        gain training efficiencies.

                         USAR UNFUNDED EQUIPMENT
                        [In millions of dollars]
------------------------------------------------------------------------
                                                               Amount
------------------------------------------------------------------------
Force protection:
    Alarm Biological Agent [BIDS] M31E2, 63 required......         $69
    Armored Security Vehicle, 27 required.................          21
Combat logistics and mobility:
    Loader Skid Steer: Type II, 40 required...............           1.2
    Rough Terrain Contain Handler, 39 required............          28.9
Ground vehicles:
    Truck Cargo, 5-ton, 771 required......................         154
    Truck Dump, 10-ton, 213 required......................          42.6
    Truck, Expandable Van, 141 required...................          28.2
Soldier systems:
    Medium Weapon Thermal Sights [MWTS]AN/PAS-13(V)2,               28.2
     1,600 required.......................................
    Thermal Sights AN/PAS-13B9V)1, 1,500, required........          25.5
    Javelin Command Launch Unit, 50 required..............          11.5
    Helicopter, Utility, UH-60L, 8 required...............          38.4
------------------------------------------------------------------------

Simulators
    The use of simulations and simulators minimizes turbulence for USAR 
soldiers and their families caused by training demands during the first 
2 years of the Army Force Generation process by enabling individuals 
and units to train at their home station and during exercises in a safe 
environment without the increased wear and tear on equipment.
Army National Guard Unfunded Equipment Requirements
    The on-hand percentage for all equipment is dropped from 92 percent 
to 87 percent, and this does not include requirements for training. 
Part of this requirement is dual use, with critical items of equipment 
being needed for homeland missions with critical use inventory at 89 
percent.
    Top Army National Guard equipping challenges are:
  --Equip units for pre-mobilization training and deployment.
  --Equip units for their homeland missions.
  --Achieve full transparency for equipment procurement and 
        distribution.
  --Modernize ARNG TWV fleet.
  --Improve interoperability with AC forces.
  --Modernize the ARNG helicopter fleet.

                         ARNG UNFUNDED EQUIPMENT
                        [In millions of dollars]
------------------------------------------------------------------------
                                                               Amount
------------------------------------------------------------------------
Strike:
    Radar Sets AN/TPQ -36(V)10 and -37(V)9, 10/9 required.        $231
Field support:
    Containerized kitchen, 69 required....................          15.5
    Bradley Fighting Vehicle, Infantry, M2A3, 45 required.         198
    Bradley Fighting Vehicle, Cavalry, M3A3, 29 required..         116.5
    Generator sets, 659 required..........................           8.2
Air defense:
    Radar set: Sentinel AN/MPQ-64.........................          66.5
Aviation:
    Helicopter, Attack AH-64D, 16 required................         402
    Helicopter, Utility, UH-60L, 55 required..............         267
    Light Utility Helicopter, UH-72A, 34 required.........         132.6
    Helicopter, Cargo CH-47F, 19 required.................         570
Medical field system:
    MES Combat Medic, 463 required........................           1.6
    Medical Communications for Combat Casualty Care [MC4]            4.6
     Program..............................................
------------------------------------------------------------------------

                marine corps reserve unfunded priorities
    Marine Forces Reserve (MFR) has two primary equipping priorities--
outfitting individuals who are preparing to deploy and sufficiently 
equipping units to conduct home station training. Individuals receive 
100 percent of the necessary war fighting equipment. MFR units are 
equipped to a level identified by the Training Allowance (TA). MFR 
units are equipped with the same equipment that is utilized by the AC, 
but in quantities tailored to fit reserve training center needs. It is 
imperative that MFR units train with the same equipment they will 
utilize while deployed.
    Top MFR equipping challenges are:
  --Implementing Results of the Strategic Review from the Force 
        Structure Review Group; 40 percent of USMCR units may be 
        impacted by this review.
  --Transitioning the KC-130 airframe.
  --Providing units the ``right amount'' of equipment to effectively 
        train in a pre-activation environment.
  --Achieving USMCR goal that the Reserve TA contains the same 
        equipment as the AC.
  --Resetting and modernizing the MFR to prepare for future challenges.

                        USMCR UNFUNDED EQUIPMENT
                        [In millions of dollars]
------------------------------------------------------------------------
                                                               Amount
------------------------------------------------------------------------
Aviation:
    KC-130J Super Hercules Aircraft Tankers, 2 required...        $184.6
    UH-1Y Helicopter, Utility, 6 required.................         184.8
    MV-22 B Tiltrotor Osprey, 2 required..................         167.5
USMCR Simulators:
    KC-130J Weapons System Trainer, 2 required............          50
    UH-1 Trainer, 1 required..............................          16.5
Ground Transport:
    Truck cargo, 22.5 ton, LVSR, 8 required...............           3.4
    Lighted Armed Vehicle, Command/Control, 5 required....           3
    Light Armored Vehicles--LAV-25, procure 1 remaining...           3.2
------------------------------------------------------------------------

              air reserve components equipment priorities
    The Air Reserve Component (ARC) is made up of both the Air Force 
Reserve (AFR) and the Air National Guard. Over the last 10 years they 
have met all tasking, and were not asked to perform at full capacity.
    ARC alone can cover:
  --75 percent of Combat Air Force tasking.
  --75 percent of Mobility Air Force tasking.
  --50 percent of Aerial Refueling tasking.
Air Force Reserve Unfunded Requirements
    AFR while fully integrated with the active for air, space, and 
cyberspace, has higher sustainment needs across its fleet. Sustaining 
operations on five continents, the resulting wear and tear weighs 
heavily on aging equipment.
    AFR has some specialized capabilities not found in regular AF 
units. These include support of counternarcotics efforts, weather 
reconnaissance including hurricane penetration, aeromedical evacuation, 
aerial spray capabilities, and forest fire suppression.
    Yet AF proposes cuts from the AFR. Even though the AF announced 
that the AFR will be reduced by 900 personnel in fiscal year 2013, more 
than 3,000 jobs will be realigned.
    There will be a risk of further reductions at some locations. There 
are 2,093 Reserve and 734 full-time staff (FTS) reductions shown in AF 
announcements at six AFR flying locations. These include:
  ---563 Lackland, Texas (-385 reserve/-178 FTS in C-5s);
  ---580 Barksdale, Louisiana (-409/-171 closing AFR A-10 combat unit 
        recently returned from Afghan);
  ---53 Homestead, Florida (-40/-13 reducing RC F-16s);
  ---1,448 Pittsburgh, Pennsylvania (-1,122/-326 closing Wing and 
        Base);
  ---53 Fort Worth, Texas (-40/-13 reducing RC F-16s); and
  ---130 Youngstown, Ohio (-97/-33 reducing C-130s).
    The closure of Air Reserve Station Pittsburg challenges the 
congressional mandate and authority of base closure with more than 300 
Federal employees.
    Next in fiscal year 2014 and out, the plan to close the entire C-
130 wing at Maxwell, Alabama; the entire C-130 wing/base at 
Minneapolis-St. Paul, Minneapolis; a C-130 flying squadron at Keesler, 
Mississippi; and the C-130 wing/base at Niagara, New York.
    These cuts will affect the surge and reversibility capabilities of 
the AF. In these proposed reductions, the AF does not seem to 
understand the importance of population/reserve demographics to cost-
effective Reserve unit locations. ROA and REA hope that this committee 
supports actions by the House to delay and proposed reductions for a 
year to properly review these recommendations.
    Top AFR equipping challenges:
  --C-5 Maintenance.
      Defensive Systems.--LAIRCM, ADS, and MWS: equip aircraft lacking 
        adequate infrared missile protection for combat operations.
      Data Link and Secure Communications.--Data link network 
        supporting image/video, threat updates, and SLOS/BLOS 
        communications for combat missions.

                           UNFUNDED EQUIPMENT
                        [In millions of dollars]
------------------------------------------------------------------------
                                                               Amount
------------------------------------------------------------------------
Aviation:
    Large aircraft infrared countermeasures...............          $4
    F-16 Systems, CDU, Combined AIFF With Mode 5/S, Sim              2
     Trainer Upgrade......................................
    C-17A upgrades........................................          10
    C-130 system upgrades.................................          13.7
    KC-135 modifications..................................           3.8
Telecommunication:
    National Airspace System..............................           1.3
    Air and Space Operations Center.......................           2
Ground transportation:
    Medium tactical vehicles..............................           2.6
------------------------------------------------------------------------

Air National Guard Unfunded Equipment Requirements
    The immediate threat the Air National Guard (ANG) was the 
threatened reduction of squadrons and aircraft proposed by the Air 
Force as cost saving measures. This included the reduction of 5,100 ANG 
billets. ROA and REA hope that this committee support actions by the 
House to delay and proposed reductions for a year to properly review 
these recommendations.


                        PROPOSED CUTS TO THE ANG
------------------------------------------------------------------------

---------------------------------
C-130 H intratheater airlift....  21 aircraft.......  Provides 40
                                                       percent of the
                                                       total fleet.
C-5A heavy intertheater airlift.  13 aircraft.......  Provides 25
                                                       percent of
                                                       outsize cargo
                                                       airlift.
C-27J short-to-medium range       15 aircraft.......  Provides 100
 tactical airlift.                                     percent of the
                                                       total fleet.
A-10C ground support fighter....  63 aircraft.......  Performed 66
                                                       percent of the
                                                       missions.
F-16 C Fighter..................  20 aircraft.......  Since 2003, 3
                                                       percent of CentAF
                                                       taskings.
C-21 A operational support......  24 aircraft.......  Provides 40
                                                       percent of the AF
                                                       fleet.
------------------------------------------------------------------------

    Given adequate equipment and training, the ANG will continue to 
fulfill its total force obligations. On-hand equipment is just under 91 
percent of requirements with dual use equipment being 88 percent of ANG 
assets, but some major items of equipment are nearing 30 years of use. 
Operations tempo has been high and prolonged, requiring equipment to be 
modernized and recapitalized concurrently.
    ANG equipping challenges:
  --Modernize aging aircraft and other weapons systems for both dual-
        mission and combat deployments.
  --De-conflict dual use equipment when required for both Federal and 
        domestic missions.
  --Acquire equipment to satisfy requirements for domestic operations 
        in each Emergency Support Function (ESF).
  --Define an Air Force validation process for both Federal and State 
        domestic response needs.
  --Program aging ANG F-16 aircraft for the Service Life Extension 
        Program (SLEP).
    An ANG wing contains not only aircraft but fire trucks, forklifts, 
portable light carts, emergency medical equipment including ambulances, 
air traffic control equipment, explosives ordinance equipment, etc., as 
well as well-trained experts--valuable in response to civil 
emergencies.

                           UNFUNDED EQUIPMENT
                        [In millions of dollars]
------------------------------------------------------------------------
                                                               Amount
------------------------------------------------------------------------
Command and Control:
    Control and reporting center systems..................          $6.6
    Air Defense Tactical Satellite Communications.........           1.2
Aviation:
    C-17 large aircraft infrared countermeasures and                36.4
     detection............................................
    C-38 replacement aircraft.............................          62
    C-40C Procurement.....................................         103
    C-130 H/J Advanced LAIRCM/Missile Warning System......          58.2
    F-15 Advance Digital Warning/Radio Frequency CSM......          85.7
    F-16 advanced targeting pod upgrades..................          83.5
Dual Mission: Rapidly deployable RPA capability...........          28.5
------------------------------------------------------------------------

                    navy reserve unfunded priorities
    Active Reserve Integration (ARI) aligns active and Reserve 
component units to achieve unity of command. Equipment used is the RC 
is often experiencing service life of more than 20 years for many 
platforms, adding sustainability and interoperability challenges, 
leading to training and deployment challenges for mobilization ready 
individuals and units. The United States Navy Reserve (USNR) has been 
the primary provider of Individual Augmentees for the overseas 
contingency operations filling Army and Air Force assignments.
    Expeditionary missions include security forces, construction 
battalions, cargo handling, and warehouse and fuel operations. The USNR 
contributes 1/3 of the personnel in support of Special Warfare 
operations. A new mission will be Maritime Civil Affairs which will be 
doubling the number of units in the near future.
    Top USNR equipping challenges are:
  --Aircraft procurement (C-40A, P-8, KC-130J, and C-37B).
  --Expeditionary equipment procurement (MESF, EOD, NCF, NAVELSG, 
        MCAST, EXPCOMBATCAM, and NEIC).
  --Navy special warfare equipment.

                         USNR UNFUNDED EQUIPMENT
                        [In millions of dollars]
------------------------------------------------------------------------
                                                               Amount
------------------------------------------------------------------------
Aviation:
    C-40 A Combo Cargo/Passenger Airlift, 4 required......        $340
    KC-130J Super Hercules Aircraft Tankers, 2 required...         162
    C-37 B (Gulf Stream) Aircraft, 1 required.............          64
    H-53 E Sea Dragon, Mine Warfare.......................          24
    F-5F Adversarial Aircraft Modification................           4.3
USNR Expeditionary:
    Maritime Civil Affairs Team, Equipment Allowance, 3              1
     required.............................................
    Tactical Vehicles.....................................          11.8
    Civil Engineering Support Equipment...................           1.2
    Materials Handling Equipment..........................           1.2
------------------------------------------------------------------------


                                              [Dollars in millions]
----------------------------------------------------------------------------------------------------------------
                                                                                                Percentage of
  Reserve  component        Requirements             On-hand                Shortage             required $$
----------------------------------------------------------------------------------------------------------------
               ARNG              105,594.3               64,867.8               40,726.5                  38.6
----------------------------------------------------------------------------------------------------------------
                 AR               27,283.6               16,634.9               10,648.7                  39.0
----------------------------------------------------------------------------------------------------------------
                USMCR              6,243.6                5,812.8                  430.8                   6.9
----------------------------------------------------------------------------------------------------------------
               USNR                9,977.4                8,978.2                  999.2                  10.0
----------------------------------------------------------------------------------------------------------------
                ANG               53,620.8               50,778.4                2,842.4                   5.3
----------------------------------------------------------------------------------------------------------------
                AFR               26,900.7               24,783.3                2,207.4                   8.2
----------------------------------------------------------------------------------------------------------------
                 USCGR                51.1                   26.1                   25.1                  49.0
----------------------------------------------------------------------------------------------------------------
              Total              229,761.6              171,881.5               57,880.1                  25.2
----------------------------------------------------------------------------------------------------------------

Chart 2.--``Beginning Fiscal Year 2013 Reserve Component Equipment $$$ 
   Shortages'' published by the Office of the Assistant Secretary of 
                      Defense for Reserve Affairs.

    The Marine Corps Reserve (USMCR) reflects a 6.9 percent shortage of 
its major items; however, the USMCR is equipped to a home station 
training allowance only.
                               conclusion
    The operations in Iraq and Afghanistan have demonstrated the 
contributions to be made by the Reserve and National Guard. It the 
future they will continue to play role in missions to maintain national 
security.
    This country cannot afford a strategy that writes them out of the 
picture. It makes sense to fully fund the most cost efficient 
components of the total force, its Reserve components.
    The ROA, again, would like to thank the subcommittee for the 
opportunity to present our testimony. We are looking forward to working 
with you and supporting your efforts in any way that we can.

    Chairman Inouye. General, I can assure you that this 
subcommittee is well aware of the important role played by 
Reserve and Guard forces in Afghanistan and Iraq, and we will 
make certain that a study be carried out on base realignment 
and closure (BRAC) recommendations and equipment. Those are 
important items for this subcommittee.
    Thank you very much, Sir.
    General Davis. Thank you.
    Chairman Inouye. Our next witness is Ms. Karen Goraleski, 
representing the American Society of Tropical Medicine and 
Hygiene.
STATEMENT OF KAREN GORALESKI, EXECUTIVE DIRECTOR, 
            AMERICAN SOCIETY OF TROPICAL MEDICINE AND 
            HYGIENE
    Ms. Goraleski. Thank you, Mr. Chairman. Mr. Chairman and 
Ranking Member Cochran: My name is Karen Goraleski. I am the 
executive director of the American Society of Tropical Medicine 
and Hygiene (ASTMH). Thank you for the privilege of testifying 
before you today. I am here on behalf of our members, who are 
the world's leading experts in the research and treatment of 
tropical diseases, to respectfully request that the 
subcommittee expand funding for the Department of Defense's 
(DOD) efforts to develop new preventions, treatments, vaccines, 
and diagnostics that will protect our service men and women 
from infectious diseases in areas of the world where many serve 
now or may serve in the future.
    ASTMH understands the rich return on this DOD investment. 
We are concerned that without the sustained resources needed to 
address health risks to our troops, we will also inadvertently 
hamper military mission success.
    As a Nation, we must Americans' tax dollars wisely, and 
this particular DOD investment has legs. First, our military 
benefits, but so do Americans that travel for business, for 
vacation, for school and faith-based volunteer work. Every gain 
also helps reduce premature death and disability of those 
living in the developing world.
    Infectious disease is the ever-present enemy. Our 
investments in new and effective tools must have a focus on 
today as well as tomorrow. The drugs and preventive measures 
used in earlier conflicts are quickly becoming resistant and we 
can always bank on Mother Nature to deliver new diseases.
    I want to highlight the smart and cost-effective work being 
done at two facilities within the DOD, Walter Reed Army 
Institute of Research (WRAIR), and the Naval Medical Research 
Center (NMRC).
    I will begin with WRAIR, which effectively leverages its 
modest infectious disease research budget through domestic and 
international partnerships, public and private, and they are 
continually seeking out new ones. WRAIR's portfolio includes 
malaria vaccine and drug development, malaria vector control, 
drug development for leishmaniasis, a tropical disease 
transmitted by sand flies that is prevalent in Africa, West 
Asia, and the Middle East, enteric disease research, and HIV/
AIDS research and treatment.
    WRAIR's success relies heavily on collaborations, as seen 
in the development of RTS,S with the malaria vaccine initiative 
and GlaxoSmithKline. Last fall, this large-scale phase 3 trial 
showed an approximate 50-percent efficacy in decreasing 
clinical episodes of malaria in African children. This is news 
we rightfully celebrate for children and parents living in 
malaria endemic countries. But for our military, right now 
RTS,S is not suitable as a vaccine for adults who have never 
experienced malaria as a child. This leaves us with more work 
to do in order to protect our troops, but it is work that is 
doable.
    The NMRC works both in the United States and in its 
overseas medical research laboratories located in Peru, Egypt, 
and Cambodia. These labs offer outstanding scientific 
collaborations and create deep and lasting relationships in 
country. The labs also offer research and education 
opportunities that are filled by local citizens, who then in 
turn build in-country capacity.
    Recently, Navy researchers announced the start of clinical 
trials for a dengue fever vaccine to protect our troops from 
this sometimes deadly virus found in tropical regions, and even 
recently found in the United States. This vaccine would be a 
game-changer in tropical medicine. No cure exists and right now 
treatment is only symptom management.

                           PREPARED STATEMENT

    In closing, our military must be ready at any time to 
embark on a new mission, to a new location, which can mean 
exposure to new and emerging health threats. This and the 
vexing problem of drug resistance serve as stark reminders as 
to why our investments cannot stop and where additional 
investments are needed.
    Thank you for this opportunity. ASTMH stands ready to serve 
as an expert resource to you. We are in this together.
    [The statement follows:]
 Prepared Statement of Karen Goraleski, Executive Director of American 
                Society of Tropical Medicine and Hygiene
    The American Society of Tropical Medicine and Hygiene (ASTMH)--the 
principal professional membership organization representing, educating, 
and supporting scientists, physicians, clinicians, researchers, 
epidemiologists, and other health professionals dedicated to the 
prevention and control of tropical diseases--appreciates the 
opportunity to submit written testimony to the Senate Defense 
Appropriations subcommittee.
    ASTMH respectfully requests that the subcommittee expand funding 
for the Department of Defense's (DOD) longstanding efforts to develop 
new and more effective drugs, vaccines, and diagnostics designed to 
protect servicemembers from infectious diseases including funding for 
the important research efforts at the Walter Reed Army Institute of 
Research (WRAIR) and the U.S. Naval Medical Research Center (NMRC).
department of defense research protects the u.s. military and civilians 
                    and contributes to global health
    A core component of ASTMH membership supports the work of the DOD, 
and we understand first-hand the important role that research and 
development play in protecting our service men and women deployed 
abroad from the threat of infectious disease, as well as contributing 
significantly to civilian medical applications. Specifically, DOD 
infectious disease research contributes to the protection of:
  --U.S. troops that are currently deployed or likely to be deployed in 
        many tropical areas;
  --The safety of U.S. citizens, working, traveling, participating in 
        volunteer work, and vacationing overseas who are impacted by 
        these same tropical diseases;
  --Our country from agents responsible for these diseases, which could 
        be introduced and become established in the United States (as 
        was the case with West Nile virus), or might even be 
        weaponized; and
  --Citizens around the world who suffer disability and death from many 
        of these same tropical diseases.
                 walter reed army institute of research
    A large part of DOD investments in infectious disease research and 
development are facilitated through WRAIR. Between 2007 and 2010, 
WRAIR's Center for Infectious Disease Research performed more than $260 
million of research for the DOD and had an additional $140 million in 
collaborative research work with external partner organizations. WRAIR 
has advanced their work through critical public-private partnerships 
and collaborative efforts with entities such as:
  --GlaxoSmithKline and Sanofi;
  --Nonprofit organizations such as the Bill & Melinda Gates 
        Foundation, Medicines for Malaria Venture, and PATH; and
  --Other U.S. agencies including Centers for Disease Control and 
        Prevention, United States Agency for International Development, 
        and National Institutes of Health.
    WRAIR invests in:
  --malaria vaccine and drug development;
  --drug development for leishmaniasis;
  --enteric disease research;
  --vector control for malaria and other vector-borne infections; and
  --HIV/AIDS research and treatment.
    One example of WRAIR's successful work and collaboration includes 
the development of several significant and promising vaccine 
candidates, including RTS,S, developed with PATH Malaria Vaccine 
Initiative and GlaxoSmithKline, which recently underwent the first-ever 
large-scale Phase 3 trial for a malaria vaccine. In trials last year, 
the vaccine candidate decreases clinical episodes of malaria in 
children in Africa by approximately 50 percent. While we celebrate this 
news and the promise that it brings for children living in malaria-
endemic countries, RTS,S is not suitable as a vaccine for adults who 
have never experienced malaria during childhood, such as our military 
personnel. As a result, there remains a significant need for continued 
research funding in order to achieve more robust results.
    WRAIR is headquartered in Silver Spring, Maryland, and has research 
laboratories around the globe including:
  --a public health reference laboratory in The Republic of Georgia;
  --dengue fever clinical trials in the Philippines;
  --malaria clinical studies and surveillance in Kenya;
  --military entomology network field sites in Thailand, the 
        Philippines, Nepal, Cambodia, Korea, Kenya, Ethiopia, Egypt, 
        Libya, Ghana, Liberia, and Peru; and
  --several other coordination efforts with national health ministries 
        and defense units.
    This diversity in research capacity puts WRAIR in a unique 
leadership position in research and development for tropical diseases--
research that aids our military men and women as well as people living 
in disease-endemic countries.
              united states naval medical research center
    NMRC and its affiliated labs conduct basic and applied research in 
infectious disease. The Infectious Disease Directorate (IDD) of NMRC 
focuses on malaria, enteric diseases, and viral rickettsial diseases. 
IDD has an annual budget exceeding $10 million and conducts research on 
infectious diseases that are considered to be a significant threat to 
our deployed sailors, soldiers, airmen, and marines.
    The primary objective of the Navy Malaria Program is to develop a 
vaccine that kills the parasite during the first few days of 
development in the liver, before it breaks into the blood. The program 
is also investigating vaccines that would target blood-stage infection 
to limit the severity of symptoms associated with this stage. Both of 
these vaccines could alleviate much of the suffering caused by this 
parasite in tropical areas.
    The research is enhanced by IDD's close working relationship with 
the Navy's three overseas medical research laboratories located in 
Peru, Egypt, and Indonesia. These laboratories, like those of WRAIR, 
afford diplomatic advancement through the close working relationships 
they have developed with governments and citizens of those countries. 
ASTMH has heard first-hand accounts of the successful diplomatic impact 
that both the WRAIR and NMRC overseas labs have on the communities 
where they are guests. Many of the researchers and staff who work in 
the labs are local to the area and speak highly of the role of the U.S. 
military labs.
             tropical medicine and u.s. military operations
    The term ``tropical medicine'' refers to the wide-ranging clinical, 
research, and educational efforts of physicians, scientists, and public 
health officials with a focus on the diagnosis, mitigation, prevention, 
and treatment of diseases prevalent in the areas of the world with a 
tropical climate. Most tropical diseases are located in sub-Saharan 
Africa, parts of Asia (including the Indian subcontinent), Central and 
South America, and parts of the Middle East. These are the same areas 
military troops are often deployed. Since many of the world's 
developing nations and economies are located in these areas, tropical 
medicine tends to focus on diseases that impact the world's most 
impoverished individuals.
  case studies--the importance of department of defense's infectious 
                        disease research efforts
    Malaria has resulted in the loss of more person-days among U.S. 
military personnel than to bullets during every military campaign 
fought in malaria-endemic regions during the 20th century.
    Because servicemembers deployed by the U.S. military comprise a 
majority of the healthy adults traveling each year to malarial regions 
on behalf of the U.S. Government, the U.S. military has understandably 
taken a primary role in the development of anti-malarial drugs, and 
nearly all of the most effective and widely used anti-malarials were 
developed in part by U.S. military researchers. Drugs that now continue 
to save civilians throughout the world were originally developed by the 
U.S. military to protect troops serving in tropical regions during 
World War II, the Korean War, and the Vietnam War.
    In recent years the broader international community has increased 
its efforts to reduce the impact of malaria in the developing world, 
particularly by reducing childhood malaria mortality, and the U.S. 
military plays an important role in this broad partnership. 
Nonetheless, military malaria researchers at NMRC and WRAIR are working 
practically alone in the area most directly related to U.S. national 
security: drugs and vaccines designed to protect or treat healthy 
adults with no developed resistance to malaria who travel to malaria-
endemic regions. NMRC and WRAIR are working on the development of a 
malaria vaccine and on malaria diagnostics and other drugs to treat 
malaria--an especially essential investment as current malaria drugs 
face their first signs of drug resistance.
    The latest generation of malaria medicines is increasingly facing 
drug-resistance. The most deadly variant of malaria--Plasmodium 
falciparum--is believed by the World Health Organization (WHO) to have 
become resistant to ``nearly all anti-malarials in current use''. The 
malaria parasite demonstrates a notorious and consistent ability to 
quickly develop resistance to new drugs. Malaria parasites in Southeast 
Asia have already shown resistance to the most recently developed anti-
malarial drug, artemisin.
    Developing new antimalarials as quickly as the parasite becomes 
resistant to existing ones is an extraordinary challenge, and one that 
requires significant resources before this becomes widespread, 
especially as United States military operations in malaria-endemic 
countries of Africa and Asia increase. Without new anti-malarials to 
replace existing drugs as they become obsolete, military operations 
could be halted in their tracks by malaria. The 2003 malaria outbreak 
affecting 80 of 220 marines in Liberia is an ominous reminder of the 
impact of malaria on military operations. Humanitarian missions also 
place Americans at risk of malaria, as evidenced by several Americans 
contracting malaria while supporting Haitian earthquake relief efforts.
    Leishmaniasis is a vector-borne disease that comes in several 
forms, the most serious of which is visceral leishmaniasis, which 
affects internal organs and can be deadly if left untreated. According 
to the WHO, more than 350 million people are at risk of leishmaniasis 
in 88 countries around the world. It is estimated that 12 million 
people are currently infected with leishmaniasis, and 2 million new 
infections occur annually. Co-infection of leishmaniasis and HIV is 
becoming increasingly common, and WHO notes that because of a weakened 
immune system, leishmaniasis can lead to an accelerated onset of AIDS 
in HIV-positive patients.
    Because of leishmaniasis' prevalence in Iraq, DOD has spent 
significant time and resources on the development of drugs and new 
tools for the treatment of leishmaniasis. As more troops return from 
Iraq and Afghanistan, it is likely DOD and the Department of Veterans 
Affairs will see an increase in leishmaniasis cases in our soldiers. 
WRAIR discovered and developed Sitamaquine, a drug that, once 
completed, will be an oral treatment for leishmaniasis. While essential 
for the safety of our service men and women abroad, these types of 
innovations will also be extremely beneficial to the at-risk 
populations worldwide living in leishmaniasis-endemic countries.
    Dengue fever (``breakbone fever''), according to the WHO, is the 
most common of all mosquito-borne viral infections. About 2.5 billion 
people live in places where dengue infection can be transmitted by 
mosquitoes, and last year we saw a few cases pop up in the United 
States. There are four different viruses that can cause dengue 
infections. While infection from 1 of the 4 viruses will leave a person 
immune to that strain of the virus, it does not prevent them from 
contracting the other three, and subsequent infections can often be 
more serious.
    The DOD has seen about 28 cases of dengue in soldiers per year. 
While none of these cases resulted in the death of a soldier, 
hospitalization time is lengthy. Currently, there are several research 
and development efforts under way within the DOD both for treatments 
and vaccines for dengue.
         u.s. government action is needed for mission readiness
    The role of infectious disease in the success or failure of 
military operations is often overlooked. Even a cursory review of U.S. 
and world military history, however, underscores that the need to keep 
military personnel safe from infectious disease is critical to mission 
success. Ensuring the safety of those men and women in future conflicts 
and deployments will require research on new tools. Additional funds 
and a greater commitment from the Federal Government are necessary to 
make progress in tropical disease prevention, treatment, and control.
    Although several promising new infectious disease drugs are in 
development at WRAIR and NMRC, the U.S. Government's funding level for 
these programs has been anemic for several years. There are indications 
that the current budget process may decrease or not keep up with 
medical research inflation, let alone an increase in real dollars, 
despite burgeoning evidence that many of our military's current drugs 
are rapidly approaching obsolescence.
    Fortunately, a relatively small amount of increased funding for 
this program would restore the levels of research and development 
investment required to produce the drugs that will safeguard U.S. 
troops. In relation to the overall DOD budget, funding for infectious 
disease research programs is very small. Cutting funding for this 
program would deal a major blow to the military's efforts to reduce the 
impact of these diseases on soldiers and civilians alike, thereby 
undercutting both the safety of troops deployed to tropical climates 
and the health of civilians in those regions.
    ASTMH feels strongly that increased support for efforts to reduce 
this threat is warranted. A more substantial investment will help to 
protect American soldiers and potentially save the lives of millions of 
individuals around the world. We appreciate the opportunity to share 
our views in our testimony, and please be assured that ASTMH stands 
ready to serve as a resource on this and any other tropical disease 
policy matter.

    Chairman Inouye. Ms. Goraleski, I thank you very much for 
your testimony.
    The Vice Chairman has a question to ask.
    Ms. Goraleski. Yes, Sir.
    Senator Cochran. Ms. Goraleski, I know that you are aware 
of some collaboration between Walter Reed Hospital and the 
University of Mississippi research capacity through the Natural 
Products Research Center there. They're working to collaborate 
to get Walter Reed Army Institute to identify safe and 
effective drugs to treat tropical-related diseases and 
illnesses, which you mentioned in your testimony.
    I was curious to know if you are aware of this and how 
effective any of these research efforts have been assumed to 
be, and whether or not we need to put more money into these 
efforts than what we have in this year's budget.
    Ms. Goraleski. Yes, Sir, I am aware of those 
collaborations. Those collaborations are really essential for 
us to move progress forward. The Federal Government cannot do 
it alone without multiple partnerships. I don't have the 
specifics on that research. I just know of it overall, that 
there is some interesting and productive developments. But I 
will certainly find out the details for you and make sure you 
get that immediately. Thank you.
    Senator Cochran. Thank you very much. We appreciate your 
assistance to the subcommittee.
    Ms. Goraleski. You're welcome.
    Chairman Inouye. Thank you very much.
    Now may I call upon Mr. John R. Davis, representing the 
Fleet Reserve Association.
STATEMENT OF JOHN R. DAVIS, DIRECTOR, LEGISLATIVE 
            PROGRAMS FLEET RESERVE ASSOCIATION
    Mr. Davis. My name is John R. Davis and I want to thank the 
subcommittee for the opportunity to express the views of the 
Fleet Reserve Association (FRA) today.
    FRA supports legislation to exclude the Defense budget from 
sequestration and agrees with the Secretary of Defense Panetta, 
who said these sequestration cuts would, ``do catastrophic 
damage to our military, hollowing out the force and degrading 
its ability to protect the country''.
    Defense accounts for 17 percent of the Federal budget but 
will receive 50 percent of the sequestration cuts. Less than 1 
percent of the population is shouldering 100 percent of the 
burden of maintaining our military and national security, and 
the punitive funding reductions mandated by sequestration would 
force across-the-board cuts to all programs that could 
potentially threaten the all-volunteer force.
    Ensuring adequate funding for the military health system 
and maintaining the current retirement system are top 
legislative priorities for the association. This is reflected 
in responses to the association's 2012 survey, completed in 
February by more than a thousand current and former 
servicemembers, who cited retirement and military health 
programs as the most important benefits. Over the past several 
years, healthcare has consistently been a top concern for all 
segments of the military community, that being the Active Duty, 
Reserve component, veterans, and retirees.
    This year's survey, however, revealed that active duty and 
reservists viewed the military retirement above healthcare and 
pay.
    FRA believes that the administration's fiscal year 2013 
budget request devalues military service by proposing drastic 
TRICARE enrollment fee increases for all retirees and excessive 
pharmacy co-pay increases. All reservists and 97 percent of 
active duty participants in the survey found retirement 
benefits as the most important benefit.
    FRA appreciates Secretary of Defense Panetta's statement 
that those currently serving would not be impacted by the 
changes proposed by the administration's proposed retirement 
commission, but wonders why there is no similar commitment to 
those who have served in the past.
    The Senate Armed Services Committee approved the markup 
recently for the Defense authorization bill and that expands 
this commission to include not just retirement pay, but also 
current active duty compensation. Although we are thankful it 
excludes currently serving and retirees, the FRA opposes this 
base realignment and closure (BRAC)-like type commission 
because it would bypass the expertise of this Committee and 
subcommittee on Capitol Hill.
    FRA supports Senators Frank R. Lautenberg and Marco Rubio's 
bill, the Military Health Care Protection Act, that would seek 
to protect TRICARE beneficiaries from excessive and unfair 
enrollment fee increases and significant hikes in pharmacy co-
pays. The bill will emphasize that military service, unlike 
other civilian occupations and associated healthcare costs, are 
earned through 20 years or more of arduous service and 
sacrifice.
    The association does support the administration's fiscal 
years 2013 and 2014 active-duty pay increase that is equal to 
the Employment Cost Index.
    FRA supports a Defense budget at least 5 percent of the 
gross domestic product (GDP), that will adequately fund both 
people and weapons programs, and is concerned that the 
administration's spending plan is not enough to support both, 
particularly given the ongoing operational commitments 
associated with the new defense strategy. Further, spending on 
national defense as a percentage of GDP will be reduced, 
despite significant continued war-related expenses and 
extensive operational and national security commitments.

                           PREPARED STATEMENT

    The Defense budget could actually shrink by more than 30 
percent over the next decade, and the administration projects 
outlays of only 2.7 percent of GDP in 2021. That would be down 
from last year's 4.5 percent of GDP. That would be down--the 
2021 outlays would be pre-World War II outlays. As recently as 
1986, though, the United States has spent 6.2 percent of GDP on 
defense, with no real detrimental economic impact.
    Again, thank you for allowing me to submit FRA's views to 
the subcommittee.
    [The statement follows:]
                  Prepared Statement of John R. Davis
                     the fleet reserve association
    The Fleet Reserve Association (FRA) is the oldest and largest 
enlisted organization serving Active Duty, Reserves, retired, and 
veterans of the Navy, Marine Corps, and Coast Guard. It is 
congressionally chartered, recognized by the Department of Veterans 
Affairs (VA) as an accrediting Veteran Service Organization (VSO) for 
claim representation and entrusted to serve all veterans who seek its 
help. In 2007, FRA was selected for full membership on the National 
Veterans' Day Committee.
    FRA was established in 1924 and its name is derived from the Navy's 
program for personnel transferring to the Fleet Reserve or Fleet Marine 
Corps Reserve after 20 or more years of active duty but less than 30 
years for retirement purposes. During the required period of service in 
the Fleet Reserve, assigned personnel earn retainer pay and are subject 
to recall by the Navy.
    FRA's mission is to act as the premier ``watch dog'' organization 
on Capitol Hill in maintaining and improving the quality of life for 
Sea Service personnel and their families. The Association also sponsors 
a National Americanism Essay Program and other recognition and relief 
programs. In addition, the FRA Education Foundation oversees the 
Association's scholarship program that presented awards totaling more 
than $120,000 to deserving students last year.
    The Association is also a founding member of The Military Coalition 
(TMC), a consortium of more than 30 military and veteran's 
organizations. FRA hosts most TMC meetings and members of its staff 
serve in a number of TMC leadership roles.
    FRA celebrated 87 years of service in November 2011. For nearly 
nine decades, dedication to its members has resulted in legislation 
enhancing quality-of-life programs for Sea Services personnel, other 
members of the uniformed services plus their families and survivors, 
while protecting their rights and privileges. CHAMPUS, (now TRICARE 
Standard) was an initiative of FRA, as was the Uniformed Services 
Survivor Benefit Plan (SBP). More recently, FRA led the way in 
reforming the REDUX Retirement Plan, obtaining targeted pay increases 
for mid-level enlisted personnel, and sea pay for junior enlisted 
sailors. FRA also played a leading role in advocating recently enacted 
predatory lending protections and absentee voting reform for 
servicemembers and their dependents.
    FRA's motto is: ``Loyalty, Protection, and Service.''
              certification of nonreceipt of federal funds
    Pursuant to the requirements of House Rule XI, the FRA has not 
received any Federal grant or contract during the current fiscal year 
or either of the 2 previous fiscal years.
                              introduction
    Mr. Chairman, the FRA salutes you, members of the subcommittee, and 
your staff for the strong and unwavering support of funding for 
programs essential to Active Duty, Reserve component, and retired 
members of the uniformed services, their families, and survivors. The 
subcommittee's work has greatly enhanced care and support for our 
wounded warriors and significantly improved military pay and other 
benefits and enhanced other personnel, retirement, and survivor 
programs. This support is critical in maintaining readiness and is 
invaluable to our uniformed services engaged throughout the world 
fighting the global War on Terror, sustaining other operational 
requirements and fulfilling commitments to those who've served in the 
past.
                stop department of defense sequestration
    As mandated by the 2011 Budget Control Act, failure of the Super 
Committee in 2011 to develop a bipartisan plan to contain the growth of 
the national debt will force implementation of ``sequestration'' in 
January 2013 unless the Congress intervenes. Failure to act will 
trigger across-the-board cuts with one-half coming from the defense 
budget. FRA agrees with Secretary of Defense Leon Panetta, who said 
these cuts ``would do catastrophic damage to our military, hollowing 
out the force and degrading its ability to protect the country.'' 
Defense counts for 17 percent of the Federal budget but will receive 50 
percent of the sequestration cuts.
    With the American military out of Iraq and the conflict in 
Afghanistan winding down, some are suggesting the possibility of a 
``peace dividend.'' Although there have been victories in the War on 
Terror, there has been no peace treaty with terrorism and an additional 
$500 billion in defense cuts beyond the already-planned reductions over 
the next decade beginning in fiscal year 2013 could jeopardize 
essential funding of military pay and benefit programs, which would 
negatively impact recruiting, retention, and overall military 
readiness. For these reasons, FRA strongly supports the ``Down Payment 
to Protect National Security Act'' (S. 2065) sponsored by Senator Jon 
Kyl and a House bill (H.R. 3662) sponsored by the House Armed Services 
Committee (HASC) Chairman, Representative Howard P. ``Buck'' McKeon. 
These proposals would amend the Budget Control Act of 2011 by excluding 
the Department of Defense budget from the first year of sequestration 
(2013).
    Less than 1 percent of the population is shouldering 100 percent of 
the burden of maintaining our national security, and the punitive 
funding reductions mandated by sequestration would force major across-
the-board cuts to all programs and could potentially threaten the all-
volunteer force.
                    budget devalues military service
    FRA's membership is especially concerned about the administration's 
proposed fiscal year 2013 budget which includes plans to drastically 
increase existing TRICARE Prime enrollment fees, implement new fees for 
TRICARE Standard and TRICARE-for-Life beneficiaries, and increase 
pharmacy co-pays. If authorized, fees would be tiered based on the 
beneficiary's retired pay. These increases are a major concern to the 
entire military retiree community and since mid-February that concern 
has prompted nearly 20,000 messages to Capitol Hill via FRA's Web site 
Action Center. Our members are also concerned that the budget calls for 
the fees to be adjusted annually based on healthcare inflation after 
fiscal year 2017.
    As this statement is being written, the Senate Armed Services 
Committee has not marked up its version of the Fiscal Year 2013 Defense 
Authorization bill. The HASC version of the legislation (H.R. 4310) did 
not authorize the proposed healthcare fee increases for all military 
retirees--including TRICARE for Life (TFL) beneficiaries. The panel 
did, however, authorize higher pharmacy co-pays. In addition, future 
co-pay adjustments will be tied to the Consumer Price Index which is 
the basis of annual military retired pay adjustments and consistent 
with future TRICARE Prime enrollment fee adjustments that became 
effective this year. The legislation also authorizes a 5-year pilot 
program that would require TFL beneficiaries to use the mail-order, 
home delivery program rather than retail pharmacies for maintenance 
drugs, and beneficiaries could opt out of the program after 1 year. 
There would be no cost for prescriptions filled at military pharmacies.
    The budget request also calls for a commission to study and propose 
changes to the military retirement system. This BRAC-like process would 
bypass the expertise of Senate and House committees and subcommittees 
and only allow the Congress an up-or-down vote on the commission's 
recommendations. All reservists responding to a recent (February 2012) 
FRA survey, and 97 percent of active duty participants ranked 
retirement benefits as a very important benefit. More than 1,000 
current and former servicemembers participated in the survey. As the 
Congress considers plans to reduce DOD costs by revamping the military 
retirement program, that benefit is particularly relevant to Active 
Duty and Reserve component personnel. Many current servicemembers have 
expressed concern about the future of the retired pay and healthcare 
benefits they've been promised after they complete a career of military 
service. FRA appreciates Secretary of Defense Panetta assuring those 
currently serving that they will come under the current retirement 
system, but wonders why there is no similar commitment for those who 
served in the past?
    The budget also requests an Active Duty and Reserve pay hike based 
on the Employment Cost Index of 1.7 percent in 2013, and only at that 
level in 2014 with capped pay adjustments below that index thereafter.
    FRA supports a defense budget of at least 5 percent of GDP that 
will adequately fund both people and weapons programs, and is concerned 
that the administration's spending plan is not enough to support both, 
particularly given ongoing operational commitments associated with the 
new defense strategy.
    Future spending on national defense as a percentage of GDP will be 
reduced despite significant continuing war related expenses and 
extensive operational and national security commitments. Wall Street 
Journal editorial writers noted, ``Taken altogether, the (defense) 
budget could shrink by more than 30 percent in the next decade. The 
administration projects outlays at 2.7 percent of GDP in 2021, down 
from 4.5 percent last year (which included the cost of Iraq and 
Afghanistan). That would put U.S. outlays at 1940 levels--a bad year. 
As recently as 1986, a better year, the U.S. spent 6.2 percent of GDP 
on defense with no detrimental economic impact. What's different now? 
The growing entitlement state. The administration is making a political 
choice and sparing Social Security, Medicare and Medicaid, which are 
set to hit nearly 11 percent of GDP (without healthcare reform costs) 
by 2020.''
    Make no mistake about the importance of these entitlement programs; 
however, DOD and VA benefits are also important and essential to 
maintaining that all volunteer force and our national security.
                         tricare fee increases
    Healthcare benefits are important to every segment of FRA's 
membership. The continued growth in healthcare costs is not just a 
military challenge but a challenge for the entire society. FRA believes 
that military service is a unique profession and notes minimal 
projected savings associated with DOD management efficiencies and other 
initiatives in fiscal year 2013 and beyond, while retirees are targeted 
for major fee hikes. These proposals also follow the 13-percent 
military retiree TRICARE Prime increase imposed this year.
    Our members are also very concerned about a proposed new TRICARE-
for-Life (TFL) enrollment fee beginning in fiscal year 2013. This is 
viewed as another failure to honor commitments to those who served past 
careers in the military. These personnel have not benefited from the 
significant pay and benefit enhancements enacted since 2000.
    The Association believes that military retirees have earned their 
TRICARE benefits with 20 or more years of arduous military service with 
low pay. As you know, many retirees believe that they were promised 
free healthcare for life.
    FRA strongly opposes premium increases for TRICARE beneficiaries' 
based on healthcare inflation. The Consumer Price Index (CPI) is the 
basis for military retiree annual cost-of-living adjustments (COLAs), 
the purpose of which is to maintain purchasing power for the 
beneficiary. The Association strongly supports adequate funding of the 
Military Health Service (MHS) without the drastic fee increases and 
extreme pharmacy co-pays for all retirees proposed by the 
administration.
                         retirement commission
    The administration proposed the creation of a BRAC-like commission 
to review and ``reform'' the current military retirement system. 
Numerous studies and commissions have focused on the military 
retirement as an opportunity to reduce overhead costs for the Pentagon. 
The latest is the Defense Business Board (DBB) proposal to replace the 
current system with a 401(k) plan similar to what corporations offer 
their employees. This concept has created significant anxiety in the 
career active duty community. An FRA online survey released last 
October resulted in strong opposition responses to proposals to 
``civilianize'' the current military retirement system. More than 1,700 
current and former servicemembers responded and nearly 95 percent 
believe retiree benefits offer the most appeal if they were joining 
today. More than 80 percent of Active Duty and Reserve component 
respondents said they'd shorten their term of service if retirement 
benefits were changed to conform with the recommendations.
    FRA believes that military service is unlike any other career or 
occupation, and requires a unique retirement system. Career senior 
noncommissioned officers are the backbone of our military and their 
leadership and guidance are invaluable and a result of many years of 
training and experience.
                            wounded warriors
    FRA believes post-traumatic stress should not be referred to as a 
``disorder''. This terminology adds to the stigma of this condition, 
and the Association believes it is critical that the military do all it 
can to reduce the stigma associated with post-traumatic stress and 
traumatic brain injury.
    FRA also believes the Armed Services and Veterans Affairs 
Committees should remain vigilant regarding their oversight 
responsibilities associated with ensuring a ``seamless transition'' for 
wounded warriors transitioning from DOD's MHS to the Department of 
Veterans Affairs (VA). FRA strongly supports efforts to create and 
adequately fund a Joint Virtual Lifetime Electronic Record (VLER) for 
every servicemember and believes this would be a major step toward the 
long-standing goal of a truly seamless transition from military to 
veteran status for all servicemembers and would permit a DOD, VA, or 
private healthcare provider immediate access to a veteran's health 
data.
    According to Navy Times editors, ``Even before sequestration takes 
effect budget cuts have impacted the Office of Wounded Warrior Care and 
Transition Policy with the elimination of 40 percent (44 positions) of 
the staff, and all 15 contract employees in the transition policy 
section that leaves only two full-time civilian employees.'' \1\ Budget 
cuts have also resulted in the cancellation of the Virtual Transition 
Assistance Program Web site that was scheduled to replace the current 
Turbo TAP Web site. FRA is concerned that these cuts could negatively 
impact transitioning wounded warriors.
---------------------------------------------------------------------------
    \1\ ``Navy Times'' editorial, January 16, 2012, page 4.
---------------------------------------------------------------------------
    The Association also notes the importance of the Navy's Safe Harbor 
Program and the Marine Corps Wounded Warrior Regiment that are 
providing invaluable support for these personnel and recommends 
adequate funding to support these programs.
                             suicide rates
    Suicide in the military is a serious concern for FRA and the 
Association notes that active-duty suicides have been reduced or at 
least leveled off, but suicides for non-active-duty Reserve component 
personnel are increasing. ``More than 2,000 servicemembers killed 
themselves in the past decade, including 295 in 2010 compared with 153 
in 2001''.\2\
---------------------------------------------------------------------------
    \2\ ABC News, ``Rising Suicides Stump Military Leaders'', September 
27, 2011, Kristina Wong.
---------------------------------------------------------------------------
    In 2011, there were 51 Navy active-duty suicides and 7 Navy Reserve 
suicides which represents an increase from 39 active-duty suicides and 
6 Reserve suicides in 2010. To reduce the suicide rate the Navy has 
implemented a multifaceted approach with communication, training, and 
command support, designed to reduce individual stress and strengthen 
psychological health of sailors. The Navy efforts fall within the scope 
of their broader family readiness programs and require adequate 
resources to sustain these efforts.
    In 2011, there were 33 marine suicides and 171 failed suicide 
attempts. During the previous year, 37 marines committed suicide and 
there were 172 failed attempts. The marines have deployed peer-to-peer 
suicide prevention training and are working with the DOD Suicide 
Prevention Office to implement the recommendations of the DOD Joint 
Task Force on the Prevention of Suicide. Despite these initiatives, 
suicides continue and efforts to address the reasons for suicides must 
continue to be a top priority. FRA appreciates the provision in the 
Fiscal Year 2012 Defense Authorization Act that requires preseparation 
counseling for Reservists returning from successful deployments. In 
addition, FRA supports Representative Thomas Rooney's bill (H.R. 208) 
that authorizes reimbursement for mental health counseling under 
TRICARE and requests full funding to support this program if 
authorized.
                       cost-of-living adjustments
    Under current law, military retired pay cost-of-living adjustments 
(COLAs) are rounded down to the next lowest $1. For many of these 
personnel, particularly enlisted retirees, their retired pay is 
sometimes the sole source of income for them and their dependents. Over 
time, the effect of rounding down can be substantial for these 
personnel and FRA supports a policy change to rounding up retiree COLAs 
to the next highest $1.
                        reserve early retirement
    A provision of the Fiscal Year 2008 National Defense Authorization 
Act reduces the Reserve retirement age requirement by 3 months for each 
cumulative 90-days ordered to active duty. This is effective upon the 
enactment of the legislation (January 28, 2008) and not retroactive to 
October 7, 2001, and the Association supports ``The National Guardsmen 
and Reservists Parity for Patriots Act'' (H.R. 181) sponsored by the 
House Personnel Subcommittee Chairman, Representative Joe Wilson, to 
authorize reservists mobilized since October 7, 2001, to receive credit 
in determining eligibility for receipt of early retired pay. Since 
September 11, 2001, the Reserve component has changed from a strategic 
Reserve to an operational Reserve that now plays a vital role in 
prosecuting the war efforts and other operational commitments. This has 
resulted in more frequent and longer deployments impacting individual 
reservist's careers. Changing the effective date of the Reserve early 
retirement would help partially offset lost salary increases, 
promotions, 401(k), and other benefit contributions. The Association 
urges support and funding for this important legislation.
              retention of final full month's retired pay
    If authorized, FRA urges the subcommittee to provide funding to 
support the retention of the full final month's retired pay by the 
surviving spouse (or other designated survivor) of a military retiree 
for the month in which the member was alive for at least 24 hours. FRA 
strongly supports ``The Military Retiree Survivor Comfort Act'' (H.R. 
493), introduced by Representative Walter Jones, which addresses this 
issue.
    Current regulations require survivors of deceased Armed Forces 
retirees to return any retirement payment received in the month the 
retiree passes away or any subsequent month thereafter. Upon the demise 
of a retired servicemember in receipt of military retired pay, the 
surviving spouse is to notify DOD of the death. DOD's financial arm 
(DFAS) then stops payment on the retirement account, recalculates the 
final payment to cover only the days in the month the retiree was 
alive, forwards a check for those days to the surviving spouse 
(beneficiary) and, if not reported in a timely manner, recoups any 
payment(s) made covering periods subsequent to the retiree's death. The 
recouping is made without consideration of the survivor's financial 
status.
    The measure is related to a similar VA policy. The Congress passed 
a law in 1996 that allows a surviving spouse to retain the veteran's 
disability and VA pension payments issued for the month of the 
veteran's death. FRA believes military retired pay should be no 
different.
                           concurrent receipt
    FRA supports legislation authorizing and funding concurrent receipt 
of full military retired pay and veterans' disability compensation for 
all disabled retirees. The Association strongly supports Senate 
Majority Leader, Senator Harry Reid's ``Retired Pay Restoration Act'' 
(S. 344) and Representative Sanford Bishop's ``Disabled Veterans Tax 
Termination Act'' (H.R. 333). Both proposals would authorize 
comprehensive concurrent receipt reform, and Representative Gus 
Bilirakis's ``Retired Pay Restoration Act'' (H.R. 303) would authorize 
current receipt for retirees receiving concurrent retirement and 
disability pay (CRDP) with a disability rating of 50 percent or less.
    FRA also strongly supports House Personnel Subcommittee Chairman 
Representative Joe Wilson's bill (H.R. 186), that expands concurrent 
receipt for servicemembers who were medically retired with less than 20 
years of service (chapter 61 retirees) and would be phased-in over 5 
years. This proposal mirrors the administration's proposal from the 
110th Congress. In 2008, the Congress voted to expand eligibility for 
combat-related special compensation (CRSC) coverage to chapter 61 
retirees and the proposed legislation would, in effect, extend 
eligibility for CRDP to all chapter 61 retirees over 5 years. A less 
costly improvement to pursue in an austere budget year would be fixing 
the so-called ``glitch'' for CRSC that result in compensation declining 
when the VA disability rating increases.
                         military resale system
    FRA strongly supports adequate funding for the Defense Commissary 
Agency (DeCA) to ensure access to the commissary benefit for all 
beneficiaries. Since 2000, DeCA's budget has remained flat in real 
dollars, meaning the agency has done more with less for the past 11 
years.
    The Association also strongly supports the military exchange 
systems (AAFES, NEXCOM, and MCX), and urges against revisiting the 
concept of consolidation. FRA instead urges a thorough review of the 
findings of an extensive and costly ($17 million) multiyear study which 
found that this is not a cost-effective approach to running these 
important systems.
                               conclusion
    FRA is grateful for the opportunity to provide these 
recommendations to this distinguished subcommittee.

    Chairman Inouye. I thank you very much, Mr. Davis, for your 
testimony, and we will most certainly look into the Lautenberg-
Rubio bill. Thank you.
    I thank this panel.
    Now, the next panel consists of: Ms. Mary Hesdorffer, 
representing the Mesothelioma Applied Research Foundation; Mr. 
Stephen Isaacs, representing Aduro Biotech; Dr. Laurence 
Corash, representing Cerus Corporation; and Ms. Sharon Smith, 
representing the National Trauma Institute.
    May I call upon Ms. Mary Hesdorffer.
STATEMENT OF MARY HESDORFFER, ARNP, MSN, MESOTHELIOMA 
            APPLIED RESEARCH FOUNDATION
    Ms. Hesdorffer. Chairman Inouye, Ranking Member Cochran, 
and members of the subcommittee: I really want to thank you 
again for allowing me to come before you to present our case on 
behalf of mesothelioma patients. I'm a nurse practitioner. I've 
been treating patients for more than 12 years with this 
disease, and I'd like to share a little bit of information that 
I think is important for the Department of Defense.
    Mesothelioma is directly related to asbestos exposure. It's 
an extremely rare disease. There's about 3,500 cases diagnosed 
per year. Of those 3,500 cases, one-third can be directly 
related to either Navy duty or working in shipyards. So we lose 
a tremendous amount of Navy vets to this disease. And it 
remains an active threat now because after exposure to asbestos 
the latency period can be anywhere from 10 to 50 years. So this 
remains a constant threat and something that we really need to 
do something about.
    From the time of diagnosis, the average survival is 
documented as 6 to 9 months. We have one approved therapy and 
that's a drug combination, and that extends the median survival 
to 12.3 months.
    I'd like to use a Navy vet who I'm very close to to give 
you an illustration of what the life of a mesothelioma patient 
is like. Tom Shikowski, who asked that I share his name and his 
story, was a sonar man. He worked as an underwater fire control 
technician on the USS Fletcher. He describes his situation as 
having spent 4 years in an asbestos cocoon on the Navy ship. He 
directly correlates his development of mesothelioma to his time 
served in the Navy.
    Tom was faced with a tough decision. He could have 
chemotherapy and extend life to 12.3 months, or try something 
experimental, and the best experimental we have right now is 
what we call an extrapleural pneumonectomy, where we remove the 
entire lung, the lining of the lung, the lining of the 
mediastinum, which is the center of the chest, and the lining 
of the heart. The heart is then encased in a sack to keep it in 
place. Patients are subjected to chemotherapy and radiation 
therapy.
    Yet this is not a cure, and in fact Tom, after having 
undergone this procedure, now faces a decision of what type of 
chemotherapy he's going to have for his fourth recurrence of 
the disease. Tom is out of options. He has one lung. It fills 
with fluid, and traveling for treatment becomes very difficult, 
especially in terms of having so few clinical trials to offer.
    What we're asking today is that the subcommittee recognizes 
the need for mesothelioma and to spur research in this field. 
We'd like you to take this up as a critical national priority 
by providing at least $5 million in funding for mesothelioma 
research through the Congressionally Directed Medical Research 
Program for the fiscal year 2013 Defense appropriations bill, 
rather than the mere eligibility in the Peer-Reviewed Cancer 
Research Program. Mesothelioma needs to be designated as a 
specific line item. Mesothelioma patients, who have already 
risked their lives by serving in their country's armed 
services, do not have this time to wait.

                           PREPARED STATEMENT

    I care deeply about my mesothelioma patients, the 
caregivers, and those people that have lost loved ones to this 
disease, and I really ask you to join me in caring deeply about 
this community as well and helping us to find a cure and to 
raise research dollars so others like Tom will not have to go 
through these devastating choices and will enjoy a better 
quality of life and extended survival.
    Thank you so much.
    [The statement follows:]
            Prepared Statement of Mary Hesdorffer, ARNP, MSN
    Chairman Inouye, Ranking Member Cochran, and members of the 
subcommittee: Thank you for the opportunity to speak with you today to 
discuss mesothelioma, its connection to military service, and the 
desperate need for research. Your support is critical to our mission, 
and I look forward to continuing our relationship with this 
subcommittee.
    My name is Mary Hesdorffer and I am a nurse practitioner that has 
worked with mesothelioma patients for over a decade. I am testifying on 
behalf of the Mesothelioma Applied Research Foundation and the 
Mesothelioma community composed of patients, physicians, caregivers, 
and family members. I would like to take this time to stress the 
importance of increased funding for the Congressionally Directed 
Medical Research Programs (CDMRP) which plays a critical role in 
finding and delivering treatments for mesothelioma.
    Mesothelioma is an aggressive cancer known to be caused by exposure 
to asbestos. Doctors say it is among the most painful and fatal of 
cancers, as it invades the chest, abdomen, and heart, and crushes the 
lungs and vital organs. Mesothelioma disproportionately affects our 
service men and women, as one-third of mesothelioma cases have been 
shown to involve exposures in the Navy or working in our Nation's 
shipyards.
    There are two types of mesothelioma--pleural and peritoneal. 
Patients with pleural mesothelioma, which affects the lining of the 
lungs, comprise 85 percent of the mesothelioma population and face a 
devastating survival time of only 9 months. Peritoneal affects the 
lining of the abdomen. The harsh reality for patients with advanced 
primary peritoneal cancer is a median survival time of 12.3 months; 5-
year survivals are rare. Mesothelioma patients not only face a 
devastatingly short survival time, but also the harsh reality that 
there is only one Food and Drug Administration-approved treatment for 
mesothelioma. Often, the only option is surgery. I have dedicated my 
life to caring for these people, and I am here today to speak for the 
many patients that will never have the opportunity to speak for 
themselves and give testimony like this.
    I am currently directing the care of a Navy veteran, Tom Shikoski. 
Tom joined the Navy directly out of high school, at the age of 18. He 
said ``I always felt it was my duty as a citizen to serve my country.'' 
His primary duty was as a sonarman underwater fire control technician 
aboard the USS Fletcher DDE445. He spent most of his time below deck, 
in his words ``a virtual asbestos cocoon''. He is certain that he was 
exposed to asbestos in his 4 years on the USS Fletcher, although he was 
never informed about the dangers of asbestos.
    Asbestos exposure among Navy personnel was widespread from the 
1930s through the 1980s, and exposure to asbestos still occurred after 
the 1980s during ship repair, overhaul, and decommissioning. We have 
not yet seen the end of exposures to asbestos. Asbestos exposures have 
been reported among the troops in Iraq and Afghanistan. Soldiers in 
wars that extend into third-world countries, where asbestos use is 
increasing without stringent regulations, may also be at risk for 
exposure during tours of duty. Even low-dose, incidental exposures can 
cause mesothelioma. For all those who will develop mesothelioma as a 
result of these past or ongoing exposures, the only hope is that we 
will develop effective treatment.
    Tom Shikoski had never even heard the word mesothelioma until his 
diagnosis. He never thought that his service to his country would come 
back to haunt him so many years later. His diagnosis came by accident. 
He had gone in for another procedure, and his doctor discovered fluid 
in his left lung. He had to undergo another surgery to drain over one 
liter of fluid from his lung, and 1 week later, he had the diagnosis of 
pleural mesothelioma. He found, through the help of a physician family 
friend, a mesothelioma specialist in Texas and had to travel across the 
country from his home in Michigan to see a mesothelioma expert. It was 
recommended that he have an extrapleural pneumonectomy, a surgical 
treatment to remove a lung, a portion of the diaphragm, the linings of 
the lungs, and heart. He then had 25 treatments of radiation, followed 
by 30 treatments of chemotherapy even though not more than 12 
treatments are recommended due to the high risk of anaphylactic shock. 
Tom is willing to do anything to spend more time with his wife, 
children, and many grandchildren.
    Patients take great risks to participate in clinical trials, but 
they feel the possibility of helping to find a better treatment is 
worth the risk. As peritoneal mesothelioma patient, Bonnie Anderson, 
said recently, ``I knew if I was going to die from mesothelioma, I was 
going to put it to good use in a clinical trial.''
    There are brilliant researchers dedicated to mesothelioma. 
Biomarkers are being identified. Two of the most exciting areas in 
cancer research--gene therapy and biomarker discovery for early 
detection and treatment--look particularly promising in mesothelioma. 
The Mesothelioma Applied Research Foundation has made a significant 
investment, funding more than $7.6 million to support research in hopes 
of giving researchers the first seed grant they need to get started. We 
need the continued partnership with the Federal Government to develop 
the promising findings into effective treatments.
    I will give you an example of how the support of the CDMRP has 
helped the promising research initiatives that are giving hope to 
mesothelioma patients:
  --A vaccine is being developed that would induce an immune response 
        against WT1, a tumor suppressor gene highly expressed in 
        mesothelioma patients. A pilot trial was conducted in patients 
        with mesothelioma to show that it is safe and immunogenic. The 
        researcher was then funded by a 2009 CDMRP award. Today, a 
        multisite clinical trial is being conducted on patients 
        following definitive surgery.
    It is efforts like these that give me faith. I am grateful for the 
Federal Government's investment in mesothelioma research, the 
discoveries being made due to the funding, and I want to see it 
continued and increased.
    Mesothelioma is known to be caused by exposure to asbestos. We can 
not only document the Naval asbestos exposures over the course of the 
20th century, but we have evidence that one-third of American 
mesothelioma patients were exposed while serving their country or 
working as civilians aboard Navy ships. The United States must take 
greater action to right this wrong and fund mesothelioma research.
    The mesothelioma community urges the subcommittee to recognize 
mesothelioma as a critical national priority by providing at least $5 
million in funding for mesothelioma research through the CDMRP in the 
fiscal year 2013 Defense appropriations bill. Rather than mere 
eligibility in the Peer-Reviewed Cancer Research Program, mesothelioma 
needs to be designated a specific line item. Mesothelioma patients who 
already risked their lives by serving in our Nation's armed services do 
not have the time to wait.
    I look to the Defense appropriations subcommittee to provide 
continued leadership and hope to the people who develop this deadly 
cancer. You have the power to lead this battle against mesothelioma. 
Thank you for the opportunity to submit testimony and for funding the 
CDMRPs at the highest possible level so that patients receiving this 
deadly diagnosis of mesothelioma may someday survive.

    Chairman Inouye. As you know, we're constantly reminded of 
mesothelioma by television ads of law firms. But your 
suggestion, I think, has some merit. We'll look into it.
    Ms. Hesdorffer. Thank you so much.
    Chairman Inouye. Thank you very much.
    Now may I call upon Mr. Stephen Isaacs.
STATEMENT OF STEPHEN T. ISAACS, CHAIRMAN AND CHIEF 
            EXECUTIVE OFFICER, ADURO BIOTECH
    Mr. Isaacs. Thank you and good morning, Chairman Inouye, 
Ranking Member Cochran, and members of the Defense 
subcommittee. It's truly an honor for me to testify before you 
today.
    I'm the Chairman and CEO of Aduro Biotech from Berkeley, 
California, and we develop modern vaccines to both prevent and 
treat serious conditions such as cancer, infectious diseases, 
and a variety of bioterror pathogens. While these vaccines are 
primarily designed for civilian use, they also have a lot to 
offer to the military.
    My purpose in testifying today is to briefly tell you about 
these new vaccine technologies that can make a big difference 
to the military and to make a few suggestions about the Peer-
Reviewed Medical Research Program that we participate in and 
how the process can be improved.
    No one knows better than your subcommittee that development 
of modern vaccines to support combat operations, to mitigate 
acts of terrorism, and to provide new therapies for DOD-wide 
populations is a top priority for DOD. I think the past 
problems of a major U.S. Department of Health and Human 
Services (HHS) effort to develop a protective vaccine against 
anthrax really illustrates the complexity and difficulty of 
developing such vaccines.
    But, fortunately, there's now a strategic opportunity to 
advance recent breakthroughs in vaccine technology, to develop 
both therapeutic and preventative vaccines. So briefly, the 
problem with many current vaccines is that they are attenuated 
or weakened pathogens and they're used to elicit an effective 
immune response, but these pathogens carry a risk of causing an 
infection. Another approach is to use so-called ``killed 
vaccines'', but these simply don't work as well.
    To address this problem, my company, Aduro Biotech, has 
really developed a very novel platform technology that combines 
the safety of a killed vaccine with the efficacy of a live 
vaccine. Since 2002 we've raised and invested more than $83 
million to the development of the Aduro vaccine platform 
technology, and we've made remarkable progress.
    Aduro is currently conducting a phase two clinical trial to 
treat metastatic pancreatic cancer, and we will begin new 
trials on mesothelioma and glioblastoma within the next few 
months. We were recently competitively selected to participate 
in the peer-reviewed Prostate Cancer Research Program, and I 
thank you for your leadership in providing the Pentagon with 
the funds for this award. We strongly believe that we can make 
a difference in vaccine programs for the Army and the Navy as 
well.
    In its medical research budget to the Congress, the Army 
notes that developing an effective malaria vaccine is a top 
priority, and the Navy notes that diseases that were once 
confined to remote areas of the world now have the capability 
to cross continents.
    In our opinion, neither the Army nor the Navy have 
sufficient funds to conduct robust vaccine development programs 
that are clearly needed to deal with these threats. The main 
purpose of testifying is to say that the military could realize 
significant breakthroughs by competitively developing modern 
preventative and therapeutic vaccines, and I strongly urge your 
subcommittee to make it a top priority to give DOD adequate 
resources for robust vaccine development programs for our 
troops.
    The other topic I'd like to briefly address is the process 
used by the Army to administer the DOD Congressionally Directed 
Medical Research Program that we believe can be improved. Here 
are a few of the issues. First, it's not always clear to us 
what DOD would like to fund. Is it innovative research or is it 
translational medicine?
    Second, some topics that are listed as areas of interest 
are not funded at all. So in spite of high scores in these 
applications, no funding is received, and this is a huge waste 
of everybody's time for both the submitters and for the 
reviewers.
    Finally, there is no path for resubmission of these 
applications, such as there is at the National Institutes of 
Health (NIH) and the Small Business Innovation Research (SBIR) 
program.
    So, specifically, we respectfully submit our 
recommendations for improving the process, which are the 
following: first, consider limiting the use of congressionally 
directed medical research funds to applied research; second, 
consider directing a specific percentage of the annual programs 
to small businesses; and finally, consider directing the 
Assistant Secretary of Defense for Health Affairs to submit a 
report on how DOD's peer-review process can be strengthened and 
approved.

                           PREPARED STATEMENT

    So thank you very much for the opportunity to express my 
views about vaccine development that are really directed at 
solving important medical issues for our troops. And thanks to 
both of you for your interest in these programs and certainly 
for your service to our country.
    Finally, I really do appreciate the opportunity to present 
today, and I invite you and other staff to come and visit Aduro 
the next time you're on the west coast.
    Thank you very much.
    [The statement follows:]
                Prepared Statement of Stephen T. Isaacs
    Chairman Inouye and Ranking Member Cochran, and members of the 
Defense subcommittee: It is an honor for me to testify before your 
subcommittee today.
    I know that your subcommittee cares deeply about the health and 
welfare of the brave men and women who serve our Nation in the Armed 
Forces, and that your subcommittee has taken a leadership role in 
providing funds for health and biodefense research. My purpose today is 
to tell you about the new vaccine technologies like ours that can make 
a big difference to the military; and second, to make some suggestions 
about the Peer-Reviewed Medical Research Program in order to make it 
better for all who participate in it and to provide better value to the 
taxpayer.
    I am Chairman and CEO of Aduro Biotech Incorporated in Berkeley, 
California. We are developing modern vaccines to both prevent and to 
treat serious diseases, and while these vaccines are designed for 
civilian use, they also offer tremendous capabilities to our Armed 
Forces. We team with other companies and nonprofit organizations to 
collaboratively develop the best vaccine technologies for specific 
purposes.
    No one knows better than your subcommittee that development of 
modern vaccines to support combat operations, to mitigate acts of 
terrorism, and to provide new therapies for the Department of Defense 
(DOD)-wide population of military personnel and their dependents is a 
top priority for DOD. The past failure of a major Department of Health 
and Human Services (HHS)-supported program to develop a prophylactic 
(protective) anthrax vaccine illustrates the difficulty in developing 
modern vaccines. There is also now a strategic opportunity to advance 
recent breakthroughs in therapeutic vaccines to develop treatments for 
serious cancers and infectious diseases that affect our war fighters 
and their dependents--particularly for pancreatic cancer for which 
survival rates are very low--as well as infectious diseases that affect 
the military, such as malaria, and improve our defense against 
engineered biological threats.
    Many current vaccines use small amounts of ``attenuated'' pathogens 
to elicit an effective immune response from the body. However, the use 
of attenuated microorganisms is often considered inappropriate due to 
potential risks that the live microbe itself may be harmful in some 
individuals and is out of the question for biodefense applications. An 
alternative is the use of ``killed-vaccines'' in which pathogens are 
completely inactivated and then used to produce an immune response 
without causing the severe effects of the disease; however, the 
efficacy of killed vaccines is often not as great as attenuated 
strains.
    To address this problem, Aduro Biotech has developed novel live-
attenuated double deleted (LADD) vaccines to target specific diseases, 
as well as a unique killed but metabolically active (KBMA) vaccine 
platform technology that combines the safety of a killed vaccine with 
efficacy similar to a live vaccine. Most recently, Aduro has developed 
a third vaccine platform in which the vaccine vector actually commits 
``suicide'' within the body after stimulating a strong immune response 
(``Suicide Strains''). All three of these platforms stimulate the 
body's immune system by using a genetically modified form of the common 
bacteria Listeria monocytogenes as the platform. Promising work has 
been done by Aduro on selected LADD vaccines that are excellent vaccine 
candidates in their own right and which require further development, 
some of which may also become more desirable if transitioned to KBMA or 
Suicide Strains. All three vaccine platforms are designed for the 
treatment of cancer, infectious disease, and protection against 
bioterror agents.
    More than $83 million of private funds have been invested to date 
in development of Aduro's revolutionary LADD, KBMA, and Suicide Strain 
technologies. These approaches use advanced technology developed by 
Aduro to specifically and selectively block the ability of a vaccine 
organism to cause disease, yet preserve its ability to stimulate a 
robust immune response against selected pathogens or cancerous tumors. 
LADD, KBMA, and Suicide Strain vaccines can also be used as therapeutic 
agents used to treat cancers such as pancreatic, lung, and melanoma, 
and chronic infections such as human papilloma virus, malaria, and 
hepatitis B and C.
    Remarkable progress has recently been made in treating pancreatic 
cancer. Aduro is currently conducting a Phase II clinical trial with a 
LADD vaccine to treat metastatic pancreatic cancer, and will begin new 
clinical trials on mesothelioma this summer and glioblastoma early next 
year.
    We were recently competitively selected to participate in the Peer-
Reviewed Prostate Cancer research program, and I am here to thank you 
for your leadership in providing the Pentagon the funds that allow 
companies like mine to competitively bring in the best new ideas and 
new technologies.
    In its medical research budget to the Congress, the Army notes that 
developing an effective malaria vaccine is a top priority since ``A 
highly effective vaccine would reduce or eliminate the use of anti-
malarial drugs and would minimize the progression and impact of drug 
resistance to current/future drugs.'' In our opinion, the Army does not 
have sufficient malaria research funds to conduct a robust vaccine 
development program that it clearly needs. United States servicemembers 
are often deployed to regions endemic for malaria. Currently, a large 
contingent of U.S. forces is deployed in malarial regions in Southeast 
and Southwest Asia. Soldiers in today's military can be exposed to more 
than one malaria-endemic region prior to diagnosis. This presents new 
complexities for disease monitoring and prevention policy development.
    In its medical research budget to the Congress, the Navy notes that 
diseases that may have once been confined to remote areas of the world 
now have the capability to swathe entire regions and to cross 
continents. United States expeditionary operational forces are 
especially susceptible due to their exposure to areas/regions of high 
risk and the potential for rapid, high-volume transmission among close 
quartered personnel. Enteric diseases are of special concern to the 
Navy and Marine Corps because of the high morbidity involved and the 
potential to infect a large number of personnel through contaminated 
food and water sources, especially in regions overseas where food 
handling, water supply, and waste disposal practices are questionable. 
Respiratory disease has been and will continue to be a main focus of 
military disease research and vaccine development. Viruses, bacteria, 
and parasites spread by arthropods (e.g., mosquitos, flies, fleas) are 
some of the most imminent threats to military forces abroad due to 
geographic risk factors and a general lack of effective vaccines and 
treatment. Emerging diseases also include new drug-resistant variants 
as well as new mutational strains of viral agents. In our opinion, the 
Navy does not have sufficient vaccine research funds to conduct a 
robust vaccine development program that it clearly needs to meet these 
requirements.
    The main purpose of testifying before your subcommittee today is to 
tell you that the military could make some significant breakthroughs by 
competitively developing modern prophylactic and therapeutic vaccines 
to solve some of the more difficult challenges for ensuring the health 
of our Nation's Armed Forces. Understanding that we are in a very 
difficult budget climate, I strongly urge your subcommittee to make it 
a top priority to give DOD adequate resources for robust vaccine 
development programs for our troops as your subcommittee crafts annual 
appropriations bills.
    The other topic I would like to briefly address today is the 
process used by the Army to administer the DOD Congressionally Directed 
Medical Research Program that we and others in our industry believe can 
be improved. Here are observations from our perspective:
  --It is not clear to the investigators whether DOD would like to fund 
        early innovative research or technology development, yet 
        analysis of after-the-fact awards indicates a bias toward basic 
        research even though solicitations seem to be inviting applied 
        research proposals. The real-world funding gap, which should be 
        the intent of the Senate's program, is in applied research not 
        basic research.
  --In some instances topics are listed in their contracting documents, 
        review panels are formed for these topics, but in the 
        subsequent review of industry proposals none of these grant 
        applications are funded--even some with exceptionally high 
        scores. This seems to be a tremendous waste of everybody's time 
        including the time of the reviewers.
  --The review process seems to be a complete hit and miss; the quality 
        of the review is highly variable and the comments are often not 
        very helpful. Steps should be taken to ensure that the 
        reviewers have a background in and understand the technology 
        being reviewed.
  --There is no path for resubmission and for addressing the reviewer's 
        comments. Unlike other similar Federal programs, DOD does not 
        allow for resubmissions. In contrast, National Institutes of 
        Health (NIH), Small Business Innovation Research (SBIR), and 
        Advanced Research Projects Agency-Energy (ARPA-E) do allow for 
        at least one resubmission. The new reviewers are provided with 
        the full review of the first submission and the investigator 
        has one page to outline how the resubmission has been changed. 
        We have had very good experience with resubmissions, which are 
        the only form of dialogue between submitter and reviewer.
    We believe that the following recommendations for improved 
management of the Peer-Reviewed Congressionally Directed Medical 
Research Programs would give DOD, the Congress, and the taxpayer better 
results:
  --Consider limiting use of congressionally added medical research 
        funds, particularly in the Peer-Reviewed Medical Research 
        Program, to applied research rather that basic research.
  --Consider directing a specific percentage of the annual programs to 
        small businesses.
  --Direct the Assistant Secretary of Defense for Health Affairs (ASD 
        (HA)) submit a report to the Appropriations Committees of the 
        House and Senate by January 31, 2013, on how DOD's peer-review 
        process for the Congressionally Directed Medical Research 
        Programs can be strengthened and improved. ASD (HA) should 
        specifically examine the procedures used by the Department of 
        Energy's ARPA-E that are efficient and consistently win praise 
        from industry.
    In closing, I would like to thank you for giving me the opportunity 
to express some priorities of vaccine development companies like mine 
on the possibilities for strategic breakthroughs in solving thorny 
medical issues for our troops through robust, competitive vaccine 
development programs.
    I would also like to thank you, Chairman Inouye, for your lifetime 
of service to our Nation and to commend the other members of the 
subcommittee for your dedication to the welfare of the young men and 
women who so ably serve our Nation. I appreciate the opportunity to 
express my views to you today, and I invite any of the members or staff 
to come visit Aduro the next time you are on the west coast.

    Chairman Inouye. I thank you very much. Your study shows 
that vaccines can have an impact upon prostate cancer?
    Mr. Isaacs. Well, we're working on that right now and we 
see a very strong impact in animal models that we've developed. 
And we've taken this on into human clinical trials in non-
small-cell lung cancer and in pancreatic cancer. We hope to 
expand to mesothelioma as well.
    Chairman Inouye. I thank you very much.
    May I now call upon Dr. Laurence Corash of the Cerus 
Corporation.
STATEMENT OF LAURENCE CORASH, M.D., CHIEF MEDICAL 
            OFFICER, CERUS CORPORATION
    Dr. Corash. Thank you, Chairman Inouye and Ranking Member 
Cochran, members of the subcommittee, for the opportunity to 
testify about the safety of blood transfusion in the military. 
I'm a hematologist and I've spent 20 years researching ways to 
prevent transfusion-transmitted infections, first at the 
National Institutes of Health (NIH), then at the University of 
California as chief of laboratory medicine, and now at Cerus 
Corporation, and in my capacity as the industry representative 
for the U.S. Department of Health and Human Services (HHS) 
Advisory Committee on Blood Safety and Availability.
    Blood transfusion is a fundamental component of healthcare. 
Patients assume that when blood is required it will be 
available and it will be safe. But this is not always the case. 
My interest in this problem began in the 1980s at the NIH and 
then at the University of California, when we saw our patients 
infected with a new disease via blood transfusion that we 
ultimately recognized as AIDS and the virus as HIV.
    We now know, though, that this is not the only threat to 
the blood supply and it will not be the last threat. Our 
patients have experienced hepatitis B, hepatitis C, West Nile 
virus, and today they're facing dengue and bebizia, new 
pathogens that cause fatal and debilitating illnesses. There 
will be new pathogens in the future.
    Improved donor testing has reduced the risk for some of 
these infections, but tests do not exist for all pathogens, and 
the blood supply remains vulnerable. Testing will always be 
inherently a reactive strategy against new pathogens. Improved 
donor testing has not solved the problem.
    Soldiers on deployment are especially vulnerable to the 
problems of providing an adequate and safe blood supply for the 
military. As to adequacy, the military relies on its own 
donors, but many of these donors are disqualified due to travel 
related to deployment. Because blood products have a limited 
shelf life and require temperature control, it's not easy to 
transport blood to forward areas of deployment where they're 
critically required. As a result, the military must frequently 
rely on personnel to donate blood in forward areas of 
deployment, where it cannot be adequately tested, and this 
creates problems of safety due to exposure to unrecognized 
pathogens.
    Today a solution exists to this problem. It's pathogen 
inactivation, treating donated blood to kill microbes. This is 
not a novel concept. We pasteurize milk and other intravenous 
medications are treated to sterilize them. However, pathogen 
inactivation of blood components has been a scientific 
challenge.
    My colleagues and I started work on this technology years 
ago and in 1999 the subcommittee provided the first year of 
funding to advance this technology for the military, and we're 
grateful for this. In 2003 the technology from our company was 
licensed in Europe, and since that time 1 million blood 
components treated with this technology have been transfused.
    In our country, the respiratory hurdles to pathogen 
inactivation have been challenging. But my focus today is on a 
modest step to improve safety for the military blood 
transfusion supply. The French military have solved the problem 
of adequacy and safety for plasma by creating a pathogen-
inactivated freeze-dried plasma. This product has been used in 
Afghanistan since 2010. It can be stored for up to 2 years at 
room temperature and it's ready for use within 6 minutes.
    The U.S. Army is aware of dried plasma, but without FDA 
agreement it cannot be used for U.S. troops. The clinical data 
from the French army support the use of this freeze-dried 
plasma, and the pathogen-inactivate plasma can be available to 
the U.S. military through a collaborative program with the 
French, at lower cost and more rapidly than other approaches.

                           PREPARED STATEMENT

    Cerus asks that the subcommittee provide funding to support 
the licensure of this product and to encourage the FDA to 
define an expeditious pathway for licensure. This action is 
consistent with the 2009 recommendation by the Assistant 
Secretary for Health for implementation of pathogen 
inactivation of civilian blood components.
    Chairman Inouye, thank you for the opportunity to testify 
and for your decades of service to our military and the Nation.
    [The statement follows:]
              Prepared Statement of Laurence Corash, M.D.
    Chairman Inouye and Ranking Member Cochran, and members of the 
Defense subcommittee: Thank you for the opportunity to testify before 
your subcommittee today about improving blood safety.
    I am the Chief Medical Officer for Cerus Corporation in Concord, 
California. In the 1980s, I was the director of a university hematology 
service in which a majority of our patients were infected by an unknown 
virus and developed a disease, we now call AIDS, but which no one knew 
existed at the time. There was no way to know at that time that blood 
being donated and transfused contained deadly pathogens that could kill 
people. Although many steps are taken today to reduce the risk of 
infection from donated blood, it is surprising and disappointing that 
for both civilian and military purposes there still remains no good way 
to prevent new and unknown emerging pathogens from entering the blood 
supply and no way to detect them prior to transfusion. Worse, if a 
terrorist organization were to engineer novel pathogens and introduce 
them into our Nation's blood supply, there is no mechanism for 
determining that they are in blood until you see the effects, when it 
is far too late. We had a close call with the anthrax event in which 
potential blood donors were unknowingly exposed.
    There is a better way, and it's called ``pathogen inactivation''. 
This is not a novel concept as all other intravenous medications are 
sterilized. Unfortunately, our Nation has been slow to implement it, 
which is a Food and Drug Administration (FDA) issue. But we are also 
asking our military personnel, who maybe wounded in combat, to take 
blood-safety risks that are not necessary. I would like to bring this 
issue to your attention today, along with an interim solution for your 
consideration.
    About 16 million units of whole blood were donated in the United 
States in 2006. Whole blood can be transfused directly or more commonly 
separated into its components:
  --red cells;
  --plasma; and
  --platelets.
    Most of the Nation's blood supply is handled by the American Red 
Cross and a small number of community blood-banks. The FDA regulates 
all blood bank operations.
    Blood centers, which have tested for risks like hepatitis C and 
AIDS since the 1980s and 1990s, have added a number of new tests on 
donated blood in recent years to deal with emerging pathogens. However, 
more pathogens have shown up in the donor population as people travel 
more, climate change, and urbanization impact pathogen vectors, and 
bacterial pathogens become more resilient to antibiotics. Without FDA 
approved tests for many infectious risks, blood centers have steadily 
added new prohibitions for people wanting to give blood which reduce 
the donor pool significantly. In 2006, for example, 12.4 million people 
volunteered to donate blood but nearly 2.6 million were turned away 
during questionnaire screening. Donors may be rejected simply on the 
region of the world to which they travelled, but many of them could be 
qualified blood donors if adequate testing was possible or other safety 
measures were taken, such as pathogen inactivation.
    The Department of Defense (DOD) is generally discouraged from 
relying on the domestic blood supply to support the military. The Armed 
Services Blood Program supplies blood for 1.3 million servicemembers 
and their families each year. Military personnel who were stationed in 
Europe for extended periods in the 1980s and 1990s are not allowed to 
donate blood, as a precaution against mad cow disease. Soldiers 
returning from Iraq and Afghanistan cannot donate blood for at least a 
year. As a consequence, a larger population of the military can no 
longer donate blood. Measures such as increasing blood recruitment 
efforts from military personnel in training billets, from the DOD 
civilian workforce, and from military dependents may not be enough.
    During recent operations in Iraq and Afghanistan, platelets were 
collected from U.S. military members and transfused with limited real-
time testing. The U.S. Army Medical Command for example stated in a 
January 2008 news release that:

    ``. . . field hospitals must rely on local personnel when treating 
someone who has suffered catastrophic injuries and needs a lot of blood 
quickly. At these times, an urgent call for blood donors is sent out 
and our men and women in uniform, already in a war zone, line up on-on 
the run to give blood.''

    As you can imagine, collecting blood in theater from deployed U.S. 
soldiers or civilians entails a significant risk of infection, because 
testing in theater is limited. Your subcommittee is aware of the 
incident where the British Government raised concerns about 18 of its 
troops and 6 civilians who received emergency blood transfusions from 
American personnel in Afghanistan without proper testing for infectious 
diseases.
    As I indicated before, there is a better way to ensure blood 
transfusion safety, and it's called ``pathogen inactivation''. In fact, 
the Assistant Secretary for Health in the Department of Health and 
Human Services established a Federal pathogen inactivation task force 
in 2009 based on recommendations from its Advisory Committee on Blood 
Safety and Availability. I urge the Senate Appropriations Committee, 
through one of its other subcommittees, to look into the lack of 
progress that has been made at the Federal level to expedite pathogen 
inactivation technology to protect our national blood supply.
    Cerus is a biotechnology company based in California founded in 
1992 with the mission to develop technology for the inactivation of 
infectious microbes, including viruses, bacteria, and parasites, in 
blood components (platelets, plasma, and red cells) used for 
transfusion support of patients. We have a process for pathogen 
inactivation in blood using chemicals and ultraviolet light that 
prevents any organism from replicating. Cerus blood technology 
inactivates all infectious agents such as bacteria, viruses, and 
parasites in blood, whether you know they are there or not. We have 
spent more than $600 million developing the technology, of which less 
than 7 percent came from the Federal Government, and we have been on an 
agonizingly slow process toward FDA approval for its eventual use in 
the United States.
    The technology is in use in Europe, Asia, Russia, the Middle East, 
and South America. The treated blood components have received national 
licensure as biologics in France, Germany, Switzerland, and Austria. To 
date more than 1 million therapeutic doses have been transfused in more 
than 100 blood centers in 16 countries. In France, more than 30,000 
patients have received the platelet and plasma products. One Belgian 
blood center has used the technology for 9 years. The Swiss Regulatory 
Authority mandated use of the platelet technology in 2010. The French 
Armed Forces Blood Transfusion Service has used this technology to 
create dried plasma which has been used in Afghanistan to treat 
severely wounded personnel at the time of injury since 2010. 
Surveillance by the regulatory authorities in these countries has shown 
that the technology is safe and effective in routine use; and that it 
has prevented transfusion-transmitted infections. The red cell 
technology is entering Phase 3 clinical trials in Europe.
    Cerus has received DOD funding to support the development of 
technology specific to the Army's blood transfusion requirements. The 
major portion of this funding has supported the red cell technology 
program that is now under discussion with FDA for design of Phase 3 
clinical trials. Recently, Cerus became aware of the Army's interest in 
dried plasma as a means to improve outcomes for severely wounded 
personnel. However, the Army has communicated to Cerus the overwhelming 
task of taking this product through FDA regulatory approval.
    The U.S. Army is aware of the French Armed Forces experience with 
the dried plasma product; and Cerus has discussed the use of data from 
the French Armed Forces clinical experience with the French Armed 
Forces Blood Service to support FDA licensure for the specific 
treatment of U.S. military personnel. Cerus believes that these data, 
in combination with the substantial European experience with this 
technology are relevant and sufficient to support licensure, but prior 
discussions with FDA have not resulted in a commitment to use these 
data. Cerus believes that there is a need for the pathogen inactivated 
dried plasma product and that this product can be made available to the 
U.S. Armed Forces through a collaborative manufacturing program with 
the French Armed Forces Blood Service. This approach would make this 
product available at lower cost and more rapidly than other approaches 
currently under consideration. Cerus requests the subcommittees 
recommend this initiative with expedited review by FDA which could 
improve the outcomes for military personnel with severe traumatic 
injuries.
    The pathogen inactivation technology will also be of benefit to the 
civilian population especially for national disaster contingency 
planning when normal channels for blood donation, preparation, and 
transport may be disrupted by natural disasters or bioterrorism events.
    Chairman Inouye, as a Medal of Honor winner who has personally 
witnessed the horrors of combat, I wanted to bring to your attention, 
and to the subcommittee, that through cooperation with the French 
military the Army can now take steps to expedite the availability of 
proven pathogen inactivation technology for the U.S. Armed Forces. That 
would mean that our soldiers and marines would have more blood 
supplies, faster treatment during the critical first moments after 
severe injuries, and improved safety during blood transfusions after 
being injured in combat.
    I thank all the members of the subcommittee for allowing me this 
opportunity to testify today, and thank you for your decades of service 
to our military and to our Nation.

    Chairman Inouye. You've brought up a matter that's very 
personal to me because during the war I got about 30 
transfusions. I just must have been lucky.
    What was the situation in World War II? Was it this bad?
    Dr. Corash. Well, it was worse, of course, because 
transportation of blood in liquid format and even of plasma was 
extraordinarily difficult, and that meant that treatment could 
not be delivered close to the point of injury. We know now that 
the first 30 minutes are very critical for survival.
    It's improved over the years by various measures, but we 
have not yet achieved the most optimal outcome. I think the 
French have really achieved this. The data from their 
experience in Afghanistan for salvage of these wounded 
personnel is quite impressive.
    Chairman Inouye. If you have any reading material on the 
French method, will you submit that, please?
    Dr. Corash. I'm sorry, Sir?
    Chairman Inouye. On the French method, if you have any 
reading material.
    Dr. Corash. Yes, I do. I can send you some publications 
that have been provided to me by the French military, and I 
work very actively with them.
    Chairman Inouye. Thank you very much.
    May I now call upon Ms. Sharon Smith.
STATEMENT OF SHARON SMITH, EXECUTIVE DIRECTOR, NATIONAL 
            TRAUMA INSTITUTE
    Ms. Smith. Thank you, Mr. Chairman and Ranking Member 
Cochran, for the opportunity to testify today to urge the 
subcommittee to invest a greater amount of DOD medical research 
funds into the primary conditions which kill our soldiers.
    According to military trauma surgeons, noncompressible 
hemorrhage is the leading cause of death among combatants whose 
deaths are considered potentially survivable. This includes 
injuries to the neck, chest, abdomen, groin, and back, where a 
tourniquet or compression cannot be easily applied. The 
National Trauma Institute (NTI) believes an accelerated program 
of research into noncompressible hemorrhage will result in the 
first truly novel advances in treating this difficult problem, 
will save the lives of soldiers wounded in combat, and will 
have tremendous impact on civilian casualties and costs.
    I'm executive director of the NTI, which is a nonprofit 
organization based in San Antonio, Texas, where so many of the 
military's medical research assets are centralized. We were 
formed in 2006 by leaders of America's trauma organizations in 
response to frustration over lack of funding of trauma 
research. Our board of directors includes civilian, active 
duty, and retired military trauma surgeons, and we advocate and 
manage funds for trauma research and are a national 
coordinating center for those funds.
    In a June 2011 letter, the Defense Health Board, which 
provides advice and recommendations to the DOD, cited an urgent 
need to improve the evidence base for trauma care, and further 
stated that, ``Due to the lack of opportunities to perform 
randomized controlled trials on the battlefield, challenges 
arise in maintaining the best practice guidelines for the 
combat environment.''
    The board then recommended that the Department endorse 
high-priority medical research, development, testing, and 
evaluation (RDT&E) funding for improving battlefield trauma 
care. Further, individual members of the board have expressed 
grave concern that when the current combat mission ends no 
further military medical research progress will be made. A 
review of medical advances available to the combat medic has 
identified no significant changes during the period of relative 
peace from the end of the Vietnam War to September 11, 2011.
    The challenge going forward is to fund medical research and 
development during peacetime, without the historical impetus 
afforded by active combat operations. A time of peace is an 
opportunity to make medical advances to ensure readiness for 
the next conflict or terrorist threat.
    NTI has been invited to meet with the Defense Health Board 
later this month to explore how we together can address these 
concerns.
    Military trauma surgeons agree that the major cause of 
death from combat wounds is hemorrhage. In recent conflicts, 21 
percent of combat deaths were potentially survivable. In other 
words, more than 1,300 warriors wounded in Iraq and Afghanistan 
might have survived, but died because treatment strategies were 
lacking. More than 600 of these were due to noncompressible 
hemorrhage.
    Currently there is no active intervention for 
noncompressible hemorrhage available to military medics, not 
even a method to detect whether the wounded warrior is bleeding 
internally and if so how much blood has been lost.
    On the civilian front, trauma injury is responsible for 
more than 61 percent of the deaths of Americans between the 
ages of 1 to 44 every year, more than all forms of cancer, 
heart disease, HIV, liver disease, stroke, and diabetes 
combined. An American dies every 3 minutes due to trauma, and 
that's 170,000 deaths, in addition to 42 million injuries every 
year, making trauma the second most expensive healthcare 
problem facing the United States, with annual medical costs of 
$72 billion.

                           PREPARED STATEMENT

    So NTI recommends that the Congress set aside a much larger 
portion of DOD medical research funding for the medical 
conditions which most seriously and severely injure, as well as 
kill, our soldiers, and in particular maintain or increase 
funding for noncompressible hemorrhage, the leading cause of 
potentially survivable deaths of our soldiers.
    So I thank you again for the opportunity to present our 
views.
    [The statement follows:]
                   Prepared Statement of Sharon Smith
    Mr. Chairman, Ranking Member Cochran, and members of the 
subcommittee: Thank you for the opportunity to testify today to urge 
the subcommittee to invest a greater amount of Department of Defense 
(DOD) medical research funds in the primary conditions which kill our 
soldiers. According to military medical officials, noncompressible 
hemorrhage is the leading cause of death among combatants whose deaths 
are considered ``potentially survivable.'' The National Trauma 
Institute (NTI) believes an accelerated program of research into 
noncompressible hemorrhage will result in the first truly novel 
advances in treating this difficult problem, will save the lives of 
soldiers wounded in combat, and will have tremendous impact on civilian 
casualties and costs.
    NTI is a nonprofit organization formed in 2006 by leaders of 
America's trauma organizations in response to frustration over lack of 
funding of trauma research. Our Board of Directors now includes 19 
leading physicians totaling hundreds of years in treating traumatic 
injuries. Some of these physicians are active duty Army, Navy, and Air 
Force doctors in organizations such as the Army's Institute for 
Surgical Research in San Antonio, where NTI is based. Others are 
retired from the military after 20 plus years serving our Nation and 
are bringing the expertise gained in combat theaters to the civilian 
setting.
    With the support and participation of the national trauma 
community, NTI advocates and manages funding for trauma research and is 
a national coordinating center for trauma research funding. In recent 
years, NTI issued two national calls for proposals and received a total 
of 177 pre-proposals from 32 States and the District of Columbia. After 
rigorous peer review, NTI awarded $3.9 million to 16 proposals 
involving 55 clinical investigators at 39 participating sites spread 
across 35 cities and 22 States nationally. Several of these studies are 
nearing completion. However, important as these studies are, they will 
barely begin to build the body of knowledge necessary for improved 
treatments and outcomes in the field of trauma in the United States.
                          defense health board
    As the subcommittee knows, the Defense Health Board is a Federal 
advisory committee which provides independent advice and 
recommendations on DOD healthcare issues including research to the 
Secretary of Defense. The Board, in a letter to the Honorable Jonathan 
Woodson, M.D., Assistant Secretary of Defense (Health Affairs) dated 
June 2011, cited ``an urgent need to improve the evidence base for 
trauma care . . . due to the lack of opportunities to perform 
randomized controlled trials on the battlefield, challenges arise in 
maintaining . . . best practice guidelines for the combat 
environment.'' The DHB then recommended that the Department of Defense 
``endorse . . . high-priority medical Research, Development, Test and 
Evaluation (RDT&E) issues for improving battlefield trauma care.''
    Further, individual members of the Defense Health Board have 
expressed grave concern that when the current combat mission ends, no 
further military medical research progress will be made. The challenge 
going forward will be to provide the necessary support for medical 
research and development during peacetime, without the historical 
impetus afforded by active combat operations. A review of medical 
advances available to the Combat Medic has identified no significant 
changes during the period of relative peace from the end of the Vietnam 
War to September 11, 2001.\1\
---------------------------------------------------------------------------
    \1\ Blackborne, L.H.C. (2011) 1831. The Army Department Medical 
Journal April-June 2011, 6-10.
---------------------------------------------------------------------------
    A time of peace is an opportunity to make medical advancements to 
ensure readiness for the next conflict or terrorist threat. NTI will be 
visiting the Defense Health Board later this month to explore how our 
country can address these concerns.
                       noncompressible hemorrhage
    According to military documents and officials, the major cause of 
death from combat wounds is hemorrhage. In recent conflicts, 21 percent 
of combat deaths have been judged to be potentially survivable.\2\ In 
other words, more than 1,300 warriors wounded in Iraq or Afghanistan 
might have survived to come home to their loved ones, but didn't 
because treatment strategies were lacking. More than 1,100 (85 percent) 
of these deaths were due to hemorrhage, and 55 percent of these, more 
than 600 potentially survivable deaths, resulted from hemorrhage in 
regions of the body such as the neck, chest, abdomen, groin, and back 
that couldn't be treated by a tourniquet or compression.\2\
---------------------------------------------------------------------------
    \2\ Eastridge, B.J., Hardin, M., Cantrell, J., Oetjen-Gerdes, L., 
Zubko, T., Mallak, C., Wade, C.E., Simmons, J., Mace, J., Mabry, R., 
Bolenbaucher, R., Blackbourne, L.H. (2011) Died of wounds on the 
battlefield: causation and implications for improving combat casualty 
care. J Trauma. 71 (1 Suppl): S4-8.
---------------------------------------------------------------------------
    causes of potentially survivable deaths operation iraqi freedom/
                       operation enduring freedom



    NTI commends the Congress for its attention to traumatic brain 
injuries and encourages a continuing focus on this potentially 
debilitating condition. Yet as the above chart shows, hemorrhage is a 
far more common killer of our soldiers, and hemorrhage has received 
relatively little funding.
    Extremity wounds are amenable to compression to stop bleeding, and 
new tourniquets and hemostatic bandages have had a major impact on the 
decline in combat deaths due to extremity hemorrhage. But compression 
is rarely effective for penetrating wounds to the torso and major 
vessels can be damaged resulting in massive hemorrhage. At present, 
such wounds are normally only treatable through surgical intervention 
and typically such patients do not survive to reach the operating room.
    Currently, there is no active intervention for noncompressible 
hemorrhage available to military medics, who along with civilian 
responders have only the tools their predecessors had in the early 20th 
century. There is not even a method to detect whether the wounded 
warrior is bleeding internally, and if so, how much blood has been 
lost. The current Tactical Combat Casualty Care guidelines for medics 
and corpsmen do not include strategies to stem bleeding from 
noncompressible hemorrhage because no solutions are available.\3\ NTI 
hopes to decrease the mortality of severely injured patients suffering 
from torso hemorrhage. This can only be accomplished through research 
into the development of simple, rapid and field-expedient techniques 
which can be used by medics on the battlefield or first responders in a 
civilian context to detect and treat noncompressible hemorrhage. 
Examples of current NTI research in noncompressible hemorrhage include:
---------------------------------------------------------------------------
    \3\ (2009) Tactical Combat Casualty Care Guidelines. http://
www.usaisr.amedd.army.mil/tccc/TCCC%20Guidelines%20091104.pdf. Accessed 
May 20, 2012.
---------------------------------------------------------------------------
  --The use of ultrasonography to measure the diameter of the vena cava 
        to determine whether this will give an accurate indication of 
        low blood volume.
  --An observational study to determine the incidence and prevalence of 
        clotting abnormalities in severely injured patients and to 
        study the complex biology of proteins to better understand, 
        predict, diagnose, and treat bleeding after trauma.
  --Supplementation of hemorrhagic shock patients with vasopressin, a 
        hormone needed to support high blood pressure. Vasopressin at 
        high doses has been shown to improve blood pressure, decrease 
        blood loss and improve survival in animal models with lethal 
        blood loss. This study investigates the use of vasopressin in 
        trauma patients.
    Another challenge in hemorrhage is resuscitation--the restoration 
of blood volume and pressure. Traditional resuscitation includes large 
volumes of intravenous fluids followed by blood and finally plasma. 
However, now this large intravenous fluid load is thought to worsen the 
trauma patient's coagulopathy (blood clotting problems), increasing 
bleeding. There is strong retrospective evidence that for patients 
requiring massive transfusion, a higher proportion of plasma and 
platelets, when compared to red cells, results in improved survival. 
Based on a 2004 research study,\4\ the current Joint Theater Trauma 
Clinical Practice Guideline for Forward Surgical Teams and Combat 
Support Hospitals advocates a plasma, platelet, and red cell 
resuscitation regime in lieu of the standard intravenous fluids. 
Currently, there is no blood substitute available for in-theater use. 
The Army Medical Department/USA Institute of Surgical Research is 
working on a freeze-dried plasma solution; however, this product has 
not yet received FDA approval. Remarkably, current treatments used by 
military medics for restoration of blood volume are very similar to 
those originally used in 1831 when saline was first given as an 
intravenous fluid to cholera patients.\1\
---------------------------------------------------------------------------
    \4\ Holcomb, J.B., Jenkins, D., Rhee, P., Johannigman, J., Mahoney, 
P., Mehta, S., Cox, E.D., Gehrke, M.J., Beilman, G.J., Schreiber, M., 
Flaherty, S.F., Grathwohl, K.W., Spinella, P.C., Perkins, J.G., 
Beekley, A.C., McMullin, N.R., Park, M.S., Gonzalez, E.A., Wade, C.E., 
Dubick, M.A., Schwab, C.W., Moore, F.A., Champion, H.R., Hoyt, D.B., 
and Hess, J.R. (2007) Damage Control Resuscitation: Directly Addressing 
the Early Coagulopathy of Trauma. The Journal of Trauma 62, 307-310.
---------------------------------------------------------------------------
    Noncompressible hemorrhage is just one example of advances in 
research that can be applied to both military and civilian casualties. 
Many of the problems associated with hemorrhage of all kinds are 
potentially solvable and are transferable between military and civilian 
trauma care. The funding recommended by NTI could have a dramatic 
impact on civilian mortality in the United States as hemorrhage is 
responsible for 30 to 40 percent of deaths following a traumatic injury 
to civilians.\5\
---------------------------------------------------------------------------
    \5\ Holcomb, J.B. (2010) Optimal Use of Blood Products in Severely 
Injured Trauma Patients. Hematology, 465-469.
---------------------------------------------------------------------------
              impact of trauma on united states civilians
    Traumatic injury is the cause of death of nearly every soldier in 
combat. On the civilian front, trauma/injury is responsible for more 
than 61 percent of the deaths of Americans between the ages of 1 and 44 
each year.\6\ That's more than all forms of cancer, heart disease, HIV, 
liver disease, stroke, and diabetes combined. An American dies every 3 
minutes due to trauma. That's 170,000 deaths in addition to 42 million 
injuries every year.\6\
---------------------------------------------------------------------------
    \6\ CDC (2006) Centers for Disease Control/WISQARS. http://
webappa.cdc.gov/sasweb/ncipc/mortrate10_sy.html. Accessed March 16, 
2012.
---------------------------------------------------------------------------
                top causes of death in 2009: 1-44 years



    Trauma is the second most expensive public health problem facing 
the United States. Data from the Agency for Healthcare Research and 
Quality (AHRQ) on the ten most expensive health conditions puts the 
annual medical costs from trauma at $72 billion, second only to heart 
conditions at $76 billion, and ahead of cancer and all other 
diseases.\7\ The National Safety Council estimates the true economic 
burden to be more than $690 billion per year, since trauma has an 
ongoing cost to society due to disability, and is the leading cause of 
years of productive life lost.\8\
---------------------------------------------------------------------------
    \7\ AHRQ (2008) Big Money: Cost of 10 Most Expensive Health 
Conditions Near $500 Billion. Agency for Healthcare Research and 
Quality http://www.ahrq.gov/news/nn/nn012308.htm. Accessed May 2, 2012.
    \8\ NSC (2011) Summary from Injury Facts, 2011 Edition. National 
Safety Council http://www.nsc.org/news_resources/
injury_and_death_statistics/Documents/Summary%202011.pdf. Accessed 
March 16, 2011.
---------------------------------------------------------------------------
      eight most expensive health conditions in the united states


             department of defense medical research funding
    For fiscal year 2012, the Congress added more than $600 million to 
the President's budget request for DOD medical research funding. While 
very significant, this sum is considerably less than that appropriated 
just 2 years prior, when the Congress added more than $1 billion for 
DOD medical research. However, roughly 60 percent of the fiscal year 
2012 funding the Congress added was not directed to those conditions 
such as hemorrhage which are common battlefield injuries and most 
severely impact our troops. NTI greatly appreciates the subcommittee's 
attention to traumatic brain injury and psychological health. NTI urges 
that the Congress set aside equivalent sums for improvements in 
treating other lethal or disabling battlefield injuries.
                             research works
    It has been proven repeatedly that medical research saves lives. 
For instance, in 1950 a diagnosis of leukemia was tantamount to a death 
sentence. Research led to chemotherapy treatments in the 1950s and bone 
marrow transplantations in the 1970s. A substantial investment in 
research has led to safer and more effective treatments, and today 
there is a 90-percent survival rate for leukemia.\9\ Another example is 
breast cancer. Thirty years ago only 74 percent of women who were 
diagnosed before the breast cancer spread lived for another 5 years. 
Due to research into early detection, chemotherapy and pharmaceuticals, 
the 5-year comparable survival rate for breast cancer is now 98 
percent.\10\
---------------------------------------------------------------------------
    \9\ (2011) Research Successes. Leukemia and Lymphoma Society http:/
/www.lls.org/#/aboutlls/researchsuccesses/. Accessed May 20, 2012.
    \10\ (2011) Our Work. Susan G. Komen For the Cure http://
ww5.komen.org/AboutUs/OurWork.html. Accessed May 20, 2012.
---------------------------------------------------------------------------
    Fifty years of dedicated research into proper diagnosis and 
treatment of leukemia has led to an 80-percent reduction in the death 
rate. Imagine even a 5 percent reduction in trauma deaths and economic 
burden--this could save the United States $35 billion, save almost 
9,000 lives every year, and significantly reduce the extent of 
disability of those who do survive a traumatic event.
    Recommendation.--NTI recommends that the Congress set aside a much 
larger portion of DOD medical research funding for the medical 
conditions which most severely injure as well as kill our soldiers and 
in particular maintain or increase funding for noncompressible 
hemorrhage--the leading cause of potentially survivable deaths of our 
soldiers.

    Chairman Inouye. I can assure you that we will discuss this 
matter with DOD to see if they cannot increase funding. Thank 
you very much.
    Now the final panel. We have: Rear Admiral Casey Coane, 
representing the Association of the United States Navy; Dr. 
Andrew Pollak, representing the American Association of 
Orthopedic Surgeons; Mr. Mark Haubner, representing the 
Arthritis Foundation; and Dr. Remington Nevin, representing the 
mefloquine research.
    May I call upon Admiral Coane.
STATEMENT OF REAR ADMIRAL CASEY COANE, U.S. NAVY 
            (RETIRED), EXECUTIVE DIRECTOR, ASSOCIATION 
            FOR THE UNITED STATES NAVY
    Admiral Coane. Chairman Inouye and Ranking Member Cochran: 
It's good to be with you again this year. On behalf of the 
Association of the United States Navy (AUSN) and our thousands 
of members, we thank you and the committee for the work that 
you do in support of our Navy, retirees and veterans, as well 
as their families. Your hard work has allowed significant 
progress in adequately funding our Nation's military that has 
also left a lasting impact on national security.
    AUSN recognizes the difficulties ahead in your obligation 
to abide by the Budget Control Act of 2011, while adequately 
funding and providing for our Nation's defense. Our top 
concerns with defense appropriations include the proposed 
TRICARE increases, Navy shipbuilding, and adequately funding 
the National Guard and Reserve equipment account for the Navy 
Reserve component. I'll make a brief comment about each and 
refer your staff to our written testimony for details.
    Regarding TRICARE, AUSN accepts proposed increases in 
pharmacy copays right now as reasonable, but urges the Congress 
to reject any new fees and any increase in TRICARE Prime fees 
that exceeds the cost-of-living adjustment (COLA)-based 
standard established just last year in the Defense 
Authorization Act.
    If we were here discussing changing the age requirements 
for social security, there isn't a person in this room who 
wouldn't agree that we must grandfather current recipients who 
planned for their retirement under the current rule set. The 
Defense Department extends no such consideration to those 
already retired. In fact, the lion's share of proposed fee 
increases applies only to retirees.
    AUSN supports legislation to protect the armed service 
retirees from proposed increases to their TRICARE coverage, 
such as S. 3203, the Military Health Care Protection Act of 
2012, which was introduced bipartisanly by Senators Frank R. 
Lautenberg and Marco Rubio.
    Senators, our Navy is stretched thin today. In this decade 
of war our Navy, while the budget has gone up, has gotten only 
smaller. Right now the budget calls for fewer ships. 
Deployments are lengthening today. We just had a ship return 
from, instead of a 6-month deployment, a 10-month wartime 
deployment, and we just sent one on a 10-month deployment last 
month. This directly impacts families. As I said, the proposed 
budget calls for fewer ships.
    As the Army and Marine Corps return from Afghanistan, the 
Navy's mission will not decrease. In fact, the President has 
directed in his January strategic guidance increased efforts in 
the Pacific.
    Therefore, AUSN urges the Senate Appropriations Committee 
to restore planned cuts to the Virginia-class submarine, to 
restore 4 of the 7 cruisers now scheduled for early retirement. 
This is both necessary to the Navy's mission and cost-effective 
for the taxpayer.
    Turning to the Reserve component, Senator Cochran, you and 
I discussed at this hearing last year the Navy's C-48 transport 
aircraft. It's a program of record calling for 17 aircraft to 
replace seriously aging C-9B's. Now, in keeping with the 
Pentagon's thoughts about unfunded lists, the Navy Reserve 
didn't ask for an airplane this year, and yet the program of 
record stands. Fourteen have been bought to this date of the 
17. Some have been bought with National Guard and Reserve 
equipment moneys, which is the right place for that, in the 
Reserve component.

                           PREPARED STATEMENT

    The Navy cannot do without this airlift capacity, and each 
year that the less capable and far more expensive to operate C-
9s remain, the taxpayers lose. There are no C-40s, as I said, 
in the fiscal year 2013 budget. AUSN urges the addition of at 
least one, funded through the National Guard and Reserve 
Equipment Account (NGREA), this year.
    That concludes my testimony, subject to your questions.
    [The statement follows:]
             Prepared Statement of Rear Admiral Casey Coane
               the association of the united states navy
    The Association of the United States Navy (AUSN) continues its 
mission as the premier advocate for our Nation's sailors and veterans 
alike. Formerly known as the Naval Reserve Association, which traces 
its roots back to 1954, AUSN was formally established on May 19, 2009, 
to expand its focus on the entire Navy. AUSN works for not only our 
members, but the Navy and veteran community overall by promoting the 
Department of the Navy's interest, encouraging professional development 
of officers and enlisted, and educating the public and political bodies 
regarding the Nation's welfare and security.
    AUSN prides itself on personal career assistance to its members and 
successful legislative activity on Capitol Hill regarding equipment and 
personnel issues. The Association actively represents our members by 
participating in the most distinguished groups protecting the rights of 
military personnel. AUSN is a member of The Military Coalition, a group 
of 34 associations with a strong history of advocating for the rights 
and benefits of military personnel, active and retired. AUSN is also a 
member of the National Military Veterans Alliance and an associate 
member of the Veterans Day National Committee of the Department of 
Veterans' Affairs (VA).
    AUSN's members are Active Duty, Reserve and veterans from all 50 
States, U.S. territories, Europe, and Asia. AUSN has 81 chapters across 
the country. Of our 18,000 members, approximately 95 percent are 
veterans. Our national headquarters is located at 1619 King Street, 
Alexandria, Virginia, and we can be reached at 703-548-5800.
                                summary
    Chairmen Inouye, Ranking Member Cochran, and members of the Senate 
Appropriations Committee, Subcommittee on Defense: AUSN thanks you and 
your Committee for the work that you do in support of our Navy, 
retirees, and veterans as well as their families. Your hard work has 
allowed significant progress in adequately funding our Nation's 
military that has also left a lasting impact on our national security.
    Last year alone, in the Department of Defense (DOD) Appropriations 
Act of 2012, AUSN was pleased to see that the Congress funded Navy 
Military personnel at $26.8 billion; Marine Corps military personnel at 
$13.6 billion; Navy Reserve personnel at $1.9 billion; and Marine Corps 
Reserve personnel at $644 million. In addition, AUSN was pleased to see 
$14.9 billion appropriated for Navy Shipbuilding and Conversion; $32.5 
billion for the Defense Health Program; and record amounts of National 
Guard and Reserve Equipment Account (NGREA) funding at $1 billion, of 
which $75 million was appropriated for the Navy Reserve.
    As part of a larger military and veteran community, AUSN recognizes 
that there are many challenges ahead, especially with the release of 
the President's fiscal year 2013 budget request this past February and 
his Strategic Guidance earlier this past January. Of great concern 
amongst our membership, as well as the Navy and military community, are 
the increases in TRICARE rates and enrollment fees in DOD's budget 
request. AUSN believes that such changes must be done in accordance 
with what is right for our military and veterans given the promises 
that were made when they signed up to serve their country, and 
especially with those retirees who have already served and whom these 
changes effect even more. The impact this will also have upon future 
recruitment and retention within the military should also be taken into 
consideration as this subcommittee begins appropriating funds for the 
various essential DOD programs our servicemembers rely on.
    Similarly, AUSN is concerned with the heavy cuts that appear to be 
disproportionately allocated to DOD. DOD requested, in the President's 
budget request, $614 billion for fiscal year 2013, which reduces $487 
billion from its projected spending over the next decade. In the 
President's Strategic Guidance, released on January 3, 2012, it states 
that, ``we will of necessity rebalance toward the Asia-Pacific 
region''; however, the proposed decommissioning of seven older cruisers 
(six of which had been scheduled for modernization), delaying the Ohio-
class submarine (SSBN-X) replacement program by 2 years, build two 
fewer littoral combat ships (LCS) over the next 5 years (one from each 
variant builder), building only one Virginia-class submarine (SSN) in 
2014 and delay it to 2018, and the reduction of the joint high speed 
vessel (JHSV) from 18 to 10 found in the President's budget seems 
counter intuitive to this new strategy.
    The overarching, long-term, concerns with the proposed DOD budget 
cuts that the AUSN has is that DOD is already requesting $614 billion 
for fiscal year 2013, already trimming down $487 billion from its 
projected spending over the next decade. However, after the failure of 
the Joint Committee on Deficit Reduction, or ``Super Committee'', 
failing to find the savings as mandated by the Budget Control Act of 
2011 (BCA), come January 2013, the ``sequestration'' mechanism would be 
triggered that would automatically slash an additional $450-$500 
billion from the military's budget by fiscal year 2021. As a result of 
such drastic cuts, Secretary of Defense Leon Panetta has already 
stated, in a letter to Senators McCain and Graham last fall, that 
sequestration represents a reduction of nearly 20 percent in DOD 
funding over the next 10 years with reductions at this level meaning 
the smallest Navy since before World War II, potential termination of 
the Joint Strike Fighter (JSF) program, delay of the next-generation 
ballistic missile submarine and cuts to our existing sub fleet as well 
as the cancellation of the LCS program.
    AUSN is working with other Military and Veteran Service 
Organizations to address these concerns, but in regards to Defense 
appropriations, our focus is on the Military Healthcare System (MHS) 
that is crucial to our military personnel and the Navy's Equipment/
Procurement needs that is vital to our national security.
                   military healthcare system funding
    AUSN was pleased to hear that the President's budget request 
included $32.5 billion for the Defense Health Program (DHP), which was 
the same level enacted for fiscal year 2012. However, for the DOD's 
unified medical budget, which includes DHP, the President's budget 
request included $48.7 billion, which is a reduction of $4.1 billion 
from the fiscal year 2012 enacted level of $52.8 billion. The reduction 
primarily comes out of the Health Care Accrual Program which includes 
healthcare contributions of the Medicare-Eligible Retiree Health Care 
Fund to provide for the future costs of our personnel currently serving 
on Active Duty and their family members when they retire. AUSN stresses 
the importance of adequately funding the MHS and ensure that changes, 
like those proposed in the President's budget request, aren't 
burdensome to our military.
                                tricare
    The administration's fiscal year 2013 budget request implements 
numerous changes to the existing MHS, which is utilized by more than 
9.6 million beneficiaries which include active military member, their 
families, military retirees and their families, dependent survivors and 
certain eligible Reserve component members and their families. Changes 
include increases to TRICARE Prime Enrollment fees. Last year, finally 
acknowledging the Congress's long-standing concerns about the 
inappropriateness of dramatic increases in beneficiary fees, the 
administration proposed a 13-percent increase in TRICARE Prime fees. In 
the absence of congressional objection, the increase was implemented as 
of October 1, 2011. However, the new proposal for fiscal year 2013 
through fiscal year 2017 is a dramatic departure, proposing to triple 
or quadruple fees over the next 5 years (for example $520 across the 
board retired pay levels for fiscal year 2012 to $600/$720/$820 tiered 
across the retired pay levels for fiscal year 2013 to $893/$1,523/
$2,048 by fiscal year 2017). AUSN urges the Congress to reject any 
increase in TRICARE Prime fees that exceeds the cost-of-living 
adjustment (COLA)-based standard established in the Fiscal Year 2012 
Defense Authorization Act.
    In addition, the fiscal year 2013 budget request institutes an 
annual TRICARE Standard Enrollment fee to be phased in over a 5-year 
period and then indexed to increases in National Health Expenditures 
(NHE) after fiscal year 2017 (for example $0 in fiscal year 2012 to $70 
in fiscal year 2013 for individuals and $0 in fiscal year 2012 to $140 
for families). The deductibles for TRICARE Standard would also increase 
from $150 in fiscal year 2012 to $160 in fiscal year 2013 for 
individuals and from $300 in fiscal year 2012 to $320 in fiscal year 
2013 for families. TRICARE for Life (TFL) would also see an 
implementation of enrollment fees for all three tiers going from $0 for 
all three for fiscal year 2012 to $35 for tier 1, $75 for tier 2 and 
$115 for tier 3 for fiscal year 2013. In total, the fiscal year 2013 
budget request contains $48.7 billion for the entire DOD unified 
medical budget to support the MHS, which is a difference of $4.1 
billion less than the $52.8 billion that was enacted for fiscal year 
2012.
    These proposed increases, which require congressional approval, are 
part of the Pentagon's plan to cut $487 billion in spending and seeks 
to save $1.8 billion from the TRICARE system in the fiscal year 2013 
budget, and $12.9 billion by 2017. These rate increases amount to an 
overall change of 30-percent to 78-percent increase in TRICARE premiums 
for the first year and explodes for a 5-year span increase of 94 
percent to 345 percent, more than three times current levels!
    AUSN, our membership and the military and veteran community 
continue to oppose the establishment of any new fees where there are 
none now (such as the enrollment fees for TFL or TRICARE Standard). Our 
veterans should get guaranteed access for an enrollment fee which is 
not always the case for those that rely on TFL or TRICARE Standard 
where many can't find doctors to see them. Where a flat fee exists now 
(which DOD is trying to dramatically increase and then index to health 
cost growth), we assert that the same rules should apply to those that 
the Congress applied to the Prime enrollment fee in the fiscal year 
2012 NDAA . . . they should be tied to COLA and not health cost growth.
    These changes in the fiscal year 2013 budget request raise concerns 
amongst the military community about the impact this will have on 
recruiting and maintaining a high quality all volunteer military force. 
These benefits have been instrumental in recruiting qualified service 
men and women and keeping them in uniform.
                 pending legislation and appropriations
    AUSN was happy to see that the House Appropriations Committee, 
Subcommittee on Defense completed its markup in mid-May and included 
$32.9 billion for DHP, which is $333.5 million more than the 
President's budget request, and $380.2 million more than the amount 
appropriated for fiscal year 2012. The markup also includes $2.3 
billion for family support and advocacy programs. Increases above the 
request include:
  --$246 million for cancer research;
  --$245 million for medical facility and equipment upgrades;
  --$125 million for traumatic brain injury and psychological health 
        research; and
  --$20 million for suicide prevention outreach programs.
    AUSN is supportive of these funding levels within the DHP to our 
military. In addition, AUSN supports legislation to protect armed 
service retirees from proposed increases to their TRICARE coverage such 
as S. 3203, the Military Healthcare Protection Act of 2012, which was 
introduced bipartisanly by Senators Frank Lautenberg (D-NJ) and Marco 
Rubio (R-FL). This bill recognizes the sacrifices made over a 20- or 
30-year military career to retirees and seeks to limit the proposed 
changes in TRICARE.
                       navy equipment/procurement
    The President's fiscal year 2013 budget request included $43.9 
billion for Navy and Marine Corps equipment funding. This is a decrease 
of $2.3 billion below the amount enacted for fiscal year 2012 (5-
percent decrease). This includes, within the fiscal year 2013 budget 
request for the Navy, the proposed decommissioning of seven older 
cruisers (six of which had been scheduled for modernization), delaying 
the Ohio-class submarine (SSBN-X) replacement program by 2 years, build 
two fewer littoral combat ships (LCS) over the next 5 years (one from 
each variant builder), and build only one Virginia-class submarine 
(SSN) in 2014 and delay it to 2018. AUSN is concerned that these 
funding level decisions are being driven by budget, rather than 
strategy, and that the Navy procurement levels do not reflect the needs 
of a strong forward presence, especially in the hostile regions of the 
Asia-Pacific Theater.
                    navy shipbuilding and conversion
    As the Congress proceeds with consideration of the fiscal year 2013 
Defense appropriations bill, it is important that the appropriated 
funding levels for Navy equipment meet the needs of our Navy as 
recommended by the President's Strategic Guidance released this past 
January. In the Strategic Guidance, the Administration highlights that, 
``we will of necessity rebalance toward the Asia-Pacific region . . . 
[providing] security in the broader Indian Ocean region.'' Yet the 
proposed cuts to Navy platforms in the President's budget request are 
alarming in that with this refocus in strategy, and the Navy's goal of 
a 300-plus fleet, appear to hamper this strategy and reduce our Navy's 
capability, making any attempt to deter hostilities in the Pacific very 
difficult.
    Last year, in the Consolidated Appropriations Act for fiscal year 
2012, the Navy was appropriated $14.9 billion for Navy Shipbuilding and 
Conversion. Of that, for the Advanced Procurement (AP) for the Carrier 
Replacement Program (AP), $554.7 million, for the Virginia-class 
submarine, $3.2 billion, for the Virginia-class submarine (AP), $1.5 
billion, for the DDG-1000 Program, $453.7 million, or the DDG-51 
Destroyer, $2.0 billion, for the DDG-51 Destroyer (AP), $100.7 million, 
for the LCS, $1.8 billion and for the joint high speed vessel (JHSV), 
$372.3 million. Along with the ship cuts in the President's fiscal year 
2013 budget request, this year's request for shipbuilding and 
conversion had dramatic cuts in funding levels from the fiscal year 
2012 enacted legislation. The fiscal year 2013 budget request includes 
a total of $13.6 billion for Navy shipbuilding and conversion (a 
reduction of $1.3 billion). Of that, for the Carrier Replacement 
Program, $608.1 million (an increase of $53.4 million), for the 
Virginia-class submarine, $3.2 billion, for the Virginia-class 
submarine (AP), $875 million (a decrease of $625 million), for the DDG-
1000 program, $669.2 million (an increase in $215.5 million), for the 
DDG-51 Destroyer, $3 billion (an increase of $1 billion), for the DDG-
51 Destroyer (AP), $466.3 million (an increase of $365.6 million), for 
the LCS, $1.8 billion, and for the JHSV, $189.2 million (a decrease of 
$183.1 million).
    Although AUSN was pleased to see funding increases between the 
fiscal year 2012 enacted level and the fiscal year 2013 budget request 
in some areas, AUSN was alarmed by some of the other drastic 
reductions, especially in the Future Years Defense Program (FYDP) 
funding levels, and its effects upon the capability of our Navy to 
forward project our forces and deter hostilities as required in the 
President's Strategic Guidance of January 2013.
   navy reserve national guard and reserve equipment account funding
    AUSN was pleased last year when the fiscal year 2012 enacted levels 
for National Guard and Reserve Equipment Account (NGREA) were in 
historic amounts of $1 billion, of which the Navy Reserve received $75 
million. Given the requirements set forth in the annual National Guard 
and Reserve Equipment Report (NGRER), AUSN would like to see the 
funding levels for the Navy Reserve increase to match their needs and 
priorities. With more than 6,000 mobilized or deployed Navy Reserve 
sailors, providing about one-half of the Navy's ground forces in the 
Central Command and in other critical roles worldwide, equipping the 
compatibility with the Active component (AC) is quite the challenge. 
Equipment in the Navy Reserve is experiencing a service life of more 
than 20 years for many platforms, adding sustainment and 
interoperability challenges in preparing Reserve units to train and 
deploy mission-ready in support of the Navy's total force.
    The Navy Reserve faces many equipping challenges. The first is 
aircraft procurement where Naval Aviation Plan 2031 provides a 
requirement to replace the aging and maintenance intensive aircraft 
that provide critical Reserve component (RC) capability enhancements. 
In particular, C-130s are a critical part of the Navy-unique fleet 
essential airlift mission between strategic airlift points and the 
carrier onboard delivery and vertical onboard delivery to the fleet. In 
addition are the C-40As, whereas they are continuously being procured, 
with 14 to date, with help from critical NGREA funding, however the C-
40A is still below requirement levels. In addition, the Navy Reserve is 
facing shortfalls in expeditionary equipment funding and increased 
procurement in force protection, secure communications and a wide range 
of logistical equipment will increase the overall capabilities of units 
serving in contingency operations. Last, the RC Navy Special Warfare 
sea-air-land (SEAL) teams have been fully integrated with the AC since 
2008, making up one-third of the personnel mobilized in support of 
overseas contingency operations. The RC relies on the equipment of the 
AC and the shortfalls become a challenge when 97 percent of special 
warfare personnel are mobilized for current operations.
    As our Nation's overseas operations decrease, i.e. Iraq and 
Afghanistan, Active Duty for Training Funding (ADT) is resulting in 
increased utilization and driving an unfunded liability as high as $200 
million. With the challenges to equip a total force and the increased 
reliance on the RC in the past decade, AUSN believes that the Navy 
Reserve should continue to have its funding requirements met to the 
best of the subcommittee's ability.
                 pending legislation and appropriations
    AUSN was happy to see that the HAC-D markup included, for Navy 
Shipbuilding and Conversion, an appropriation of $15.2 billion to 
remain available for obligation until September 30, 2017 (an increase 
of 1.7 billion from the fiscal year 2013 budget request). Highlights of 
this appropriation include for:
  --Carrier Replacement Program: $578.3 million;
  --Virginia-class submarine: $3.2 billion;
  --Virginia-class submarine--Advance Procurement (AP): $1.6 billion 
        (increase of $723 million for the subcommittee's return of the 
        fiscal year 2014 Virginia-class submarine, from the President's 
        fiscal year 2013 budget request of $874.9 million);
  --DDG-1000 Program: $699.2 million;
  --DDG-51 destroyer: $4 billion (increase $1 billion from President's 
        fiscal year 2013 budget request of $3 billion due to 
        subcommittee adding one additional DDG-51 Arleigh Burke-class 
        destroyer);
  --DDG-51 Destroyer--Advance Procurement (AP): $466.3 million;
  --LCS: $1.8 billion; and
  --JHSV: $189.2 million.
    In addition, AUSN was pleased to see that the NGREA amount was to 
include $2 billion; a $1 billion increase in last year's enacted level. 
We look forward to seeing the Senate Appropriations Committee consider 
these funding levels in the Senate's fiscal year 2013 DOD 
appropriations bill.
                               conclusion
    The Association of the United States Navy understands that there 
are difficult decisions ahead in regards to this year's fiscal year 
2013 budget and how the Senate Appropriations Committee considers 
adequately funding our military, while adhering to the Budget Control 
Act. Amongst our Legislative Objectives/Priorities for fiscal year 2013 
is the looming concern of the effects of an automatic sequestration 
trigger upon DOD. AUSN was pleased that the Office of Management and 
Budget ruled in favor of exempting the Department of Veterans' Affairs. 
However, with our military community relying on TRICARE and DHP, as 
well as the President's strategic guidance shifting focus to a volatile 
Asia/Pacific region, cuts to DOD need to be carefully looked at and 
decisions need to be made based on strategy, rather than budget. On 
March 15, 2012, in a Senate Armed Services Committee hearing on the 
fiscal year 2013 budget request, the Secretary of the Navy highlighted 
how the goal is to have a Navy of more than 300 ships by no later than 
2019. In the same hearing, Admiral Jonathan W. Greenert, the Chief of 
Naval Operations, testified that ``In my view, if sequestration kicks 
in . . . I'm looking at not 285 ships in a given year. I'm looking at 
230. We don't have enough force structure to accrue that kind of 
savings without reducing procurement.'' However, this raises the 
concern that as budget cuts progress, with looming DOD sequestration, 
our fleet size could be drastically reduced, and consequently, so could 
our capabilities with forward force projection. AUSN urges this 
subcommittee to look at all proposals to ensure that vital DOD programs 
and platforms, for our military personnel and our strategic 
capabilities, aren't subject to further debilitating cuts and 
sequestration. In addition, we encourage members of the subcommittee to 
look at our Web site which contains detailed analyses of past and 
current DOD appropriations measures as the House and Senate 
Appropriations Committee's markup and consider the fiscal year 2013 DOD 
appropriations bills. (http://www.ausn.org/Advocacy/AppropriationBills/
Defense/tabid/2758/Default.aspx)
    Thank you.

    Chairman Inouye. As you can imagine, Admiral, this 
subcommittee has that assignment of preventing sequestration, 
and we will do our absolute best. I can assure you that.
    Admiral Coane. Thank you, Sir. It's absolutely essential 
that we do.
    Chairman Inouye. Now may I call upon Dr. Andrew Pollak.
STATEMENT OF ANDREW N. POLLAK, M.D., TREASURER, 
            AMERICAN ASSOCIATION OF ORTHOPAEDIC 
            SURGEONS
    Dr. Pollak. Thank you, Mr. Chairman and Ranking Member. I'm 
Dr. Andy Pollak, treasurer of the American Association of 
Orthopaedic Surgeons (AOS) and immediate past president of the 
Orthopaedic Trauma Association. I'm also chief of orthopaedic 
traumatology at the University of Maryland's R. Adams Cowley 
Shock Trauma Center in Baltimore.
    On behalf of the AOS and my orthopaedic colleagues across 
the country, thank you for inviting us to testify before you 
today on the Peer-Reviewed Orthopaedic Research Program 
(PRORP).
    The events of September 11, 2001, catalyzed the global war 
on terror, a war that's resulted in thousands of wounded 
warriors, most of whom wind up with an extremity injury, an 
injured arm or leg. Between Operations Enduring Freedom, Iraqi 
Freedom, and New Dawn, more than 47,000 service men and women 
have been injured, and of those more than 80 percent have 
suffered a limb injury.
    The issue of treating the sheer volume of injuries has been 
compounded with the newness of the injuries. Improvised 
explosive devices (IEDs) have overwhelmed our military medical 
providers with new injuries and scant data on how to best treat 
them, initially forcing our military surgeons to amputate limbs 
at an alarming rate.
    The PRORP and the Orthopaedic Extremity Trauma Research 
Program (OETRP) were both created as a result of the Congress's 
action, specifically this subcommittee's leadership in 
recognizing the need for more research to save limbs and limit 
disability in our wounded warriors. PRORP is funded through 
DOD's health program and was established to quickly develop 
focused basic and clinical research through direct grants to 
research institutions across the country. The goal is to help 
military surgeons address the leading burden of injury and loss 
of fitness for military duty by finding new limb-sparing 
techniques to save extremities, avoid amputations, and preserve 
and restore the function of injured limbs.
    PRORP aims to provide all warriors affected by extremity 
war injuries the opportunity for optimal recovery and 
restoration of function. One of the greatest successes of OET 
and PRORP has been the establishment of the Major Extremity 
Trauma Research Consortium (METRC). METRC works to produce the 
evidence needed to establish treatment guidelines for the 
optimal care of the wounded warrior and ultimately improve the 
clinical, functional, and quality of life outcomes of both 
servicemembers and civilians who sustain high-energy trauma to 
the extremities. This research is presently being coordinated 
at 54 military and civilian sites throughout the country, 
making it a true military-civilian partnership to help our 
wounded warriors while learning more about relevant comparable 
civilian injuries as well.
    One important recently published advance attributable 
directly to OET and PRORP has been the research on heterotopic 
ossification (HO). HO comes in two main forms, one that appears 
in children and is congenital and another that strikes wounded 
military personnel and surgery patients and is triggered by 
severe injuries and wounds such as amputation.
    With HO, the bone grows in abnormal locations and can press 
against nerves and blood vessels, resulting in severe pain, 
limited motion, problems fitting prosthetic limbs, and skin 
breakdown. Nearly 65 percent of wounded warriors with extremity 
injuries suffer HO, a problem we understood little about prior 
to this program.
    Through a grant from OETRP, researchers at Children's 
Hospital of Philadelphia have shown that a drug that interrupts 
a specific signaling pathway can prevent HO. The potential 
benefit to our wounded warriors is astronomical and that 
represents an advance that would not have been possible absent 
this program.

                           PREPARED STATEMENT

    We're under no illusion that this kind of research is 
cheap. We further understand that we're in an era of 
unprecedented budget austerity. But the cost of not doing this 
research is exponentially higher. An amputation costs three 
times more than limb salvage in future medical care and 
significantly more than that after accounting for increased 
disability payments and the need to replace trained 
servicemembers with new recruits.
    Furthermore, while we need to get our fiscal house in 
order, it can't be done on the backs of our men and women in 
uniform. If we put them in harm's way, we have a solemn duty to 
give them the best possible medical care, backed by the best 
possible science. The Peer-Reviewed Orthopaedic Research 
Program helps accomplish just that.
    Thank you.
    [The statement follows:]
              Prepared Statement of Andrew N. Pollak, M.D.
                              introduction
    Good morning, Chairman Inouye, Ranking Member Cochran, and other 
distinguished members of the subcommittee. I am Dr. Andrew N. Pollak, 
treasurer of the American Association of Orthopaedic Surgeons (AAOS), 
and immediate past president of the Orthopaedic Trauma Association. I 
am also the chief of orthopaedic traumatology at the University of 
Maryland Shock Trauma Center in Baltimore. On behalf of the AAOS and my 
orthopaedic surgeon colleagues across the country, thank you for 
inviting our organization to testify before you today on the Peer-
Reviewed Orthopaedic Research Program (PRORP) as part of the fiscal 
year 2013 budget.
                                overview
    The events of September 11, 2001, served as a catalyst for the 
global war on terror. This war has resulted in thousands of wounded 
warriors, most of whom wind up with an extremity injury. Between 
Operations Enduring Freedom, Iraqi Freedom, and New Dawn, more than 
47,000 service men and women have been injured.\1\ Of the injured, more 
than 80 percent have suffered a limb injury.\2\
---------------------------------------------------------------------------
    \1\ Wounded Warrior Project. http://www.woundedwarriorproject.org/
mission/who-we-serve.aspx.
    \2\ United States Army Institute of Surgical Research. http://
www.usaisr.amedd.army.mil/
extremity_trauma_research_regenerative_medicine.html.
---------------------------------------------------------------------------
    The issue of treating the sheer volume of injuries has been 
compounded with the newness of the injuries. Our men and women in 
uniform are facing a new type of weapon that causes a new type of 
injury: improvised explosive devices. Overwhelmed with new injuries and 
scant data on how best to treat them, our military surgeons were 
amputating extremities at an alarming rate.
    PRORP and the Orthopaedic Extremity Trauma Research Program (OETRP) 
were both created as a result of the Congress's action, specifically 
this subcommittee's leadership in recognizing the need for more 
research to save limbs and limit disability in our wounded warriors. 
PRORP is funded through the Department of Defense Health Program, and 
was established to quickly develop focused basic and clinical research 
through direct grants to research institutions. The goal is to help 
military surgeons address the leading burden of injury and loss of 
fitness for military duty by finding new limb-sparing techniques to 
save extremities, avoid amputations, and preserve and restore the 
function of injured extremities. PRORP aims to provide all warriors 
affected by extremity war injuries the opportunity for optimal recovery 
and restoration of function.
                          benefits of research
    One of the greatest successes of OETRP and PRORP has been the 
establishment of the Major Extremity Trauma Research Consortium 
(METRC). METRC works to produce the evidence needed to establish 
treatment guidelines for the optimal care of the wounded warrior and 
ultimately improve the clinical, functional, and quality-of-life 
outcomes of both servicemembers and civilians who sustain high-energy 
trauma to the extremities. This research is being coordinated at 54 
military and civilian sites throughout the country making it a true 
military civilian partnership to help our wounded warriors while 
learning more about relevant comparable civilian injuries.
    One important recently published advance attributable directly to 
OETRP and PRORP has been the research on heterotopic ossification (HO). 
HO comes in two main forms--one that appears in children and is 
congenital, another that strikes wounded military personnel and surgery 
patients and is triggered by severe injuries and wounds such as 
amputation. With HO, the bone grows in abnormal locations and can press 
against nerves and blood vessels, resulting in severe pain, limited 
motion, problems fitting prosthetic limbs, and skin breakdown. It is so 
prevalent after high-energy trauma that nearly 65 percent of wounded 
warriors with extremity injuries suffer HO.\3\ Through a grant from the 
OETRP program, researchers at The Children's Hospital of Philadelphia 
have shown that a drug that interrupts a signaling-nuclear protein 
pathway can prevent HO. The potential benefit to our wounded warriors 
is astronomical.
---------------------------------------------------------------------------
    \3\ Science Daily. http://www.sciencedaily.com/releases/2011/04/
110403141331.htm.
---------------------------------------------------------------------------
                                  cost
    We are under no illusion that this kind of research is cheap, we 
further understand that we are in an era of unprecedented budget 
austerity. But the cost of not doing the research is exponentially 
higher. An amputation costs three times more than limb salvage in 
future medical care and significantly more than that after accounting 
for increased disability payments and the increased need to replace 
trained servicemembers with new recruits. Indeed, 65 percent of all 
combat related medical care resources go to treating extremity 
injuries, and almost 70 percent of wounded warriors who suffer an 
unfitting condition are unfit to return to duty because of an extremity 
injury.\4\
---------------------------------------------------------------------------
    \4\ Masini BD, Waterman SM, Wenke JC et al. Resource utilization 
and disability outcome assessment of combat casualties from Operation 
Iraqi Freedom and Operation Enduring Freedom. J Orthop Trauma. 2009. 23 
(4): 261-266.
---------------------------------------------------------------------------
    Furthermore, while we need to get our fiscal house in order, it 
cannot be done on the backs of the men and women in uniform. If we put 
them in harm's way, we have a solemn duty to give them the best 
possible medical care backed by the best possible science. The Peer-
Reviewed Orthopaedic Research Program helps accomplish just that.
                                closing
    On behalf of the AAOS, I would like to thank the Chairman, the 
Ranking Member, and the entire subcommittee for your interest in and 
attention to this important issue facing America's military, and the 
surgeons who treat them. We look forward to continuing to work with you 
on this matter.

    Chairman Inouye. Dr. Pollak, did I hear you say that there 
were 47,000 injured in Iraq and Afghanistan, and of that number 
80 percent had limb injuries?
    Dr. Pollak. Yes, Sir. Yes, the most common injury 
sustained. Many of them sustain multiple injuries to multiple 
parts of their body. But the limbs are disproportionately 
exposed, as the chest and abdomen are protected with body armor 
and the head's protected with a helmet.
    Chairman Inouye. Do we have enough orthopaedic surgeons?
    Dr. Pollak. That's a separate question, Sir. I don't 
believe we do at this point. Our orthopaedic surgeons at Walter 
Reed and at our military facilities throughout the country 
right now are terribly taxed with the number of wounded 
warriors returning.
    Chairman Inouye. I thank you very much, Sir.
    Dr. Pollak. Thank you, Sir.
    Chairman Inouye. May I now call on Mr. Mark Haubner and Ms. 
Erin O'Rourke.
STATEMENT OF MARK HAUBNER, ARTHRITIS FOUNDATION
    Mr. Haubner. Chairman Inouye, Ranking Member Cochran, and 
distinguished members of the subcommittee: It's an honor to 
have the opportunity to speak with you, especially today, June 
6, regarding the importance of funding arthritis research to 
benefit the health of our men and women in uniform, our 
military veterans, and our Nation.
    We would first like to thank the Arthritis Foundation's 
2012 Advocacy Leadership Award recipient, Senator Murkowski, 
for being a champion for the cause of arthritis research in the 
past.
    My name is Mark Haubner, from Aquebogue, New York, and with 
me in the audience today is Erin O'Rourke from Lake Ronkonkoma, 
New York. We are here today as Arthritis Foundation advocacy 
ambassadors and as concerned citizens representing 50 million 
Americans with arthritis, the number one cause of disability in 
the United States. We hope that our comments today give voice 
to this very important request in support of peer-reviewed 
competitively awarded arthritis research funded by the DOD.
    I would like to tell you how arthritis has affected our 
lives and the relevance to our military personnel. I broke my 
leg while skiing at the age of 14, underwent many operations as 
a result, and suffered my first total joint replacement at 44, 
which forced me into retirement. I'm having my fifth total 
joint replacement next month, 1 of 1 million joint replacements 
being done in the United States every year now.
    Research now shows that the rampant presence of 
osteoarthritis in all of my joints is a result of a post-
traumatic trigger event suffered 30 years before. My colleague 
Erin O'Rourke, who began suffering from severe pain in her 
hands and fingers at the age of 34, was diagnosed with 
rheumatoid arthritis (RA), a debilitating autoimmune disease 
that causes unrelenting and destructive inflammation in the 
joints. The medications she is taking treat, but do not cure, 
arthritis. Due to RA, Erin has twice the risk of developing 
heart disease and diabetes, which will likely lead to a 
shortened life by almost a decade.
    Studies show that our Nation's servicemembers are 32 
percent more likely to develop osteoarthritis than the general 
population, and the damage is presenting itself within a few 
years of active duty. This is already becoming a great burden 
on the long-term healthcare provided by the Department of 
Veterans Affairs and can only increase with time.
    One-third of our combat personnel what are medevaced out of 
the field are suffering from a musculoskeletal injury, and 
these injuries represent one of the leading causes of 
disability and medical discharge for active servicemembers 
under the age of 40. Research is needed for arthritis because 
the military is facing skyrocketing numbers of Active Duty and 
retired personnel fighting the high costs of pain and 
disability associated with arthritis, part of a total of $128 
billion per year in this country.
    Another area of research concerns the inflammation that 
occurs with RA. Further investigation of these inflammatory 
characteristics will help us to understand and improve the 
healing times and skin graft outcomes in wound care.
    Thank you all for recognizing the need over the last 3 
years to include post-traumatic osteoarthritis and last year 
arthritis, which includes both osteo and RA, in the DOD budget 
for Congressionally Directed Medical Research Program (CDMRP). 
We deeply appreciate the peer-reviewed research funding awards 
of almost $5 million from DOD appropriations over the last 2 
years.
    In conclusion, we ask for your consideration and support of 
the following: to continue to include the topics of post-
traumatic osteoarthritis and rheumatoid arthritis in the fiscal 
year 2013 DOD appropriations bill for the peer-reviewed medical 
research program, CDMRP, under the account of Defense Health 
Programs, research and development. Maintaining arthritis 
research in the fiscal year 2013 DOD appropriations bill will 
aid Armed Forces personnel in active service, military 
veterans, and millions of Americans.
    I thank you very much for your time and consideration.

                           PREPARED STATEMENT

    Chairman Inouye. Did I hear you say that 30 percent of the 
troops were evacuated because of skeletal injury?
    Mr. Haubner. Sorry, Sir. It's 32 percent of the military 
population that's indicating osteoarthritis and one-third of 
the military population medevaced out, is suffering from a 
musculoskeletal injury, that's correct.
    Chairman Inouye. Can that be traced to the load they have 
to carry?
    Mr. Haubner. Much is indicated by both Navy and Army 
studies that have been done in the past 5 or 10 years. They're 
carrying 100-pound packs, 120-pound packs, through the field, 
broken field running. It's making an immediate impact on their 
health.
    Chairman Inouye. World War II was easy. My pack was about 
20 pounds.
    Mr. Haubner. And the rifle was probably 18 more.
    [The statement follows:]

             Prepared Statement of the Arthritis Foundation

    Nearly 6.5 million Americans have wounds that take months 
or even years to heal. Many of these wounds are a consequence 
of diabetes, which damages blood vessels and interferes with 
normal skin repair. But new research from Georgetown University 
Medical Center in Washington, DC, points to another cause: 
autoimmune diseases such as rheumatoid arthritis (RA) and 
lupus.
    The research was presented earlier this month at the 
American College of Rheumatology's annual conference, in 
Chicago, by rheumatologist and lead author Victoria Shanmugam, 
M.D. It has been accepted for publication in the International 
Wound Journal.
    Dr. Shanmugam had noticed an unusual number of nonhealing 
wounds--mostly leg ulcers--in people with autoimmune disorders. 
``What I saw clinically was that people who had autoimmune 
disease did not respond as well to the usual wound care 
treatments. I wanted to try to understand the reason for this 
by comparing healing times and [skin] graft outcomes,'' she 
says.
    Treatment for nonhealing wounds depends on the wound, but 
might include special dressings, hyperbaric oxygen, growth 
factors, bioengineered skin substitutes and skin grafts. If 
treatment doesn't work, the patient faces amputation.
    Dr. Shanmugam and her colleagues reviewed the charts of 340 
patients who sought care at Georgetown's Center for Wound 
Healing and Hyperbaric Medicine during a 3-month period in 
2009. Only those with open wounds that hadn't healed after at 
least 3 months of normal therapy were included.
    Forty-nine percent of these patients had diabetes (both 
type 1, which is itself an autoimmune condition, or type 2). 
This isn't unusual--diabetes accounts for about one-half of all 
chronic wounds. Others had vascular or arterial diseases that 
typically cause poor wound healing. What surprised Dr. 
Shanmugam was that 23 percent had autoimmune disorders--a far 
greater rate than had been expected or previously reported. The 
most prevalent autoimmune diseases were RA (28 percent), lupus 
(14 percent), and livedoid vasculopathy, a vascular disease 
that causes ulcers on the lower legs (also 14 percent).
    Dr. Shanmugam then looked at how the people with underlying 
autoimmune disease responded to therapy. ``These patients had 
larger wounds at the first visit, had higher pain scores and 
took significantly longer to heal--14-and-a-half months 
compared to just over 10 months for other patients'', she 
explains. ``Clearly, there is something in the autoimmune 
milieu that is inhibiting wound healing,'' says Dr. Shanmugam.
    The next step is a 3-year study funded by the National 
Institutes of Health. Under way since May, the study will 
monitor autoimmune-related wounds over time. ``We are hoping to 
get some understanding of what happens on the cellular and 
molecular level in people who don't heal well,'' Dr. Shanmugam 
says.
    One theory is that diabetes and autoimmune disorders cause 
wounds to become stalled in the inflammatory stage of repair, 
when the body normally develops new blood vessels. Why this 
occurs and what happens at the level of the wound itself are 
questions she hopes to answer.
    She also will explore whether treating underlying 
autoimmune diseases such as RA improves wound healing. ``There 
is concern about using potent immune suppressants in people 
with open wounds,'' she says, noting that immunosuppressive 
drugs are known to interfere with wound healing after surgery. 
``But in a cohort of rheumatoid arthritis patients, we found 
that aggressive treatment before skin graft surgery resulted in 
better outcomes.''
    Eric Matteson, M.D., chairman of rheumatology at Mayo 
Clinic in Rochester, Minneapolis, agrees with the approach. 
``People with rheumatoid arthritis develop wounds for many 
reasons. One is that they may have low-grade vasculitis--
inflammation affecting the small blood vessels in the skin. 
When the wound is related to the underlying systemic 
inflammation of rheumatoid arthritis, not having that 
inflammation under control makes it much more difficult to 
achieve good wound healing.''
    He says that successful wound care requires cooperation and 
vigilance. ``Perhaps the biggest message here is that treating 
people with autoimmune-related wounds really calls for a team 
approach among the rheumatologist, wound-care specialist and 
surgeon'', says Dr. Matteson. ``What you often see, 
unfortunately, is a primary care doctor who can't properly 
manage the wound because of the complexity of the underlying 
disorder.''
    Dr. Shanmugam believes her findings will affect patient 
care in the future. ``Understanding how people respond to wound 
care on a molecular level can help guide therapy and may reduce 
the risk of infections, which can lead to surgery and even 
amputation,'' she says.
    As important, she hopes her research will alert other 
physicians to this under-recognized problem. ``When a patient 
has a leg ulcer that hasn't healed after 3 or 4 months of 
normal treatment, I hope doctors will check for autoimmune 
disease,'' says Dr. Shanmugam.

    Chairman Inouye. I thank you very much.
    Mr. Haubner. Thank you, Sir.
    Chairman Inouye. And now may I call upon Dr. Remington 
Nevin.
STATEMENT OF REMINGTON NEVIN, M.D., MEFLOQUINE RESEARCH
    Dr. Nevin. Good morning, Mr. Chairman and members of the 
subcommittee. My name is Dr. Remington Nevin. I am a board-
certified preventive medicine physician, epidemiologist, and 
medical researcher. I'm a graduate of the Uniformed Services 
University School of Medicine, the Johns Hopkins Bloomberg 
School of Public Health, and the residency program in 
preventive medicine at the Walter Reed Army Institute of 
Research, where I was awarded the Distinguished George M. 
Sternberg Medal. I have published extensively in medical and 
scientific journals and my research has informed and broadly 
influenced military public health policy over the past 7 years.
    I'm here today to testify on an important issue which I 
fear may become the Agent Orange of our generation, a toxic 
legacy that affects our troops and our veterans. This is a 
critical issue that is in desperate need of research funding. 
I'm referring to the harmful effects of the antimalarial drug 
mefloquine, also known as Lariam, which was first developed 
more than 40 years ago by the Walter Reed Army Institute of 
Research.
    Mefloquine causes a severe intoxication syndrome 
characterized by vivid nightmares, profound anxiety, 
aggression, delusional paranoia, dissociative psychosis, and 
severe memory loss. Experience has shown that this syndrome, 
even if rare, can have tragic consequences both on the 
battlefield and on the home front.
    My recent research has helped us understand this syndrome 
as a toxic encephalopathy that affects the limbic portion of 
the brain. With this insight, we now understand the drug's 
strong links to suicide and to acts of seemingly senseless and 
impulsive violence. Yet new research suggests that even mild 
mefloquine intoxication may also lead to neurotoxic brain 
injury associated with a range of chronic and debilitating 
psychiatric and neurologic symptoms.
    It is unknown how many of the hundreds of thousands of 
troops previously exposed to mefloquine may be suffering from 
the devastating effects of this neurotoxicity. However, I can 
tell you that I am contacted nearly every day by military 
patients and veterans from the United States and from around 
the world seeking diagnosis and care for their symptoms. Their 
compelling and often heart-wrenching stories can be found 
regularly in media reports worldwide. Invariably, these 
patients are frustrated by lack of resources and information 
specific to their condition.
    A recent publication by the Centers for Disease Control 
suggests that the side effects of mefloquine may even confound 
the diagnosis and management of post-traumatic stress disorder 
and traumatic brain injury.
    Given our research commitments to post-traumatic stress and 
traumatic brain injury, the first two signature injuries of 
modern war, this observation calls for a similarly robust 
research agenda into mefloquine neurotoxic brain injury to 
ensure that patients with either of these conditions are 
receiving accurate diagnosis and the very best medical care. 
Some concrete actions for facilitating this research include 
expanding the scope and mission of the defense centers of 
excellence and the National Intrepid Center of Excellence, to 
include the evaluation and care of patients suffering from the 
effects of mefloquine, and funding a dedicated mefloquine 
research center at a civilian medical school or school of 
public health to attract the very best minds to this problem 
and to coordinate broad investigations into the 
pathophysiology, epidemiology, clinical diagnosis, and 
treatment of mefloquine intoxication and neurotoxic brain 
injury.
    A commitment to this research roughly commensurate with our 
initial investment in mefloquine's development will allow us to 
mitigate the effects of the toxic legacy it has left behind. If 
this issue is left unaddressed, mefloquine could become our 
next Agent Orange, but it does not have to. With action, 
mefloquine neurotoxic brain injury could join post-traumatic 
stress and traumatic brain injury as the third recognized 
signature injury of modern war and as a result receive the same 
level of commitment shown for these first two conditions.

                           PREPARED STATEMENT

    I would again like to thank you, Mr. Chairman and members 
of the subcommittee, for the opportunity to appear before you 
and bring this issue to your attention. I should emphasize in 
closing that the opinions I express today are my own and do not 
necessarily reflect those of the United States Army.
    This concludes my prepared statement and I am happy to 
answer any questions that you may have.
    [The statement follows:]
            Prepared Statement of Remington Nevin, M.D., MPH
    Good morning, Mr. Chairman and members of the subcommittee. My name 
is Dr. Remington Nevin. I am a board-certified preventive medicine 
physician, epidemiologist, and medical researcher. I am a graduate of 
the Uniformed Services University School of Medicine; the Johns Hopkins 
Bloomberg School of Public Health; and the residency program in 
preventive medicine at the Walter Reed Army Institute of Research, 
where I was awarded the distinguished George M. Sternberg Medal. I have 
published extensively in medical and scientific journals, and my 
research has informed and broadly influenced military public health 
policy for the past 7 years.
    I am here today to testify on an important issue which I fear may 
become the ``Agent Orange'' of our generation: a toxic legacy that 
affects our troops, and our veterans. This is a critical issue that is 
in desperate need of research funding.
    I am referring to the harmful effects of the antimalarial drug 
mefloquine, also known as Lariam, which was first developed more than 
40 years ago by the Walter Reed Army Institute of Research.
    Mefloquine causes a severe intoxication syndrome, characterized by 
vivid nightmares, profound anxiety, aggression, delusional paranoia, 
dissociative psychosis, and severe memory loss. Experience has shown 
that this syndrome, even if rare, can have tragic consequences, both on 
the battlefield, and on the home front.
    My recent research has helped us understand this syndrome as a 
toxic encephalopathy that affects the limbic portion of the brain. With 
this insight, we now understand the drug's strong links to suicide, and 
to acts of seemingly senseless and impulsive violence. Yet new research 
suggests that even mild mefloquine intoxication may also lead to 
neurotoxic brain injury associated with a range of chronic and 
debilitating psychiatric and neurologic symptoms.
    It is unknown how many of the hundreds of thousands of troops 
previously exposed to mefloquine may be suffering from the devastating 
effects of this neurotoxicity. I am contacted nearly every day by 
military patients and veterans, from the United States, and from around 
the world, seeking diagnosis and care for their symptoms. Their 
compelling and often heart-wrenching stories can be found regularly in 
media reports worldwide. Invariably, these patients are frustrated by a 
lack of resources and information specific to their condition.
    A recent publication by the Centers for Disease Control suggests 
that the side effects of mefloquine may even confound the diagnosis and 
management of post-traumatic stress disorder (PTSD) and traumatic brain 
injury (TBI).
    Given our commitment to post-traumatic stress and traumatic brain 
injury, the first two signature injuries of modern war, this 
observation calls for a similarly robust research agenda into 
mefloquine neurotoxic brain injury, to ensure that patients with these 
conditions are receiving accurate diagnosis and the very best medical 
care.
    Some concrete actions for facilitating this research include:
  --Expanding the scope and mission of the Defense Centers of 
        Excellence and the National Intrepid Center of Excellence to 
        include the evaluation and care of patients suffering side 
        effects from mefloquine; and
  --Funding a dedicated mefloquine research center at a civilian 
        medical school or school of public health, to attract the very 
        best minds to this problem, and to coordinate broad 
        investigations into the pathophysiology, epidemiology, clinical 
        diagnosis, and treatment of mefloquine intoxication and 
        neurotoxic brain injury.
    A commitment to this research, roughly commensurate with our 
initial investment in mefloquine's development, will allow us to 
mitigate the effects of the toxic legacy it has left behind. If this 
issue is left unaddressed, mefloquine could become our next ``Agent 
Orange'', but it does not have to. With appropriate action, mefloquine 
neurotoxic brain injury could join PTSD and TBI as the third recognized 
signature injury of modern war, and as a result, receive the same level 
of commitment and care shown for these first two conditions.
    In conclusion, I would again like to thank you, Mr. Chairman and 
members of the subcommittee, for the opportunity to appear before you 
and bring this issue to your attention. This concludes my prepared 
statement and I am happy to answer any questions that you may have.

    Chairman Inouye. I thank you very much, Doctor. I have a 
question here submitted by Senator Dianne Feinstein and it 
says: Do you believe the mefloquine research you're working on 
could develop treatments to reverse intoxication and brain 
injury?
    Dr. Nevin. Mr. Chairman, despite the permanent nature of 
the neurotoxicity produced by mefloquine, I believe that there 
may be effective treatments available right now, provided that 
the diagnosis of mefloquine neurotoxicity is made. I have 
personally treated a number of patients whose conditions have 
proven fairly responsive to rehabilitation, including 
vestibular, physical, and neuro-optometric therapy. Speech 
therapy and cognitive rehabilitation therapy may also hold 
promise.
    However, obtaining access to such therapy requires that 
mefloquine neurotoxic brain injury be correctly diagnosed, such 
that patients receive appropriate specialist referrals. This 
cannot happen if these symptoms are poorly understood by 
healthcare providers or if they are mistaken for such things as 
malingering, personality disorder, conversion disorder, or 
factitious disorder, as they have been in the past.
    For this reason, simply raising awareness of this diagnosis 
may prove very helpful in facilitating early treatment.
    Now, regarding other therapies, such as potential drug 
treatments, evaluating these would require registered clinical 
trials, which typically have a time horizon of some years 
before they yield results to inform clinical practice. I am 
confident that such trials hold promise in identifying drug 
therapies that alleviate symptoms and improve patient outcomes, 
while not risking a further exacerbation of the condition.
    Chairman Inouye. Where does mefloquine come from?
    Dr. Nevin. Mr. Chairman, mefloquine is the end product of a 
multiyear drug development and discovery effort conducted by 
the Walter Reed Army Institute of Research beginning in the 
early 1960s. Of more than 300 compounds screened for their 
effectiveness and toxicity, mefloquine was one of a handful of 
compounds that passed this testing and later went on to 
commercial development by the F. Hoffman LaRoche Company.

                           PREPARED STATEMENT

    Chairman Inouye. I thank you very much, and I'd like to 
thank all of the witnesses who've testified this morning.
    Two organizations have submitted testimony. Without 
objection, the testimony of Cummins, Incorporated and Research 
Advisory Committee on Gulf War Veterans' Illnesses will be made 
part of the record along with any other statements that the 
subcommittee may receive.
    On behalf of the subcommittee, I thank all the witnesses 
for their testimony, and the subcommittee will take these 
issues in consideration and I can assure you will look at it 
very seriously.
    [The statement follows:]
 Prepared Statement of Dr. Wayne A. Eckerle, Vice President, Research 
                      and Technology, Cummins Inc.
    Cummins Inc., headquartered in Columbus, Indiana, is a corporation 
of complementary business units that design, manufacture, distribute 
and service engines and related technologies, including fuel systems, 
controls, air handling, filtration, emission solutions, and electrical 
power generation systems. The funding requests outlined below are 
critically important to Cummins' research and development efforts, and 
would also represent a sound Federal investment toward a cleaner 
environment and improved energy efficiency for our Nation. We request 
that the subcommittee fund the programs as identified below.
                         department of the army
Army Procurement
    Other Procurement, Budget Activity 03, Other Support Equipment, 
Line No. 171, Generators, Line Item: 0426MA9800, Generators and 
Associated Equipment.--Support the administration's request of $60.3 
million in fiscal year 2013. $67.8 million was appropriated in fiscal 
year 2012. Specifically support the $16.7 million for M53500, Medium 
Generator Sets (5-60 kW) and $33.983 million for R62700 Power Units/
Power Plants. Advanced Medium Mobile Power System (AMMPS) generators 
and AMMPS Power Units and Power Plants (trailer-mounted AMMPS generator 
sets) are the latest generation of Prime Power Generators for the 
Department of Defense (DOD) and will replace the obsolete Tactical 
Quiet Generators (TQGs) developed in the 1980s. AMMPS generator sets 
are 21 percent more fuel-efficient, 15 percent lighter, 35 percent 
quieter, and 40 percent more reliable than the TQG. Generators are the 
Army's biggest consumer of diesel fuel in current war theatres. When 
AMMPS generator sets are fully implemented, the Army and Marines will 
realize annual fuel savings of approximately 52 million gallons of JP-8 
fuel and more than $745 million in savings based on fuel costs and 
current use pattern. This will mean fewer fuel convoys to bases in 
active war zones resulting in saved lives of military and civilian 
drivers. AMMPS generators will result in annual carbon emissions 
reductions of 500,000 metric tons CO2 or 7.7 million metric 
tons over the expected life of the generators.
    Weapons and Tracked Combat Vehicles, Budget Activity 01, Tracked 
Combat Vehicles, Line No. 07, Modification of Tracked Combat Vehicles, 
Line Item 2073GZ0410, Paladin Integrated Management Mod In Service, 
Paladin Integrated Management.--Support administration's request of 
$206.1 million in fiscal year 2013. $46.8 million was appropriated in 
fiscal year 2012 to begin low-rate initial production. The M109A6 
Paladin is the primary indirect fire weapons platform in the U.S. 
Army's Heavy Brigade Combat Team (HBCT) and is expected to be in the 
Army inventory through 2050. The PIM program will incorporate Bradley-
based drive-train and suspension components which reduce logistics 
footprint and decrease operations and sustainment costs. PIM is vital 
to ensuring the long-term viability and sustainability of the M109 
family of vehicles (Paladin and FAASV). The program will significantly 
reduce the logistics burden placed on our soldiers, and proactively 
mitigate obsolescence. The system will feature improved mobility (by 
virtue of Bradley-based automotive systems) allowing the fleet to keep 
pace with the maneuver force. The system will improve overall soldier 
survivability through modifications to the hull to meet increased 
threats.
Research and Development Test and Evaluation Programs
    Budget Activity 05, System Development and Demonstration, Line No. 
121, Program Element No. 0604854A: Artillery Systems, Paladin 
Integrated Management .--Support the administration's request of $167.8 
million in fiscal year 2013. $120.1 million was appropriated in fiscal 
year 2012. The M109A6 Paladin is the primary indirect fire weapons 
platform in the U.S. Army's HBCT and is expected to be in the Army 
inventory through 2050. This request is to further develop Paladin 
Integrated Management (PIM) vehicles and conclude testing. The PIM 
effort is a program to ensure the long-term viability and 
sustainability of the M109A6 Paladin and its companion ammunition 
resupply vehicle, the M992 FAASV. PIM is vital to ensuring the long-
term viability and sustainability of the M109 family of vehicles 
(Paladin and FAASV). The program will significantly reduce the 
logistics burden placed on our soldiers and proactively mitigate 
obsolescence. The system will feature improved mobility (by virtue of 
Bradley-based automotive systems) allowing the fleet to keep pace with 
the maneuver force.
    Budget Activity 07, Operational Systems Development, Line No. 165, 
Program Element No. 0203735A: Combat Vehicle Improvement Programs.--
Support the administration's request of $253.9 million in fiscal year 
2013. $36.2 million was appropriated in fiscal year 2012 to initiate 
the program. Specifically support $74.1 million for the Armored Multi-
Purpose Vehicle (AMP-V) program. AMP-V is an Army program that replaces 
the M113 platforms, which cannot be optimized for future U.S. Army 
combat operations. The Army has identified a significant capability gap 
within the HBCT formation. The Bradley Family of Vehicles are the most 
capable and cost effective platform for replacement of the M113. Along 
with established production, the recapitalized Bradley vehicles bring 
combat- proven mobility, survivability, and adaptability to a variety 
of missions. The Army currently has approximately 1,900 Bradley hulls 
that could be inducted into the production process. This low cost, low 
risk, Military-off-the-Shelf (MOTS) to replace the M113 addresses the 
significant capability shortfalls within the HBCT formation. In 
addition, it is an efficient use of existing Government-owned assets 
and existing Public-Private Partnership arrangements to bridge the 
modernization gap. Recapitalizing existing Bradley chassis provides the 
most survivable, mobile and protected solution for our soldiers at a 
significant lower cost.
                      department of the air force
Other Procurement
    Budget Activity 04, Other Base Maintenance and Support Equip, Item 
No. 62, Mobility Equip.--Support the administration's request of $23.8 
million ($14.4 million Base and $9.4 million OCO) in fiscal year 2013. 
$20.3 million was appropriated in fiscal year 2012. Specifically 
support $6.7 million ($4.6 million base and $2 million OCO) in fiscal 
year 2013 for the Basic Expeditionary Airfield Resource (BEAR). The 
BEAR product is an 800kW prime power mobile generator used by Combat 
Air Forces to power mobile airfields in-theatre and around the world. 
The finished product will replace the existing MEP unit that is 25 
years old and will offer greater fuel economy, increased fuel options 
(JP-8), improved noise reduction, and the latest innovative control 
technology and functionality. With the ever-increasing global reach of 
the U.S. military, the need for reliable mobile power is paramount. 
This program is currently funded for the design, development and 
preproduction of eight individual BEAR units. These units will undergo 
a battery of validation tests. Design and development of the BEAR 
product is on schedule. There is interest from other branches of the 
military for the BEAR product as well given the increased need for 
mobile electric power.
                         department of the navy
Other Procurement, Marine Corps
    Budget Activity 06, Engineer and Other Equipment, Line No. 47, Line 
Item 6366, Power Equipment Assorted.--Support the administration's 
request of $76.5 million ($56.3 million Base and $20.2 million OCO) in 
fiscal year 2013. $27.2 million was appropriated in fiscal year 2012. 
Specifically support $26.5 million ($19.5 million Base and $7 million 
OCO) in fiscal year 2013 for AMMPS. AMMPS generators are the latest 
generation of Prime Power Generators for the DOD and will replace the 
obsolete Tactical Quiet Generators (TQGs) developed in the 1980s. AMMPS 
generator sets are 21 percent more fuel-efficient, 15 percent lighter, 
35-percent quieter and 40 percent more reliable than the TQG. 
Generators are the Army's biggest consumer of diesel fuel in current 
war theatres. When AMMPS generator sets are fully implemented, the Army 
and Marines will realize annual fuel savings of approximately 52 
million gallons of JP-8 fuel and more than $745 million in savings 
based on fuel costs and current use pattern. This will mean fewer fuel 
convoys to bases in active war zones resulting in saved lives of 
military and civilian drivers. AMMPS generators will result in annual 
carbon emissions reductions of 500,000 metric tons CO2 or 
7.7 million metric tons over the expected life of the generators.
                                 ______
                                 
   Prepared Statement of James Binns, Chairman of Research Advisory 
               Committee on Gulf War Veterans' Illnesses
    Dear Chairman Inouye and Ranking Member Cochran: The Gulf War 
Illness Research Program (GWIRP) of the Department of Defense (DOD) 
Congressionally Directed Medical Research Program (CDMRP) has made 
remarkable progress during the past 2 years. As Chairman of the 
Research Advisory Committee on Gulf War Veterans Illnesses, created by 
Public Law 105-368, I deeply appreciate your support, which has made 
this progress possible.
    I also appreciate the hearing you held this week to consider 
appropriations to CDMRP programs for fiscal year 2013 and am pleased to 
submit this letter for the record, to review these recent developments.
    In its landmark 2010 report, the Institute of Medicine (IOM) 
recognized that the chronic multisymptom illness that affects 250,000 
gulf war veterans is a serious disease (not attributable to psychiatric 
illness) that also affects other U.S. military forces. It called for a 
``renewed research effort with substantial commitment to well-organized 
efforts to better identify and treat multisymptom illness in Gulf War 
veterans.''
    The scientific community responded with a dramatic increase in the 
quality and quantity of proposals submitted to the GWIRP at CDMRP. Most 
importantly, last summer CDMRP-funded researchers from the University 
of California, San Diego, completed the first successful pilot study of 
a medication to treat one of the major symptoms of gulf war illness. It 
is not a cure, and the study needs be replicated in a full-clinical 
trial, but the result is extremely encouraging. As the IOM committee 
chair, Dr. Stephen Hauser, chairman of Neurology at the University of 
California, San Francisco, and former president of the American 
Neurology Association, emphasized in his preface to the IOM report, 
``we believe that, through a concerted national effort and rigorous 
scientific input, answers can likely be found.''
    The GWIRP is the only national program addressing this problem. It 
is a peer-reviewed program open to any doctor or scientist on a 
competitive basis. By contrast, Department of Veterans Affairs (VA) 
research programs are only open to VA doctors, few of whom have 
expertise in chronic multisymptom illness. To effectively address a new 
and difficult problem like this, it is necessary to enlist the entire 
medical scientific community. Because VA has not been able to find 
enough qualified researchers, it has reduced funding for gulf war 
illness research in its fiscal year 2013 budget from $15 million to 
$4.9 million. In contrast, the DOD CDMRP program is attracting a 
surplus of excellent investigators. It is critical to shift resources 
accordingly to the DOD program, so that the overall Federal research 
effort is not reduced just at the time it is producing results and the 
Institute of Medicine is pointing the way. The VA budget data is at 
http://www.va.gov/budget/docs/summary/Fy2013_Volume_II-
Medical_Programs_Information_Technology.pdf on page 3A-5.
    As stated by Dr. Hauser, in his attached letters to you, this 
subject is ``vital to the health and effectiveness of current and 
future military forces, in addition to Gulf War veterans.'' Recognizing 
this importance, last summer the House of Representatives in a 
bipartisan roll-call vote increased funding for the program to $10 
million in the 2012 DOD appropriations bill, and this figure was 
adopted by the Senate-House conference committee.
    The Research Advisory Committee has recommended funding this 
program at the $40 million level. It is recognized that in fiscal year 
2013 such an increase may not be possible. However, this effective 
program demonstrably merits increased investment, even in a time of 
fiscal austerity. Dr. Hauser has recommended $25 million. An 
appropriation of $20 million would hold Federal gulf war illness 
research level from last year, taking into account the $10 million VA 
reduction.
    These funds would be productively spent to capitalize on the 
progress that has already been made. Specifically, there are quality 
projects in the pipeline that substantially exceed $25 million. These 
include highly ranked treatment pilot studies not able to be funded in 
previous years due to financial constraints (approximately $20 
million), a followup clinical trial of the treatment shown effective in 
the completed pilot study (approximately $8 million), and three joint 
``consortium'' treatment research programs developed with earlier 
planning grants by teams of researchers at different institutions 
(approximately $24 million, of which only $4 million has been funded).
    At long last, the scientific community has recognized the severity 
and scope of this problem and is engaged in its solution. The Congress 
has created this superb program, which is succeeding where others have 
failed. Please enable these scientists to continue their work.

                         CONCLUSION OF HEARINGS

    Chairman Inouye. This subcommittee will take these issues 
into consideration, I can assure you, as we develop the fiscal 
year 2013 defense appropriations bill.
    This subcommittee will reconvene on Wednesday, June 13, at 
which time we'll meet to receive testimony from the Secretary 
of Defense and the Chairman of the Joint Chiefs of Staff on the 
fiscal year 2013 budget request for DOD.
    We stand in recess.
    [Whereupon, at 12:02 p.m., Wednesday, June 6, the hearings 
were concluded, and the subcommittee was recessed, to reconvene 
subject to the call of the Chair.]
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