Part of the genius in linking VA health care with the academic medical system, an idea that first occurred back in Gen. Omar Bradley’s time, is that it brings academic physicians into VA health care. In Boston, for example, many of the people treating our veterans also carry titles like professor of medicine, Harvard University. They’re pretty top-rate people.

At the same time, obviously, there’s sometimes a crunch in health care access for veterans. Health care needs are immediate, and research is seen as having a future payoff. So there can be a tendency to say: ‘Well, we’ll put off the research and see our patients now.’ For a short period of time, this is perfectly appropriate and reasonable. But over a long period of time, if this continues, it’s like eating your seed corn. You have a problem with next year’s harvest. And so having a health care system embedded in a deeply political environment, I think, creates challenges, because the political system is not always as strong in thinking about the future as it is in dealing with the present. And we all know that of late we have been practicing government by crisis management in many ways. I think this is a concern for missions not only in VA but in our research partners as well.

PTSD and TBI are often called the “signature wounds” of the conflicts in Iraq and Afghanistan. But there seem to be other health problems that are more prevalent among veterans than among Americans as a whole – diabetes, for example, and hepatitis C. Are there other health challenges that are more particular to veterans? Do these disparities affect the apportionment of resources in VA research?

Diabetes, of course, predisposes to other health problems, one of which is cardiovascular disease. And in the VHA, we take care of a population that is somewhat older than the population as a whole, and as you get older, your risk of developing cardiovascular disease and stroke goes up. So we do take care of more people who are suffering from these vascular diseases than the population as a whole.

I think tissue regeneration, and some of the work going on in spinal cord injury, for example – is suggesting that certainly animals, and hopefully someday people, who have had long-standing injuries may be able to get partial restoration of spinal cord function. I think that’s a true game-changer. I mean, until now, the idea has been that if somebody was paralyzed through a spinal cord injury, it was for life.

Another thing that happens is that smoking has been increasing among veterans who have come back from Iraq and Afghanistan – smoking rates that are maybe twice what we see in the population of the United States as a whole. And of course, that’s associated with lots of things. It’s probably associated with certain mental health conditions. It’s certainly associated with the development of cardiovascular and pulmonary disease. And as you know, we have concerns about pulmonary health in people that have participated in this conflict, either because of dust in the atmosphere or burn pits. If we bring that together with smoking, this is clearly an important area for us to move forward on.

So we need to continue with a strong research program associated with cardiovascular disease, which may also be increased in people with PTSD. There is evidence that mortality rates among people who suffer from PTSD are higher than those that suffer in the general population – cardiovascular mortality is probably a piece of that. We struggle to find a balance between treating what you think of as general health conditions, like cardiovascular disease and stroke, for which the peculiarities of military service, such as taking up smoking or PTSD, exacerbate the risks.

To some degree, the investigator-initiated components of our research program actually help us to achieve this balance. As with NIH, much of our research – not all of it, but much of it – begins with an investigator, usually a clinician investigator who sees a problem they deal with in their clinical practice and makes a proposal for funding to us. And they have the opportunity to evaluate that in terms of scientific merit. But part of that merit evaluation is an assessment of the scope of the issue for the population as a whole, and VA in particular. So if our clinical care system is dealing with a tremendous amount of issues associated with mental health, as it has over the last few years, the number of mental health professionals and mental health investigators will go up – and even without much intervention on our part, the tendency will then be to shift resources to where those applications are coming from, because that’s an indicator of a real set of issues within our health care system. We hope we get a balance in the course of doing it.

We have analyzed this and we find that, aside from a few things, as a whole our recent portfolio actually tracks our health care expenditures pretty well – with the exception that we spend more on things like PTSD and polytrauma and military occupational exposures than you would expect from their prevalence in VA health care. And that seems to be the right thing to do. So I think we’re in a good place. But there is no magic formula, and there are certainly going to be those who think we should have a somewhat different balance.

VA research seems to have been involved in several historic milestones in the past year alone – for example, the evaluation at the James J. Peters VA Medical Center, Bronx, New York, of the robotic ReWalk™ exoskeleton, which is now commercially available, has shown that paraplegics can stand and walk again. Researchers at the Miami VA Medical Center demonstrated that an artificial pancreas, developed in Israel, can be implanted in human subjects without being rejected. Are there other advances, either being developed through the VA research program or in partnership with other researchers, that we’re going to look back on as game-changers in 20 to 30 years?

That artificial pancreas was interesting; while that was not a VA product, it built on a lot of work by VA researchers who were looking at how glucagon and insulin work together to regulate blood sugar. In the past, we’ve tried to regulate insulin alone. More recently, at least one of the bio-artificial pancreas designs uses both insulin and glucagon in a feedback loop. And that work really is very much built upon work in which the VA investigators were pioneers.