Why military medical research?

The challenging circumstances that confronted military caregivers during the years of war in Afghanistan and Iraq established the imperative for military-oriented medical research. The burden of injury and illness resulting from this long period of combat operations, and the unique clinical and logistical considerations it engendered provide a compelling rationale for requirement-driven, well-coordinated medical research. Also referred to as “gap” driven and programmed, military trauma research is specifically aimed at providing readily deployable solutions to reduce morbidity and mortality from war-related injury. From a strategic standpoint, the approach taken by military medical research is quite different from that sponsored by other federal research agencies, which typically fund investigator-initiated studies of interest to the scientific community, irrespective of the urgency of the question to society. Importantly, neither these agencies nor private foundations dedicate funding to injury research of the type or severity that can be anticipated in modern warfare including terrorism. Military research has been shown effective in reducing the case fatality rate during combat and has established itself as the centerpiece of the military’s continuously learning health system. It has also generated numerous advances that are being translated to improving civilian trauma care. The following paragraphs of this preface and the articles in this supplement provide examples that serve to emphatically answer the question, “Why military medical research?” Between 2005 and 2013, the fatality rate for service personnel injured in Afghanistan decreased by 50% while the severity of injury was increasing. The reason for this unprecedented achievement is multifactorial, but two factors stand out. At the height of the wars in Afghanistan and Iraq, the military health system made (1) significant investments in requirement-driven, programmed trauma research, and (2) an extraordinary effort to codify a trauma system that identified emerging needs for research, and rapidly translated results from military research into best clinical practices. The first element was comprised of programmatic research performed by the individual services (Army, Navy, and Air Force) and through the Joint-service, Defense Health Program. The second was the Joint Trauma System or JTS, which has developed into the Department of Defense’s (DoD) “go-to” entity for real-time process improvement to optimize survival and recovery of the warfighter. The swift translation of evidence from military research through the JTS to the battlefield represents a “first” in military medical history. Recently formalized as a Defense Center of Excellence (DCoE), the JTS maintains the DoD Trauma Registry, which is the largest repository of combat injury and trauma management information in history. In this capacity, the JTS and the process it supports serve as a fitting “bedside” to generate many of the clinical questions that need answers from military medical and trauma research. Many experts refer to the various DCoEs as the “bookends” to medical research (Fig. 1). In this context, the JTS’s ability to identify relevant clinical gaps is the left-side bookend and the more than 30 evidence-based clinical practice guidelines maintained by the JTS are a fitting and right-side bookend. Although this association continues to evolve, the relationship between the nation’s Combat Casualty Care Research Program and the JTS is a compelling model with research bridging the chasm that would otherwise exist between clinical needs and relevant evidence to advance military trauma practice. The other factor intertwined with military research is the sustaining educational and academic value of America’s Medical School, the Uniformed Services University of the Health Sciences (USUHS), the nation’s leadership academy for military health. Without the academic support provided by faculty and graduates from the USUHS, military research would be hollow. As depicted in Figure 1, the military-unique “Joint from the beginning” educational and academic excellence promulgated by USUHS provides the foundation for military research and its clinical bookends. Likewise, without sustained research investments, USUHS would be significantly constrained in advancing the field. Working together, the various DCoEs and USUHS comprise the elements of what the Institute of Medicine has referred to as a “continuously learning health system.” From the standpoint of combat-related injury, the benefits of this partnership are clear, but it is equally apt for other areas of health care, including infectious diseases, traumatic brain injury, rehabilitation, and psychological health. Underlying all of these activities is a robust military health system that has captured the wartime experience, integrated it with a medical research program and translated the experience and research into more effective care for warfighters and ultimately the American public. The final answer as to “Why military research?” becomes clearer as our nation approaches the terminal stages of war in Afghanistan. As reports of violent acts on U.S. soil become *U.S. Combat Casualty Care Research Program, 722 Doughten Street, Room 3, Fort Detrick, MD 21702. †U.S. Army Medical Research & Materiel Command, 504 Scott Street, Building 810, Fort Detrick, MD 21702. ‡U.S. Army Institute of Surgical Research, 3650 Chamber Pass, Fort Sam Houston, TX 78234. The views expressed in this article are those of the authors and may not necessarily be endorsed by the U.S. Army. doi: 10.7205/MILMED-D-14-00245