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i 

57–401 2010

[H.A.S.C. No. 111–149] 

DEPARTMENT OF DEFENSE MEDICAL 

CENTERS OF EXCELLENCE 

HEARING 

BEFORE THE

MILITARY PERSONNEL SUBCOMMITTEE 

OF THE

COMMITTEE ON ARMED SERVICES 

HOUSE OF REPRESENTATIVES 

ONE HUNDRED ELEVENTH CONGRESS 

SECOND SESSION 

HEARING HELD 

APRIL 13, 2010 
(II) 

MILITARY PERSONNEL SUBCOMMITTEE 

SUSAN A. DAVIS, California, Chairwoman 

VIC SNYDER, Arkansas 

LORETTA SANCHEZ, California 

MADELEINE Z. BORDALLO, Guam 

PATRICK J. MURPHY, Pennsylvania 

HANK JOHNSON, Georgia 

CAROL SHEA-PORTER, New Hampshire 

DAVID LOEBSACK, Iowa 

NIKI TSONGAS, Massachusetts 

JOE WILSON, South Carolina 

WALTER B. JONES, North Carolina 

JOHN KLINE, Minnesota 

THOMAS J. ROONEY, Florida 

MARY FALLIN, Oklahoma 

JOHN C. FLEMING, Louisiana 

DAVID KILDEE, Professional Staff Member 

JEANETTE JAMES, Professional Staff Member 

JAMES WEISS, Staff Assistant 
(III) 

C O N T E N T S 

CHRONOLOGICAL LIST OF HEARINGS 

2010 

Page 

HEARING: 

Tuesday, April 13, 2010, Department of Defense Medical Centers of Excellence ...................................................................................................................... 1 

APPENDIX: 

Tuesday, April 13, 2010 .......................................................................................... 19 

TUESDAY, APRIL 13, 2010 

DEPARTMENT OF DEFENSE MEDICAL CENTERS OF EXCELLENCE 

STATEMENTS PRESENTED BY MEMBERS OF CONGRESS 

Davis, Hon. Susan A., a Representative from California, Chairwoman, Military Personnel Subcommittee ............................................................................. 1 

Wilson, Hon. Joe, a Representative from South Carolina, Ranking Member, 

Military Personnel Subcommittee ...................................................................... 3 

WITNESSES 

Green, Lt. Gen. Charles Bruce, USAF, Surgeon General, U.S. Air Force .......... 6 

Rice, Dr. Charles L., President, Uniformed Services University of Health 

Sciences, Performing the Duties of the Assistant Secretary of Defense for 

Health Affairs, U.S. Department of Defense ..................................................... 4 

Robinson, Vice Adm. Adam M., USN, Surgeon General, U.S. Navy ................... 5 

Schoomaker, Lt. Gen. Eric B., USA, Surgeon General, U.S. Army ..................... 4 

APPENDIX 

PREPARED STATEMENTS: 

Davis, Hon. Susan A. ....................................................................................... 23 

Green, Lt. Gen. Charles Bruce ........................................................................ 56 

Rice, Dr. Charles L. .......................................................................................... 29 

Robinson, Vice Adm. Adam M. ........................................................................ 49 

Schoomaker, Lt. Gen. Eric B. .......................................................................... 41 

Wilson, Hon. Joe ............................................................................................... 26 

DOCUMENTS SUBMITTED FOR THE RECORD: 

[There were no Documents submitted.] 

WITNESS RESPONSES TO QUESTIONS ASKED DURING THE HEARING: 

[There were no Questions submitted during the hearing.] 

QUESTIONS SUBMITTED BY MEMBERS POST HEARING: 

[There were no Questions submitted post hearing.] 

(1) 

DEPARTMENT OF DEFENSE MEDICAL CENTERS OF 

EXCELLENCE 

HOUSE OF REPRESENTATIVES, COMMITTEE ON ARMED SERVICES, MILITARY PERSONNEL SUBCOMMITTEE, Washington, DC, Tuesday, April 13, 2010. 

The subcommittee met, pursuant to call, at 5:30 p.m., in room 

2118, Rayburn House Office Building, Hon. Susan A. Davis (chairwoman of the subcommittee) presiding. 

OPENING STATEMENT OF HON. SUSAN A. DAVIS, A REPRESENTATIVE FROM CALIFORNIA, CHAIRWOMAN, MILITARY 

PERSONNEL SUBCOMMITTEE 

Mrs. DAVIS. Good afternoon. I was going to say good evening. 

Good late afternoon. 

Today the Military Personnel Subcommittee meets to receive testimony on the progress of Medical Defense Centers of Excellence. 

Three years ago, as different types of casualties than had been initially anticipated mounted, Congress realized that the Department 

of Defense [DOD] had to do a better job preventing, diagnosing, 

mitigating, treating, and rehabilitating these injuries. 

One of these injuries, traumatic brain injury, or TBI, was somewhat new for the military and, in truth, for medicine in general. 

Advances in both protective armor and battlefield medicine were 

saving lives that would have been lost in previous wars. The 

knowledge and expertise to deal with TBI was not resident anywhere. So, as has been the case in previous wars, the Department 

of Defense will need to be at the leading edge of medical research. 

Another injury, post-traumatic stress disorder, or PTSD, was better known, but the clinical expertise to deal with it was more resident in the Department of Veterans Affairs [VA]. 

After many years of relative peace followed by an intense period 

of conflict, the medical research and development functions of the 

Department of Defense found themselves inundated with requirements. The military medical establishment has been made great, 

heroic even, improvements to trauma care during this conflict, but 

more remains to be done both for initial battlefield treatment and 

long-term rehabilitation. 

This is why these Medical Centers of Excellence that we are 

going to be talking about today are so important, and why our frustration is so pronounced with the excessive amount of time it has 

taken to get these centers up and running. 

The first appropriation for this purpose was made almost three 

years ago. Several months after that the House and Senate Armed 

Services Committees included a requirement to establish centers of 
2 

excellence in TBI, PTSD, and vision in the National Defense Authorization Act of 2008. Today, only two of these are in actual operation, combined by the Department as the Defense Center of Excellence. 

Little apparent progress has been made in establishing the Vision Center of Excellence nor, as far as we can tell, with either the 

Hearing Center of Excellence or the Traumatic Extremity Injuries 

and Amputation Center of Excellence required by the National Defense Authorization Act for 2009. So clearly we are concerned about 

the Department’s slow pace in developing such an important function. 

Excessive delays are not our only issue, however. The center that 

has been established, the Defense Center of Excellence, while having achieved some notable small-scale successes, has not inspired 

great confidence or enthusiasm thus far. The great hope that it 

would serve as an information clearinghouse has not yet materialized. The desire that the center become the preeminent catalogue 

of what research has been done, what is being done, and what 

needs to be done has not been realized. Part of this is no doubt due 

to the fact that the Department’s Center of Excellence, what we 

know as DCoE, has had to create or, more accurately, recreate all 

of the administrative infrastructure and processes required to oversee medical research on such a monumental scale. However, the 

center has also made some serious management missteps that call 

into question its ability to properly administer such a large and important function. 

We look forward to hearing how the Department plans to improve this organization going forward so it can realize the goals set 

for it by Congress. 

Today we will hear from the senior medical leadership from the 

Department of Defense. Dr. Charles Rice is the President of the 

Uniformed Services University of Health Sciences and is currently 

performing the duties of the Assistant Secretary of Defense for 

Health Affairs. In this role, Dr. Rice directly oversees the Defense 

Center of Excellence, as well as the establishment of the other centers of excellence. 

We are also fortunate to have with us Surgeons General, Lieutenant General Eric Schoomaker from the Army, Vice Admiral 

Adam Robinson from the Navy, and Lieutenant General Bruce 

Green from the Air Force. They will all describe how well the current centers support the requirements of their services. 

Welcome, gentlemen. 

General Green, I know this is not the first time you have appeared before our panel, but it is the first time since your promotion to Surgeon General of the Air Force, so we welcome you. 

And thank you to all of you for being here. 

Throughout our conversation today, it should go without saying 

that all of us, members of the legislative and executive branches, 

are committed to providing the very best care possible to our 

wounded warriors. It is not hyperbole to say that our military 

health system has made previously impossible feats routine. This 

is a testament to the commitment displayed on a daily basis by everyone who is associated with the military health system. We must 

do our part to make this trend continue. 
3 

Once again, thank you for being here. We look forward to an active discussion, and I will turn now to Mr. Wilson for any remarks 

he would like to make. 

[The prepared statement of Mrs. Davis can be found in the Appendix on page 23.] 

STATEMENT OF HON. JOE WILSON, A REPRESENTATIVE FROM 

SOUTH CAROLINA, RANKING MEMBER, MILITARY PERSONNEL SUBCOMMITTEE 

Mr. WILSON. Thank you, Chairwoman Davis, and thank you for 

holding this hearing. I cannot overemphasize the importance of the 

four Department of Defense medical centers of excellence established by Congress to meet the needs of our returning wounded and 

injured service members. The medical centers of excellence were intended to be the overarching body for each of the focus areas that 

coordinates, inspects, and oversees the tremendous amount of good 

work being done across the nation to help our troops returning 

with brain injuries, mental health problems, vision and hearing injuries, and extremity injuries and amputations. 

As a veteran myself and father of four sons currently serving in 

the military, I particularly have an understanding of what you are 

doing and I am so grateful that my second son is a graduate of the 

Uniformed Services University. I am very grateful that he has 

served as a Navy doctor with the SEALs and the Rangers in Iraq. 

General Green, I also have to point out I have a nephew who just 

concluded six months service in the Air Force in Iraq. So our family 

is joint service. 

I continue to be amazed by the dedication and remarkable accomplishments of the health care and scientific community both in 

the public and private sectors that have led to the innovation and 

advancement of battlefield medicine in post trauma care and rehabilitation. 

Because of the volume of work being done, it is important to 

make sure that the efforts are focused and coordinated to avoid duplication and ensure the best use of our resources. In my mind, 

that is the role of the centers of excellence. 

With that, I recognize some of the centers of excellence have been 

in existence longer than others and thereby there will be a difference in the level of achievement among the centers. I am concerned it takes such an inordinate amount of time to establish a 

center and to get it up and running once it has been legislated. 

I am anxious to hear from our witnesses today how well the centers of excellence are operating and how effective they are in getting the best care and treatment available to our wounded and injured service members. They deserve no less. 

Finally, I would like to welcome our witnesses. All of you are so 

well thought of in the military and by the citizens of our country. 

Thank you for participating in the hearing today. I echo Chairwoman Davis’ welcome in particular to General Green, and I look 

forward to your testimony. 

[The prepared statement of Mr. Wilson can be found in the Appendix on page 26.] 

Mrs. DAVIS. Thank you, Mr. Wilson. 

We will start with you, Dr. Rice. 
4 

STATEMENT OF DR. CHARLES L. RICE, PRESIDENT, UNIFORMED SERVICES UNIVERSITY OF HEALTH SCIENCES, 

PERFORMING THE DUTIES OF THE ASSISTANT SECRETARY 

OF DEFENSE FOR HEALTH AFFAIRS, U.S. DEPARTMENT OF 

DEFENSE 

Dr. RICE. Madam Chair, distinguished members of the subcommittee, good afternoon and thank you for the opportunity to 

discuss with you today the Department’s Centers of Excellence. I 

have submitted a much more comprehensive summary of the accomplishments of the centers as well as an outline of the major 

milestones for the coming year. So I will confine my remarks to 

what needs to be accomplished during this year. 

Of our four Centers of Excellence in the military health care system, the Center for Psychological Health and Traumatic Brain Injury has been established for the longest period of time and is the 

furthest along in an operational sense. The Hearing, Vision, and 

Traumatic Extremity Injuries and Amputation Centers were designated more recently and they are catching up in their organizational development. 

Since stepping into my current role six weeks ago, I have communicated to my staff and to the services that we must execute our 

responsibilities expeditiously in order to meet our obligations. Specifically, the most critical item is the approval of a concept of operations that will be coming to me for final approval very shortly. 

Governance issues are equally critical, and we will seek to exercise a consistent governance model across all of the centers. I plan 

to have our governance structure developed and approved by the 

end of May. 

This summer we will open the National Intrepid Center of Excellence at Bethesda, a major milestone. 

We are working closely with our colleagues at the Department of 

Veterans Affairs to ensure that our approach is integrated and represents the clinical best practices and is informed by the most current research to serve our wounded warriors and our veterans. 

We have embarked on a course that will result in more patient 

centers and higher quality care and service to our patients and to 

their families. The Department is appreciative of the support and 

the guidance that the committee has made in the establishment of 

our Centers of Excellence. 

Thank you again, Madam Chair and members of the committee, 

for the opportunity to be with you today. I look forward to your 

questions. 

[The prepared statement of Dr. Rice can be found in the Appendix on page 29.] 

Mrs. DAVIS. Thank you very much. I appreciate your being brief. 

We are trying to do these special hearings in an hour and to be 

able to pinpoint the most essential issues that we need to address. 

General Schoomaker. 

STATEMENT OF LT. GEN. ERIC B. SCHOOMAKER, USA, 

SURGEON GENERAL, U.S. ARMY 

General SCHOOMAKER. Chairwoman Davis, Representative Wilson, and distinguished members of the Personnel Subcommittee, 

thank you for inviting us to discuss the five Centers of Excellence 
5 

directed by Congress in the 2008 and 2009 National Defense Authorization Acts. Like my colleagues, I have submitted a much 

lengthier statement, but anticipating that your questions will be 

more illuminating, I will keep my comments very brief. 

These Centers of Excellence offer great promise to our warriors 

and patients, to the Department of Defense and to the nation. I 

foresee a day when these centers are acknowledged as worldwide 

leaders in their respective disciplines. However, we are not there 

yet; and we are moving slowly in some areas, as should be expected 

of any undertaking of this magnitude. 

Despite the growing pains we experienced standing up these centers, I am confident the Department is now moving in the right direction to provide the centers with the governance and the support 

to allow them to flourish. 

Like the Congress, I remain concerned about unnecessary duplication of programs and unnecessary competition among the services and federal agencies that are conducting research and providing care. 

Perhaps the greatest contribution offered by these centers will be 

their role as the conduit for a two-way dialogue receiving external 

expertise from federal agencies and private industry and academia, 

and communicating the Department’s internal perspective to those 

same leaders in government, science, education and industry. 

These centers serve as what I call the catcher’s mitt, a single 

point of contact for vetting new ideas, for synchronizing competing 

interests, and for standardizing evidence-based practices and clinical guidelines. Alignment of these programs under a single overarching construct would be ideal to reduce the number of oversight 

groups and administrative overhead, while ensuring agile and responsive translational research and medical programs. 

The Department and the services are working together to establish favorable conditions for these five centers to be models of 

health care excellence. Ultimately, the centers will achieve their 

original vision and be critical enablers to improving readiness, 

health and quality of life for our service members, our veterans, 

and our family members. 

Thank you for holding this hearing and for your steadfast support of Army medicine and the entire military health system. 

Thank you, ma’am. 

[The prepared statement of General Schoomaker can be found in 

the Appendix on page 41.] 

Mrs. DAVIS. Thank you. 

Admiral Robinson. 

STATEMENT OF VICE ADM. ADAM M. ROBINSON, USN, 

SURGEON GENERAL, U.S. NAVY 

Admiral ROBINSON. Chairwoman Davis, Mr. Wilson, and distinguished members of the subcommittee, thank you for the opportunity to provide my perspective on the Defense Centers of Excellence. More importantly, thank you for your leadership on this 

issue. Your vision and direction provided us a solid foundation on 

which to build the Centers of Excellence and further support our 

responsibility and privilege for the care of our wounded warriors 

and their families. 
6 

As our wounded warriors return from combat and begin the healing process, they deserve a seamless and comprehensive approach 

to their recovery. We want them to mend in body, mind, and spirit. 

The Defense Centers of Excellence for Psychological Health and 

Traumatic Brain Injury were established to leverage the collective 

efforts of the services by bringing together treatment, research and 

education and support of this psychological health and traumatic 

brain injury. 

In addition, the DOD has been working to establish three additional Centers of Excellence which Congress directed. These include 

the Traumatic Extremity Injuries and Amputation, the Center of 

Excellence for Vision and the Center of Excellence for Hearing. 

I have often referred to our obligation to our wounded warriors 

and their families as a commitment measured in decades, not 

years. To meet our obligations, we much build supporting organizations for the long haul and continuously adapt our practices to 

meet the emerging needs of our patients. Military medicine leadership must determine how to best to maximize the operational efficacy of the DCoE and help facilitate their important synchronization efforts. The DCoE must be organized and aligned to provide 

for the efficient delivery of services to our clinicians, to our patients, and to our families. Our goal must be to enable the DCoE 

to focus on its core competencies and operate efficiently with the 

necessary supporting command and control elements in place. 

Associated with review of options for the DCoE realignment, 

there is consensus among the ASD–HA [Office of the Assistant Secretary of Defense for Health Affairs] leadership and the Surgeons 

General, that the National Intrepid Center of Excellence, the 

NICoE, currently a DCoE component center, should be organized 

under the Commander National Naval Medical Center [NNMC] 

and subsequently the Commander Walter Reed National Military 

Center Bethesda. As a clinical entity, the model of NICoE being organizationally aligned in NNMC is consistent with the construct of 

the Center for the Intrepid currently in place at Brooke Army Medical Center, BAMC, in San Antonio. 

I, along with my fellow Surgeons General, and the ASDHA leadership are committed to ensuring that we will build on the vision 

advanced by the Members of Congress and the hard work of the 

dedicated professionals at all the Centers of Excellence, medical 

treatment facilities, research centers, and our partners in both the 

public and private sector. 

I want to thank the committee for your support, for your confidence and your leadership. It has been my pleasure to testify before you today. I look forward to your questions. 

[The prepared statement of Admiral Robinson can be found in 

the Appendix on page 49.] 

Mrs. DAVIS. Thank you. 

General Green. 

STATEMENT OF LT. GEN. CHARLES BRUCE GREEN, USAF, 

SURGEON GENERAL, U.S. AIR FORCE 

General GREEN. Chairwoman Davis, Congressman Wilson, and 

distinguished members of the committee, thank you for the opportunity to discuss the DOD Centers of Excellence, and specifically 
7 

the plans for the Air Force Medical Service to establish the Hearing Center of Excellence. We believe these centers support the military health service strategic goals and our mandate for trusted care 

to those who serve. 

The creation of a Hearing Center of Excellence is relevant and 

necessary for military members and veterans. Hearing loss is a 

major cost incurring disability for both DOD and VA. In fact, 

tinnitus and hearing loss were the most prevalent service-connected disabilities for veterans who began receiving compensation 

in 2009. The Hearing Center of Excellence will be a collaborative 

DOD and VA team focused on prevention, diagnosis, mitigation, 

treatment, and rehabilitation of hearing loss and auditory problems. It will bring new technology and research to current hearing 

conservation programs, but will not replace existing efforts. 

The Hearing Center of Excellence executive hub will be in San 

Antonio at Wilford Hall Medical Center, leveraging the robust Air 

Force and Army staffing of ENT [ear, nose, throat] and audiology 

experts, as well as established partnerships with VA hospitals and 

the University of Texas San Antonio Medical School. San Antonio 

is a rich research environment with many military and civilian research entities to help with the outreach. 

A central aspect of our Hearing Center of Excellence will be a 

hearing loss and auditory system injury registry that will record injury, diagnose surgical and other inventions for hearing loss and 

auditory system injuries. An electronic bidirectional exchange of information with the VA will ensure tracking of hearing outcomes for 

veterans entered into the registry who receive treatment, whether 

at DOD facilities or the VA. 

The Air Force is committed and well prepared to fulfill this important mission. Our long experience with hearing programs will 

serve as a strong foundation for this center, and we will build upon 

the many outstanding DOD and VA efforts already in progress. 

Plans are well underway, and we look forward to exploring new opportunities with our colleagues in DOD, our sister services, the VA, 

and civilian academic institutions. 

We truly appreciate the committee’s support, and thank you for 

this opportunity to testify. We stand ready for your questions. 

[The prepared statement of General Green can be found in the 

Appendix on page 56.] 

Mrs. DAVIS. Thank you very much. 

To all of you, I appreciate your being here and the work you are 

doing in the centers. 

Dr. Rice, if I can just turn to you first, in your testimony you say 

that the centers will lead our efforts to identify gaps in our scientific knowledge about wounds, injuries, and diseases, as well as 

prioritizing and coordinating research efforts to fill those gaps. I 

think that is really what Congress was intending because we know 

that there is great interest, and I certainly appreciate my colleagues in wanting to do all that we can for the service members 

and also for their families who serve as chief caregivers in many 

of these areas. 

And yet that is really what the goal was three years ago, and I 

know you have only been in this position and it is a temporary one, 

and we want to acknowledge that. I want to know how you see our 
8 

ability to actually realize those goals. What have you done since 

you have had a chance to just begin this, and I know it has been 

very, very short, how much longer will it take before the Department actually starts achieving some of those goals and really have 

the kind of strategic plan to prioritize and do exactly what I think 

the Surgeons General are saying, we don’t want to duplicate a lot 

of efforts. What do you see more specifically? 

Some of this was in your address but you had very brief remarks, 

so we want to give you an opportunity to talk about that more. 

Dr. RICE. Thank you. 

I bring to this my perspective from having spent much of my career in the civilian academic world and understanding how efforts 

like this come together. They are not easy to do when you reach 

across disciplines, and as I am sure Dr. Snyder will attest, the 

bringing together different specialties inside the house of medicine 

and then reaching across into other disciplines, psychology, engineering, pharmacology, what have you, becomes an increasing challenge. 

In fact, if you take probably the prototype in academic centers, 

the canary in the mine, is cancer centers. And the National Institutes of Health recognized the complexity of this problem by actually awarding planning grants for universities that want to establish Cancer Centers of Excellence. These grants go up to five years 

in length. So the understanding is that bringing a group of disparate professionals together is a complex undertaking. 

That said, we all recognize a sense of urgency and feel that sense 

of urgency. 

I think another level of complexity for this particular constellation of injuries is that there is no gold standard diagnostic test for 

traumatic brain injury or post-traumatic stress, unlike say a myocardial infarction where we have an array of screening tests and 

then more confirmatory tests, including an angiogram or a technician scan to define precisely the anatomy and the physiology of the 

injury. In the case of traumatic brain injury or post-traumatic 

stress, we don’t have anything quite like that. 

So bringing all of these aspects together has been a complex undertaking. I think we have had some growing pains, and I think 

we are beginning to get our arms around it. I am very encouraged 

by what I have seen. 

Mrs. DAVIS. Dr. Rice, as you look at organizationally what we 

have tried to do, and there is discussion about whether the program should basically nest or rest in any one of the services and 

how that is organized, are there some things, even in this relatively 

short time you have looked at and you have said, I wonder why did 

they set that up that way? What were they thinking? Where are 

those areas? 

Dr. RICE. I think General Schoomaker very accurately pointed 

out that we have an infrastructure for the management of research 

that all the services share. Much of it is based up at the Medical 

Research and Materiel Command at Fort Detrick. It is a very well 

developed and organized operation, and one of the options under 

consideration for us is to put much of the infrastructure there. The 

three Surgeons General are discussing that. That is what I alluded 

to in my testimony. We expect a recommendation to come from 
9 

them very shortly that will help us get this organizational infrastructure in the right place so that we can execute swiftly. 

Mrs. DAVIS. Is there a sense that perhaps that discussion needed 

to be much earlier? Is this a little delayed in terms of where we 

are, and I will certainly give all of the Surgeons General a chance 

to address that, but has it taken the knowledge of trying to do this 

time for everyone to catch up in terms of trying to figure out where 

the best is organizationally? 

Dr. RICE. Certainly in retrospect you can make that argument. 

Prospectively, alluding back to my experience in the civilian academic world, when you are bringing together professionals from, 

say, the college of nursing, the college of medicine, the college of 

pharmacy and the school of social work, the only place that this 

winds up is in the office of provost, which is not really well set up 

to manage an operational organization. 

I think that is analogous to what we saw with the development 

of the Defense Centers of Excellence. And as time has gone by, I 

think the realization has come that keeping an operational responsibility inside of what is primarily intended to be a policy development office was not the best choice. 

Mrs. DAVIS. Thank you. I want to follow up with one more question. I guess my colleague had to leave already. I am sorry he 

didn’t have a chance to ask a question. 

I know you are aware that the House Appropriations Subcommittee on Defense was concerned about the fact that all of the 

DCoE folks went from Washington to San Diego, and we are always happy to have people in San Diego, for a conference, and 

there was some concern that perhaps the entire department, everybody involved, did not need to go to build the relationships I happen to believe that are required when people are working together, 

but there was a way to do this without having it be so costly. 

Would you like to add to that in any way because I know that they 

were concerned and they even asked us to help answer that question better. 

Dr. RICE. Well, I think we are certainly looking into issues like 

that and putting management controls, better management controls into place so we make sure that we don’t spend money unnecessarily. I can’t speak to the decision making that went into that 

particular conference at the time, but I can assure you that we will 

make sure that the controls are in place in the future. 

Mrs. DAVIS. Thank you. 

Mr. Rooney. 

Mr. ROONEY. Thank you, Madam Chair. Thank you to the panel. 

I don’t necessarily have any questions. I just want to thank you 

personally for the work that we are trying to accomplish here, I 

think together. Having worked on a few pieces of legislation that 

specifically deal with post-traumatic stress disorder and terminal 

brain injury, it is enlightening, and I understand it can be as frustrating for you as it is for us. But it is good news that we are able 

to sit here today and talk about how we are going to get this done, 

and I know that is the objective of everybody on the panel, as it 

is for this committee. 
10 

With that being said, I just want to thank you for all of the work 

you have put in and look forward to having a continuous working 

relationship with all of you. 

I yield back. 

Mrs. DAVIS. Thank you. Dr. Snyder. 

Dr. SNYDER. Thank you, Madam Chair. I want to be sure I understand the very basics. We have five Centers of Excellence at 

least on paper, correct? Traumatic Brain Injury, Traumatic Injury 

to Extremities; is that correct? 

General SCHOOMAKER. The Defense Center of Excellence for 

Traumatic Brain Injury and Psychological Health are combined 

into one center. So two of the centers are combined into one. 

Dr. SNYDER. They were authorized by separate appropriations. 

General SCHOOMAKER. But the Department chose to put them as 

a single center. 

Dr. SNYDER. Which makes sense. And then we have Extremities 

Center? 

General SCHOOMAKER. Yes. Extremities and Amputation. 

Dr. SNYDER. So it was referred to as five, but two were combined 

into one. 

General SCHOOMAKER. Yes. 

Dr. SNYDER. Regarding Dr. Rice’s comments earlier, I think these 

have all been set up or established or mandated to do them by legislation and my question is: Did we make a mistake? We are House 

Members. We are prepared to acknowledge that we make mistakes 

sometimes. We didn’t set up Centers of Excellence for neurological 

problems or for orthopedic neck injuries or Centers of Excellence 

for cancer or heart disease or lung disease or toxicological injuries 

or from fires. We set up these because we hear from constituents 

and we thought there was a gap. 

My question is a general one. Are we barking up the wrong tree 

here? Perhaps we should not have mandated Centers of Excellence, 

perhaps there should be other ways, maybe greater funding of research, maybe oversight and coordination amongst different health 

care institutions? I am almost asking your personal opinion, did we 

make a mistake by requiring these Centers of Excellence? Dr. Rice, 

do you want to start? 

Dr. RICE. No, sir, I don’t think so. I think what you did was galvanize the Department’s attention around a complex set of injuries 

that we had not really dealt with very much in the past, in part 

because this is a different kind of war with a different kind of 

enemy and in part because our success rate for resuscitation in the 

field is so much greater than it was in previous engagements. 

I do think that you bring up a very good point, and if I may draw 

on my civilian academic experience, one of the things that has 

served most institutions well is to require somewhere around the 

five to seven-year mark a review to ask is this structure really still 

the right one? Is it necessary for this to continue as is? And if I 

might suggest, I would propose that perhaps we have a discussion 

about whether undertaking something like that might serve our 

patients well. 

Dr. SNYDER. At the five-year mark should this be continued or 

completely discontinued, and recognize that there may be a different way of getting at it or adjust it? 
11 

Dr. RICE. Or evolve into a different structure, yes. 

General SCHOOMAKER. Well, sir, I would have to agree with Dr. 

Rice. I think that the Congress did not fundamentally make an 

error in directing that these centers be established. But I will concede that I don’t think that we executed it flawlessly. 

I think having said that, I believe there has been more done than 

may be readily apparent to many folks. These are not brick and 

mortar centers. We avoided deliberately the attempt to put structure, physical structure, where it was not needed. And I would 

point out that Congress preceded this in the NDAA [National Defense Authorization Act] 2006 by mandating that the Department 

look very proactively and exhaustively at all, especially research 

dollars, that were directed to the same language, prevention, mitigation, management, and treatment of blast injury. That was without money attached to it, but it forced us and the Department 

chose to take that legislative mandate and to delegate that to the 

Army and then to Army Medicine and then to the Medical Research and Materiel Command [MRMC] where we did a gap and 

redundancy analysis and identified what areas both in research 

and treatment we were most lacking in. 

I always saw that as an effort on the part of Congress and the 

Department to create the highway for when moneys began to flow 

to direct those efforts. When you all then created the five centers, 

I saw that as highlighting areas within the blast injury program 

we had identified as particularly vulnerable areas and where we 

were getting most of our concerns for patient care. 

And it is at that point I think we began the internal dialogue 

that you are hearing us talk about here in how do we execute those 

centers. I do believe and I hope we have an opportunity to talk 

about what the centers have achieved because again, for example 

in the case of extremity injury and amputation, I think we have 

done some terrific things, and that your mandating in legislation 

that we have this center has allowed us to align and cobble together efforts across all of the three services and the Veterans Administration and the private sector in I think a very positive and 

proactive way. 

Admiral ROBINSON. First of all, I am not going to be the only SG 

[Surgeon General] that says you made a mistake; you did fine. And 

I mean that sincerely. I think what we have found is in executing 

this we haven’t been very facile in our attempts to get the organizational structure to execute the plan. I think that the MRMC, 

which is long established and has the infrastructure, as already 

has been stated, was the right thing. And once we got the DCoE, 

the psychological health, once we got some of the DCoE studies 

there, we have made tremendous progress. For example, hyperbaric 

oxygen therapy, does it work? Is it helpful in traumatic brain injuries? We don’t have the answers to that, but we have a really good 

prospective randomized trial set up and ready to go and it is being 

executed now. It took us a long time to get there but the reason 

is we didn’t have the proper infrastructure, which MRMC had and 

we were looking at the wrong places. 

We thought, General Schoomaker and I thought of that a couple 

of months back, but it took a while to get there. 
12 

Also, and it has been alluded to, the Centers of Excellence have 

to leverage the Department of Veterans Affairs as well as the academic community, and I underline the Department of Veterans Affairs because, as I have said repeatedly through the year, the systematic rehabilitative care issues, which are now becoming all of 

our responsibilities, need to be funded through the traditional organization that had the responsibility for systematic rehabilitative 

care. So I am not suggesting that it is now only residing with DVA 

[Department of Veterans Affairs], it resides with us also. But we 

need to leverage that information and a lot of the resources, both 

intellectual, academic, and research and practical that DVA has. 

So I think to add onto this, I think it is a focused area that we 

now have and we need to be very careful as to how we proceed. I 

would also say in a five-year period or some period of time, looking 

back and being honest with do we need this center now, may be 

the thing to do or how should we change this center as opposed to 

just letting it go in perpetuity. 

General GREEN. Dr. Snyder, I would say on first blush I agree 

with you, that we have looked at certain centers and didn’t take 

on a lot of other disease processes and perhaps things that would 

be equally valuable to gain research and put dollars towards. But 

I have to admit as I looked into this, and I will talk more to the 

hearing, but even with all of the other centers, it was an extremely 

wise thing to identify gaps and get us thinking. And so with the 

five centers that have been stood up, looking at what has happened 

over in the AOR [area of responsibility] and the type of injuries 

that have been coming back and the rehabilitative needs of those 

folks and our wounded warriors, in essence what Congress was 

able to do for us was to get us to improve our communication. The 

influx of dollars gave the ability for us to not only talk better with 

our civilian counterparts, but also amongst ourselves to leverage 

the different assets that we had. 

I think it was wise for us not to set up brick and mortar structures to do this. I think this is really about establishing research 

networks. So the tricky part is kind of establishing what are those 

governance and the controls, if you will, on how we are going to 

do that. Should it all be conferences or research, or should it all 

be telemedicine in terms of how we communicate? And the answer 

is it is taking a little bit of all of them. 

So what you are seeing evolve over the last two years is the understanding that we don’t necessarily need to build new infrastructure to do this, that we need to take advantage of the structures 

that are in place. We all recognize the large dollars that are up at 

MRMC in terms of how they manage the research agenda for us 

in large part. The Navy labs are also quite large, and the Air Force 

is a fairly small player in terms of how this works, and yet we have 

good programs just like the other services and the civilian sector 

does. And so when you get us all talking together, and similar to 

how the NIH [National Institutes of Health] doles out dollars for 

research based on the most promising technologies and ways we 

can move forward, you now start seeing the progress that we are 

hoping for. 

So what we have learned is that we don’t want to set up duplicative infrastructure, that we do want these registries to be attached, 
13 

and we do want to be able to share information even between the 

centers, and the way to do that is to kind of look at front shop, 

back shop where not everybody needs to have public affairs guidance and ways to interface with Congress but there needs to be 

that back shop activity that knows the questions that are being 

asked and knows how to formulate solution sets to move forward 

and to get things out into the public domain so that we can let contracts and seek researchers who have promising technologies. So I 

think that is where we are right now. We are realizing that we 

need to leverage the services’ existing capabilities, place back shop 

functions in places where they have those skills, and take the research agenda and perhaps the executive oversight for a particular 

research area, one of these COEs [Centers of Excellence], and now 

leverage that expertise to bring a whole different group of people 

together rather than just putting money into some of the older 

projects that have been ongoing because there may be new things 

that haven’t been considered simply because of how they were 

funded. 

So I think that is the advantage of doing the COEs. Whether we 

pick the right gaps or not, I can’t answer for you, sir, but it is creating communication and it is moving us forward. 

Dr. SNYDER. Thank you. 

Mrs. DAVIS. Thank you. I think that your responses get largely 

into the interchange that I would love to see amongst the three of 

you as thinking about perhaps ways in which the Congress set this 

up or the way some of the organization moves forward, it has created some inhibitions in terms of what you have actually wanted 

to see accomplished or where you felt some of the frustrations in 

not being able to move forward in the way that you thought. Are 

there some things that we could even at this point, because not all 

of this is so developed that you cannot go back and say okay, there 

is another way to do this, are there some areas in which you would 

really like to have it move in somewhat of a different direction perhaps? 

You mentioned the NIH, the way the NIH doles out grants. I 

don’t have a clear picture. If there is a really great idea out there, 

how does that get heard and how are those grants realized at this 

point, either within, among the services and through the DCoE as 

a whole? 

General SCHOOMAKER. I think this is really one of the real benefits of the approach that we now are taking. I talked about that in 

my opening statement, we have a single catcher’s mitt now. 

One of the things that we need to acknowledge, ma’am, I think 

all of us do, is that none of this has been static. Even battlefield 

injury hasn’t been static. The definition of what constitutes concussive injury, the fact that sequential concussive injury, undiagnosed, 

unmanaged, untreated, as it is on the sports field or in the civilian 

sector, has contributed to some of our problems. And the overlap 

between concussive injury and post-traumatic stress and post-traumatic stress disorder, those are only being defined as the war has 

been fought and as we have tried to grapple with these. 

What I think the centers do offer us is an opportunity to in a 

sense funnel in all of those interests and emerging ideas, practices, 

research avenues and, as I said before, to focus the dialogue inter-
14 

nally from the standpoint of the provider and the communities of 

our services in such a way that we vet and prioritize rack and 

stack and how we go forward and, once those have been established, to clearly establish practice guidelines, standard policies as 

they apply to how we manage them. And I think we are starting 

to get some experience with that. 

The Defense Center of Excellence for Traumatic Brain Injury and 

Psychological Health, for example, has helped us with battlefield 

protocols, with how we identify and manage at the point of injury 

concussive injury and such mundane matters as what do you do 

with your soldiers, sailors, airmen and marines who have had a 

concussive injury when it comes time to drive a vehicle. 

Those kinds of standard protocols and standard practice guidelines are now being generated by the centers, and I anticipate that 

is going to be more and more the work while the services execute 

how the programs are done sort of in the field. 

Admiral ROBINSON. I would then say taking that broad view and 

taking a much less broad view and one that is going into the administration and the process, something that General Green talked 

about in terms of the infrastructure, don’t create five registries, 

create one and make sure that we can overlap those. Don’t create 

an IT [information technology] system for each new center, have 

one and make sure that we are interconnected. Don’t create practice guidelines in one center and find out they are sort of contradictory with a center over here. Put them together and make sure 

that we have this integrated from an infrastructure and a process 

point of view from the beginning as we start this. 

I think part of the slowness in getting the centers up, I will just 

comment, we were trying to figure out in some respects how to execute this, and it became very clear to General Schoomaker and myself a while back that there were—MRMC was in place and there 

were processes and there was infrastructure that was in place at 

the Navy Medical Command and the Air Force has similar things, 

we didn’t have to recreate or create new things, but we needed to 

get these centers into the right places so we could actually execute 

what we had. That was making sure that we were in alignment 

and that was Health Affairs and others giving us that policy guidance to make sure that we were together, and then leveraging our 

interagency partners and the academic community in addition. 

So it has been slow, but it has been fruitful in that this has been 

an ongoing and a very robust discussion within the services. 

Dr. RICE. One of the issues, one of the opportunities that we 

have had the opportunity at the university in a parallel effort was 

given to us by the 2008 appropriation which established the Center 

for Neuro Regenerative Medicine, also focused on traumatic brain 

injury and post-traumatic stress. But from much more of a basic 

point of view, I alluded earlier that there is no gold standard for 

the diagnosis of these injuries, and this is an effort to help identify 

those. 

That language in the appropriation specifically authorized the 

Department of Defense to reach across Wisconsin Avenue to collaborate with the National Institutes of Health and that has proven to have a galvanic effect. The people at the National Institutes 

of Health were eager to assist us in dealing with these injuries, 
15 

and that particular language made that easy to do without the constraints of using part of a defense appropriation at another agency. 

So that is one example of something that the Congress might consider. 

Mrs. DAVIS. General Green, did you want to add to that? 

General GREEN. Briefly, I think it is important to understand 

whenever you are trying to arrive at a common vision, you have to 

basically explore where you are coming from. And so the trick with 

the COEs are when you bring a lot of different efforts together, especially when you go outside of medicine, each person thinks that 

they have the answer. So then you have to design the studies to 

try and find out what the evidence truly says is correct. 

You folks, probably much more than us, are approached by lobbyists and special interest groups from all over who think that they 

have a solution set for what we need. And what this effort is about 

is trying to find out what is it we need and how do we prove that 

this will actually do what it is said it will do. That takes a lot of 

time actually to design some of these things. Although I would love 

for us to have this infrastructure set up a little more robustly so 

that we could move forward, I am not too surprised that it has 

taken us some time to reach a common vision and that vision I 

think is to use our existing resources and now start defining these 

problems more closely. 

General SCHOOMAKER. Ma’am, two more comments, quickly because I think there are some features of how we are now operating 

these three services in health affairs at the DOD level that are 

very, very favorable. The first is the rapidity with which we are 

making clinical improvements in battlefield medicine, evacuation, 

and care back here in CONUS [continental United States] based 

upon what my colleague, Admiral Robinson, just talked about is 

the creation of a single database. The Joint Theater Trauma Registry and its application through the three services and the DOD 

to look comprehensively across all services in all venues at how we 

manage traumatic care is almost unprecedented. We have essentially established what a large metropolitan community in the 

United States would have but across three continents and 8,000 

miles. In doing that, we have created the framework for rapid 

movement of new knowledge and standardization of practices that 

has resulted in some of the unprecedented survival that you see 

today. And that has penetrated all of the way into areas like amputee care, which really quite frankly begins at the battlefield. Amputation medicine and extremity injury medicine begins in Balad, it 

begins in Bagram, at the first—in the corpsmen and the medic forward. Penetrating head injury is another good example in which 

the services have collaborated in advancing very rapidly the science 

and the clinical practice of penetrating injury. 

The second area that I think you need to recognize as a Congress 

that we are doing very well within the services is translational 

medicine: taking bench insights and basic science insights that are 

historically the purview of the Academy and groups like the NIH, 

and rapidly moving them across into applications, either intellectual products as in the case of battlefield medicine, or in the creation of new material products. That really requires the focus that 

these centers can provide for us. That is that we are not going to 
16 

stop simply at proliferating new ideas and new basic science insights, we are going to rapidly move them across the chasm into 

the kind of advanced development, clinical trials and material development of new products that we need. 

Mrs. DAVIS. Thank you. I appreciate that. I guess the one question and sort of the bottom line on this is whether or not the work 

that is being done and the data that is being collected is being 

translated in the field to the extent that unit commanders are respectful of that data. Is that a concern that maybe I shouldn’t be 

worried about? When we hear about the number of traumas, or 

even the multiple deployments for that matter that people have 

sustained, and we know that that cumulative effect has obviously— 

is going to have an impact on the service member. I don’t know 

whether that is in your purview, to have a sense of whether people 

are really listening to that information you are working so hard to 

obtain. It obviously can restrict the commander in the field in 

terms of their ability to mobilize units to do the work that needs 

to be done out there. 

Admiral ROBINSON. Well, I will speak for the Marine Corps in 

one example, and that is with blast injuries. With blast injuries, 

there are a couple of examinations that can be given, the ANAM 

[Automated Neurological Assessment Metric] and the MACE [Mild 

Acute Concussive Evaluation]. The key here is that with the Marine Corps in the field, the Marine Corps leadership has recognized 

that there are a number of men and women who are subjected to 

blast that aren’t unconscious or don’t have any outward effects and 

we don’t necessarily know that they are not injured. So there is a 

database in theater in Afghanistan in which they are looking at the 

number of personnel and the number of people that have three 

blasts. And three blasts, it doesn’t mean that you come all of the 

way back to the states, but you come out and get a complete neurological exam and actually get looked at professionally to decide and 

determine if you have been injured and that injury was just unseen. 

I will leave that. 

There is the attempt to have baseline studies for the ANAM and 

other neurologic exams so that as we put people in theater we will 

have a baseline so we know if it does change. 

My point is there are attempts to look exactly at some of the 

things that you are saying, real-time actually today based upon 

what we have learned over the last two, three, four, five, six years 

regarding how we are taking care of individuals. 

Dr. SCHOOMAKER. In the Army, ma’am, there is a growing and 

profound recognition on the part of the field commanders of the 

value of the joint medical system for the well-being of their soldiers 

and by extension their families. 

I have had field commanders tell me that it goes down to the detail of support, say, of medical evacuation in theater in Iraq and 

Afghanistan today. That combat aviation brigades, in whom we 

now embed Army medical evacuation, have organized much of their 

battlefield processes around support of the medical evacuation. 

What has been more difficult, because this is a learning process 

for us, is the impact of psychological health and such injuries as 

concussion. You know, I have said before we are in unfamiliar ter-
17 

rain: an Army entering into its ninth year of war in a cycle of deployment and redeploying soldiers that has never been experienced 

in history, with a dwell time back at home that is well below where 

we would like to see it. So I think this is a very active process of 

learning. 

But to answer your question directly, the respect that I think our 

line commanders have for this all of the way up to the senior leadership of the Army is very profound. 

Mrs. DAVIS. Dr. Snyder. 

Dr. SNYDER. Just a follow-up question that maybe can be answered just with a nod of the head or shaking of the head. Going 

back to how Congress should provide oversight of this, I came into 

the hearing today thinking we have got five different centers and 

two of them combined and established at different times. If I heard 

you correctly, would a more helpful way for Congress to look at this 

and follow this along in the next several years would be to see this 

as five different centers but they are all attacking the same problem which is the blast injury? There are clearly going to be things 

that each of these centers look at that are apart from blast injuries, 

but we should see each of these centers of attacking the same problem of blast injury and we ought to look at all them together, not 

as five separate entities. Is that a fair statement, Dr. Rice? 

Dr. RICE. Yes, sir, I think it is. The fact is that patients don’t 

get just a single injury. They may very well have mild TBI as well 

as hearing loss and loss of an extremity. So I think it is very important that these centers work together in a cohesive manner. 

Dr. SNYDER. Thank you. 

General SCHOOMAKER. Sir, I have rejected the notion that we 

have a signature injury of this war. We have a signature weapon 

of this war, and it is blast. That blast burns, it blinds, it deafens, 

it takes off limbs, and it causes enormous extremity injury. And I 

fully agree with what you said. 

Mrs. DAVIS. Thank you. The bells are ringing, but just a quick 

question. 

General, you mentioned the Joint Center of Excellence for Battlefield Health and Trauma Research that is under construction in 

San Antonio. What is that supposed to do when it is finished? 

General SCHOOMAKER. We didn’t mention this, but it was alluded 

to by General Green that in addition to the alignment of clinical 

and research efforts through things like the blast injury program 

and now these centers, is the alignment physically and collocation 

through the base realignment and closure of many of our assets. 

So Navy medicine and trauma is being relocated with Army medicine and trauma along with the Air Force. 

That includes things like biodefense assets which are being collocated in some laboratories in Fort Detrick and other places. So we 

are going to see an alignment, as in the Joint Battlefield Trauma 

Center down in San Antonio of the Army’s Institute of Surgical Research along with the Air Force and the Navy’s efforts in dental research and in other aspects of trauma. 

Mrs. DAVIS. And that doesn’t represent any kind of duplication 

then? 

General SCHOOMAKER. No, ma’am. I think that is the physical 

brick and mortar of this. 
18 

Mrs. DAVIS. The ability to focus it together. Okay. Thank you. 

And Admiral Robinson, could you just provide us a little bit more 

detail on the hyperbaric oxygen therapy clinical trials that are 

being conducted right now? Is there something particular that we 

should know about that? 

Admiral ROBINSON. Nothing except we have now with the help 

of Colonel Scott Miller, who is an infectious disease physician at 

MRMC, he is also an Army physician, we have been able to actually develop prospective randomized trials to look at patients who 

have had had traumatic brain injuries, mild traumatic brain injuries, and whether they would benefit from having hyperbaric oxygen therapy. We have several centers where this is now occurring—Pendleton, LeJeune, Fort Carson I think, and also San Antonio. It is a tri-service event. We have now included more patients 

in the studies that we have to date than we have had in any of 

the literature that has been describing it for the last many years. 

And I think we have—it is blinded and it actually has a cohort that 

is a sham which means we are going to see if this actually works 

or if this is just a placebo effect. 

So I think we have good science and a good study in place that 

over the course of the next 24 to 36 months is going to actually give 

us definitive information as to whether hyperbaric oxygen works, 

at what tour it works, and also if it is harmful because that is the 

other question that people have. And from this, I think we can develop practical and successful and reproducible clinical guidelines 

or not based upon science and not anecdotal evidence. 

Mrs. DAVIS. Thank you. 

General SCHOOMAKER. And, ma’am, for the record, lest our critics 

point out that we are using an infectious disease expert to run 

hyperbaric oxygen research, his expertise in infectious disease gave 

him great skills in randomized prospective trials and in FDA [Food 

and Drug Administration] certification of trials. So we have leveraged that. 

Mrs. DAVIS. Great. Thank you. As we look at the next authorization, maybe for the record some things that you would particularly 

like us to focus on, if we were to even have a hearing even six or 

nine months from now, you know, just thinking a little bit more 

about shortcomings that you think we might be talking about at 

that time that are of concern to you but also where we might place 

some additional resources to help you further do your jobs and to 

make certain that this does all the things that we really would like 

it to do for our service members. If you could be thinking some 

about that and get us that information, that would be helpful. 

Anything you want to add right off the bat to that? Or we will 

come back. All right. Thank you very much for all of you for being 

here. Thank you for the work that you do. 

General SCHOOMAKER. Thank you. 

[Whereupon, at 6:45 p.m., the subcommittee was adjourned.] 
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