So it’s really kind of fun to see the maturation of the field, and at the same time to see that all these new technologies have come into medicine to improve diagnosis, starting in the early ’70s and ’80s with CT scanning and MRI becoming widely available and being brought together with other technologies for development.

One of the technologies that’s fascinated me has been, since the 1990s, the increasing penetration of genetic analysis into the understanding and treatment of cancer. In the early part of the 20th century – and in the 19th century – cancer was treated primarily by surgery, and then in the mid-20th century physicians began using chemicals to poison cancer cells. Since 2000, we’ve recognized that you can look at genetic changes in cancer, and perhaps in other diseases, and target therapies to those specific changes – and get more effective treatment at lower cost. So it’s really an amazing evolution in medicine as a whole. And in many cases, VA has been at the leading edge of this transformation in medical research over the last 90 years.

And at the same time it’s begun to work more closely with other research institutions and programs.

Yes, and I think another evolution we’ve seen, really from the 1950s on, is increasing attention to those things that are specific consequences of military service. The first large multi-site trial done in the United States was a cooperation between VA and the Department of Defense on the treatment of tuberculosis in soldiers that had returned from the Second World War. And it showed that streptomycin was effective in treating this disease. This trial, followed by other trials that found yet other effective drugs, was a large part of the reason why the tuberculosis sanitariums that many of us saw as we were growing up in our communities have largely disappeared. This was later followed on by other large clinical trials, which were organized by VA, and which, in the 1960s, became the VA Cooperative Studies Program, which in turn provided a stable platform for the conduct of large multi-site trials.

As that platform was constructed, we see – and particularly over the last 20 years – increasing attention to things like post-traumatic stress disorder [PTSD], the treatment of traumatic brain injury, the long-term consequences of dealing with amputation. This is perhaps surprising, but it points to a post-Vietnam era evolution toward having this much stronger emphasis on those things uniquely related to service in the military, and uniquely related to service in combat, rather than simply being related to being a veteran who is eligible for care in VA.

But this growth hasn’t led us to neglect the issues associated with veterans we care for as they age. We consider having that broad research portfolio to be critical to assuring that we treat all the conditions veterans have in a scientifically and clinically meritorious way. But nonetheless it has been, it seems to me, a significant expansion.

And that expansion, over the last two or three years, has come to the point of very close collaboration and integration with the research program at the Department of Defense. And we routinely integrate our research programs in areas like traumatic brain injury and PTSD. We, in many cases, may plan studies together. When we don’t do that, we divide up the work, and more and more, although our focus is on different points in the lifespan, with theirs being on the active-duty military and ours being on the veteran coming out of military service, we do look at this as a continuum of research. Both departments feel an obligation to make sure we view that service member or veteran as a whole person who doesn’t fundamentally change when they take off the uniform for the last time. I think that’s a really good thing for service members and veterans, and a really good thing for the taxpayer.

We’ve also studied the use of drugs for treating PTSD – but those studies have not yielded good pharmacologic interventions, so there’s a need to understand better what is happening in the brain in PTSD. And that’s being pursued in several different ways. One is studies using functional imaging technologies to see what communication looks like in PTSD. Investigators are using all sorts of technologies. Some of them are using something called functional magnetic resonance imaging. Apostolos Georgopoulos in Minneapolis has used something called magnetoencephalography, to look at communication pathways. And on the more basic side of things, a study building upon the Million Veteran Program has begun to look at the genetic heterogeneity, the actual gene changes, that may be associated with PTSD, building upon the Vietnam Twin study that showed there is a genetic influence.

Increasingly, too, we are engaging with the Department of Health and Human Services – predominantly the National Institutes of Health – to similarly balance and make sure that together our efforts cover the waterfront as well as we possibly can. And to the best I can tell, that was not a strong focus prior to a few years ago, and represents a really very recent evolution.

In addition to the examples you’ve already given from cardiovascular investigators, are there other particular focus areas that offer insight into the then-and-now of the VA research program?

I think research into topics related to aging and associated disorders, such as Alzheimer’s disease, has changed tremendously everywhere, and the research program in VA really is multifaceted. On the one hand, we have worked on things, such as the genetics of Alzheimer’s disease, which are very fundamental and general. But of course in response to the more recent conflicts, as well as to studies that VA investigators and others have done related to sport injuries, there is a lot of work aimed at determining how chronic low-grade trauma to the brain may lead to degenerative brain disease such as Alzheimer’s, and the development of a strong conjecture that chronic traumatic encephalography, an inflammation of the brain resulting from multiple episodes of trauma, can lead to cognitive decline. So again there’s been a shift in emphasis, with the consequences of military service, and of combat specifically, strongly influencing where we’re going.

Since the number of effective therapeutic interventions for Alzheimer’s is modest, this is also an area in which the clinical research program that addresses it is looking at an earlier phase than we did in the clinical COURAGE trial. A good example of this kind of research was published by the VA Cooperative Studies Program in JAMA [Journal of the American Medical Association] in January 2014 on the effect of vitamin E and a drug called memantine on decline in Alzheimer’s disease.