One of the many things people don’t know about the Veterans Health Administration (VHA) – the nation’s largest, and indeed only, publically funded, integrated healthcare system – is the scope and importance of its research. While most members of the public think only in terms of the VHA’s provision of clinical care to the nation’s veterans, the VHA actually has a tripartite mission. In the process of fulfilling President Lincoln’s promise, “To care for him who shall have borne the battle, and for his widow, and his orphan,” the VHA provides not only clinical care, but also has an educational and research mandate. When it comes to fulfilling its educational mission, the VHA has established partnerships with 1800 health professional educational institutions, and trains 62,000 medical students and residents each year, as well as 23,000 nursing students and 33,000 health professional students in other fields. About 70% of all physicians in the US have trained at a VHA institution and it has the largest nursing force in the country.
Its research has proven to be critically important to veterans and to a broader public. VHA researchers have won 3 Nobel Prizes and seven Lasker awards. The VHA also has a unique partnership with NCIRE, a non-profit research institute located at the San Francisco VA Medical Center (SFVAMC), which is the leader in Veterans Health Research. VHA research was the first to link traumatic brain injury to early onset of dementia. It has been a leader in research in Alzheimer’s and brain imaging, and developed brain stimulation techniques to improve patients’ ability to move around and function with Parkinson’s disease.
Each year NCIRE puts on a research conference entitled the Brain at War, which spotlights leading researchers who, in partnership with UCSF, produce fascinating insights and treatments to deal with healthcare issues that affect veterans. The advances produced by this research – as well as all other VHA research — have ripple effects far beyond the veteran population.
This year, as part of my year- and- a -half long research into a book I am writing on VHA healthcare, I attended the NCIRE conference. Its theme was “Mending Minds and Wounds Returning Health to Those Returning Home.” It’s impossible in a short article to catalogue all the research presented at the conference, but let me tell you some of the highlights.
Although many of us might think that the biggest problems that brings veterans to the VHA is traumatic brain injury (TBI) or Post Traumatic Stress Disorder (PTSD), it’s in fact tinnitus – that ringing of the ears that comes with hearing loss in aging. The veteran population is far older than those treated in other healthcare systems. The average veteran is 62, and many are much older. So tinnitus would be a big problem for them even if they hadn’t served in the military. My husband, who is not a veteran, had to visit a hearing specialist to get help with his ear ringing. I notice mine late at night, when I am falling asleep.
Veterans have even more problems with hearing loss because the conditions of their work subject them to the kind of loud, percussive noises that damage the ear. As researcher Steven W. Cheung, MD, Staff Physician on the Surgical Service at SFVAMC and Professor of Otolaryngology at SCSF, pointed out in his presentation on Advances in Tinnitus Imaging and Treatment, there is no part of the military where service members can avoid the kind of loud noises that produce tinnitus. The constant hum on ships impacts the ears of sailors; the whirr of engines does damage to airmen and women; while those in the Marines and Army are subjected to a constant barrage of artillery fire and explosives even in training. I met one patient at the VHA who had hearing loss and tinnitus because he served in Arlington National Cemetery where he shot off guns all day as part of the standard salute at military funerals. This was during the Vietnam era and he and his fellow soldiers wore no protective hearing gear.
For most people tinnitus is a minor annoyance. For three percent of people who have it, it’s problematic, and for ½% it severely disrupts normal life. As Cheung described it, for those sufferers, tinnitus is a form of chronic auditory pain. Although a lot of people think of tinnitus as an ear problem, Cheung explained that it’s a whole brain problem. To deal with that, researchers at UCSF, the VHA, and NCIRE have utilized research they have conducted on people whose brains have been impacted by Parkinson’s disease. They have discovered that patients undergoing deep brain stimulation (DBS) had a dramatic reduction in severity of symptoms (loudness) from their tinnitus. In the course of his talk, Cheung showed an amazing video of a veteran who had been treated with DBS for the motor problems brought on by Parkinson’s disease. In the first segment of the short video, the veteran could barely get up from his chair and make it across a room. In the second, after DBS, he practically bounded out of his seat and launched himself almost missile like across the space in front of him. It was quite a sight. Inspired by what by what can be achieved for patients with Parkinson’s disease, Cheung and his colleagues hope DBS for tinnitus will bring meaningful relief for those who suffer from the condition.
This complex treatment is promising for people whose lives are made an auditory nightmare by tinnitus, which again includes far more patients than those in the veteran population. I couldn’t help thinking, for example, about what the ears of all those young people hanging around nifty bars or restaurants in San Francisco would be like after age 45 – when hearing loss normally begins. Or about those poor bartenders and waiters and waitresses subjected to that percussive force day in and day out. Maybe some of them will benefit from VHA research.
Another session of the conference dealt with Innovative Approaches to Mental Health. Veterans suffer from a variety of complex problems, sometimes brought on by military service, sometimes exacerbated by it. These include Post Traumatic Stress Disorder (PTSD) and insomnia, which again, are not problems exclusive to the veteran population. In one presentation Thomas C. Neylan, MD, Professor of Psychiatry at UCSF and Director of the Stress and Health Research Program at SFVAMC described a study that was funded by the Department of Defense (DOD) and conducted by the SFVAMC. The study compared two different sleep medications – Zolpidem (Ambien) and something called Almorexant. The study focused on the cognitive side effects of these drugs. Pharma funded studies comparing one drug’s effectiveness, or even side effects, against another’s are rare. Few pharmaceutical companies are interested in potentially demonstrating that one of their medications is not as good as one produced by another company.
In his presentation, Neylan reported that the study showed that Almorexant had fewer cognitive side effects then Zolpidem. Although the company that developed Almorexant –Actelion — has stopped its work on the medication, a cousin of this drug, Suvorexant, has been approved by the FDA and others in this class are being developed.
As Neylan explained to me, “The cognitive side effects of sleeping medication result in accidents and injuries. People get up in the middle of the night to use the bathroom or are awakened in the middle of the night unexpectedly. The worry is that if you are awakened under the influence of a sleeping medication, you are at higher risks of injuries, and accidents, and making mistakes because of the cognitive side effects of sleeping pills. So a new sleeping medication that has fewer cognitive side effects would be important to a very large population.”
As someone who has taken Zolpidem (who hasn’t?) for occasional sleep problems, I can certainly attest to the relevance of a study to millions of people like me who have never seen a battlefield or been trained to perform on one.
Another presentation shifted the focus to the social and emotional aspects of veteran’s problems. In her presentation on dealing with chronic pain, Karen Seal, MD, PhD, and director of the Integrated Pain Team at the SFVAMC, and a Professor of Medicine and Psychiatry at UCSF discussed a different approach – an integrative rather than biomedical approach –to the kind of chronic pain that many veterans experience. Rather than searching for a silver bullet medication – say opioids – to treat pain, her work looks at how those who treat chronic pain can integrate other kinds of treatments like, for example, yoga, that are proven to help with pain while avoiding the downside of opioid use and abuse. At the San Francisco VA Medical Center, chronic pain groups now emphasize restoration of function, and refer patients for acupuncture, chiropractic, and relaxation techniques among other things.
Over 100 million Americans suffer from chronic pain. Chronic pain costs the nation about $600 million a year. The success of such an approach in the veteran population could clearly help those treated outside the VHA system as well.
Over the past year and a half, the VHA has received little praise for the excellent care it provides the nation’s veterans. Many Congressional Republicans, pushed and prodded by the Koch brothers financed veteran group Concerned Veterans for America, are trying to promote the partial or even complete privatization of the VHA. Members of the public, swayed by a barrage of all too often highly exaggerated accounts of VHA failings (failings, for example, by one hospital that are used to tarnish an entire system) may support these proposals. What they ignore are the many accomplishments of the nation’s largest integrated healthcare system. That’s why conferences like the Brain at War are so important. They remind us of these accomplishments and about the significant research mandate the VHA fulfills. It is hard to imagine how this research would be funded and conducted in the private healthcare system. But it is easy to imagine how veterans and many others would suffer without it.
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