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Over ten years old now, MVP is truly history in the making. MVP is a national research program to learn how genes, lifestyle, and military exposures affect health and illness.
Welcome to Standing Ready: An Inside Look at the Untold History of the VA's Medical Innovations. Join us as we elevate and highlight significant medical and scientific contributions of the nation's largest healthcare system.
Join us for interviews with VHA innovators and pioneers, exploring how VHA has changed the landscape of medicine over 75 years with topics on the history of prosthetic limbs, adaptive sports, how history has influenced VHA’s response to the COVID-19 pandemic, and more!
The Department of Veterans Affairs does not endorse or officially sanction any entities that may be discussed in this podcast, nor any media, products or services they may provide.
Unknown: By standing read the
podcast that gives you an inside
look at the Untold History of
the VA medical innovations with
your host, Katie della sensory
and Shawn Spitler.
Shawn Spitler: Were talking to
the director of the Million
Veteran Program. And she has a
lot of really fascinating things
to say. It's such a forward
looking episode and kind of how
we can think of the future as
history.
Katie Delacenserie: You're
exactly right. I think that this
program is history in the
making, if you look at the
Million Veteran Program, and you
know, it was just established 10
years ago, but there is so much
potential for how this can
change the lives of veterans and
the whole world really, that I
think, you know, 1020 years in
the future. Historians will be
talking about this program and
the impact it's going to have on
medicine as a whole. So I love
that we're sort of ending on
this note. Today, we're joined
by Sumitra Mora leader who is
the director of the Million
Veteran Program. Suma, thank you
so much for taking time to be
with us today. Can you tell us a
little bit about what the
Million Veteran Program is? And
how did this come about?
Unknown: Sure, first of all,
thank you for having me here,
Katie. So the Million Veteran
Program is really a large
research program that's designed
to better understand the effects
or genetics, the environment,
and lifestyle have on our health
and well being. So in order to
understand how all these factors
influence our health, we really
needed to do establish a very
large database that has all
these types of information,
health information, lifestyle,
military experience, and
genetics. And so we started
setting up a way of collecting
blood samples from million
veterans, enrolling them in the
program, and it's a research
program. So it's entirely
voluntary, so they go through an
informed consent process, and
HIPAA authorization, and then
they sign up, they essentially
give a blood sample for genetics
and other molecular data. They
do two surveys, one on
lifestyle, and the other on the
military experience and, and
more in depth, health
information, nutrition, and all
of that. And they give us access
to their health records. So
that's what it does. It's about
setting up a platform, a
discovery platform, if you will,
to make scientific discoveries.
And then the goal is to take
those findings and then
translate them into the clinic.
So we can actually use that
information to improve health.
Can you tell us?
Shawn Spitler: How many veterans
are signed up already? And are
there any demographics that the
program needs more of?
Unknown: You? Yeah, sure, I'm
happy to report that as of
February, we have crossed the
870,000 veterans, and we are
getting very close to our
million milestone. And you know,
when we initially launched this
program, we opened it up to any
veteran who gets at least part
of the care within the VA. And
so we were taking all comers to
just get to these large numbers.
But when we looked at the
demographic breakdown of who has
enrolled in the program, it
aligns very well with who
enrolls in the VHA. For example,
if you look at gender, it's,
it's about 90%, male and 10%,
close to 10%. Female. And then
if you look at race, we are
actually doing a little bit
better than the VHA percentage.
We are close to 20% of blacks
enrolled. We have about 8%
Hispanics in this cohort. And
it's very small representation
of Asians and Native Americans
and other minority populations.
But in the recent years, we've
tried to now focus on how do we
fill those gaps have really
enhance the number of the
underrepresented demographics in
this cohort. And that is very
important because, you know,
historically, most genetic
studies have been done in
people, but largely male of
European descent. And so the
findings from those studies are
not always applicable across all
populations. And so this is one
of our strengths, but we do have
a pretty diverse population. We
did roll out a women's campaign
last year just to increase the
number of women enrolled in the
program. And we're now looking
at doing similar focused
campaigns for different groups
that are underrepresented in the
Million Veteran Program.
Katie Delacenserie: This is a
pretty huge, big and ambitious
program. Can you talk about how
this kind of came about? And and
how some of those early days of,
you know, deciding that this was
this was really something that
would be worth focusing on, it'd
be worth getting a million
veterans. How did this come
about? Yeah,
Unknown: sure. So this was back
around 2005 2006. You know, in
2003, the human DNA was
completely sequenced. And there
were a lot there was like an
explosion of genomic
technologies way to understand
the sequencing, and make sense
of it. And so at that time, the
undersecretary for Health, Dr.
Jonathan Berlin, was very
interested in seeing how can we
leverage this information and
use these technologies to
improve the health and well
being of veterans. And so he
actually charged the Office of
Research and Development to come
up with a an initiative that
might help with this. And so we
established an advisory
committee brought together some
of the best and the brightest
brains from around the country
and establish an advisory
committee. And this included,
you know, a director of NIH like
Francis Collins, we had Dr.
Watson who is the Director for
the American College of Medical
Genetics. And, and you know,
I'll forget some names. So I
won't go and name everybody. But
we had really people who were
big, who had made huge
contributions in the area of
genetics and health. On our
advisory board, we had academic
affiliates represented, we had
our Bas, best scientists, we
also had a veteran on the on the
advisory committee. And so it
started with them. So how do we
get started? And the first thing
was, we wanted to know, well,
what do veterans think about
this? You know, would they what
would they expect tations be of
this, what are their concerns?
Do they understand? How much do
they understand about genetics
and health? And if we build it,
will they come? Right? So that
was the question. And so we then
took upon ourselves to go about
and do a large number of focus
groups and surveys of veterans,
to get a better understanding of
all this. And it was very
encouraging, like, you know,
almost 70% of veterans said
that, if we had a program like
this, they were, they were
enrolled, and they were very
supportive of the VA doing
something like this. And the
striking piece was, that was the
altruism, they didn't expect
anything in return. They looked
at this as well, if we can help
other veterans, our brothers and
sisters, we would do this, that
was the that was the spirit, you
know, that what we saw. So
taking all that encouraging
information, we then brought
together a group of people from
within the VA, who are leaders
in Epidemiology and Genetics.
And together, we actually got
together in a little place in
Rockville and kind of
sequestered ourselves for two
days, you know, just to
brainstorm, look at all the
results that we've got from the
focus groups and surveys, and
what can we do in the VA. And
the, you know, we had a lot of
good things going for us. We are
a research program, embedded in
a health care system, with some
of the best scientists and
clinicians, most of our
researchers are actually
clinicians who treat veterans
you know, so that's a plus. And
we have one of the best
electronic medical health
records in the world, you know,
that goes back about 30 years.
So we had much of the pieces
that could make VA an ideal
place to roll out and build a
program like this. And then so
the first big question was, how
big do we go, you know, it looks
like if we start building this
veterans are interested, but how
big do we make this? And so if
we're like, do we do 100,000 Do
it to 500,000. And then,
actually, that evening, over
dinner, Dr. Mike Gaziano, who
was one of the principal
investigators of this program,
and from Boston VA Healthcare
System, he was just writing on a
piece of napkin, Million Veteran
Program, MVP, and that kind of
really resonated with everybody
and said, Let's go for a
million. And that's how that
name came about. And, and the
reason is that we really need
large numbers of people if you
want to understand what role
genetics play in any particular
condition, health condition, we
need very large numbers of
people who have that condition,
and an even larger number of
people without it so we can
actually compare these results
and make these discoveries. And
so we, you know, we had a small
All biobank in the Boston VA.
And so we thought, well, that's
something that we can expand on
the infrastructure to
build a huge biobank. If you
want to enroll a million
veterans and get samples from
all of them, we really needed a
very large capacity of biobank
that could house the samples
ways to develop processing it,
collecting the blood samples
from veterans from across the
country, you know, how do we
collect them? Do we have staff
at sites. And that's how we
started actually, with small
pieces building piece by piece.
We, most of everything was by
mail until were till a few years
ago, when we launched an online
portal to the United States
Postal Service really served as
well, you know, it was we've
sent over 8 million pieces of
mail, to veterans inviting them
to participate. And we funded
staff, we started small, the
first veteran was enrolled at
the Boston VA Healthcare System.
And then at West Haven, and then
slowly we expanded to, we had
nine Vanguard sites, where we
tested the entire process, end
to end to make sure it works.
And then we expanded 25 sites,
50 sites, and now we are over 60
main hospitals and about 70
Community Based outpatient
clinics. So we're at several
points of care now, rolling in
person as well as we have an
online portal launched. But it
took a lot of people it took a
village really a lot of
expertise in various areas of
health genetics research, human
subjects research, in
particular, to build this and
bring it to where it is today.
Shawn Spitler: How many years is
this? Go back again?
Unknown: So we launched the
program formally in 2011. So
last year was our 10th
anniversary. Okay,
Shawn Spitler: has that been
long enough for the program to
reveal anything interesting?
Unknown: Yes. So about five
years ago, we we didn't wait to
complete, you know, enrolling
all veterans before we started
the science, you know, so five
years ago, we opened up the data
for VA researchers, we beta
tested it. And then to larger
number of researchers, we have
about 35 projects that are
ongoing now. And because of the
large numbers we've made, we've
identified new genetic markers
for a number of diseases,
whether it's heart disease, or
PTSD, chronic kidney disease and
many other illnesses. And some
of these findings have actually
been in blacks, and Hispanics,
in some cases, okay, so we've
been able to, but this is the
first first part, we find we
make a discovery. Now taking it
from here to being able to use
it in the clinic is still a long
way. But but we are we have
started to make scientific
discoveries that are being
published in very reputed
scientific journals.
Shawn Spitler: Now, you said
something that's very
interesting. And I want to make
sure that we touch on that,
because you said that there's
genetic markers for PTSD, which
I think is quite fascinating.
Can you touch on that anymore,
or in more depth to that?
Unknown: Well, at this point,
it's just the very initial
findings. You know, in PTSD,
there are different symptoms,
you know, startling, or having
nightmares and different types
of sense some types of PTSD. So
we were able to find genetic
markers that are specific for
some of these subtypes of PTSD,
and a one marker, particularly
in blacks. And so we now have to
validate these markers, we also
found that some of them actually
are the same markers that are
important for other mental
health conditions like
depression, and anxiety. And so
there might be, you know, these
common biological pathways that
are involved in a lot of these
conditions. And so this gives us
clues to you know, if what
biological pathways are
impacted, we could find new
treatments for these illnesses.
So that's the direction we're
heading it right now.
Katie Delacenserie: Is this the
largest genetic study in the
world at the moment? Or it seems
it seems like just it's such a
large program? Is it one of the
world's largest,
Unknown: it is one of the
world's largest, it's the
largest in the United States.
And if you look at health care
system based programs on
genetics and health, this is the
largest in the world as well, as
far as we can tell, you know,
some we don't know, if things
aren't available as public
information we don't know. But
as far as we know, this is the
largest.
Shawn Spitler: And what are some
of the biggest successes, maybe
this kind of ties into my
previous question, but what are
some of the biggest successes
and some of the biggest
challenges that you guys have
faced?
Unknown: Well, I think even just
being able to create this large
database is a huge success, you
know, when getting to the
100,000 never been done in the
VA before no research study had
enrolled 100,000 people, and now
we're talking about 870,000
plus. And so that itself, in and
of itself is a huge success, I
would say, yeah. And then, you
know, when we started isolating,
and you know, kind of figuring
out what genetic markers are
present, we have to use what is
called a chip, that's what we
use for identifying the genetic
markers. So initially, we've
even with the chip we had, we
were able to get some markers
from blacks and Hispanics, for
example, but we found that they
weren't good enough. So we then
created a customized chip that
is enhanced for discovery in
these minority populations. So I
think that's another huge piece
we are contributing to, not just
the VA, but to the world. That
is possible. And, you know, a a
biobank that can now process
this many samples coming in. And
generating data. That's a huge
thing. And so and, and having
some results, scientific
results, the initial ones, not
just for the general population,
but also in some of these
subpopulations, I would say is a
big success. And whatever we
find here within the Million
Veteran Program, for most of the
chronic diseases, it's not just
important for veterans, it's
going to inform everybody else
too. So all people. So what we
learn here will help with that.
And then I think, more recently,
we've had studies come out that
are that are related to breast
cancer screening and women. And
that's sort of giving us the
impact of like, we need to have
enroll, enroll more women and do
more studies in women. So that's
another piece that we've learned
recently. And being able to
successfully launch a digital
campaign to enroll women has
taught us how we can now expand
this beyond to have more focused
campaigns.
Shawn Spitler: Now, you
mentioned a chip, is that a
computer chip?
Unknown: No, it's not a computer
chip, actually, it's a
biological chip, it essentially
has little markers on it. And by
using that you can take a DNA
from a person, and you kind of
layer on it. It will light up
the sections where it matches
with those markers. And that's
how you identify does this
person have this particular
marker or not? Oh, wow. Okay.
Chemical Chip, I should say
you've
Katie Delacenserie: discussed
enrolling a little bit has,
how's that grown over time? Was
it easy to enroll people in the
study initially? Or have you
found did you find that it was a
slow going at first, and then a
lot of people started to enroll
and and telling other veterans
about this? Yeah,
Unknown: that's a great
question. I think, you know,
word of mouth. And this peer to
peer communication is really
important. So I think first
year, we enrolled, a little
under 10,000. Veterans, and then
it kind of really started
getting larger from there
100,000. I think it's about all
about communication and the
altruism of veterans, they want
to help other veterans. And I
think that played a big role.
And also the high touch, you
know, we had people at VA
Medical Center, talking to the
veterans explaining the program,
answering all the questions. You
know, it's different from being
online and just doing this on
your own. So we had this really
very personal feel to this
program. And we still do, and I
think our veterans have really
enjoyed that. And I think it's
the numbers started growing from
there. And we've partnered with
a lot of other program officers
within the VA, and also with
veteran service organizations.
By far, five years ago, we
actually started attending their
summer. VSO meetings, we, we
have boots at those meetings, we
enroll. We give talks at those
meetings. So that's been another
way of spreading the word and
bringing people to the program.
And and I do want to mention a
very exciting point when we
enrolled our 500,000 Veteran,
the program, this was at a VSO
meeting in Atlanta, and
President Obama had announced
the Precision Medicine
Initiative at that time that
year. He was going to be there
at that meeting as a speaker.
And he actually announced that
if the program and that we
enrolled the 500,000 veteran at
that event So that was very
exciting. And of course, in
2019, we launched we launch an
online portal, which came in
very handy during this pandemic.
You know, as you know, we had to
shut down in person enrollment
in 2020 in March 2020. And we
are still just now ramping sites
back up. It's not fully backup
yet. But the online portal
allowed us to then test that
mechanism to see, you know, if
veterans will be willing to do
it online, and we have over
10,000 veterans enrolled now,
online, we're still perfecting
that process.
Shawn Spitler: So this is a
history of innovation podcast,
I'm going to steal Katie's
thunder a little bit, our
historian here. And I want to
know, what do you think MVPs
place in history will be?
Unknown: Wow, I think we're
creating the legacy here. So I
think we we will be driving
precision medicine, the future
of medicine, it's really what we
want. Like, when a veteran comes
to visit a doctor at a medical
center, we want the doctors to
have access to all this
information that you know about
the genetic risk or a disease.
Or you can also talk about how
responses to medications that's
dependent upon genetics as well.
So whether you can whether
you're at a greater risk,
whether there are medical
medications that work better for
you, and can we prevent some of
these illnesses, we want to
tailor treatment and diagnosis
and prevention to a particular
person, rather than have just a
general, you know, one size fits
all type of medicine. So I think
we MVP will be is driving the
precision medicine in the VA.
And we will probably teach a lot
of the rest of the world to
about this, how to go about
this, the other a lot of gaps
like provider, education,
patient education, there's a lot
of things to do, to be able to
deploy this and in the clinics
in the clinical space. And so I
think MVP will be a leader in
this
Katie Delacenserie: Summa, I can
just sense the history around
this. And so thank you so much
for taking the time to share so
much about this program with us.
But I do kind of want to touch
on the future. You know, you're
you're close, you're nearing in
on that Million Veteran, what is
the future after that? What what
is the what does the future hold
for MVP.
Unknown: So we are not going to
stop at a million. So we will
keep the program open for any
veterans who want to continue to
join the program. But our goal
would be focusing on now are
three things actually, the first
thing is to improve the
diversity of the cohort. So
we're looking at these very
focused campaigns, how can we
increase the number of
underrepresented populations,
and not only by demographics,
but also by the conditions
represented, we are in the
process of actually launching a
sub initiative under MVP called
MVP mind, then we're trying to
enroll 50,000 veterans with
serious mental illness. So we
can really have a focused group
where we can study the genetics
of mental illness. So you can
also so we're looking at how can
we expand the program and
increase these underrepresented
health conditions, as well as
demographics? That's one piece.
The second piece is you can
collect all the data in the
world, but if nobody's analyzing
it, or you don't have enough
people accessing the data and
analyzing it, it's of no use.
And it actually speaks to one of
the things that I did not
answer. Shawn, you asked me
about challenges, and that's
about having sufficient
scientific computing. You know,
we are pioneers, nobody has
sequenced, we are sequencing,
you know, over 100,000 plus
240,000. Veterans have their
samples, sequenced entirely. The
whole it's called whole genome
sequencing. And no one has dealt
with this much amount of data.
How do you process it? How do
you make this available for
researchers? So our second,
looking at the future is, how do
we know there have probably be a
lot of new tools and new ways of
analysts now analyzing this data
that will come out of MVP as
well. So we're looking at that
making the data available
broadly to researchers. Right
now. It's only open to
researchers within the VA who
have VA appointments, but in the
future, it will be open to
researchers are across the
country, within the VA and
outside the VA. So that's the
second piece. And then the third
piece looking into the future is
this clinical translation piece
which is really really, the
reason we're doing this all
that's, that's why we're here.
And so we've established a trust
task force to look at different
ways we can take the scientific
discoveries from MVP, and make
it applicable in the clinic are
our veterans and beyond. So
that's, that's where we're
headed.
Shawn Spitler: I think it might
be important to address like,
this is not a program like
23andme, this is not where the
veteran is going to receive
information back telling them
about their genetic history,
correct?
Unknown: That's correct. So this
is set up entirely as a research
program. And so we are not
giving out individual level
results. At this point, we are
doing two pilots where we can,
we will have to validate those
results. So we don't have to, we
can give up these research
results as they are, we will
have to get another blood
specimen collected in what is
called a clear compliant way.
And that that's what's done. If
you want to use those genetic
results for clinical application
to make clinical decisions, you
have to have it done in a
certain way. And we would have
to do that before we can return
individual level results. So
this is just, you know, to
pursue scientific discovery,
primarily. And then to find ways
to validate it, then return
results.
Shawn Spitler: Interesting. So
not off the table entirely in
the future as a possibility.
Yeah.
Unknown: Okay. Well, it would be
different than 23 and me in the
sense that, you know, we are
within a healthcare system. So
we also want to have all the
pieces there, the providers that
need to know what's happening,
provide genetic counseling to
veterans when they need it. So
we have to put all these other
pieces of infrastructure in
place before we do that. The
pilots we're doing now will
inform us about all that summer.
Thank
Katie Delacenserie: you so much
for joining us today. Can you
share with us where veterans can
find more information about MVP?
Unknown: Yes, so the best way is
to go to our portal mvp.va dot
gob. And that will give them all
the information on how to
enroll, get more information. We
also have an MVP Information
Center that they can call and
they can talk to somebody about
it, and get more information as
well. And all that information
is on our mvp.va dot DOB.
Shawn Spitler: Thank you again
sumo so much. Just we love
having you. This is really
fascinating topic.
Unknown: So thank you, Sean. And
thank you, Katie. Thanks for
having me.
Katie Delacenserie: Thank you.
We're really excited to see you
get to that million. Thank you.
Unknown: Thank you. We need
everybody's support and cheering