Does the work of other WRAIR researchers have similar translational benefits? One of the institute’s most talked-about innovations is the creation of the Mental Health Advisory Teams (MHATs), which have been forward deployed to Iraq, Afghanistan, and Africa periodically since 2003.

The methodology used by those researchers – which is aimed at collecting behavioral and mental health information about subjects in real time – is not unique to the military. It’s applicable to many kinds of behavioral studies. What’s distinctive about the MHAT – and the results of our ninth MHAT were just recently reported – is that we can help identify what’s going on with soldiers in a theater environment, and also in some cases how programs launched in response to earlier findings have made an impact on things like resiliency, family stressors, divorce rates, unit cohesion, multiple deployments, and small unit leadership.

What’s been unique about this opportunity is that as we’ve gone through the years, both in Iraq and Afghanistan, and evolved through the time lines of events in those countries, we’ve been able to connect that work with research unfolding in the states, to get information that can inform policy and programs.

What’s been unique about this opportunity is that as we’ve gone through the years, both in Iraq and Afghanistan, and evolved through the time lines of events in those countries, we’ve been able to connect that work with research unfolding in the states, to get information that can inform policy and programs. The MHATs give us the ability to determine, in real time, how well we’re doing with the prevention and treatment of war-related concerns. We can use those same processes in the United States and take a look at what is happening at units in places like Fort Hood, as well as in places like Germany.

Right now, for example, as we draw down in Europe, we’re looking at a study with some units in Germany on the effect of unit movements and changes in morale, capability, and cohesion. We can study that there, and we can also look into the stressors associated with being located near the DMZ [demilitarized zone] in Korea, where there are constant tensions and family separations.

So the MHATs give us an opportunity, and a process, to answer questions that have arisen regarding the effects of war – and some of these questions have never been asked before. Never in our nation’s history have we been at war for 12 years. We’ve never had situations where folks have deployed so many times, and so frequently.

 

In addition to the psychological toll of multiple deployments over a long period of time, the conflicts in Iraq and Afghanistan also have their signature physical wound – the traumatic brain injury (TBI). How have WRAIR researchers stepped up to help service members – either to prevent head trauma or treat an injury?

At our neuroscience branch, much of the research is focused on studies of animal models to identify the effects of concussion and more severe brain injury. Researchers are also working to identify the biomarkers of brain injury, which have implications not only for diagnosis, but also perhaps for treatment of TBI as well.

One of the biggest challenges right now for military medical personnel is that a lot of symptoms associated with PTSD [post-traumatic stress disorder] are similar to the symptoms associated with concussion – and yet treatments for PTSD or depression and treatments for concussion would likely be different if you could tease apart the causes. In some cases, they’re multi-factorial. But if we can get diagnostic tests that can help us more specifically identify the causes of those symptoms, this can lead to better treatments.

One of the things we’ve learned is that head injuries from blasts are different from head injuries caused by falls, blunt trauma, or the acceleration associated with things like car accidents. It probably took us six to eight years to prove that and agree on that. And that means the research we’ll be doing should be focused on those kinds of injuries – the blast injuries more common to military personnel – but by the same token, it will translate overall to the field of general brain injury research.

We can also demonstrate that treatments are effective by correlating changes in these biomarkers that we can find in the bloodstream, with clinical improvement. We can take that information, share it with our partners who are conducting clinical research on treatment paradigms, and eventually help our military folks – and then ultimately, the civilians as well who get head injuries from accidents and other traumas.

One of the things we’ve learned is that head injuries from blasts are different from head injuries caused by falls, blunt trauma, or the acceleration associated with things like car accidents. It probably took us six to eight years to prove that and agree on that. And that means the research we’ll be doing should be focused on those kinds of injuries – the blast injuries more common to military personnel – but by the same token, it will translate overall to the field of general brain injury research.

It’s interesting to look over the past decade and see how the nature of the conflicts in Iraq and Afghanistan, and their effects on an all-volunteer force fighting for more than a decade, have altered the way WRAIR is organized and operates. We’re headed into a new period of transition – a drawdown, accompanied by a period of certain fiscal constraint. WRAIR has always evolved to meet the Army’s mission – how do you think it will continue to evolve in the coming years?

Well, certainly we’re already evolving in very specific ways. As new priorities come into play, we have to be flexible and adaptable enough to provide research that supports the investigations and/or treatments associated with those priorities. For example, one of the priorities we have now has been established by the Army Surgeon General and also by the Assistant Secretary of Defense for Health Affairs. And that is that our military health care system will focus on the overall health of the soldier and their families and not just specific combat-related injuries or disorders.

The Surgeon General has put together a program to develop a system of health focused on a vision she calls “the Performance Triad,” composed of activity, nutrition, and sleep. The research out there on sleep – much of which has been performed or supported by researchers in our own Behavioral Biology Branch – has demonstrated a clear link between sleep and performance. But there is also research out there that suggests if you sleep more, your risk of becoming obese decreases. You’ll actually lose weight if you sleep more.

WRAIR fits right into the Surgeon General’s vision. We’re the Army’s primary sleep research facility, investigating the effects of sleep, how to improve sleep, the obstacles to good sleep. We’ve developed a product, a caffeinated gum, used by service members to improve alertness and performance and overcome sleep deprivation in the short term. That’s an example of how we adapt to new priorities that arise. We may not ever have thought of the need to develop a product like that if we hadn’t been doing unit-based research, and discovered its importance to the war effort.

Through our MHATs, we’ve also identified small unit leadership as a key determiner not only of the behavioral and mental health of service members, but also of the willingness of unit members to seek mental health care. We’ve helped the Army put programs in place to train leaders to avoid stigmatizing unit members who seek help. And so it seems fair to say we’re helping to reduce future barriers to care for soldiers and their families who look to improve their overall health, rather than limiting our focus to deployment-related health problems.

Now in terms of fiscal constraints, the future looks challenging. We’re looking at an uncertain environment with sequestration, budgetary restrictions, and personnel drawdowns in a postwar period. But we’ve always worked with partners, both in government and the private sector, who have helped to encourage and support our research through grants, MOUs [memorandums of understanding], or other cooperative agreements. That extramural funding is critical to our effort. We receive a lot of funding to do some of these research programs from our external partners to perform collaborative research. We always make sure that the research that is being done fits within the mission of the WRAIR and what the Army needs. But we partially rely on external funding sources to accomplish the things that we do.

 Now in terms of fiscal constraints, the future looks challenging. We’re looking at an uncertain environment with sequestration, budgetary restrictions, and personnel drawdowns in a postwar period. But we’ve always worked with partners, both in government and the private sector, who have helped to encourage and support our research through grants, MOUs [memorandums of understanding], or other cooperative agreements.

Do you foresee that WRAIR and other military medical researchers will have to rely more on external funding in the future, just to maintain continuity? I know some programs – such as WRAIR’s leishmaniasis laboratory, the only one of its kind – have been scuttled in the past, only to be hurriedly reactivated once personnel were deployed to endemic areas.

Well, if our core appropriated funds are decreased, then there will be a corresponding decrease in the amount of research and productivity we can provide, of course. We’ll then have to make choices as to which research gets higher priority for funding. And in some cases, I suppose we could make up for a funding shortfall through continued work with our external partners – though certainly there are many items in our budget that can only, by statute, be paid with appropriated funds. In other cases, we would make a deliberate decision to decrease the research effort in one area, and increase it in another, but leave enough of the expertise available so that it could be ramped back up if the prioritization changes.

One of the things we really have to look out for is the loss of civilian scientists in our workforce. We need to maintain our scientific expertise in order to sustain our working relationships with those external partners.

 

So given these challenges, do you think WRAIR’s work – which has been so influential, bringing about historic changes in military medical research and the delivery of care – will continue to be as important to the Army, and to the United States, in the future?

Among other things, I think the OCONUS labs – which were established out of necessity, because our researchers needed access to the places where these diseases existed in order to do research – will be key to our continued importance. When we made it a requirement that any research we conducted in those areas would also benefit those populations, we enabled our partners to build scientific and medical capability and capacity.

The majority of the people who are working for us now in Thailand, for example, are Thai nationals who have been with us, in some cases, for close to 50 years. They’ve increased their capacity and capability through their universities, and built networks of their own. The same thing happens when we work in Cambodia, or in the Philippines, or in some of the African nations where we do HIV and malaria research. And it has made a difference. It adds to medical diplomacy – we are closely embedded, in some cases, with the embassies in those countries, and identify the overall diplomatic benefit to participating in some of this research.

If it weren’t for the military relevance of these research programs, some probably wouldn’t have much relevance in the United States at all – for example, malaria isn’t a big threat inside the United States, nor is leishmaniasis, unless someone sick travels back to the U.S. from an endemic area. There wouldn’t be a lot of interest from the big pharmaceutical companies to research medications and vaccines for these diseases, because there’s no market for them.

The other thing to remember about the relationships we build internationally is that the clinical discoveries we’re hoping to enable not only make a difference to people in that part of the world – they make a difference to U.S. military service members. Our soldiers who are going to get infected if they’re deployed to those parts of the world are going to be infected with the diseases endemic there – malaria and dengue, for example. Dengue virus has four subtypes, and we’ve only been able to develop vaccines specific to a subtype.

If it weren’t for the military relevance of these research programs, some probably wouldn’t have much relevance in the United States at all – for example, malaria isn’t a big threat inside the United States, nor is leishmaniasis, unless someone sick travels back to the U.S. from an endemic area. There wouldn’t be a lot of interest from the big pharmaceutical companies to research medications and vaccines for these diseases, because there’s no market for them. When we – WRAIR and our partners – start to develop products that will help protect our soldiers, we’re setting in motion events that have the potential to save or improve millions of lives.

This article first appeared in Walter Reed Army Institute of Research: 120 Years of Advances for Military and Public Health.