Target: Warfighter Health
By George Jagels
During the thirteen years of U.S. operations in Iraq and Afghanistan, servicemembers were exposed to psychological and physical strains common to warfare and yet unique to their wars. Survival rates from combat wounds are currently at their highest levels in history, which is a remarkable scientific and organizational feat; at the same time, concerns over traumatic brain injury and a lack of psychological healthcare as well as scandals at DoD health facilities dominate headlines related to military medicine. Clearly, there is more work to be done.
The DoD’s Military Operational Medicine Research Program (MOMRP) is one joint effort to improve the lives of warfighters in theater and back home. With a mission “to develop effective countermeasures against stressors and to maximize health, performance, and fitness,” MOMRP works to identify issues that affect soldiers now and in the future, resulting in research efforts that will be relevant long after the last American forces have left Afghanistan.
According to Army Lieutenant Colonel Dennis McGurk, deputy director of MOMRP, the program funds investigators who delve into problem areas, while he and his staff manage and coordinate the process. This may sound simple, but it requires balancing both the complex factors at work in military medicine and the great demand for research in numerous areas. To do this, MOMRP received between $120-140 million in FY 14 from the Army’s Assistant Secretary for Acquisition, Logistics, and Technology and from the Office of the Secretary of Defense for Health Affairs.
MOMRP is divided into four research focus areas: Injury Prevention and Reduction, Psychological Health and Resilience, Physiological Health, and Environmental Health and Protection.
Guidance on what research to pursue comes from multiple sources. “Everything starts from the White House and the National Defense Authorization Act,” McGurk said. “The priorities from the services and DoD also come down, and [we] react to those.” Congress can direct the program to fund research in specific topics.
MOMRP also seeks to find research topics using a bottom-up approach. “We meet regularly with the key people who are out with the troops to find out ‘What are the gaps that research could identify and address?’” McGurk said. This can include speaking with doctors and medics recently back from deployment. The Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, for example, helps the program by speaking with medical personnel about what treatment gaps research can improve upon.
The above processes provide MOMRP with some research focus, but the specifics of a project are not always known beforehand: MOMRP receives proposals for research projects from researchers through broad agency announcements. These proposals are scientifically reviewed, then programmatically reviewed, and finally, if budget allows, funded.
Another way the program finds researchers is Requests for Proposals (RFPs). These are often specific in their description of the problem and the assessment methodology that should be used. Research is performed by academicians, Army and DoD laboratories, and others. McGurk was very positive about the range and balance of the researchers MOMRP funds—he considers their data gathering and problem solving abilities to be remarkably strong.
Spreading the Word
McGurk spelled out MOMRP’s mission very clearly: “What we’re trying to do is make sure that [our research influences] decisions made by policymakers, clinical practice guidelines, and training.” He explained to C&CC that senior leaders in the DoD—MOMRP is a joint effort—want evidence-based research to affect positive change. Overall, the program’s research findings are accepted due in part to the passion that flag officers and top civilians have about improving soldier care.
Researchers publish their findings to inform the public and DoD community of their results. These findings can be used to make recommendations for policy changes, such as new training that could help prevent injuries or modifications to clinical practice guidelines. MOMRP teams with organizations such as the Defense Suicide Prevention Office and Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury to help disseminate their findings.
Not all research programs are geared towards the future—sometimes their effect can be immediate. For example, in 2013, a mental health advisory team (MHAT) deployed to Afghanistan to perform a mental health assessment of the entire theater. The MHAT spoke with and tested soldiers and Marines on the ground. “They run analyses while in theater and give findings to the leaders in theater on what care is provided or what trainings might happen,” McGurk said. “This is the first time these sort of assessments have been conducted during the war with the intent to make changes in real time to take care of servicemembers.”
Following Army Surgeon General LTG Patricia Horoho’s guidance to move military medicine to a “system of health” from a healthcare system, MOMRP is already deep into managing research on adequate sleep, proper exercise, and nutrition, among other subjects. With numerous projects in different domains, McGurk unpacked a few ongoing programs as examples of the projects larger efforts.
MOMRP’s Deputy Director discussed a Walter Reed Army Institute of Research sleep group funded by MOMRP that studies the effects of partial or full sleep deprivation. “A lot of operations take place at night, and folks by nature become shift workers when they are deployed,” he said. “So they’re doing research to look at the effects of sleep deprivation and countermeasures that would help improve performance when people are sleep deprived.” Some of the results have indicated that caffeine gum and sleep banking—extra sleep before a long night of operations—can mitigate the negative effects of sleep deprivation.
Another effort relevant to all the services regardless of peace or war conditions is further developing return to duty standards. Broad guidelines exist already, but research managed by MOMRP hopes to refine these, improving efficiency and safety. New research will tailor return to duty to specific military occupational specialties. “If you’re an artilleryman where you have to lift a heavy projectile, that might be a different return to duty standard than someone who works as a medic in a hospital,” McGurk said. This effort includes the development of both physical and psychological standards.
Psychological metrics, however, are less well defined than physiological standards. “It has been recognized for a long time that when a leg is broken, it has to heal to a certain extent before a soldier can return to duty and function in their job,” McGurk said. “I think there’s been a good recognition recently about the psychological difficulties that servicemembers came into the military with or developed during deployments. There is research to determine as well as you can objective standards to see when they are able to return to duty.”
As the military tries to reduce suicide rates, suicide prevention is another area of critical importance to MOMRP, which manages the Military Suicide Research Consortium—whose goal is “to quickly identify those at risk for suicide and provide effective evidence-based prevention and treatment strategies.” McGurk claimed the effort has yielded some promising interventions that have the potential to reduce the suicide rate amongst veterans and serving soldiers.
Another such project is Army STARRS (Study To Assess Risk and Resilience in Servicemembers), which is developing algorithms that can help identify those at high-risk of suicide or other conditions. Virtual reality therapy research is also being funded.
On the physiological side, injury prevention is an important portfolio for MOMRP. Musculoskeletal injuries are common in the course of military service, regardless of whether someone has been in combat or not. “In training is where a lot of folks get injured, so this work won’t stop when the wars are over,” McGurk said. “Prevention is an important thing in training, in garrison, and when deployed.” MOMRP funds a U.S. Army Institute for Environmental Medicine project looking at the effects of loads on soldier performance and solider injuries.
Pressing Ahead: Future Research
Despite the end of major overseas combat operations, in the next few years MOMRP will be supporting a variety of new research. For example, a project for determining specific criteria for military occupational specialties will develop and test evidence-based standards to find the best people for certain jobs. “This would be gender neutral,” McGurk told C&CC. “As females enter combat occupations, the standard would be ‘Can you do the job?’”
Concerning environmental health, the harsh environments of Iraq and Afghanistan are a reminder of how difficult it is to fight at and maintain peak performance. MOMRP is addressing this problem, backing research into monitors that sense the conditions and algorithms that may help predict when someone has acute mountain syndrome or potentially let a leader know when and how much hydration is required in certain conditions.
McGurk, who holds a PhD in Experimental Psychology, was very bullish on two ongoing efforts to improve psychological care: compressed Post-traumatic Stress Disorder (PTSD) therapy and biomarkers. PTSD therapy normally comprises approximately 15 weeks for a full treatment; MOMRP is funding a study that is assessing whether 15 weeks of treatment can be accomplished in approximately two weeks. This more intensive version should allow servicemembers to receive treatment with fewer distractions.
Biomarkers, defined by the National Institutes of Health as “key molecular or cellular events that link a specific environmental exposure to a health outcome,” can result from studies in genomics, proteomics, or hematology. “The hope would be—not in the too distant future—to have a way to look at blood or neuroimaging to be able to determine whether someone has a disorder,” McGurk said. If biomarkers could be developed to diagnose PTSD, for example, then “we could determine if we gave them an evidence-based treatment did it work for them? Or are there some populations it would work better for? Then you can have targeted treatment or individualized medicine.”
Top photo caption: Major Brad Warr, Army Research Institute of Environmental Medicine researching physician assistant, uses a digital gauge to measure how much weight a soldier lifts when recovering the spade trail arm and blade on an M777 howitzer on 5 June 2013. Warr was part of the Gender-Neutral Physical Standards Study. (Staff Sgt. Timothy Hughes)
This article was originally published in the Q3 2014 issue of Combat & Casualty Care magazine.