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April – June 2007

Perspective 1

MG Russell J. Czerw

Army Public Health and Preventive Medicine: Proactive Approaches to Readiness 3

BG Michael B. Cates

“Sick, Dead, & Discharged”: Disease and the Defeat 5

of the Confederate Campaign into New Mexico, 1862

Wayne Austerman, PhD

Integrated Disease Management: An Old Idea Ready for Our Time 13

COL (Ret) Daniel Strickman, MS, USA

Expanding the Role of Preventive Medicine in the United States Army: 16

Integration and Cooperation

LTC James Sheehan, MC, USA; CPT(P) Brent Gibson, MC, USA; MAJ Bryan Sisk, AN, USA

How to Stop Fighting Ourselves: Removing the Stigma 20

of Mental Health Treatment for Soldiers

Kay Shepard, MSW

Demystifying the Environmental Health Site Assessment 25

LTC Timothy Bosetti, MS, USA

Water Purifiers for the Warfighter 31

MAJ William Bettin, MS, USA

A Guide to Brigade-Level Preventive Medicine: 35

Stryker Brigade Experience in Operation Iraqi Freedom II & III

CPT Stephen Lewandowski, MS, USA; CPT Jason Faulkenberry, MS, USA

Measuring Effectiveness of Deployed Medical Detachments 41

LTC Sonya Schleich, MS, USA; MAJ Mark Carder, MS, USA

Challenges of Effective Vector Control: Operation Iraqi Freedom 05–07 46

LTC Jamie Blow, MS, USA, CPT Darryl Forest, MS, USA; CPT Lewis Long, MS, USA, et al

Preventive Medicine Support in Afghanistan During Operation Enduring Freedom VI 56

MAJ Christopher Gellasch, MS, USA; CPT Lesly Calix, MS, USA

Preventive Medicine Support to Operation Lifeline: Pakistan 2005 65

CPT Owen Price, MS, USA; LTC David West, MS, USA; MAJ James Mancuso, MC, USA
MG Gale S. Pollock

Acting The Surgeon General

Commander, US Army Medical Command

MG Russell J. Czerw

Commanding General

US Army Medical Department Center and School

April– June 2007 The Army Medical Department Center & School PB 8-07-4/5/6

0707809

GEORGE W. CASEY, JR

General, United States Army

Chief of Staff

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April – June 2007 1

Since the beginning of warfare, the medical challenges

of deployment have remained unchanged. Soldiers still

require protection from the natural elements; they still

need safe food and water and must deal with diseases

and insects. The science and practice of preventive

medicine in the military has long been recognized as

paramount to the achievement of a relevant and ready

force and the sustainment of combat power. This fact

is well supported in Field Marshal Viscount Slim’s

Defeat Into Victory. This great account of fighting in

the jungles of Burma during WWII provides a superb

testimony of the applicability of preventive medicine

to warfare, as Field Marshal Slim assesses the

deplorable health condition of his forces, derives a

plan to fix it, and then, as every great commander

does, he enforces it.

To that end, we are indeed fortunate to have our own

professional publication, the AMEDD Journal, in

which to showcase the topical scope and intellectual

depth represented by this and the other areas of Army

medicine. This issue focuses on that critically

important discipline, with an emphasis on the special

considerations demanded by the combat environment.

For the second year in a row, COL Mustapha

Debboun, Chief of Medical Zoology Branch at the

AMEDD Center and School, has organized and

compiled an outstanding collection of articles from

preventive medicine professionals throughout the

Army. This issue is just one more example of the level

of skill, capability, and dedication of medical

professionals who selflessly choose to serve our

country with distinction and honor.

BG Michael Cates, the Commanding General of the

US Army Center for Health Promotion and Preventive

Medicine and the Functional Proponent for Army

Preventive Medicine, opens with a superb introduction

to the breadth of responsibilities and concerns

addressed by those involved in public health and

preventive medicine. His observations are sobering,

while at the same time challenging and exciting.

Throughout history, the outcomes of wars and military

campaigns have often been determined by noncombat

factors, especially debilitating diseases, nonbattle

injuries, and unhealthy personal habits. Indeed, the fate

of the United States as we know it may have hinged on

one ambitious, albeit little-known campaign early in

the Civil War. Dr Wayne Austerman tells the story of

the Confederate attempt to seize the western territories,

from Texas to California, early in the war. The effort

was hampered from the start by poor planning and

leadership, which rendered the force unable to cope

with the inevitable onset of disease, injury, hunger,

and disability. These circumstances doomed the effort

to early failure. Dr Austerman’s article is very

informative, illuminating, and instructive. The story of

such failure in planning and execution underscores the

importance of the emphasis the modern Army places

on public health and preventive medicine.

Among the various disciplines in medical science,

preventive medicine is one that absolutely cannot be

practiced in isolation. The next 2 articles clearly

illustrate that fact. First, COL (Ret) Daniel Strickman

revives and clarifies the concept of integrated disease

management, which ties multiple aspects of public

health and preventive medicine together in a

coordinated, task-oriented fashion to attack all facets

of a given public health threat, both clinically and in

everyday life. Next, LTC James Sheehan and his

coauthors detail an exercise in which a major military

facility collaborated with state and local public health,

safety, and security agencies in an integrated reaction

to a simulated bioterrorism threat. The exercise

highlighted the numerous ways in which the military

and civilian public health expertise, resources, and

requirements are interrelated. Their excellent article

illustrates how such cooperative working relationships

are essential for the protection and improvement of

both individual health and unit readiness.

Perspective

Major General Russell J. Czerw
2 Army Medical Department Journal

Although the debilitating affect of the combat

environment on mental health has been long

recognized, treatment is still problematic. Great

progress has been made in training our leaders as to

the value of mental health evaluation and treatment for

their troubled Soldiers. However, the societal stigma

of almost any concerns related to an individual’s

mental health still persists. Kay Shepard addresses

these problems directly and effectively in an important

and very timely article about this critical area of public

health of our forces. She provides an excellent

overview of the problems, and describes the successes

of the Schweinfurt medical community, spearheaded

by Social Work Services, in providing services to the

Soldiers who were rotating into and out of combat

operations in the Iraq theater.

LTC Timothy Bosetti contributes an important,

informative article clarifying an essential part of

preventive medicine planning and operations, the

Environmental Health Site Assessment. He presents a

well-organized explanation of the requirements,

components, and applications for this documentation,

with special emphasis on its value to those charged

with protecting the health of our deployed Soldiers.

Potable water is essential to the combat effectiveness

of any military organization. Dehydration or

waterborne disease has resulted in the collapse of

many military campaigns. MAJ William Bettin’s

article looks at the Army’s effort to provide individual

Soldiers with the best possible capability to generate

their own safe water for emergency situations. He

describes the Army’s detailed, deliberate testing of

various individual water purification systems, and the

results. An important offshoot of the study was the

development of a standardized test protocol for use in

evaluating future products, thus eliminating the need to

“reinvent the wheel,” saving critical time and money.

The last 5 articles provide insights and lessons learned

from recent deployments of preventive medicine

Soldiers into combat theaters. First, CPT Stephen

Lewandowski and CPT Jason Faulkenberry detail the

experiences of the first operational deployments of

brigade combat teams with organic preventive

medicine assets. They cover the growing pains

associated with a new organizational structure, as well

as the most important aspects of predeployment

preparation and operations in the deployment area. The

information is timely and important, as the Army

rapidly transforms its force structure into the brigade

combat team model, and the roles and responsibilities

of preventive medicine adapt accordingly.

Those charged with optimizing application of

resources must have a method of measuring the

effectiveness of those assets. LTC Sonya Schleigh and

MAJ Mark Carder detail a spreadsheet based

evaluation matrix that was the result of a collaborative

effort by the 5 medical detachments deployed with the

61st Multifunctional Medical Battalion to Iraq. The

article describes the careful, deliberative process

involved in developing and implementing a tool which

provides relevant information which is not affected by

the character of the detachment or the respective

deployment environments.

For over a century, vector control has been a vital

element of preventive medicine and public health

responsibilities. LTC Jamie Blow and her team of

coauthors present a detailed account of the problems

and solutions to vector control which are encountered

during current operational deployments. Their article

provides valuable insights into the myriad situations

faced by preventive medicine specialists, including

insects, feral animals, birds, and bats. They describe

the various attempts at control, some more successful

than others. Also, to reemphasize the critical

importance of personal protective measures in control

of vectorborne illness, the AMEDD Center and School

Medical Zoology Branch has provided important

information on the DoD Insect Repellent System as an

addendum to the article.

Operations in Afghanistan are no less challenging for

our preventive medicine specialists. MAJ Christopher

Gellasch and CPT Lesly Calix relate their experiences

providing support across the widely dispersed forces in

an area with considerably less infrastructure than Iraq.

Their article describes the challenges encountered in

providing all levels of preventive medicine services,

especially in the support of the forward operating

bases which are located in truly remote locations.

Again, this article is a valuable resource for those

preparing for deployment into the vitally important

operational environment.

Humanitarian missions introduce their own sets of

concerns and challenges. CPT Owen Price and his

coauthors contribute a detailed, extremely informative

account of their rapid deployment into Pakistan (from

Afghanistan) to provide relief after the devastating

earthquake in October 2005. In addition to the

expected public health and preventive medicine

responsibilities, their experiences as part of a

multinational relief team are a valuable insight into the

cultural, political, and functional complexities

involved in such nonmilitary environments.

Perspective
April – June 2007 3

From my perspective as the Functional Proponent of

Army Preventive Medicine, military public health

includes essential elements that contribute to the

overall health and well-being of our Soldiers, civilian

employees and Families. Successful prevention leads

directly to enhanced readiness through health. All

Army leaders, Soldiers, civilian employees, and

Families have a role in protecting their own health, and

the Army Medical Department (AMEDD) has

outstanding military and civilian experts ready and

able to assist them.

Army public health encompasses a wide variety of

expertise and capabilities, with personnel in over 50

specialties from every corps in the AMEDD. This

team includes deployable individuals and units

embedded in brigade combat teams up through the

combatant commands’ headquarters, preventive

medicine personnel assigned to Army headquarters,

military treatment facilities and installations, Army

veterinary personnel, and the professionals assigned to

the US Army Center for Health Promotion and

Preventive Medicine.

Current public health challenges in our military

include injuries, behavioral health issues, infectious

diseases, chronic diseases and other conditions related

to “lifestyle choices,” environmental exposures,

occupational hazards, and food and water

vulnerabilities. All have various causes and effects,

and all require a diverse set of solutions.

Injuries, mostly nonbattle injuries, place the largest

burden on our military healthcare system, in garrison

and during deployments. Falls, sports injuries, physical

training, and private motor vehicle accidents are the

major causes of nonbattle injuries in our military,

creating significant productivity loss across the entire

Department of Defense.

Behavioral health issues are a growing concern,

especially among those who have deployed. There is a

wide range of diagnoses in this field currently

affecting an increasing number of our Soldiers.

Appropriate and timely identification of those who

need mental health care is difficult and, thus, a key

piece toward successful resolution. Also, the stigma

associated with any type of mental health care creates

a disincentive for Soldiers to get the care they need.

Education and training efforts are among the most

important, proactive tools here, focused on improving

behavioral health through early identification and

reduced stigma.

Health threats from emerging or reemerging diseases

include tuberculosis, malaria, drug-resistant

Acinetobacter infections, leishmaniasis, and zoonotic

diseases associated with indigenous animals. A full

understanding of the epidemiology and pathogenesis

of many of these is often lacking. So, surveillance,

effective prophylaxis, early detection and rapid

mitigation are the best approaches to decrease the

impact of such health threats.

Recognizing that many of the health threats that

Soldiers, civilians, and Family members face are

caused by lifestyle choices, the Army public health

and preventive medicine programs have embraced the

Army Public Health and Preventive Medicine:

Proactive Approaches to Readiness

Brigadier General Michael B. Cates

BG Cates is the Commanding

General, US Army Center for Health

Promotion and Preventive Medicine;

the Functional Proponent, US Army

Preventive Medicine; and Chief,

Army Veterinary Corps.
4 Army Medical Department Journal

concept of educating individuals to prevent illness and

injury through an aggressive health promotion and

well-being campaign. Three continuing problems in

Soldier health are tobacco use, weight control, and

alcohol abuse. Each poses tremendous short-term and

long-term health risks, and recent surveys depict

negative trends among our military personnel and their

Families that we must continue to address.

Our military has personnel deployed to more than 100

countries in any given week. The infrastructures of

many of those countries are poor. Many times, we

have very little knowledge of the history of those

environments and their associated health risks, and

when we do, the information we have may have

already changed. Sampling may be slow or difficult as

we attempt to learn more about the potential health

risks to our military personnel deployed there. Yet,

environmental surveillance—monitoring air, water,

and soil for indigenous threats to health—is an

absolutely necessary piece of the preventive medicine

program.

New weapons and new vehicles employed by the

military are better, bigger, and bring new health risks,

such as acoustic energy, temperature extremes, shock

and vibration, and oxygen deficiency. Of these

examples, acoustic trauma, with resulting hearing loss

or other problems, is the biggest concern.

In the future, food and water have growing potential

for health risks. The United States has the best food

and water safety program in the world, yet the Centers

for Disease Control and Prevention estimate the

incidence of foodborne illness at 76 million cases a

year. As we deploy personnel into more than 100

countries with public health infrastructures not as

robust as ours, the health risks from food and water are

much higher. Today, we must also be concerned about

intentional contamination of food and water, or the

destruction of our water supply systems.

Our Army public health and preventive medicine team,

relatively small in size, but broad and deep in

expertise, is currently working toward solutions to

these current challenges around the world. Team

members strive to protect our Soldiers, civilian

employees, and Families locally while remaining

ready and willing to project globally. They are an

amazing group that rarely receives the credit they

deserve for ensuring true Force Health Protection and

Readiness. I am excited that this edition of the

AMEDD Journal showcases, for the second straight

year, some of their capabilities and contributions.

As we move forward, especially in a time of war, we

must continue to improve our military public health

efforts. For one, we must place greater emphasis, from

all levels, on preventive health, to include more of an

investment, looking for the long-term, as well as the

short-term benefits of such efforts. Our surveillance

must be more synchronized within the Department of

Defense and the rest of the US Government, with easy

information links between human and animal health,

as well as with the environment. We must provide

timely, accurate, and actionable data to our

commanders in the field to quickly identify and

mitigate any significant health risks, and we must have

effective ways to change risky behaviors and reduce

injuries. Most importantly, partnerships and

collaborative efforts should be enhanced among our

military public health experts in all of the uniformed

services, as well as with outside agencies.

Preventive medicine is crucial in maintaining the

readiness of our most important resource—our people.

Sustaining, and even improving, a Soldier’s health is a

much wiser use of resources than waiting until that

Soldier becomes sick or injured before attempting to

restore health. The better we prevent diseases,

conditions and injuries, the more resources will be

available to apply to those things we cannot prevent.

While there is continuing and growing emphasis on

proactive approaches to health in today’s society and

military, we must all strive toward translating that into

real, even greater long-term investments in the future

of our personnel. Prevention is the best way to health.

Army Public Health and Preventive Medicine: Proactive Approaches to Readiness
April – June 2007 5

On May 31, 1861, Henry Hopkins Sibley, an

articulate, alcoholic, 45-year-old major in the 2nd US

Dragoons who suffered from chronic renal colic,

resigned his commission at Fort Union, New Mexico,

and traveled eastward to Richmond, Virginia, capital

of the newly formed Confederate States of America.

There he gained an audience with President Jefferson

Davis, winning a commission as a brigadier general

and official sanction for his audacious plan to seize

modern-day New Mexico and Arizona for the

Confederacy as a prelude to launching offensives

against the silver mines of Colorado and gold fields of

Unionist California. The decision made in Davis’

office during the meeting with Sibley sealed the fate of

hundreds of young Texans doomed to die in the course

of his ill-starred campaign and committed the

manpower and materiel-poor Confederacy to an effort

whose modest demand on resources promised

potentially decisive strategic results. That was before

Sibley’s alcohol-addled ineptitude as a commander

and his force’s lack of an adequate field medical

support system allowed exposure and disease to sap its

strength and dictate defeat in the arid highlands of

New Mexico.1

When Sibley arrived in San Antonio, Texas, on August

12, 1861, he found that part of his mission had already

been accomplished for him. Lieutenant Colonel John

R. Baylor of the 2nd Texas Mounted Rifles had taken

a battalion of the regiment westward over the 500

miles to El Paso early in June and seized the

abandoned post of Fort Bliss early in July. On July 25,

the aggressive Baylor took his 350-odd troopers 40

miles up the course of the Rio Grande and fought a

pitched battle on the outskirts of Mesilla, New Mexico,

with the garrison of nearby Fort Fillmore,

subsequently compelling the entire 7th US Infantry

regiment to surrender. As a result of Baylor’s zeal, the

gateway to Unionist New Mexico lay open to invasion

by Confederate forces. It remained for Sibley to recruit

and equip his new brigade in the San Antonio area

before marching westward to resume and expand

Baylor’s offensive.1(pp209-221),2,3

Sibley had begun assembling a staff before he left

Richmond with his new commission. He selected Dr

Edward N. Covey as his brigade surgeon. A veteran

contract surgeon who had earlier served with Sibley in

New Mexico, Dr Covey remains an enigmatic figure in

the campaign’s history. He must have been aware of

Sibley’s debilitating problem with kidney disease and

his advanced alcoholism, yet he seems to have joined

the enterprise with little reservation and to have

exerted little restraint on Sibley’s appetite for the

bottle.1(p219),4,5

By mid October, Sibley had mustered, organized, and

equipped a brigade of 2,500 men consisting of the 4th,

5th, and 7th Regiments of Texas Mounted Volunteers

along with 2 batteries of field artillery. Because of an

anticipated shortage of water and grazing on the trail

to the west, the brigade was broken down into several

march increments, the first of which departed for El

Paso on November 9 as the cooler autumn weather

finally swept over the state.

Contemporary accounts are devoid of any detailed

information on the brigade’s medical establishment.

There are no references to ambulances or enumeration

of medical supplies in the record of its organization in

San Antonio. Accounts of subsequent combat actions

in New Mexico are devoid of any references to the

field medical support system and its functional

organization. It is known that Sibley took 10

ambulances to El Paso with him, but no documentation

survives to detail how they were organized for casualty

evacuation or even if they were assigned to that

mission or used simply as general utility vehicles. A

novice regimental quartermaster sergeant gave Sibley

high marks as a logistician when the unit left San

Antonio, calling it “the most complete and perfectly

equipped brigade sent out by the Confederacy during

“Sick, Dead, & Discharged”: Disease and the

Defeat of the Confederate Campaign into

New Mexico, 1862

Wayne R. Austerman, PhD
6 Army Medical Department Journal

the war.” When the command departed for El Paso, its

supply train consisted of over 300 wagons laden with

materiel, while “the quartermaster, brigade and

regimental headquarters, and the medical corps also

had wagons.” Even so, shortages would stalk the

wards long before the campaign reached its dismal end

by the following spring.3(p96),6

The three mounted regiments counted a total of 10

surgeons serving in that official capacity, while

numerous other physicians filled the rolls as company

commanders and even common riflemen. There was

no shortage of medical men in the brigade, but little

sign of any united organizational framework capable

of exploiting their talents efficiently above the

regimental level. There were to be no Lettermans

serving with Sibley amid the mesquite and chaparral.

The long march in autumn weather took its toll before

the first company reached El Paso. Measles erupted on

the trail, afflicting an entire company of the 7th

Regiment so badly that the unit was left in quarantine

at a post along the way and missed the entire

campaign, losing 15 men to the disease during one 3-

week period. Young men from rural backgrounds

assembled in large groups for the first time typically

lacked an immunity to such diseases and thus proved

uniquely vulnerable. The command’s modern

chronicler related:

Disease plagued the command on its march across

Texas and fresh graves marked the brigade’s route.

Hospitals along the way were filled with patients from

Sibley’s brigade.... Smallpox, already present in

Arizona, posed a threat; regimental surgeons countered

by vaccinating most of their men. Other volunteers fell

ill on the march, far from even the relative comforts of

the crude medical facilities. Routine camp diseases,

especially dysentery, affected some troops. Pneumonia

also appeared in the command.... Although few of the

troops were diagnosed as having pneumonia during the

march, many had acquired an unsettling, rattling

cough.4(p 220),6(pp124-125)

The vanguard of Sibley’s brigade reached El Paso in

mid-December, but the balance of the unit was not at

Fort Bliss until January 19, 1862. Absorbing Baylor’s

battalion and sundry local volunteer companies into

his command, Sibley confronted continuing attrition of

his force due to disease. One trooper remarked at the

end of December how “our company is in bad health

now. There is about half of the company sick.... I

think there is poor prospect of our company going out

this winter, if the boys keep getting sick.” The unit in

question, Company A of the 2nd Texas Mounted

Rifles, suffered a 50% sickness rate through January

1862, and was forced to remain in the rear throughout

the rest of the campaign, rendered fit only for light

occupation duties.3(pp126-136),4(p304),7

“...sick, dead & discharged...”

In early January, Sibley resumed the offensive initiated

by Baylor 5 months earlier by sending units northward

to occupy a new forward base of operations at the

abandoned prewar post of Fort Thorn, sited on the

west bank of the Rio Grande approximately 40 miles

upriver from Fort Fillmore. The movement and

occupation took place without any interference from

the Union forces assembled further upstream at Fort

Craig, although Apache raids were a constant

nuisance. It was at this post that Sibley’s failings as a

planner first became manifest to his troops.

“The arrival of the brigade added more than 2

thousand temporary residents who descended on the

area like a human avalanche,” noted a recent

chronicler of the campaign. “Food, both purchased and

stolen, became scarce, and prices rose. Contractors for

the army...increased their earnings while poor farmers

and their families went hungry.... Baylor’s Texans had

been a curiosity, Sibley’s liberators were a calamity.”

At Fort Thorn the brigade’s supply depot held over a

month’s rations, and “additional supplies were

expected to be taken from the enemy,” but the arid

countryside and sparse farming population found even

in the green, cultivated acreage along the river valley

made it clear that New Mexico would offer poor

foraging to any army hoping to live off the land.

Sibley’s antebellum service in the region must have

made him aware of the dire logistical problems

confronting any sizeable military force seeking to

conduct extended operations amid the mountainhemmed desert country. The forced sale or

confiscation of food from the local Hispanic

population began the process of alienation from the

invaders which would cast most of New Mexico’s

native population into the Unionist camp as the

campaign continued.*

While food was not yet a pressing concern, exposure

was already a problem among the Texans, most of

Sick, Dead, & Discharged: Disease and the Defeat of the Confederate Campaign into New Mexico, 1862

*References 2(pp 55-56), 3(pp 135-138), 6(p 18).
April – June 2007 7

whom came from the warm latitudes of the Gulf

coastal plain. Unaccustomed to the winter chill

of the high desert country, they suffered

accordingly as up to 4 inches of snow blanketed

their new camp. Lacking adequate tentage, the

troops slept in the open and soon pneumonia was

running through the brigade. The “wheeze and

rattle” ravaged Company I of the 5th Texas in

particular, killing 3 men within the first week of

February, leaving “the most of the men in our

company...sick, dead & discharged,” lamented a

soldier. The harsh weather also made bathing

and laundering of clothes difficult. The result

was a plague of lice which soon had the entire

brigade scratching and searching the seams of its

uniforms for deposits of eggs.*

Any veterinary surgeons serving with the

brigade also had their hands full, for poor diet,

hard usage, and exposure also took a heavy toll

among the command’s horses and mules, and the

mineral-impregnated water of the Upper Rio

Grande had given the animals an ailment called

“the scours.” Even more troubling was the lack

of proper feed for the stock, which led to a

progressive physical deterioration of the teams.

A force of 2,000 troops typically required a train

of 350 supply wagons in support. Sibley had

barely enough wagons and teams to support his

brigade at the start of the campaign in San

Antonio. By the time he struck northward into

New Mexico, the shortage of teams and scarcity

of forage for those remaining dictated that his

command would exist on a steadily fraying

logistical shoestring unless and until large

quantities of supplies could be captured from the

enemy early in the campaign. The steady

attrition of the animals due to hunger and enemy

action would eventually leave most of the proud

mounted volunteers afoot and reduce the brigade

trains to a few score wagons.2(pp49-50),3(pp141,149)

On February 7, Sibley resumed his advance upriver

with the 5th Texas in the van. The shortage of healthy

mules forced the brigade to leave half its wagons

behind at Fort Thorn, and priority of space in the

remaining ones was given to food and ammunition.

The men began the march on half-rations, and

although a herd of beef cattle accompanied the

column, the steers’ condition was so poor that they

could barely stagger along, and the men found their

meat barely palatable, but it was all to be had amid that

desolate country of want.3(p149)

By this time, Sibley’s kidney disease and alcohol

abuse had begun to visibly affect his fitness to

command. A surgeon of the 7th Texas had already

*References 2(pp 52, 55), 3(pp 137-139, 141-142, 155),

6(pp 16-20, 25-28), 8, 9.

The Confederate Army campaign into the New Mexico

territory, January to May, 1862.
8 Army Medical Department Journal

observed that there was “too much drunkenness”

among the commander and his staff. His kidney

disease had plagued him for years, and while whiskey

softened the pain it also exacerbated the severity of his

condition. Unable to ride on horseback, he led the

advance from an ambulance. “I believe that General

Sibley was a brave and gallant man, and a true

patriot,” wrote one of his officers. “His health was

such that he was not fit to command. The mind

naturally becomes turned when disease and pain racks

the body. (He) ought to have resigned.”*

As Sibley’s command slogged northward, the enemy

awaited his approach behind the network of field

fortifications encircling Fort Craig. There, Colonel

Edward Canby commanded a force of 3,800 regulars

and territorial militia. Sibley’s commanding officer at

one posting in the old prewar service, Canby was a

cautious and prudent commander, who realized that

the entire southwestern region of the nation was his to

lose in a struggle with the rebels. Reasonably well

supplied and commanding an adequate force for

defense, he would challenge Sibley but once in the

field, then leave him with the options of battering his

force bloody in futile assaults against Fort Craig’s

heavy guns and fieldworks, or risking starvation in

attempting to continue his march northward against

Santa Fe and the other major bluecoat bastion at Fort

Union, northeast of the territorial capital.2(pp59-82)

“...a spectacle that was horrible...”

By February 15, Sibley’s 2,500 men were deployed for

battle roughly 6 miles south of Fort Craig. The still

ailing Sibley had temporarily yielded command of the

brigade to Colonel Thomas Jefferson Green of the 5th

Texas. Green attempted to draw Canby’s force out into

the open for a battle, but the Union garrison remained

safely behind its fieldworks, with heavy cannon which

held the Texans at a respectful distance. Green faced a

dilemma as the brigade’s rations dwindled to a 10-day

supply. He elected to cross to the east bank of the Rio

Grande, march upstream for 6 miles, and then recross

the river at Valverde Ford, hoping that such a move

might prod Canby into coming out to fight for fear that

the Texans might sever his line of communications

northward. Canby divined Green’s intentions,

however, and when the Confederates reached the ford

on the morning of February 21, they found a blocking

force occupying the east bank of the crossing site.

A major battle erupted as Sibley sat stuporous with

drink in an ambulance in the company of two women

of uncertain virtue. Musketry and artillery fire lashed

the field until Canby’s unsteady militia fled the scene

and the Texans overran a battery of Union guns,

ending the battle as the defenders escaped across the

ford and returned to the sanctuary of Fort Craig. Union

losses at Valverde Ford totaled 112 dead and 189

wounded along with 204 missing in action, or nearly

18% of the force engaged. The Texans counted 36

dead, 150 wounded and 1 missing. Forty-three of their

wounded subsequently died after reaching the

makeshift field hospital erected 2 miles upstream. The

Confederates had lost 10% of their force and Canby

was still secure in an impregnable position.†

A Union officer recalled how “the field was covered

with blood, horses, torn and dismembered limbs, and

heads separated from their bodies—a spectacle that

was horrible.” Even the northerners were short of

litters and ambulances, for some of their casualties

were carried from the site in “barrows.” The

Confederates borrowed lanterns and shovels from their

opponents as darkness fell while both sides combed

the battlefield for wounded to retrieve and dead to

bury.10(pp102,159)

The Confederates had not only failed to win any

meaningful sort of victory, they had suffered a severe

logistical defeat. Union artillery and small arms had

wreaked havoc among the saddle horses and draught

animals as they stood tethered in the rear, killing

nearly a thousand of them. “The whole seemed to be

the abode of death itself,” wrote one grieving trooper

of the human and equine losses alike. Many of the

troops were now put afoot, while much clothing,

blankets and other equipment had to be abandoned for

lack of transport. As the brigade by necessity

continued its advance northward in search of supplies

on February 23, 6-man details carried some of the

wounded on litters, while others occupied spaces in the

remaining wagons. On the 25th, they captured a Union

supply depot at Socorro and established a hospital in a

church and private home in order to shelter their 200

Sick, Dead, & Discharged: Disease and the Defeat of the Confederate Campaign into New Mexico, 1862

*References 1(pp 251-252), 3(pp 145, 149), 6(p 42).

†

References 1(pp 252-258), 2(pp 77-103), 3(pp 150-185),

9(118), 10.
April – June 2007 9

sick and wounded, while men were detailed to serve as

nurses and stewards. It was the first time any of the

brigade’s sick or wounded had been under a roof since

leaving Fort Thorn, over a month previously. Dr

Covey and Dr Samuel B. Maney, a former rifleman,

used newly captured medical supplies to ease the

men’s suffering.3(pp180-184),10(pp102-103)

Sibley paused in Socorro long enough to reorganize

the brigade and leave his casualties in the hospital

under the care of Dr Henry J. Hunter of the 7th Texas.

He then resumed the march to Albuquerque, where

upon arrival on March 2, the troops found a major

enemy supply depot reduced to charred ruins by the

departing Union troops. It was a bitter blow, but some

of the disappointment receded soon afterward when Dr

Finis E. Kavenaugh, a former US Army contract

surgeon and Confederate sympathizer, seized an

ordnance and quartermaster depot that had been

established in the hamlet of Cubero, 65 miles to the

west. The coup netted Sibley 25 wagonloads of

precious supplies and put the invaders on the best

logistical footing they had enjoyed since leaving Fort

Thorn. Sibley estimated that he could sustain the

brigade for another 3 months on the booty Dr

Kavenaugh seized at Cubero. It was the most fateful

single act performed by a physician on either side

throughout the campaign.*

By March 4, the Union garrison of Santa Fe had

torched the supply depot there and abandoned the

town. Nine days later a Confederate advance guard

entered the capital to sift through the ashes of the

charred warehouses. The bulk of Sibley’s brigade

remained well to the south near Albuquerque for 2

weeks as the onset of severe winter weather forced it

to suspend operations for a time. Sibley ordered large

portions of the unit to move eastward into the Sandia

Mountains in order to block the road linking Fort

Craig with Santa Fe and Fort Union, while utilizing the

scant shelter afforded by the scattered small villages in

the highlands. The hospital established in Albuquerque

“was soon filled with dozens of pneumonia cases.”

The 5th Texas had marked an upsurge in the disease

after leaving Socorro. “We buried four men,” a

despondent soldier wrote. “Pneumonia, measles,

small-pox, itch and body lice are getting in their work

on us.” The deployment to the mountains destroyed

the health of many, for a hospital attendant recorded

how “a great many more come in from the mountains

and report snow all over everything, blankets and all.

That foolish move out in those mountains will cause

the death of many a poor fellow.”3(pp184-201),8(p138),11

“...unprotected, with no medicine...”

Sibley continued to ignore Canby as he kept his

command massed at Fort Craig. Having taken Santa Fe

with a token advance guard, he was poised to renew

the advance northward from Albuquerque with the

objective of clearing the passes northeast of the capital

to seize the major enemy supply depot at Fort Union.

If that rich lode of materiel was taken, Canby would be

forced to concede his isolation and defeat, while

Sibley would then be poised to strike northward into

Colorado or conceivably even mount a threat to Union

control of California and its Pacific seaports.

At Fort Union, newly arrived Colorado volunteers

joined the regulars and militia at the post to spearhead

the defenders’ riposte to the Texan advance. Colonel

John P. Slough led 1,342 men southward from the fort

to bar the enemy advance at Glorieta Pass, a 7-mile

long notch in the Sangre de Cristo range. Barely a

quarter of a mile wide at its midpoint, the pass was key

terrain for any force seeking to strike at either Santa Fe

or Fort Union. Elements of Sibley’s main force were

either still encamped or on the march from

Albuquerque when Slough’s Coloradoans sent an

advance guard into the pass from the east on the 25th

of March. Shortly before 11 o’clock on the morning of

the 28th, Colonel William R. Scurry led a thousand

men of Sibley’s brigade into action against the

Coloradoans near the western end of the long defile.

While Scurry fought Slough to a near-defeat, a

detachment of Union troops executed an arduous

flanking march via a little-known route through the

mountains and then made a precipitous descent from a

mesa to strike Scurry’s baggage camp, burning 80

supply wagons and killing hundreds of horses and

mules. A regimental chaplain was also slain when he

attempted to halt the small arms fire that raked the

nearby Confederate field hospital.2(pp125-160),3(pp207-230),12

With the destruction of his supply train, Scurry was

forced to concede defeat and begin a withdrawal

*References 2(pp 115-116, 122-123), 3(pp 184-185, 196),

6 (pp 79, 87).
10 Army Medical Department Journal

southward to Santa Fe. It was the first step on the long,

punishing road back to San Antonio. Sibley had been

unable to bring the bulk of his command to the

battlefield at the decisive time and place at Glorieta

Pass. Logistical problems and the mounting sickness

rate which sapped his manpower and impeded his

movements had kept much of his force far southward

near Albuquerque while the course of the campaign

was being decided in the windswept maw of the

Sangre de Cristos. The turning point of the campaign

had come, and events conspired against the

Confederates, but Scurry was still faced with the issue

of burying his 42 dead and evacuating his 203

wounded over the 23 miles westward to Santa Fe. His

opponent had his own 47 dead and 78 wounded to

bury or bandage, and the Texans faced no immediate

threat of pursuit as the combatants mutually agreed

upon an 18-hour truce. Once again, the southerners

borrowed picks and shovels from their foes in order to

bury their dead. With no wagons or ambulances left

for transport, nor even animals available to haul

travois or slung litters, the Texan wounded faced a

slow, painful passage back to shelter at Santa Fe.*

When Scurry’s column arrived in Santa Fe on the

morning of March 29, they found that none other than

Union Colonel Canby’s wife had organized the ladies

of the town in preparations to receive casualties from

the battle. Confronted with the shortage of Texan

ambulances, she hit upon the expedient of nailing tent

canvas across wagon beds in order to make

hammocks, and organized a flow of supplies back to

Scurry’s camp at the pass in order to help those

wounded too badly to be moved. Soon regarded as a

heroine by the admiring Texans, Mrs. Canby was still

unable to stem the ravages of pneumonia among the

wound-weakened men under her care.†

In Albuquerque, Sibley received news of the fights

north of Santa Fe on March 30, and he initially thought

that Scurry had won a major victory. He and his staff

left for Santa Fe soon afterward, and on April 4 they

reached town in company with Colonel Green’s 4th

Texas. Once again, the entire brigade was assembled

in one place, its numbers shrunken to approximately

1,700 men by death, wounds, and disease, which had

steadily attrited the force from El Paso and Fort Thorn

through Albuquerque to Glorieta Pass, reducing it to

perhaps two-thirds of its peak strength during the

campaign to date.2(pp163-166)

Sibley was pondering his next move when word

arrived that Canby had departed Fort Craig and

marched eastward to combine forces with units from

Fort Union. The Texans had no choice but to stage a

retreat. The brigade hurriedly countermarched

southward, reaching Albuquerque on April 10. Sibley

left 250 sick and wounded men behind in Santa Fe,

trusting them to the enemy’s mercy. Relieved of that

burden, the brigade commenced what proved to be a

harrowing retreat southward down the corridor of the

Rio Grande river valley.2(pp167-185),3(pp235-245)

Lashed by wind and rainstorms, the Confederates

fought a minor skirmish with Union troops at the

village of Peralta on April 16 and 17, suffering only 4

killed and 6 wounded. However, the rapidly

deteriorating physical condition of their wagons’ teams

forced them to leave additional sick and wounded

behind in the tiny village, “without attendants or

medicines and almost without food.” The retreat

continued to a point 70 miles north of Fort Craig,

where Sibley, fearing being caught between a sortie by

the fort’s garrison and Canby’s pursuing force behind,

proposed leaving the west bank of the river and taking

a torturous route westward through the mountains to

regain the river road below the Union bastion. What

followed was a nightmare march of 5 days and 80

miles as the Texans spiked most of their artillery,

burned most of their wagons, loaded supplies on pack

mules, and began a torturous passage down the

western slopes of the Magdalena and San Mateo

ranges. All of the remaining sick and wounded who

could not ride or walk were abandoned prior to the

march on April 17, huddled around a fire beneath a

yellow hospital flag. A Union patrol found them a few

days later, “unprotected with no medicine, no

physician and but few attendants.”2(pp186-191),3(pp246-251)

“...how general is the debility...”

The rugged country and failing teams soon forced

Sibley to abandon the rest of his artillery, burn another

22 wagons and carriages and all 10 ambulances,

leaving only 7 wagons to carry the remaining sick.

Sibley, “much of the time, unknown to the rank and

Sick, Dead, & Discharged: Disease and the Defeat of the Confederate Campaign into New Mexico, 1862

*References 2(pp 162-163), 13(pp 101-109), 13.

†

References 2(pp 163-165), 3(pp 231-234), 6(pp99-100), 14.
April – June 2007 11

file, ...was drunk.” The casualties he abandoned fell

into Union hands, as did the ones left in the hospital at

Socorro during his earlier march northward. Canby

subsequently reported that at the campaign’s end he

had paroled approximately 240 enemy prisoners of

war, while another 240 remained on his hands, of

whom “about two-thirds consisted of sick, wounded,

and hospital attendants.” Canby wisely decided to

forego another battle and simply let the starving enemy

depart in peace, for he had no desire to assume the

burden of feeding hundreds of additional prisoners or

caring for their sick and wounded following a final

needless clash. As the rest of the ragged, famished

brigade stumbled southward for Mesilla and El Paso,

muted criticism of Sibley became open contempt

among officers and men alike.*

Upon arrival at Fort Bliss, the brigade reassembled for

the first time since leaving the river road above Fort

Craig and took stock of its remaining strength and

condition. The experience of the 4th Texas Mounted

Volunteers was perhaps typical. The unit had left San

Antonio with 927 officers and men. By campaign’s

end it mustered 552 present and fit for duty. It had lost

7 dead and 10 medically discharged en route to El

Paso. Forty-seven men were killed in action or died of

wounds. Another 28 died of disease during the

campaign, while 194 were captured, of whom 51 were

wounded, 3 of whom subsequently died. At the close

of the campaign at Fort Bliss and enroute back to San

Antonio another 20 men succumbed to illness. One

surgeon and 2 “left behind sick” at Fort Bliss were

taken prisoner. By the time of the brigade’s Fort Bliss

muster, less than 1,800 men remained of the 2,515

who had marched northward with Sibley barely 3

months previously. “All the men are more or less

unwell, and it is distressing to notice how general is

the debility in camp,” recorded a soldier. Measles,

smallpox, and pneumonia continued to claim men.

Bleeding gums and toothaches were pervasive

symptoms of scurvy and vitamin deficiency. One

officer lamented that “I have scarcely ten men in my

company fit for duty and seven of my best men are

dead.... We have many sick...there are many

complaining and some just getting over measles, being

quite weak.”†

The remnants of the brigade made the long march back

to San Antonio in June and July 1862. Reconstituted,

the unit gave gallant service in Texas and Louisiana

through the rest of the war, but Sibley had lost their

trust. He spent the autumn of 1862 defending himself

against the charges of drunken misconduct brought

against him by his own officers. Escaping conviction,

he retained command of his disgruntled brigade, but

his drunken incompetence during an April 1863 action

in Louisiana led to his relief and a second courtmartial. Escaping conviction yet a second time, he was

left without a command and never led Confederate

troops again. After the war he secured a general’s rank

in the army of the Khedive of Egypt, but his

alcoholism led to his loss of that position as well. He

died in poverty in Fredericksburg, Virginia in 1886,

besotted, diapered, and incontinent.1(pp301-369),2(pp203-206)

The Confederate offensive into New Mexico had been

doomed from the start due to Sibley’s deluded belief

that his force could live off the land until it captured

sufficient enemy supplies to sustain its drive all the

way northward to seize Fort Union. His logistical

planning failure was particularly inexcusable in light

of his extensive prewar service in the desert

Southwest. His opponent’s biographer cited several

major factors for the defeat of the Confederate

offensive. The first lay in the mixed apathy and

hostility of the native Hispanic population, who found

no reason to ally themselves or their resources with the

invaders’ cause. More important were the related

elements of time and supply. The Texans’ fitful rate of

movement north from Mesilla gave Canby time to

organize the defenses of Unionist New Mexico and

summon reinforcements from Colorado. “The

demolition, by a number of those troops, of the

Confederate supply train at La Glorieta Pass was the

immediate cause of the failure of the Southern

venture.” In addition, the drought which had afflicted

the region during the past 2 years resulted in a shortage

of local foodstuffs and range forage for the Texans’

horses and mules, further complicating the problem of

supply.14(pp180-181)

Optimistic zeal and personal ambition may have

colored Sibley’s judgment to a degree, but the

suspicion lingers that John Barleycorn occupied as

large a role in Sibley’s planning processes as did the

maxims of Napoleon, Jomini, or Clausewitz.

Alcoholism was by no means uncommon among

*References 2(pp 199-203), 3(pp 235, 252-260).

†

References 3(pp 262, 264), 4(pp 37, 54), 9(132).
12 Army Medical Department Journal

senior officers on either side in that conflict, but

seldom did the liquor-fueled failings of one man have

a more profound effect upon the course of an entire

campaign. The logistical failure ensured that his troops

lacked adequate tentage, winter clothing, medical

supplies, and transport for what supplies they did

possess. Noted a veteran of the campaign:

While we had good, kind and able surgeons, who were

always willing and anxious to do all in their power to

heal the wounded, cure the sick and alleviate their

sufferings, yet they were utterly without the medicines

and hospital stores to do so. And to such extremities

were we reduced, that men would linger and die in their

companies, rather than go to the hospitals.6(pp128-129)

The brigade’s high disease rates and the fate of its sick

and wounded, so often abandoned to the enemy, must

have sapped the Texans’ morale as they fought both

the elements and the Yankees in that bleak field of

operations. In the end, Sibley could not concentrate

adequate combat power at the decisive time and place

to destroy the enemy. Measles, pneumonia, dysentery,

and malnutrition had beaten his command long before

the Coloradoans trekked south from Fort Union to

Glorieta Pass. Sibley’s personal health problems and

his failure to safeguard his men from the ravages of

malnutrition and microbes alike doomed one of the

most audacious and potentially decisive operations in

all of American military history. The student of this

tragic episode is left pondering the enigmatic figure of

Dr Covey, who gave such able service to the brigade’s

sick and wounded throughout the campaign, and yet

silently acquiesced in the retention of command by an

ailing alcoholic who was unfit to oversee a recruiting

depot, much less a campaign of potentially strategic

importance. In Dr Covey’s reticence lay the seeds of

disaster for the Confederacy’s New Mexico Campaign.

REFERENCES

1. Thompson JD. Henry Hopkins Sibley: Confederate

General of the West. Natchitoches, LA: Northwestern

State University Press; 1987.

2. Hall MH. Sibley’s New Mexico Campaign. Austin,

TX: University of Texas Press; 1960:26-28.

3. Frazier DS. Blood and Treasure: Confederate Empire

in the Southwest. College Station: TX: A&M

University Press; 1995:23-72.

4. Hall MH. The Confederate Army of New Mexico.

Austin, TX: Presidial Press; 1978:46-47.

5. Heitman FB. Historical Register and Dictionary of

the United States Army from its Organization,

September 29, 1789, to March 2, 1903. Vol 2.

Washington, DC: US Government Printing Office;

1903:330.

6. Thompson JD, ed. Civil War in the Southwest:

Recollections of the Sibley Brigade. College Station,

TX: Texas A&M University Press; 2001:7.

7. Hall MH, ed. The Taylor letters: Confederate

correspondence from Fort Bliss, 1861. Mil Hist Texas

& Southwest. Fall 1980;15:59.

8. Faulkner WA, ed. With Sibley in New Mexico: the

journal of William Henry Smith. In: West Texas

Historical Association Yearbook. Vol 27. Lubbock,

TX: Texas Tech University; 1951:127-133.

9. Alberts DE. Rebels on the Rio Grande: The Civil War

Journal of A.B. Peticolas. Albuquerque, NM:

University of New Mexico Press; 1984:33.

10. Taylor J. Bloody Valverde. Albuquerque, NM:

University of New Mexico Press; 1995:17-44.

11. Thompson JD, ed. Westward the Texans: The Civil

War Journal of Private William Randolph Howell. El

Paso, TX: Texas Western Press; 1990:95.

12. Edrington TS, Taylor J. The Battle of Glorieta Pass.

Albuquerque, NM: University of New Mexico Press;

1998:28-39,41-100.

13. Scott R. Glorieta: The Gettysburg of the West.

Boulder, CO: Johnson Books; 1992:181-190.

14. Heyman ML Jr. Prudent Soldier: A Biography of

Major General E.R.S. Canby 1817-1873. Glendale,

CA: The Arthur H. Clark Company; 1959:183.

AUTHOR

Dr Austerman is Command Historian, US Army

Medical Department Center and School, Fort Sam

Houston, Texas.

Sick, Dead, & Discharged: Disease and the Defeat of the Confederate Campaign into New Mexico, 1862
April – June 2007 13

We human beings are surrounded by systems wherever

we go. Those systems might be positive, like the ones

that produce clean air through photosynthesis, or they

might be negative, such as the ones that result in

violent cultural opposition. Disease and health are also

the result of systems around us; ones that we very

much want to manipulate in order to favor the latter

and not the former.

Medical entomologists are used to thinking about the

many environmental factors that lead to excessive

populations of whatever insect is causing a problem.

For example, some of the mosquitoes that transmit

Plasmodium, and therefore cause malaria, in east

Africa develop in weedy, sunlit pools as aquatic

larvae. The adults emerge and take blood meals every

2 or 3 days, preferring humans as hosts. Females mate

after the first blood meal and lay eggs on the water of

those sunlit pools a couple of days later. Females keep

feeding on blood and laying eggs for at least 6 weeks

or until they meet with an untimely end. Temperatures

near the equator in that part of the world hardly vary

during the year, but the rainfall is very seasonal. The

rhythm of the rainy seasons is the rhythm of the

mosquito populations. The mosquito populations

multiply when pools are abundant, producing many

young females. At the end of the rainy season, the

population declines so that the average age of biting

mosquitoes gets older and older. It is a dangerous

world for the adult mosquitoes, with approximately

20% of them dying each day.

People in that part of the world often live in simple

homes that are almost completely open to mosquitoes,

so that getting a meal from a sleeping person is no

problem. They are also very poor, with sporadic access

to health care and difficulty buying household items

that we might think of as necessities. The combination

of a pathogen that stays in the blood for weeks, a

mosquito that bites repeatedly and prefers humans, and

a human population that is freely available for bites

makes for the explosive malaria situation commonly

observed in east Africa and elsewhere.

The challenge for those charged with the alleviation of

infectious diseases is to determine how to affect a

disease system at exactly those points that will have

the biggest negative impact on the pathogen and

positive impact on the human population. Prior to the

common availability of antibiotics and vaccines,

people had to rely on sanitation and avoidance to

escape disease. Even before the germ theory of

disease, many people seem to have valued clean water,

clean habits, and wholesome food, as documented in

the scripture of western religions, guides to health, and

the wisdom of ancient luminaries such as Aristotle and

Galen. Once the nature of pathogens was discovered in

the late 19th century, many schemes emerged for

disease prevention based on detailed studies of the

natural history of the pathogens. The world’s various

populations desperately, and sometimes successfully,

assembled the tools available to mitigate the ravages of

malaria, plague, typhus, and other scourges of public

health. With the exception of a few vaccines, most of

these interventions were outside the human body until

the rapid discoveries of effective drugs began in the

late 1940s.

We are now in a position to combine the interventions

outside the human body with those inside the human

body to make dramatic progress against infectious

disease. There is much room for improvement, but

there are wonderful examples of applying exactly that

combination to defeat disease. Certainly tuberculosis

and enteric infection would be much worse without the

multilayered interventions of sanitation, detection, and

treatment that the public has come to expect.

It is possible that the professional communities that

deal with arthropod-transmitted (vector-borne)

pathogens have been less able to communicate with

each other than with communities involved in other

aspects of medicine. The reason may lie in the great

breadth of medicine, an obviously all-consuming

profession, and applied medical entomology, an

equally complicated endeavor. Medicine applied in the

clinic under the auspices of public health has some

Integrated Disease Management:

An Old Idea Ready for Our Time

COL (Ret) Daniel Strickman, MS, USA
14 Army Medical Department Journal

difficulty communicating with vector control that

operates in sewers, swamps, and backyards under the

auspices of environmental health and public works.

The military makes a vigorous attempt to facilitate

communication, but in practice, the assessments of one

side are not studied consistently by the other, except

when energetic and well-intentioned individuals force

the process to work.

Integrated disease management is not a new catch

phrase, but it is certainly not as commonly practiced as

it could be. Entomology has possibly developed a

better framework for applying integrated intervention

through its own development of integrated pest

management in the 1950s through the 1970s.

Integrated pest management can be divided into 4

components:

1. Risk assessment (what we find out remotely

from existing information)

2. Surveillance (what we find out by measurements

on the ground)

3. Control (the full complex of vector control and

personal protection)

4. Monitoring (that which is done to detect a

resurgence of the problem and to stimulate

maintenance of the program)

Integrated disease management extends the range of

tools to include those of public health and medicine,

with the objective of limiting pathogen transmission

by combining all measures that are effective. Risk

assessment includes epidemiology as well as

entomology. Surveillance includes passive and active

human surveillance, as well as vector surveillance.

Control includes drug prophylaxis, vaccination,

medical treatment of existing disease, and other

medical interventions as well as entomological

interventions such as community vector control and

personal protective measures. Monitoring looks at

incidence, damage to human activity and quality of

life, and other potential damage from a disease, as well

as distribution of the pathogen and vectors.

The term “integration” is often used freely without a

great deal of explanation. When thinking about

integrated disease management, it is possible to picture

the disease as a system. Malaria and dengue have

humans as their principle reservoirs, greatly

simplifying the situation in comparison to diseases

such as West Nile virus fever or Lyme disease, which

involve animal reservoirs. It is probably accurate to

consider malaria or dengue as 3 part systems

consisting of the pathogen, the human, and the vector.

Interventions that reduce any of these 3 components

are likely to reduce transmission. Experience in

operational medical entomology and common sense

suggest that using more different methods to attack all

three of the components of the system is more likely to

succeed than using a single method. For example,

imperfect vector control and imperfect case detection

and treatment might be combined to achieve regional

eradication of malaria, as probably occurred in

Thailand. Malaria has been virtually eliminated in

most of the country by the systematic application of

house spraying for mosquitoes and case detection and

treatment for humans. House spraying has been done

in response to foci of malaria detected through a

network of free clinics dedicated solely to malaria. The

simple clinics were carefully placed in locations that

could be reached by the majority of rural populations

and became the common destination for anyone with

fever. Thailand created a specialized corps of malaria

workers who could detect malaria with cheap

equipment, dispense antimalarial drugs, and follow-up

with visits to households where necessary. The success

of the program has been the result of thoughtful

application of economical methods in response to

actual risk.1

The usual approach to integration is to combine

methods in hopes of achieving the sum of the effect of

all the actions. It is unusual to truly integrate the

methods into a system that specifically targets

vulnerable aspects of the disease system. For example,

the distribution of repellents during the West Nile

virus outbreak in New York City was done in the hope

that enough people would use the repellent to

supplement aerial spraying, an additive, rather than

integrated, approach. On the other hand, a strategy of

vector control and personal protection in primary

schools in areas of endemic dengue transmission might

limit transmission of the virus in a location where it

travels most easily from family to family. The

systematic study of susceptible stages of institutional

food preparation, and the construction of practical

procedures to protect each susceptible stage, is another

example of true integration of preventive effort.

If we were able to take integration a step further and

apply medical interventions in coordination with

Integrated Disease Management: An Old Idea Ready for Our Time
April – June 2007 15

environmental interventions, we would have true

integrated disease management. However, such

coordination is often made difficult by the lack of an

overall authority in a position to direct cooperation of

the disparate elements that must work in concert to

achieve success. An example of the successful

employment of this structure is the modern US

military, where hierarchical systems have achieved a

large measure of this sort of integration by creating a

small group of empowered experts at the highest level

of an operational theater. Despite the frustration of

relative distribution of resources, imperfect reporting,

and limited tools for intervention, the US military has

sometimes been able to achieve remarkable levels of

health in a deployed theater. One case in point is

Operation Enduring Freedom, when, for a few months

in 2001 and 2002, military personnel scattered from

Uzbekistan to Kenya experienced one of the lowest

rates of disease (in military terms, disease nonbattle

injury) in military history. As shown in the illustration,

the 3rd Medical Command’s force health protection

experts were colocated with the operations cell,

allowing rapid evaluation of situations. The resulting

decisions were accomplished in one location, then

quickly implemented into the flow of operations.

Broader application of the coordination of

environmental health and clinical medicine could

achieve integrated disease management in more areas

and in response to more challenges. In the civilian

environment, the structure to drive the necessary

coordination would likely be the province of local,

regional, and federal governments, as well as private

and autonomous entities like hospitals, mosquito

abatement districts, and contractors. Most

governments already have some responsibilities in

many of the disciplines involved in both

environmental and health interventions. However,

successful integrated disease management will require

tact, skillful diplomacy, and a high level of

management skills to gain cooperation of various

agencies that may already compete among themselves

for resources and areas of overlapping authority. In

most cases it will not be simple or straightforward, but

over the long run the improvements could result in the

conquest of persistent infectious diseases,

improvements in population-level health, and

dramatically reduced costs for society.

REFERENCE

1. Malikul S. The current situation of the anti-malaria

programme in Thailand. Southeast Asian J Trop Med

Publ Health. 1988;19(3):355-359.

AUTHOR

COL (Ret) Strickman is the National Program Leader,

Veterinary, Medical, and Urban Entomology at the US

Dept of Agriculture, Agricultural Research Service,

Beltsville, Maryland.

The group of professionals in the 3rd Medical Command

who managed force health protection during Operation

Enduring Freedom from December 2001 through May

2002. Working under such confined conditions, a

sanitarian, physician, entomologist, veterinarian, and

dentist were able to come to decisions quickly with

consideration of all aspects of health, a process that

approximated a real application of integrated disease

management. The military operations (G-3) function is in

the background, its proximity allowing health protection

decisions to be quickly translated into operational

practice under these conditions.
16 Army Medical Department Journal

The US Army has a long-standing global public health

presence, operating a network of community hospitals

and clinics in rural and urban areas around the world.

It is from these communities that the Army draws the

majority of its civilian work force, and it is these

communities that in turn benefit from well-run public

health programs. In some instances, the Army may be

the most accessible public health presence in these

areas, providing services to the populations that have

supported and lived in harmony with the military for

decades. In addition, many military missions support

uniquely hazardous industrial operations, including

munitions manufacturing and storage; as well as

nuclear, chemical, and biological material storage,

research, and destruction. In a deployed or

humanitarian setting, the Army may be the only formal

public health presence, and is uniquely suited to

support infrastructure rebuilding and/or modernization.

Military preventive medicine assets, the Army analog

of civilian public health departments, are uniquely

suited to operate in this environment.

Since September 11, 2001, the public health threat has

become more complex, stimulating a rapid change in

the practice of public health. Military public health

nurses, environmental scientists, sanitary engineers,

physicians, veterinarians, physician’s assistants,

medical entomologists, health physicists, audiologists,

medics, preventive medicine specialists, and many

others are faced with the monumental task of

responding to this ever-changing environment. The

most efficient way to fulfill the obligation to protect

the public’s health is for military and nonmilitary

agencies to work together and share resources when

dealing with common issues. Collaborative efforts

with local, county, and state health departments, as

well as with schools of public health, are mutually

beneficial and natural. Public health professionals

across all disciplines are now under training to be

experts in a standard set of proficiencies usually

referred to as the Ten Essential Services of Public

Health, shown in the table. These common

competencies promote partnerships, standardize

processes, and streamline communication, thus

providing a more robust assessment of a community’s

health. Overall, partnerships enhance the ability to

protect our communities as the demands on public

health professionals intensify. An illustrative example

of this relationship was evident during a combined

training exercise held in Oklahoma during the summer

of 2005.

Beginning in late 2004, the State of Oklahoma began

planning a statewide mass prophylaxis exercise in

Expanding the Role of Preventive Medicine

in the United States Army: Integration and

Cooperation

LTC James Sheehan, MC, USA

CPT (P) Brent Gibson, MC, USA

MAJ Bryan Sisk, AN, USA

National Public Health Performance Standards Program

Ten Essential Services of Public Health

1. Monitor health status to identify and solve community

health problems.

2. Diagnose and investigate health problems and health

hazards in the community.

3. Inform, educate, and empower people about health

issues.

4. Mobilize community partnerships and action to

identify and solve health problems.

5. Develop policies and plans that support individual

and community health efforts.

6. Enforce laws and regulations that protect health and

ensure safety.

7. Link people to needed personal health services and

assure the provision of health care when otherwise

unavailable.

8. Assure competent public and personal health care

workforce.

9. Evaluate effectiveness, accessibility, and quality of

personal and population-based health services.

10. Research for new insights and innovative solutions to

health problems.
April – June 2007 17

order to upgrade its State Department of Health

preparedness status from amber plus to green. The

exercise was designed to test the state’s response to a

bioterrorism attack, particularly its ability to work with

the Strategic National Stockpile (SNS) and to ensure

the safe, secure, and timely distribution of SNS

medications to the general population. Comanche

County, Oklahoma, was one of 3 major regions

participating in the exercise. This county is home to

Lawton, the fourth-largest city in Oklahoma and the

community that supports the US Army installation at

Fort Sill. The population in the Lawton–Fort Sill area

is 100,000, with approximately half of the population

having ties to the military installation which includes

Soldiers, their Families, and employees working on the

installation.

The Fort Sill Commanding General allowed the base

to participate in the exercise, a first for any

Department of Defense installation. The Fort Sill

planning team consisted of the Public Health

Emergency Officer (the preventive medicine

physician), an Army Public Health Nurse, the

Reynolds Army Community Hospital emergency

planner, and the preparedness planner from the

installation. The team worked closely with the

Comanche County Health Department and the

Oklahoma State Department of Health planners to

Oklahoma State Department of Health News

State Department of Health Bioterrorism Exercise

Scheduled July 12-14

Public Encouraged to Participate

As part of a large-scale effort to test emergency response systems in a public health catastrophic event, the Oklahoma

State Department of Health announced today that a bioterrorism exercise simulating a terrorist release of plague will be

held in three Oklahoma counties next month. The exercise, called Operation Firework Fanfare, is one of the most

ambitious and complex exercises of its kind ever held in Oklahoma.

The exercise, scheduled July 12-14, will be a realistic simulation designed to challenge the state’s response to a

catastrophic health emergency. This simulated event would result in pneumonic plague, a disease that can be transmitted

person to person, in addition to those originally exposed. Such an attack would require a massive coordinated response

to deliver antibiotics to affected persons in the three counties participating in the exercise: Comanche, Oklahoma, and

Tulsa.

A key component of the exercise will be demonstrating the Oklahoma State Department of Health’s ability to request,

receive and distribute emergency supplies from the Strategic National Stockpile. The Strategic National Stockpile can

deliver medicine, vaccine, and antidotes within 12 hours and is maintained by the federal Centers for Disease Control

and Prevention in a constant state of readiness to respond to a public health emergency. On July 12 and 13, the exercise

will focus on the identification of the biologic agent and emergency procedures necessary to request, receive and

distribute supplies from the stockpile to appropriate areas within the state.

On July 14, Oklahoma, Tulsa, and Comanche counties will operate countywide medication dispensing sites to simulate

dispensing antibiotics from the stockpile to mass populations who might be at risk of acquiring pneumonic plague.

“Operation Firework Fanfare will demonstrate what we have accomplished in preparing to respond to a serious public

health threat as well as identifying areas for future improvement,” said State Health Commissioner Dr Mike Crutcher.

“In addition, the exercise will demonstrate the close working relationship between branches of federal, state and local

governments and local first responders in preparing for a bioterrorist attack.”

To help make the exercise more realistic, state health officials are asking Oklahomans to volunteer July 14 as mock

“patients” for the exercise by simulating the types of crowds at medication dispensing sites that might occur in a real

public health emergency. People interested in participating are encouraged to contact the local health departments in

Comanche, Oklahoma, and Tulsa counties.

State partners in the exercise include the Oklahoma Department of Emergency Management, Oklahoma Office of

Homeland Security, Oklahoma Department of Public Safety, and the Oklahoma Department of Transportation. County

health departments participating include the Comanche County Health Department, the Oklahoma City-County Health

Department, and the Tulsa City-County Health Department.
18 Army Medical Department Journal

ensure that the installation and the population it

supported were accounted for in the final SNS

distribution plan. One misconception, identified early,

was the belief that the military has its own version of

the SNS, when, in fact, military installations are

counted as part of the local community by the US

Centers for Disease Control and Prevention. The

establishment of lines of communication with the

surrounding county’s officials clarified this issue and

ensured that the installation received its allotment of

medications and supplies. Ultimately, the installation

was incorporated into the county distribution plan.

During the exercise, the installation established a point

of dispensing (POD) site which expected to dispense

50,000 doses to individuals. Two additional PODs,

established by the county, would dispense to the

remaining local population, as well as to residents

from rural areas and smaller towns in the county. The

expected hourly through-put at each POD site was 750

individuals per hour. The community benefited greatly

from the establishment of the third POD by the

military, as the county was able to position its

dispensing sites further from the center of town. The

third, more centrally located, military venue made it

easier for those living outside of Lawton to receive

their medications from the other 2 PODs. Individuals

benefited from decreased travel time to and from the

sites, as well as from dilution of the crowds at each site

(less wait time, safer environment, and less chance for

exposure from proximity to potential carriers). The

military benefited from this arrangement as well.

Soldiers and their Families did not have to drive

through the city to receive their prophylactic doses;

they only had to travel to the POD closest to their

home.

Despite these benefits, there were several challenges

that posed significant barriers to mission success. For

example, there was a notable lack of interoperability

between communications systems. Military radios

could not communicate with civilian radios and, even

in the community, fire services could not directly

communicate with police agencies. This was not a

novel finding in emergency response, but it prompted

the installation and community to work on acquiring a

single communication system that would allow all

agencies to talk directly to each other. This system,

once operational, will improve the flow of

information, both in a crisis situation and during

routine operations.

Force protection status of the installation was another

important consideration. The immediate reaction by

installation leaders was to significantly restrict access

to the installation to only those personnel on active

duty and their families. In many emergencies, this may

not be necessary. In fact, by the time the installation

was effectively sealed off in this scenario, the disease

process was already established within the base, and

the level of security would undoubtedly delay access

to treatment or prophylaxis, and potentially cost more

lives.

Expanding the Role of Preventive Medicine in the US Army: Integration and Cooperation

At the military points of dispensing, gates, tables, and

high visibility markings were set up to support logical

patient flow and decrease the need for verbal

instruction. This is an important consideration in fastpaced, tense, noisy environments.

Soldiers queue at designated stations to be screened

for allergies to medication. Local, state, and federal

officials observed as 750 Soldiers per hour passed

through the point of dispensing site.
April – June 2007 19

Another area of concern that emerged involves the

respective lines of authority. While the Army has a

well-established command structure that mirrors the

Incident Command System used by the civilians, there

is some ambiguity surrounding the interplay of federal

and state authorities during a domestic emergency. In

most scenarios, the governor is the ultimate authority

within a state and military participation requires that

the installation respond to the instructions and

directives issued by state officials. This is in addition

to following direction and guidance issued by the

military chain-of-command, and the potential therefore

exists for conflict between opposing directives.

One final, yet key, element was that control of the

POD mission was deferred to the military medical

treatment facility (MTF). However, in this scenario,

the MTF was overrun with patients. Consequently,

physicians, nurses, and medics were not available to

staff the POD site. Another perspective, provided by

population-oriented preventive medicine experts, was

that medication distribution would be just as

effectively managed by any number of personnel

under the guidance of public health physicians and

nurses. This approach preserves remaining clinical

providers for those roles which are less easily

delegated, such as diagnosis and treatment of affected

patients.

The Oklahoma State Department of Health exercise is

only one example of military-civilian public health

cooperation. Looking beyond this example, there are

many other military communities where facilities,

supplies, and training of civilian personnel are jointly

exercised. The synergy of local healthcare, public

health assets, and their military equivalents is essential

for successful accomplishment of the overall mission

of protecting the public’s health. Extending even

beyond the boundaries of the United States, these same

principles and skill sets are essential to the

accomplishment of military missions abroad. The

assessment of established public health infrastructure

and cooperation with local officials creates a system

that ultimately impacts the health of the host nation in

a positive manner.

Military preventive medicine assets are uniquely

trained to work with local governments in domestic,

deployed, and humanitarian settings. They provide

training and assistance with assessment of

communities, setting goals, and establishment and

evaluation of interventions in support of the local

governments’ objectives. These efforts not only

contribute to the host communities, but also build

goodwill, permit our forces to gain vital insight into

endemic diseases, and prioritize interventions that

protect the health of the local population and US

forces. Effective oversight of such cooperative efforts

depends heavily on preventive medicine and public

health’s population-based perspective on healthcare.

These components are absolutely essential in assuring

seamless mutual public health support.

AUTHORS

LTC Sheehan is Chief, Community Health Practices

Branch, Army Medical Department (AMEDD) Center

and School, Fort Sam Houston, Texas.

CPT (P) Gibson is the Occupational Medicine

Instructor/Writer for the Community Health Practices

Branch, AMEDD Center and School, Fort Sam

Houston, Texas.

MAJ Sisk is the Deputy Chief, Community Health

Practices Branch, AMEDD Center and School, Fort

Sam Houston, Texas.

Fort Sill, Oklahoma
20 Army Medical Department Journal

How to Stop Fighting Ourselves:

Removing the Stigma of Mental Health

Treatment for Soldiers

Kay Shepard, MSW

ABSTRACT

Soldiers’ fear of stigmatization by peers and superiors is the primary barrier that the US Army must overcome as

a prerequisite to providing successful mental health treatment to Soldiers who have been exposed to the combat

environment. Untreated mental health conditions can lead to increased severity of symptoms and adversely

affect mission readiness. Command leadership must become aware of the effects of combat exposure upon their

Soldiers, and refer Soldiers to behavioral health facilities when necessary, so that their Soldiers are peak

performers and mission ready.

INTRODUCTION

Soldiers’ fear of stigmatization is the primary barrier

that the US Army must overcome as a prerequisite to

providing successful mental health treatment for

combat stress. Soldiers deploy to Operation Enduring

Freedom and Operation Iraqi Freedom (OIF) on a

rotation basis and are repeatedly exposed to the

combat environment. Soldiers are returning from the

combat environment with major depression,

generalized anxiety, and Post Traumatic Stress

Disorder (PTSD). There is a clear correlation “between

combat exposure and PTSD, with greater levels of

exposure leading to greater prevalence.”1Individuals

need treatment for these mental health conditions in

order to be a good spouse and parent in the family

environment and a Soldier who is mission ready.

Soldiers express several concerns with seeking mental

health treatment. A dominant concern is that they

believe it will affect their careers. In 2002, the

Epidemiological Consultation team examined the

circumstances surrounding 5 murders and 2 related

suicides at Fort Bragg. They found that Soldiers

resisted seeking mental health services from military

resources “for fear of jeopardizing their careers.”2

PERCEIVED BARRIERS TO SOLDIERS SEEKING

MENTAL HEALTH TREATMENT

Soldiers’ concern about confidentiality in matters

involving mental health is understandable if they are

receiving information only from peers who are

involuntarily sent to treatment by their commander.

Soldiers hear rumors of the separation of Soldiers from

the Army after visiting Community Mental Health, and

about the chain of command’s involvement with a

Soldier’s attendance for treatment at Social Work

Services (SWS). The first situation could occur if the

commander deems an individual in need of a duty

fitness evaluation. The second situation could occur if

a Soldier is directed to the SWS Family Advocacy

Program because of a domestic violence incident in the

home. Soldiers who voluntarily refer themselves to

either SWS or Community Mental Health receive a

higher level of confidentiality. These Soldiers typically

will not volunteer information to their peers or chain

of command that they are participating in mental

health treatment. Both the Health Insurance

Portability and Accountability Act of 1996 3and

Military Rules of Evidence4preclude the staff at the

behavioral health facility from even acknowledging

the individual’s attendance at treatment, unless the

individual had previously signed a release form

permitting the disclosure of such legally privileged

information. Furthermore, licensed providers working

at SWS are bound to uphold client confidentiality by

the codes of ethics of both the National Association of

Social Workers5and the American Association for

Marriage and Family Therapy.6

Client confidentiality is not absolute. It becomes

limited when someone tells a therapist that they are

going to harm themselves, or another person. In such a
April – June 2007 21

case, the therapist is required to report this danger to

authorities. A review of the status of the psychological

health of Soldiers who are in either the personnel

reliability or nuclear surety programs, or have a Top

Secret clearance, may be required at any time. The

information is disclosed on a need-to-know basis.

According to Hoge,7Soldiers who are most in need of

treatment are the same ones who are most resistant to

seeking help. The respondents in this study thought

they would be seen as weak (65%) or be treated

differently by unit leaders (63%). Soldiers who visit

Schweinfurt SWS repeatedly mention the difficulty

they experience in obtaining time off from their duties

to attend their appointments. On rare occasions,

Soldiers report being humiliated by their superiors

after mentioning a personal appointment at SWS.

Soldiers do not want to appear weak. This fear was the

number one barrier to seeking mental health treatment,

according to Hoge’s study. It is important that the

Soldier be able to receive treatment without pressure

from his peers or superiors. At Ledward Barracks in

Schweinfurt, Germany, all returning units conducted a

90-day postdeployment screening. During this

screening, one Soldier was observed by his peers in the

area sitting in the hallway completing the form. The

Soldier administering the screening summarized the

entire form for the Soldier with words to the effect:

Are you hitting people? You’re okay.

Just mark the form that you’re okay.

The postdeployment screening was poorly

administered because it failed to provide

confidentiality, permitted the influence of peer

pressure, and potentially failed to reach Soldiers that

may have needed mental health services.

Part of being a leader in the Army is to be a role

model. Positive leadership adopts a holistic view of

individuals, and acknowledges the mental and

emotional forces acting upon the Soldiers and the

leaders themselves. Only rarely do leaders publicly

participate in mental health activities. One captain

from Schweinfurt boldly did this by attending and

participating in a Critical Incident Stress Management

Debriefing that he had requested for his Soldiers upon

return from OIF. It takes courage for any Soldier in a

leadership position to be a role model in the field of

mental health treatment. According to COL Thomas

Burke, Director of Mental Health Policy for the

Department of Defense, the chain of command may

elect to remove a Soldier who is receiving treatment

for a mental health condition from a leadership

position.8 While some Soldiers get medals after

receiving physical injuries in the line of duty, a Soldier

whose mental condition is injured and is in need of

treatment because of combat exposure receives no

medals. Rather, that Soldier may suffer further with

diminished promotion opportunities if the perception

of instability remains.

EFFECTS OF UNTREATED MENTAL HEALTH

CONDITIONS

Untreated combat stress or other mental health

conditions can lead to increased symptoms, or an

escalation of the severity of their diagnosis. Examples

of this are evident when untreated combat stress

deteriorates into PTSD, or when substance abuse and

marital difficulties lead to irreversible behaviors such

as suicides and the murders at Fort Bragg. Untreated

mental health conditions affect mission readiness.

Following the Vietnam War, PTSD affected 25% to

30% of the returning veterans. Currently, 15% of those

veterans still suffer from this disorder. World War II

veterans were tested 45 years after returning home. Of

that group, Soldiers who had served in combat areas

had a 13.3% greater risk of having PTSD symptoms

than the Soldiers who had not been in areas involving

direct combat.9

Another consequence of untreated mental health issues

is the prevalence of self-medication. In response to the

stress created by these unresolved issues, many

Soldiers increase their consumption of alcohol. In

reply to the predeployment survey question, “Have

you felt you wanted or needed to cut down on your

drinking?” 12.5% of the Soldiers answered “yes.”

After returning from their deployment to Iraq,

response to the same question increased to a 20.6%

response of “yes.”7 Gerry Warner, Clinical Director of

the Schweinfurt Alcohol and Substance Abuse

Program, provides anecdotal figures relating to the

treatment of individuals referred 90 days after

returning from OIF. Ms Warner stated that about “50%

of our referrals had been to combat and scored on the

moderate to high range on the PTSD questionnaire and

50% of the cases were new Soldiers just getting to

Germany on their first enlistment.” Captains report

that they and their friends are using alcohol to help

them sleep at night (G. Warner, e-mail, 22 February

2006). A Soldier with mental health concerns that uses

alcohol as a sleep aid is not mission ready. Even
22 Army Medical Department Journal

worse, this type of mission impediment does not show

up on the radar of their chain of command and is not

factored into strategic readiness planning. This blind

zone for the chain of command could easily lead to

overestimation of force capabilities and fatal results

when those unready individuals are relied upon in

combat.

TREATMENT OF MENTAL HEALTH

Although known by a variety of names, PTSD has

existed as long as war itself. In World War I, the

effects were called “shell shock.” In World War II and

Korea, it was called combat fatigue or battle fatigue. In

Vietnam, it came to be known as Post Traumatic Stress

Disorder.4In 1980, the American Psychiatric

Association added PTSD to its publication, Diagnostic

and Statistical Manual of Mental Disorders.

10

In World War I, many Soldiers were sent away from

the combat area if it was determined that they were

suffering from shell shock. This resulted in a shortage

of Soldiers. To remedy this, the Army changed

procedures and relocated treatment providers near the

front lines to treat Soldiers and get them back into

combat. The long-term effects of shell shock appeared

to be minimal for those Soldiers treated using this

method who returned to the battle lines.1

Today, the Army has Combat Operational Stress

Reaction (COSR) teams that go to the units. To date,

the effectiveness of these behavioral health teams is

inconclusive. During 2004, SWS conducted mental

health screenings of Schweinfurt Soldiers returning

from Iraq. These Soldiers confirmed that they were

directed to meet with the COSR team after incidents

where they had seen people killed or injured.

However, the Soldiers also stated that they generally

did not report any disturbance to the COSR team

because they did not want to be seen as weak. They

also questioned how helpful it would be to report any

mental health concerns.

During his interview, COL Burke discussed combat

stress control units and the Soldiers whose screenings

identified symptoms requiring treatment performed

near the area of their unit but away from the combat.

In about 95% of the cases, their symptoms were

addressed and they were returned to their units.

According to COL Burke, 70% of the Soldiers sent to

a hospital in Iraq returned to duty, 50% of those

evacuated to Kuwait returned, 10% of those evacuated

to Germany returned, and none of those sent to the

United States returned to the theater.8 The provision of

treatment in the Soldiers’ own environment where they

know they will return to duty, and where they are

assured that their feelings are a normal response to an

abnormal circumstance, allows Soldiers to avoid the

feeling of being adversely labeled with a mental health

diagnosis. This level of treatment introduces Soldiers

to the concept of caring about mental and emotional

health, in addition to their physical health. This

method of treatment may also have the unexpected

benefit of weakening the structure of the barriers to

Soldiers seeking mental health treatment.

Mental health services offered to the Soldier returning

from deployment may vary from post to post. In

Schweinfurt, Soldiers can receive services from a team

of behavioral health professionals including Social

Work Services, Community Mental Health, and

Division Mental Health. Recent history from the

Schweinfurt behavioral health team and collaborating

agencies illustrates the positive effects of mental

health care for Soldiers and Family members. Prior to

the redeployment of Soldiers, SWS, Army Community

Service, and the Family Life Center chaplain met with

every family readiness group and conducted briefings.

Social Work Services (SWS) briefings covered topics

such as: combat stress, possible effects of combat

exposure, effects upon the family, and services offered

by SWS. During reintegration in February 2005, over

18% of approximately 4,900 returning Soldiers were

individually screened or assessed by a professional of

the Schweinfurt behavioral health team. These

Soldiers’ responses to the medical questionnaire

indicated symptoms related to a combat

environment—combat stress, depression, anxiety, or

PTSD. SWS also conducted combat stress group

briefings with every returning Soldier and with some

spouses who joined their husbands during the

reintegration process. Ongoing briefings to battalions,

commands, and units on combat stress and Critical

Incident Stress Management Debriefings continue to

be conducted by SWS upon request. Schweinfurt SWS

saw an increase in Soldiers self-referring for treatment

related to the combat environment. It is typically

difficult to link prevention work with results because it

requires a comparison of the number of events that did

occur with the number of events that would have

occurred in the absence of preventive measures. The

second component of this equation is always an

unknown factor. However, reliable estimates can be

obtained by comparing the local rate of domestic

Removing the Stigma of Mental Health Treatment for Soldiers
April – June 2007 23

violence incidents after deployment to OIF to those of

other military communities with demographically

similar populations. In comparison with locations with

similarly combat exposed populations but less

preventive community outreach, Schweinfurt saw only

a small spike during the first 45 days after troops

returned from Iraq.

One year after their return from OIF as Soldiers again

prepare for deployment, reports of domestic violence

remain at all time lows. Schweinfurt reports zero

incidents among its 6,000 troops during January and

February of 2006. More Schweinfurt Soldiers are

mission ready for the upcoming deployment because

they have taken care of themselves mentally and

emotionally. The many Soldiers who participated in

the Combat Operational Stress Group have done the

smart thing by proactively dealing with emotional

issues while in the safety of the garrison environment,

rather than waiting and being distracted by those

concerns in life or death situations on the battlefield.

They voluntarily attended the Combat Operational

Stress Groups where they talked about their thoughts

and feelings about what they saw, with other Soldiers

who had the same experiences. The Soldiers and their

spouses participated in marital therapy, addressing

issues that came up both during the last deployment

and while the Soldier was home. During an interview,

Steve Robinson, the Executive Director of the National

Gulf War Resource Center stated, “There’s enough

evidence to show that if people get help early and

often, they can recover and continue to fight.”11

RECOMMENDATIONS TO DESTROY THE

BARRIERS

The military should include outreach, education, and

additional easy access to mental health care to address

the barriers.7 Army leaders at all levels should speak

out clearly, decisively, and frequently on the

importance of mental health as a coequal factor with

physical health as a determinant of duty fitness.

Leaders must discourage disparaging comments about

Soldiers who seek mental health treatment with the

same emphasis that they would discourage disparaging

sexual or racial remarks about fellow Soldiers, and

must recognize these comments as similarly harmful

verbal self-attacks upon our own Soldiers.

Information dissemination is a key factor in bulldozing

the barriers. Outreach programs of the medical

command’s behavioral health teams should ensure that

briefings reach entire units. Briefings attended by

everyone from the unit commander to the most junior

Soldier promote development of a cohesive unit

attitude of solidarity towards overcoming mental

health issues. Additionally, since public briefings

about treatment programs do not openly discuss any

individual’s confidential information, officer

attendance can visually demonstrate leadership support

of mental health programs to the enlisted Soldiers

without raising concerns of diminished perceptions of

those officers. Thus, not surprisingly, the first step in

removing the barriers begins with Army leader

participation in behavioral health briefings, leading

their Soldiers by example and participating

themselves. An example of the powerful nature of this

influence can be seen from the events following an

SWS briefing in 2005. At the request of an infantry

battalion, Schweinfurt SWS conducted a briefing on

combat stress and its effects on the Soldier and Family.

The whole battalion, including the commander,

attended the briefing. The following day, Schweinfurt

SWS began receiving calls from those infantry

Soldiers requesting services. The stream of phone calls

continued for several weeks following the briefing.

Proactive outreach services such as Critical Incident

Stress Management (CISM) Debriefings can forewarn

unit personnel of the effects of combat exposure on an

individual’s mental and emotional states, and lead to

early recognition and treatment of these symptoms.

CISM debriefings can be flexibly scheduled, both in

time and location, for maximum convenience of each

unit. The provision of ready access to CISM

debriefings from behavioral health providers can be a

critical factor in lowering the barriers confronting

Soldiers who are deciding whether to seek treatment or

ignore their symptoms. The increase of self-referrals

for treatment and decreased levels of domestic

violence following the implementation of Schweinfurt

SWS outreach programs illustrate the tangible benefits

to the Army. Fewer Soldiers were embroiled in legal

proceedings following domestic violence, and Soldiers

were mission ready sooner because they were

proactive, rather than reactive, in dealing with their

symptoms.

No weapon in the Army’s arsenal is accurate or

sophisticated enough to recognize and override flawed

decisions of an overstressed Soldier. Therefore, our
24 Army Medical Department Journal

most sophisticated and advanced technology has

human emotion as its weakest link. Reason would then

dictate that productive utilization of technological

resources will be maximized by reduction of

counterproductive influences resulting from emotional

distress. To reach this objective, behavioral health

professionals must recognize that barriers which

prevent Soldiers from reaching out to them currently

exist, and compensate with initiatives to reach out to

the Soldiers instead. This direct connection with

Soldiers is only possible when unit level Army leaders

understand the importance of this issue, and take the

final step of using the available behavioral health

resources.

CONCLUSION

To treat combat stress effectively, the primary barrier

that the US Army must overcome is the fear of

stigmatization that Soldiers associate with mental

health treatment. The Global War on Terrorism has

brought to the forefront mental health issues related to

combat exposure. Soldiers are returning from combat

zones in need of treatment for combat stress,

depression, anxiety, and PTSD. Soldiers will continue

to avoid voluntary treatment unless they believe that

they can avail themselves of mental health services

without it affecting their career or causing them to be

viewed as weak by their peers and superiors. Army

leaders must place increased emphasis on reducing the

barrier of that stigma Soldiers fear when seeking

mental health treatment. Command leadership must

 Become aware of the effects of combat exposure

on their Soldiers.

 Be able and willing to refer Soldiers to behavioral

health facilities.

 Invest the duty time necessary to ensure treatment

is accomplished so that their Soldiers are peak

performers and mission ready.

REFERENCES

1. Cozza SJ. Combat exposure and PTSD. PTSD Res Q.

2005;16(1):1-8.

2. Mientka M. Fort Bragg killings investigated. US

Med. December 2002. Available at: http://

w w w . u s m e d i c i n e . c o m / a r t i c l e . c f m ?

articleID=561&issueID=45. Accessed 4 February

2006.

3. Public Law 104-191 Health Insurance Portability

And Accountability Act Of 1996. August 21, 1996:

Available at: http://aspe.hhs.gov/admnsimp/

pl104191.htm.

4. Joint Service Committee on Military Justice. Manual

for Courts Martial United States (2005 Edition).

Washington DC: US Dept of Defense; 2005: Part III,

Section V, Rule 513.

5. Code of Ethics of the National Association of Social

Workers. Washington DC: NASW Press; 2006.

6. AAMFT Code of Ethics. Alexandria, VA: American

Association for Marriage and Family Therapy; 2001.

7. Hoge CW, Castro CA, Messer SC, et al. Combat duty

in Iraq and Afghanistan, mental health problems, and

barriers to care. N Engl J Med. 2004;351(1):13-22.

Available at: http://content.nejm.org/cgi/content/

full/351/1/13. Accessed 17 January 2006.

8. The Soldier’s Heart Interview, Thomas Burke

[transcript]. “Frontline.” PBS television. March 01,

2005. Available at: http://www.pbs.org/wgbh/pages/

frontline/shows/heart/interviews/burke.html.

Accessed 04 February 2006.

9. Spiro SA, Aldwin CM. Combat-related post

traumatic stress disorder symptoms in older men.

Psychol Aging. 1994;9:17-26.

10. Diagnostic and Statistical Manual of Mental

Disorders, Third Edition. Arlington, VA: American

Psychiatric Publishing, Inc; 1980.

11. The Soldier’s Heart Interview. Steve Robinson

[transcript]. “Frontline.” PBS television. March 05,

2005. Available at: http://www.pbs.org/wgbh/pages/

frontline/shows/heart/interviews/robinson.html.

Accessed 19 February 2006.

AUTHOR

Ms Shepard is Chief, Social Work Services at the US

Army Health Clinics in Katterbach and Illesheim,

Germany. At the time this article was written, she

was Chief, Social Work Services, US Army Health

Clinic, Schweinfurt, Ledward Barracks, Schweinfurt,

Germany.

Removing the Stigma of Mental Health Treatment for Soldiers
April – June 2007 25

WHAT IS AN ENVIRONMENTAL HEALTH SITE

ASSESSMENT?

What is an EHSA and why would it be relevant in an

expeditionary Army? These are questions many have

asked. Unfortunately, few can provide a sound answer

to these questions. The answer is not complicated and

does not require years of experience and training.

Simply, the EHSA is designed to protect our deployed

force and document potential exposures resulting from

their deployment. The EHSAs are living documents

that describe environmental and health conditions at

deployed locations. They identify, describe, and

document potentially complete and completed

exposure pathways. This article provides an overview

of the EHSA process, the site assessment, and the final

report in order to demystify the EHSA process and its

usefulness to preventive medicine personnel.

The objective of the EHSA is to identify complete and

potentially complete exposure pathways at deployment

sites that may affect the health of deployed personnel.

Data generated from the EHSA is used to conduct

operational (composite) health risk estimates. The

EHSA process consists of 5 components:

predeployment activities, site reconnaissance,

conceptual site models, environmental sampling, and a

report to document findings.

The need for a standard methodology for documenting

environmental conditions at deployed locations first

became evident after Operations Desert Shield/Storm.

However, it was not until the US involvement in the

Balkans that the need for a methodology to document

environmental conditions that may affect health were

required. This documentation had to be separate from

the existing environmental baseline survey conducted

by the Army Corps of Engineers. The Joint

Environmental Surveillance Working Group (JESWG)

recognized the need for a standard practice among the

military services and the methodology to document

environmental health conditions at deployment

locations. Although some deployment environmental

surveillance was conducted, it was not necessarily a

systematic, scientifically based methodology that was

recognized by all services. In 2003, the American

Society of Testing and Materials (ASTM) International

published the Standard Guide for Environmental

Health Site Assessments for Military Deployments.

1

This was the result of a joint effort championed by the

JESWG. The publication of this methodology through

the ASTM provided a peer-reviewed, third-party

accepted standard that is scientifically defensible.

DoDI 6490.03 2provides implementation guidance for

Environmental Health Site Assessments. Although the

1997 version mentioned the need to document baseline

Demystifying the Environmental Health

Site Assessment

LTC Timothy G. Bosetti, MS, USA

ABSTRACT

At the request of the Multinational Corps-Iraq (MNC-I), the US Army Center for Health Promotion and

Preventive Medicine deployed a Special Augmentation Response Team-Preventive Medicine to support

MNC-I and preventive medicine assets in Iraq in order to complete environmental health site assessments

(EHSAs) for major forward operating bases. Prior to the mission, there was a lot of concern from the field on

what constituted an EHSA and how to conduct one. The EHSA is a living document that describes

environmental and health conditions on a forward operating base. It identifies, describes, and documents

potentially complete and completed exposure pathways. The 90-day mission involved conducting 2 iterations

of EHSA training to preventive medicine detachments and brigade combat team Environmental Science and

Engineering Officers, conducting site assessments of major forward operating bases in Iraq, and completing

over 25 EHSA reports. This article provides an overview of the EHSA process, the site assessment, and the

final report in order to demystify the EHSA process and its usefulness to preventive medicine personnel.
26 Army Medical Department Journal

conditions and conduct environmental baseline studies,

specific guidance on the EHSA was not available. As a

result, policy guidance from the Joint Staff did not

specify the need to conduct an EHSA. The Joint Staff

memorandum has been updated to incorporate specific

language that requires EHSAs.

As base camps began to appear all over Iraq, the need

to document existing environmental conditions arose

again. Although some EHSAs were conducted, it was

not a standard practice. In 2005, the US Central

Command (CENTCOM) Surgeon’s staff exerted

pressure to have EHSAs conducted at all troop

locations within the CENTCOM area of responsibility.

This high-level push, quoting nebulous third-party

agencies and Department of Defense-level

requirements, resulted in the belief that EHSAs were

beyond the capabilities of preventive medicine assets

in theater. From there, the mystery surrounding the

EHSA grew. Concerns were that the EHSA was a

burden to theater preventive medicine assets—a

boulder in their already full rucksack. However, in

reality, the EHSA is nothing more than packaging

what is already done by field preventive medicine

personnel at all levels of support.

In November 2005, the US Army Center for Health

Promotion and Preventive Medicine (USACHPPM)

received a mission request from the MNC-I to conduct

EHSAs for the major forward operating bases (FOB)

in Iraq and to train preventive medicine personnel on

the EHSA process. The USACHPPM Special

Augmentation Response Team-Preventive Medicine

(SMART-PM) consisted of personnel from both

USACHPPPM Headquarters and Europe with

specialties in environmental engineering, industrial

hygiene, public health, and 2 preventive medicine

technicians.

In January 2006, the team deployed to Iraq to begin its

mission. Two training classes were held at Camp

Anaconda, Balad, Iraq. Over 40 preventive medicine

personnel from the Army and Air Force were trained.

Upon completion of training, the team moved around

the theater, visiting the major FOBs, providing

additional EHSA training, and completing the EHSAs

for each major FOB. Within 60 days, the USACHPPM

SMART-PM had completed 25 EHSAs, which

included not only the major FOBs but several satellite

camps and camps designated for closure. While exiting

the theater, the team stopped in Kuwait and provided

EHSA training to preventive medicine personnel in

Kuwait.

PREDEPLOYMENT ACTIVITIES

Predeployment activities for an EHSA are the same as

those for preparing for deployment or mission. In

preparation for deployment, preventive medicine

personnel identify the medical threats to deployed

forces. The threats can be in the form of environmental

stressors, endemic diseases, vector-borne diseases,

environmental and industrial contamination. The

predeployment activities related to the EHSA are not

different from those already performed by preventive

medicine personnel.

WHERE DOES THE INFORMATION COME FROM?

There are many sources of information. Among the

commonly known are the Armed Forces Medical

Intelligence Center, the Central Intelligence Agency

World Fact Book,3and the World Health

Organization. These are typically used to develop

medical threat briefings and preventive medicine

estimates of the situation for a deployment. Most are

aware that the USACHPPM Deployment

Environmental Surveillance Program is a great

resource for gathering health information papers and

products, and medical threat briefings. However, the

USACHPPM also has a resource that can be used to

develop the preventive medicine operational picture

for the deployment location. This capability is called

the Global Threat Assessment Program (GTAP). The

GTAP can provide a Phase I Deployment

Demystifying the Environmental Health Site Assessment

EHSA Process

EHSA ORM

Preliminary

Hazard

Analysis

Risk

evaluation

Risk analysis

and other

ORM

components

Report

CSM 1

CSM 2

CSM 3

CSM 4

Pre- Deployment

Activities

Site Recon

and

Interviews

Sampling

EHSA Process1

Predeployment

Activities
April – June 2007 27

Occupational and Environmental Health Risk

Summary that includes an overview of the site and

geographic location, samples collected, potential

hazards in the area, surrounding industries, and

potential medical threats.

There are several sources of information for preventive

medicine personnel from which to gather data

concerning the deployment site. All of these

information sources should be used to develop the

preventive medicine estimate of the situation to

identify the potential medical and health threats. That

estimate can then be used to develop the medical threat

brief, and serve as the background research for your

EHSA and the foundation for the development of the

conceptual site models.

CONCEPTUAL

SITE MODELS

The conceptual

site model (CSM)

is a graphical

representation of

a n e x p o s u r e

pathway for a

contaminant of

c o n c e r n . I t

describes how a

contaminant of concern moves through the

environment (air, soil, and water), identifies the

activities that could result in potential exposures, and

identifies the potential routes of exposure. Although

that process sounds complicated, it is actually quite

simple.

First is the identification of the contaminants

of concern. This comes from the

predeployment activities and the medical and

health threats that were identified.

Second is the determination of how the

contaminant exists in the environment. This

is nothing more than identification of the

physical properties of the contaminant of

concern and how it exists in the environment:

liquid, solid, or gas. The physical properties

determine how the contaminant of concern

behaves and moves through the environment,

and how it enters the human body: dermal

contact, ingestion, or inhalation.

Third is the determination of what, if any, activity will

result in an exposure to the contaminant of concern.

This is critical, if there is no route of exposure, there is

no exposure. Remember that time, distance, and

shielding determine the amount of exposure. After the

route of exposure has been identified, we need to

assess the potential routes of exposure: dermal contact,

ingestion, or inhalation.

Finally, in the conceptual site model, we make an

assumption as to whether that exposure pathway ends

with a human receptor. This model, or conceptual

exposure pathway, remains until we can validate,

through sampling, whether it exists as a complete

exposure pathway, a potentially complete exposure

pathway, or an incomplete exposure pathway, ie, no

exposure.

The conceptual site model assists in answering the

following questions:

 What are the contaminants of concern and what

is the source of contamination?

 How does the contaminant exist in the

environment?

 How are deployed forces exposed? What is the

activity that causes their exposure?

 What is the exposure route: dermal, ingestion, or

inhalation?

 Is there a completed exposure pathway?

That last question is key—is there a completed

exposure pathway? That is what we as preventive

Exposure Pathways

Water

Deposition Inhalation

Ingestion

Soil

Ingestion/

Dermal Absorption

Dermal Contact

Air

Deposition

Source Pathway Receptor

Deposition

Potential Exposure Sources

Hazardous material/waste

storage areas

Motor pools

Existing contamination & spills

Industry

Fuel storage areas

Waste disposal areas
28 Army Medical Department Journal

medicine professionals are attempting to determine,

and answer. We answer that by using the CSM

developed for a contaminant of concern and

developing a sampling program to determine whether

that exposure pathway is completed and if there is a

human exposure.

The CSM should be used to develop the sampling and

analysis plan (SAP) for the deployed site. The SAP

should be discussed in the EHSA report (typically in

paragraph 5), or it can be detailed as an appendix to

the EHSA. Either way, the SAP should provide a

description of the objectives for the sampling and the

rationale for conducting the sampling. The purpose of

the sampling is to document

environmental conditions to

v a l i d a t e t h e C S M a n d

characterize potential exposure

pathways. But what does that

really mean?

Any sampling done at the site

should have a purpose, and that

purpose should relate back to the

CSM. The CSM shows how a

contaminant moves through the

environment (air, soil, and water)

and to a human receptor through

an exposure pathway (ingestion,

dermal contact, or inhalation).

The sampling to be conducted

should focus on those exposure

pathways to determine whether

they are potentially complete or

complete exposure pathways. The

goal is to answer the question:

does that contaminant exist at a

concentration which can pose a health threat to

deployed forces? The more detailed the sampling plan,

the less opportunity for oversight or misunderstanding

during the sampling, analysis, and data management.

The confidence in which you can answer that question

is related to the detail in the CSM and SAP.

SITE RECONNAISSANCE AND INTERVIEWS

Information from site reconnaissance and interviews is

important to verify information collected during the

predeployment activities, answer questions about the

site, and identify information that was not previously

known. In most cases, the ground truth can be very

different from what was thought from a thousand miles

away. Therefore, it is important to stay objective and

make a list of questions that must be addressed once

you are on the ground. There are many checklists

available from doctrinal manuals, technical guides, and

references. Any of these can be used.

However, the best means of both gathering

information on the site and conducting the site

reconnaissance is through the performance of normal,

routine preventive medicine inspections. As preventive

medicine professionals, there are a variety of routine

inspections and surveys that we conduct that, when

evaluated holistically, develop the site picture better

than any checklist. Individually, these routine

inspections may not seem significant, however, when

combined and compared to other inspections, surveys,

and reports, the resulting data can be used to identify

commonalities between potential exposures. Looking

at these inspections across the continuum of preventive

medicine support may also help identify what should

be accomplished for Deployment Occupational and

Environmental Health Surveillance (DOEHS)

sampling.

Demystifying the Environmental Health Site Assessment

CONCEPTUAL SITE MODEL

LEAD INDUSTRIES IN MITROVICA, KOSOVO

Example of a conceptual site model developed for a prior deployment into a

potentially contaminated area of operations.

Lead

Industries

Smelting

Batteries

Mining

Air

Soil

Water

Particulate emissions

Volatilization (smelting)

Digging

Agricultural activities

Local wells and

surface water

Wind-blown dust

Leaching/runoff

Inhalation Yes

Dermal Contact No

Ingestion No

Inhalation No

Dermal Contact No

Ingestion Yes

Inhalation No

Dermal Contact Yes

Ingestion Yes

POINT OF

EXPOSURE

ROUTE OF

EXPOSURE

HUMAN

RECEPTOR

ENVIRONMENTAL

MEDIA

SOURCE
April – June 2007 29

DEPLOYMENT OCCUPATIONAL AND

ENVIRONMENTAL HEALTH SURVEILLANCE

SAMPLING

There is a link between the conceptual site model and

the sampling and analysis plan. The sampling plan

should be based upon the conceptual site model and

should support your conclusion. In the conceptual site

model, we make an assumption as to whether that

exposure pathway ends with a human receptor. This

model, or conceptual exposure pathway, remains until

we can validate, through sampling, whether it exists as

a complete exposure pathway, a potentially complete

exposure pathway, or an incomplete exposure

pathway— no exposure.

Many of the baseline requirements for DOEHS

sampling are identified in policy guidance documents.

The minimum requirements for environmental

sampling should identify the existing site

characteristics and potential areas of contamination. It

should be evaluated frequently to ensure that the

correct data is collected and adjusted to cover areas

that need more attention. The baseline requirements

should remain centered on the conceptual site models

and potential exposures.

Archiving data collected is important, however, most

people only focus on the significant findings or

research the data if there is a problem. Although these

are important, the most important piece of data and

inspection report is the one of negative findings. We

often overlook these reports because there was nothing

of note, however, these complete the picture of

deployment exposures. They are the missing data link.

We can identify when there is a problem, but what

about the other 99% of the time? Were there any

issues? Without the complete picture we will never

know. This is why it is important to document your

findings, both positive and negative. The EHSA

provides a standard format for documenting conditions

at a deployment site.

DOCUMENTATION: THE EHSA REPORT

The ASTM standard1provides a basic format for the

EHSA. This is a suggested format. The conditions on

the ground or the nature of the operation may require

modifications to the suggested format. Changing the

format is acceptable. The emphasis and goal is on

documentation of the data; not ensuring that you

followed the format. The major components do not

necessarily change, however, the details will vary

depending on the deployed site.

The EHSA is and must be a living document. Just as

we do not conduct an initial inspection and never

return to ensure things are still meeting the standard,

we should never complete an initial EHSA and file the

document away. It should be revisited frequently to

ensure that there are no changes and to update findings

based upon newly discovered information. The same

applies to the conceptual site models and exposure

pathways. Are they still valid? Are there changes to

the mission or situation that potentially affect the

assumptions or route of exposure? Only through

routine review can such issues be addressed.

Archiving the EHSA can also provide a later rollup of

the preventive medicine activities conducted at a

deployed location. It can serve as an historical report

and a transition book for the upcoming rotation.

CONCLUSION

The DOEHS sampling should be conducted at all

major FOBs and other troop locations. Documentation

of baseline conditions and routine surveillance should

continue in accordance with current DoD guidelines

and policies (eg, DoDI 6490.03 2). The EHSA provides

the means and an approved standard for the

documentation of baseline conditions and potential

exposures to deployed forces. It can also serve as a

EHSA Report Format1

Introduction

Site Description

Information Sources

Information from Site Reconnaissance

Environmental Sampling Data

Conceptual Site Models

Conclusion

Findings and Recommendations

Technical Assistance

Appendices

References

Photographs

Site Maps

Sample Locations

Analytical Data
30 Army Medical Department Journal

tool for preventive medicine units and personnel

during their transfer of authority by providing

documentation of environmental conditions and

potential issues at each base or support area. The

EHSA is not a complicated or mystical process that

requires an advanced degree. It is designed to be a tool

for all preventive medicine personnel, and provide a

standard, logical process for our profession to

document what we already do to protect the health of

deployed Soldiers, Sailors, Airmen, and Marines.

REFERENCES

1. American Society for Testing and Materials

International. ASTM E2318-03: Environmental

Health Site Assessment Process for Military

Deployments. West Conshohocken, PA: American

National Standards Institute; 2003.

2. Department of Defense Instruction 6490.03:

Deployment Health. Washington, DC: US Dept of

Defense; August 11, 2006.

3. The Central Intelligence Agency. The World

Factbook. Available at: https://www.cia.gov/cia/

publications/factbook/index.html.

AUTHOR

LTC Bosetti is Chief, Environmental Engineering

Division, US Army Center for Health Promotion and

Preventive Medicine-Europe, Landstuhl, Germany.

Demystifying the Environmental Health Site Assessment

Archiving Data and Reports

SUBMIT DIRECTLY TO DOEHRS DATA PORTAL

http://doehrswww.apgea.army.mil/doehrs-oehs/

Any user with a military (.mil) domain email

address

DOEHS DATA SUBMITTED VIA EMAIL

Data may be submitted to the following address

Unsecured: oehs@apg.amedd.army.mil

or

Secure: oehs@usachppm.army.smil.mil

DOEHS DATA SUBMITTED VIA MAIL

Deployment Data Archiving and Policy

Integration Program

USACHPPM ATTN: MCHB-TS-RDD

5158 Blackhawk Road

Building E-1675

Arlington Proving Grounds, MD 21010-5403

FAX: (C) 410-436-2407 DSN 312-584-2407
April – June 2007 31

Warfighters need ample supplies of safe, drinkable

water to fight and win on the battlefield. In cases

where they do not have access to drinking water

provided by military sources, they must rely on

emergency individual water purifiers (IWP) to meet

their drinking water needs. Current military-issued

emergency water purifiers work slowly, and may

produce microbiologically unsafe water. Commercial

vendors have marketed alternate purifiers to the

military, but none have been systematically tested by

military agencies.

To remedy these shortcomings and to better protect

Warfighter health, the US Army Center for Health

Promotion and Preventive Medicine’s (USACHPPM)

Water Supply Management Program recently

performed an in-depth performance and health risk

assessment of commercial off-the-shelf individual

water purifiers in order to develop simple, direct

recommendations for the Warfighter. The

USACHPPM has presented the results of this study,

and created an internet accessible database of

commercially available IWPs.*

PROBLEM BACKGROUND

Water supply obviously remains a critical requirement

for force sustainment on the battlefield—Warfighters

need ample supplies of safe, drinkable water to fight

and win. Emergency IWPs are an important

component of water supply. Currently fielded

individual water purification options for the

Warfighter include iodine tablets and chlor-floc

tablets. Neither method fully meets the needs of

modern Warfighters in terms of ease of use, volume of

water produced, or confidence that the final product is

microbiologically safe. Many small, hand-operated

water purifiers, including both filtration and

disinfection-based devices, have been commercially

developed in recent years for campers and hikers.

Although military units have used unit funds to

purchase commercial purifiers for deployments (in

some cases individual Warfighters have even

purchased their own purifiers), their selections have

been primarily based on packaging and marketing,

rather than a science-based, systematic assessment of

device performance in a military environment. Lack of

such an assessment has placed the Warfighter at risk of

contracting waterborne diseases through the ingestion

of waterborne pathogens. The USACHPPM

recognized this risk through the many requests from

deployed units and individuals for recommendations.

Its resulting assessment was sponsored by the office of

the Deputy Assistant Secretary of the Army for

Environment, Safety and Occupational Health, and

then funded by the Army Study Program.

RESULTS

No matter the methodology employed, ultimately the

IWP must provide safe drinking water. In evaluating

the safety of IWP-produced drinking water, the

USACHPPM study made exposure assumptions

regarding population and duration. The study team

Water Purifiers for the Warfighter

MAJ William J. Bettin, MS, USA

*http://usachppm.apgea.army.mil/WPD/
32 Army Medical Department Journal

assumed that only the deployable military population

would use the IWPs, and that this population would

only use them infrequently and for short periods of

time. Based on these 2 assumptions, the most

significant risk to Warfighter health in using an IWP is

the risk from ingesting water-borne microbial

pathogens. Thus we evaluated an IWP’s ability to

provide safe drinking water in terms of its ability to

reduce the number of active pathogens in water to a

safe (noninfectious) level.

For our test standards we used the test protocol metric

widely accepted in drinking water science and in the

drinking water industry: a safe level of pathogen

removal equates to 6-log (99.9999%) removal of

bacteria, 4-log (99.99%) removal of viruses, and 3-log

(99.9%) removal of parasitic cysts. Thus a “best” IWP

should meet this pathogen removal metric. The study

found that few commercially available IWPs could

meet this metric. Most commercial IWPs reduce

pathogens based on one of two primary mechanisms,

either filtration or disinfection. Each has inherent

technology limitations to meeting the best pathogen

reduction metric.

Filter-based IWPs reduce pathogens in water through

size exclusion. They generally do well at reducing the

larger pathogens, bacteria and cysts, from water, but

do not reduce the smaller viral pathogens to safe

levels. Many filter-based IWPs evaluated in this study

could successfully remove bacteria and cysts. A small

number also showed promise of viral reduction

through adsorption on a proprietary filter medium, but

require further independent testing to verify the

capability. One filter-based IWP was commercially

packaged with disinfectant drops as a second

purification step, and successfully met the best purifier

pathogen reduction metric.

Disinfectant-based IWPs kill or inactivate microbial

pathogens in water, thus rendering them noninfectious.

Chemical disinfectants generally reduce bacteria and

viruses well, but struggle to reduce the tougher, more

chemically resistant parasitic cysts to safe levels. Even

at high chemical dose and long treatment time, IWPs

based on chlorine or iodine could not safely reduce

cryptosporidium, the toughest of the pathogens.

However, at proper dose and treatment time, the

chlorine dioxide-based IWPs could kill

cryptosporidium and meet the best IWP metric for

pathogen reduction.

Beyond reducing pathogens, a best IWP also had to be

small and lightweight, purify quickly, purify turbid

(cloudy) waters, not make the water smell or taste bad,

be simple to use, and be durable under field

conditions. The study found that choosing a best IWP

involves inherent tradeoffs between these

characteristics because no single IWP received the

highest rating for each. The required tradeoff is usually

based on the primary pathogen-reducing technology of

the IWP, either filter or disinfectant. For example,

disinfectants are inherently small, lightweight, and

simple to use, but purify slowly and leave water with

an unpleasant chemical smell and taste. Filters purify

quickly and can reduce bad tastes, odors and turbidity,

but are bigger, heavier, and more complex to use than

disinfectants.

Overall, the study team assessed 68 IWPs produced by

27 different manufacturers. Of these, 53 used filtration

as the primary means of pathogen reduction while 15

used disinfection. The results were packaged by

USACHPPM and made available as a web-based IWP

decision tool* to help Warfighters make IWP choices

that better protect their health. This decision tool

contains a comparative, searchable, relational database

of the technical specifications, operating

characteristics, and the pathogen removal capabilities

of available commercial IWPs as evaluated by

USACHPPM.

DATA COLLECTION AND EVALUATION

To identify and collect IWP data, the USACHPPM

study team conducted an extensive market survey of

commercially available IWPs that could be purchased

by units or individual Warfighters. As part of this

survey, the team attempted to contact all identified

IWP manufacturers to request detailed technical

information and performance test data. Manufacturers

were informed of the nature of assessment as the basis

for the request. Only publicly available product

information was collected for the IWPs of those

manufacturers that did not respond.

The evaluation of IWP pathogen reduction capability

by USACHPPM was a key part in the development of

database information. Laboratory testing results were

critical to a high-confidence evaluation of this

capability. The study team made deliberate and

Water Purifiers for the Warfighter

*http://usachppm.apgea.army.mil/wpd/comparedevices.aspx
April – June 2007 33

exhaustive efforts to locate and review all available

laboratory test results showing device efficacy at

pathogen reduction. The team evaluated the quality of

test data based on these characteristics:

1. How closely the testing followed an applicable

test protocol

2. The degree of independent, third-party status of

the testing organization

3. The degree to which testing was conducted in

accordance with manufacturer-specified device

operating conditions

4. The degree to which testing was device-specific,

versus based on technology or product family

similarities

EXPERT PANEL SUPPORT AND

MULTIATTRIBUTE ANALYSIS

As part of this study, USACHPPM also developed

specific scenario-dependent recommendations for best

IWPs. The study team developed these

recommendations through an operational analysis,

followed by a multiattribute decision model analysis

performed by 2 multiservice, interdisciplinary,

intradepartmental expert panels. To facilitate the

decision analysis, USACHPPM also added decision

analysis experts to the study team.

To verify USACHPPM’s operational analysis and to

develop the decision model, the study team first

convened a panel of multiservice combat developers,

material developers, and logisticians as userrepresentative experts. The panel included

representatives from the US Army Infantry Center,

Directorate of Combat Developments; the Marine

Corps Combat Development Command; the Army G4;

and the Product Manager, Petroleum and Water

Systems. This expert panel developed a decision

model, shown in the Figure, that identified, defined,

and weighted the 12 most important IWP

characteristics required for the best IWP.

Next, the study team convened a panel of multiservice

water scientists, engineers, and preventive medicine

personnel as technical experts to evaluate IWPs

against the decision model. In addition to the

USACHPPM in-house experts, this panel included

representatives from the US Army Tank and

Automotive Research, Development, and Engineering

Center; the US Army Natick Soldier Research,

Development, and Engineering Center; Naval Sea

Systems Command; Naval Facilities Engineering

Command; and the Air Force Institute for Operational

Health. They developed consensus characteristic

scores for each IWP. Because there were incomplete

data for some IWPs, the expert panel’s knowledge,

experience, and professional opinion were critically

important in technical evaluation to generate IWP

characteristic scores.

Overall scores were then calculated using a linear

additive approach, in which the converted score for

each characteristic was multiplied by its weight, and

then summed for all model characteristics.

TEST PROTOCOL DEVELOPMENT

As part of this study, USACHPPM also developed an

IWP test protocol. The study team found that there was

no single, accepted performance measure by which to

assess and compare IWP pathogen removal

performance in military operations. Incorporating

lessons learned from its technical expert panel and

building on related test protocols, the study team

developed a military-oriented IWP test protocol to be

that single, comparable measure of IWP performance.

The significant and unique military-specific

components developed for this protocol included:

1. A list of desirable characteristics and operational

capabilities that impact device suitability for use

in various emergency military field scenarios.

The USACHPPM decision model used to identify,

define, and weight the 12 most important characteristics

required for the best individual water purifier.

BEST INDIVIDUAL

WATER PURIFIER

Remove

Taste/Odor

Reduce

Turbidity

Reduce

Pathogens

Purify

Quickly

Small

Resist

Clogging

Function

Indicator

Lightweight

Easy to

Use

Durable

Simple

Storage

Long

Shelf Life

Performance Operational Logistics

DECISION MODEL
34 Army Medical Department Journal

2. The specification that the IWP manufacturer or

vendor, together with the equipment testing

organization, produce a written, device-specific

test plan and forward it for review to the

government review agency before testing.

3. An updated discussion and specification of the

selection of microorganisms for performance

testing.

The study team then engaged NSF International (Ann

Arbor, Michigan 48113, 734-769-8010), a recognized,

reputable, third-party entity specializing in standards

development, product certification, education, and

risk-management for public health and safety, to

publish the protocol as “NSF Protocol P248

Emergency Military Operations Microbiological Water

Purifiers” (Available at: http://www.nsf.org/business/

newsroom/nsfremarks/reMarks-spring06.pdf, page 2).

CONCLUSION

The USACHPPM has successfully performed an indepth performance and health risk assessment of

commercial off-the-shelf individual water purifiers in

order to develop simple, direct recommendations for

the Warfighter. In meeting this project’s objectives,

USACHPPM continues to support the Global War on

Terror, sustaining a campaign-capable expeditionary

Army through providing the means to assess and

identify safe, effective commercial water purifiers for

emergency individual use. It has also supported Army

Transformation by identifying sustainment enablers

for the Future Force concept of extended autonomous

operations.

Water Purifiers for the Warfighter

AUTHOR

MAJ Bettin is Chief of the Field Water Section, Water Supply Management Program, at the USACHPPM, Aberdeen

Proving Ground-Edgewood Area, Maryland.
April – June 2007 35

A Guide to Brigade-Level Preventive

Medicine: Stryker Brigade Experience in

Operation Iraqi Freedom II & III

CPT Stephen A. Lewandowski, MS, USA

CPT Jason B. Faulkenberry, MS, USA

INTRODUCTION

The transformation of traditional Army brigades into

modular brigade combat teams (BCT) brings an

environmental science and engineering officer (ESEO)

and preventive medicine specialist (military

occupational specialty (MOS) 68S) to the brigade

level. Prior to 2004, doctrine provided organic

preventive medicine capabilities at division level or

higher. The formation of Stryker brigade combat teams

(SBCT) first tested this change, designed to improve

force health protection and make the units more selfsustainable. The 3rd Brigade, 2nd Infantry Division

(3/2) SBCT and the 1st Brigade, 25th Infantry

Division (1/25) SBCT were the first Stryker brigades

to deploy, serving from fall 2003 to fall 2005,

primarily in Nineveh province in northern Iraq.

Due to this restructuring, the inexperience of many

junior ESEOs and MOS 68S personnel filling these

authorizations, the wide scope of defined

responsibilities, and limited training time prior to

deployment, a potential exists for underutilization or

misuse of the BCT preventive medicine section. This

article provides a general overview and focus to new

preventive medicine personnel and informs

commanders and medical planners of their expected

roles and value to the organization.

BACKGROUND

The BCT preventive medicine section is authorized 2

entry-level personnel, one each of MOS 72D and a

68S10. It is frequently a first assignment for the

Medical Service Corps officer who may be direct

commissioned with little experience in the Army. The

officer will have a degree in a science-based field and

may have attended a 9-week specialty training course,

Principles of Military Preventive Medicine, following

Officer Basic Leadership Course.

Both the ESEO and the chain of command must have a

solid understanding of the expected roles and

responsibilities for the position. Field Manual 3-90.6,

1

which describes tactics, techniques, and procedures for

the tactical employment of the BCT, states simply that

the preventive medicine section assists unit

commanders through sanitary inspections of food

service, latrines, and shower points; medical

surveillance of field water supplies; and sample

collection for potential toxic industrial materials. DA

Pamphlet 40-11,

2

used with Army Regulation 40-5,

3

states that the section provides level II support by

means of basic field sanitation, unit field sanitation

team training, field screening and presumptive analysis

of water supplies, basic pest management and

surveillance, focal application of pesticide, and limited

medical surveillance. Field Manual 4-02.17 4lists a

similar scope of services (discussed as division

preventive medicine since the regulation was written

prior to the development of brigade combat teams).

Although the listed responsibilities alone account for a

full workload for preventive medicine when applied

across the brigade operational environment, they are

not all-inclusive. Most significantly, the preventive

medicine team must consider their role in conducting

occupational and environmental health surveillance to

characterize long-term health threats. With

consideration of this wide range of preventive

medicine objectives and the importance of

implementation, coordination and communication

become critical.

COORDINATION

Coordinating the brigade preventive medicine mission

can be a complicated task for the ESEO. The ESEO

has to work through proper command and technical

chains of multiple levels of support. The SBCT

preventive medicine section falls under the brigade

support medical company (BSMC) as part of the
36 Army Medical Department Journal

brigade support battalion (BSB). The BSMC

commander is responsible for operating a level II

medical treatment facility and providing health service

support to all units in the brigade, while the BSB

commander provides the core of sustainment for the

brigade. These leaders have many other pressing issues

and may have to be convinced of the magnitude of

preventive medicine priorities. The level of support of

the chain of command has a great impact on the

ESEO’s ability to execute the mission, especially when

it comes to avoiding overstrain of additional duties.

The extra assignments will always be present in the

BSB, with many company-grade officers already

pushed out to combat repair teams and a constant need

for bodies in the guard towers and the motor pool. On

the technical side, the ESEO’s relationship with the

brigade surgeon is vital. The brigade surgeon serves as

the primary advisor to the brigade commander on the

health of the brigade. The BCT surgeon section (BSS)

integrates the health service support plan with the

brigade maneuver plan. Another important contact for

mission planning is the support operations office

medical operations officer, also part of the BSB. The

support operations office manages support operations

and is a key interface with supported units.

COMMUNICATION

The difficulty of communication is compounded while

supporting the brigade in a noncontiguous area of

operations. With the advanced in-theater mobility of

the SBCT, the ESEO may have Soldiers to support at a

dozen locations or more at distances of over 250 km

away. Furthermore, contact with key leaders may be

limited by the separation of forward operating bases

(FOBs). In Operations Iraqi Freedom II & III, the

SBCT BSB and brigade headquarters were based on

opposite sides of the city of Mosul. This separation

made communication with the BSS more difficult and

was a hindrance to involvement with medical planning

for future operations and influence on the command.

However, a location in proximity of the BSB provided

the advantage of available transportation through

logistics packages and a greater ability to monitor the

distribution of preventive medicine supplies

throughout the brigade. The BSB also contains field

feeding teams and water purification units that work

closely with preventive medicine personnel.

Communications above the BCT level are necessary

for situational awareness and support agreements. For

technical preventive medicine support, this included

communications with preventive medicine

detachments assigned in the region, preventive

medicine officers assigned to Multinational CorpsIraq, and the US Army Center for Health Promotion

and Preventive Medicine (USACHPPM). Assets from

the 224th and 793rd Medical Detachments, although

widely dispersed and limited, conducted valuable

base-camp assessments in our sector as part of their

mission. An Area Medical Laboratory may also be

available for support. The next higher headquarters for

our SBCTs in Mosul were Task Forces Olympia and

Freedom, consecutively. In our situation, neither Task

Force Surgeon had an assigned preventive medicine

staff, and consequently worked directly with us on

preventive medicine issues.

The method of communication within the brigade can

also have a big impact on how the preventive medicine

mission is received. It is preferable to transmit

necessary preventive medicine measures as part of an

operations or fragmentary order than to send

memoranda of recommendations. Company

commanders and first sergeants will make the effort to

comply with the order, whereas a memo with

suggestions from a lieutenant in the medical company

is more likely to be lost to higher priorities. It is in the

ESEO’s best interest to keep both the command and

technical chains well informed of activities and to

provide courtesy copies of reports at multiple levels. It

is not easy to respond to so many parties, but, on the

other hand, these contacts can provide supplies,

transportation, and authority. The level of interaction

with the different sections (eg, the support operations

office or BSS) will vary with each ESEO and BCT

depending on individuals’ personalities, backgrounds,

abilities, and emphasis on preventive medicine. These

relationships are important since they determine how

the preventive medicine perspective is accepted, as

well as the degree of independence given to the ESEO

to set priorities.

While the BCT ESEO’s mission is to provide direct

support to the brigade as the first line of defense

against disease and nonbattle injuries, he or she may

also be called upon to provide services to units outside

of the BCT task organization. In our case, we

conducted routine inspections at a logistics support

area with a Corps Support Command Combat Support

Hospital, and other joint and combined forces adjacent

to our primary FOB. SBCT Soldiers would refuel and

eat at this location, so there was still a payoff. This

A Guide to Brigade-Level Preventive Medicine: Stryker Brigade Experience in

Operation Iraqi Freedom II & III
April – June 2007 37

coverage freed the preventive medicine detachment to

cover other bases and minimize risks of travel. We

also inspected detention facilities, a Multinational

Security Transition Command-Iraq training post, and a

rest and recuperation pass site. Such adjustments are in

line with the guidance of DA Pam 40-11:

In the theater of operations, preventive medicine

support is tailored and phased to enhance mission

requirements, counter the medical threat, and provide

preventive medicine support as far forward as the

tactical situation will permit. Preventive medicine

resources providing level II, III, and IV preventive

medicine support will be employed on an area basis to

provide the utmost benefit to the maximum number of

personnel in the area of operations.2

However, it is advisable to ensure the chain of

command is well aware of the requirements and the

reasoning behind the decision before engaging in a

mission outside of the direct scope of the BCT.

PREDEPLOYMENT

Preventive medicine efforts prior to deployment

substantially reduce dependence once deployed and

provide for a more sustainable and healthier force.

With preparation and training, the ESEO will have a

more attainable mission, allowing focus on areas other

than basic sanitation. Given a high operations tempo

and full training calendar, it is necessary to take

advantage of every opportunity. The preventive

medicine section should:

 Train field sanitation team (FST) members.

 Evaluate companies for their preventive medicine

readiness.

 Inspect the condition of the brigade’s water

trailers, water purification and distribution

equipment, and field feeding equipment.

 Incorporate preventive medicine into field training

exercises as much as possible.

 Obtain and maintain preventive medicine medical

equipment sets.

 Train to maintain technical proficiency on mission

essential tasks and the sustainment of Soldier

readiness and survivability.

Once deployment orders are received, preventive

medicine can assist planners in the medical

intelligence preparation of the battlefield, conduct

information briefs to key leaders and Soldiers on

preventive medicine measures to counter the

anticipated medical threat, and ensure specific

measures such as uniform permetherin treatment are

fully accomplished. The ESEO has access to a wealth

of medically significant information through the

USACHPPM Deployment Environmental Surveillance

Program and Global Threat Assessment Program as

well as the Armed Forces Medical Intelligence Center

to aid in the risk management process.

FIELD SANITATION

Basic field sanitation constitutes the most immediate

requirement for BCT preventive medicine to prevent

acute outbreaks of disease. Soldiers at all levels are

responsible for implementing preventive medicine

measures and each company is supplemented by a

field sanitation team. On paper, the 2-member FST is

certified and equipped to supervise the construction of

preventive medicine devices, monitor hand-washing,

test the unit water supply, ensure food is stored

properly, control arthropods and rodents, ensure the

proper disposal of trash, and request preventive

medicine support for problems beyond their

capabilities.

The authors observed variable FST effectiveness

throughout the brigades. Adequate numbers of

Soldiers received a 40-hour field sanitation team

training course sponsored by the multiple preventive

medicine units on Fort Lewis prior to deployment. For

the most part, however, these trained Soldiers were not

fully utilized for preventive medicine oversight. In

Deep pit latrine, Euphrates River Valley
38 Army Medical Department Journal

some cases, when questioned in the field, companies

were unable to identify their FST members.

Additionally, FST members were not always available

when needed due to injuries, leave rotations, or

company operations from multiple locations. In place

of active FSTs, medics from the battalion aid stations

often took initiative and served as points of contact for

field sanitation. Another challenge was maintaining

accessibility of unit FST supplies which would be

stored somewhere in aluminum chests. Accordingly,

the preventive medicine section received frequent

requests for basic supplies such as fly strips and mouse

traps. FST supplies are Class II or Class IX items, and

units should be directed to obtain them through

company supply chains. The ESEO can provide

assistance, but should not be expected to act as a

supply officer for FSTs.

The life support services provided by contractors on

the major FOBs contributed to a sense of complacency

regarding sanitation duties. However, even in such a

relatively comfortable FOB environment, FSTs were

needed to inspect water tanks, control mice and flies,

and ensure Soldiers were using the standard military

topical clothing insect repellent, among other duties.

The true value of the FST became apparent to units

moved to expedient outposts, whether in the open

desert or urban slums. With the loss of all external

support, essential tasks now included the construction

and maintenance of field waste disposal devices and

close monitoring personnel hygiene. Most Soldiers had

minimal hands-on familiarity with the operation of

such devices due to restrictions against digging and

burning in training areas. Common mistakes included

lack of maintenance or failure to cover waste with dirt,

air gaps in latrines that allowed filth flies to breed, lack

of hand-washing devices at each site, and the location

of garbage burn pits in close proximity to or upwind of

living areas.

OCCUPATIONAL AND ENVIRONMENTAL HEALTH

SURVEILLANCE

Level III preventive medicine detachments may take

the leading role in collecting occupational and

environmental health surveillance (OEHS) samples,

but brigade preventive medicine should assume that

responsibility when operating in remote locations or

when resources are limited. These water, soil, and air

samples are needed to fulfill directed requirements to

document environmental hazards wherever Soldiers

may be exposed. The samples also provide data for

detailed long-term health assessments to the command,

although results will not be immediately available. The

BCT preventive medicine must contend with the

difficulties of balancing time to develop and

implement comprehensive sampling plans with

immediate sanitation concerns, and finding ways to

ship samples to Germany or the US in a timely

manner. Whereas standard field sanitation and hygiene

are tasks common to all Soldiers for which the

preventive medicine section provides oversight and

recommendations, the OEHS mission requires specific

technical skills to leverage the sophisticated

laboratories available for valid data collection and

analysis.

BASE CAMP ASSESSMENTS

The preventive medicine section serves as the eyes of

the BCT surgeon and chain of command for disease

and nonbattle injury issues across the area of

operations. The ESEO functions as a “medical scout”

in the sense that he or she is the forward preventive

medicine asset and can anticipate, recognize, and

prioritize health hazards from multiple locations and

battle positions. The base camp assessment is the

reporting mechanism for summarizing findings from

preventive medicine inspections. The exact formats

varied, some were up to a dozen pages long, but the

checklists ensured all areas of concern were evaluated.

The key areas of focus always included food, water,

and pest control.

A Guide to Brigade-Level Preventive Medicine: Stryker Brigade Experience in

Operation Iraqi Freedom II & III

The collection of OEHS water samples at FOB Marez
April – June 2007 39

Food service facilities ranged from large, contracted

kitchens to mobile kitchen trailers. The contracted

facilities generally maintained good practices once

trained to the Army standard, as long as they were

regularly inspected. Communication could be difficult

with staffs comprised of third-country nationals, but

the general managers spoke English. One of the

biggest problems encountered was the abundance of

foreign vendors selling products from nonapproved

food sources to Soldiers on the FOBs. Through

insistence by preventive medicine and veterinary

personnel, FOB leaders eventually placed these sites

off-limits to Soldiers. This change took considerable

effort since the vendors had well-established

relationships on the bases and enjoyed popularity

among Soldiers seeking a change from the mess hall

and lacking any familiar fast food sources in the

region. In addition to violating theater medical policy

for unapproved food sources, the cooks at these food

stands and restaurants were unaccustomed to our food

handling requirements and required considerable

oversight. These establishments increased the

vulnerability of our Soldiers due to lack of control

over the food supply chain and placed a large demand

on preventive medicine.

Bottled water was used for drinking, with bulk treated

water used for such purposes as cooking and hygiene.

The majority of the treated water came from

contracted reverse osmosis water purification units

(ROWPUs), however, Army ROWPUs were used on a

small scale. The initial setup of the contracted units

required heavy preventive medicine oversight.

Assigned operators lacked experience, the Italiandesigned units were not configured for

postchlorination, and water testing supplies were

lacking. In addition to routine water quality checks,

preventive medicine should monitor how the water is

distributed to ensure untreated water is not placed in

containers marked potable, and ensure that water

trucks are secured and only used to transport water.

Whether for water or food, the ESEO should maintain

contact with the government contracting officer

representative to report any failures of contractors to

meet Army standards or to recognize positive efforts.

Insects and rodents are ubiquitous in northern Iraq.

Different nuisance pests seemed to emerge with each

change of season. Filth flies, sand flies, mosquitoes,

rats, and feral dogs and cats were all cause for health

concerns and required pest control measures. The

disease vector potential of these common pests

increased due to conditions of poor sanitation and

improper waste disposal. Pest control was exceedingly

difficult at bases within or on the fringe of urban areas

due to nearby open sewage, trash piles, and standing

water (see related article, page 46). However, the filth

flies even surfaced as “camp followers” at previously

uninhabited areas with less than perfect sanitation.

Cutaneous leishmaniasis became the most significant

insect-borne disease we faced in terms of prevalence

and potential effect on the mission. Where infection

rates were high, such as the area around Tal Afar,

preventive medicine implemented measures to educate

Soldiers on avoiding sand fly bites, reduce the animal

reservoirs (intensive rodent destruction), and control

the sand fly population in coordination with contracted

pest control where available.

CONCLUSION

Preventive medicine personnel in the BCT carry a

unique skill set and have many varied responsibilities

which may not be widely understood. When properly

employed, the preventive medicine section can have a

significant impact on the health and readiness of the

force, helping to ensure that Soldiers are available

when and where they are needed most. Command

emphasis enables the ESEO to be effective, giving the

preventive medicine section the time it needs to

complete its surveys and identify problems before they

impact the Soldier. The health hazards and priorities in

the combat environment continue to change, requiring

a preventive medicine section that is agile and adaptive

like the Soldiers it supports. In addition to unit field

sanitation and OEHS duties, demand is growing for

preventive medicine support of civil affairs and

security force training missions. All of these factors

dictate that the ESEO must communicate extensively

with technical and command chains to ensure

provision of the best service to safeguard the health of

all Soldiers in contingency operations.

REFERENCES

1. Field Manual 3-90.6: The Brigade Combat Team.

Washington, DC: US Dept of the Army; August

2006.

2. DA Pamphlet 40-11: Medical Services: Preventive

Medicine. Washington, DC: US Dept of the Army;

July 22, 2005.
40 Army Medical Department Journal

A Guide to Brigade-Level Preventive Medicine: Stryker Brigade Experience in

Operation Iraqi Freedom II & III

3. Army Regulation 40-5: Medical Services: Preventive Medicine. Washington, DC: US Dept of the Army; July 22, 2005.

4. Field Manual 4-02.17: Preventive Medicine Services. Washington, DC: US Dept of the Army; 28 August 2000.

AUTHORS

CPT Lewandowski is Chief, Environmental Health, Dewitt Health Care Network, Fort Belvoir, Virginia. Previously he

was Brigade Environmental Science Officer, 1/25 SBCT, Fort Lewis, Washington.

CPT Faulkenberry is Chief, Field Preventive Medicine Division, USACHPPM-West, Fort Lewis, Washington.

Previously he was Officer in Charge of Preventive Medicine for the 3/2 SBCT during its inaugural deployment to Iraq.
April – June 2007 41

INTRODUCTION

Currently, 3 types of medical detachment (preventive

medicine) Tables of Organization and Equipment exist

in the combat health service support force structure.

Two types, sanitation and entomology, were developed

in support of Medical Force 2000 (MF2K) and consist

of 10 personnel and equipment. The third will replace

those MF2K types and consists of 13 personnel and

equipment under the Medical Reengineering Initiative

designed to support combat health service support to

the Force XXI Army.2

As delineated by the US Army Center for Health

Promotion and Preventive Medicine (USACHPPM)

Technical Guide 248 3and discussed by Sames et al,4

the unit responsibilities and scope of essential services

required of a preventive medicine medical detachment

to maintain and sustain a healthy force include the

following:

 Provide assistance in the control of arthropodand rodent-borne diseases, including technical

consultation, entomological surveys and/or

investigations, and reinforcement of the unit’s

organic pest management capabilities.

 Provide assistance in the control of waterborne

diseases by monitoring water quality.

 Provide assistance in the control of foodborne

diseases by monitoring food service operations

and provide guidance to commanders. (The

actual function of safety and quality assurance

food inspection is a veterinary responsibility.)

 Provide policy guidance and monitoring

c o m p l i a n c e f o r i m m u n i z a t i o n ,

chemoprophylaxis, antidotes, and pretreatment

activities and barrier cream use.

Measuring Effectiveness of

Deployed Medical Detachments

LTC Sonya S. Schleich, MS, USA

MAJ Mark C. Carder, MS, USA

ABSTRACT

The Army Medical Department’s (AMEDD) efforts to provide on-target combat health and combat health

service support to the Warfighter continue to evolve. Within the framework of modularizing the force, The

AMEDD integrated the medical battalion (area support), medical battalion (evacuation), and medical

logistics battalion into a single multifunctional medical battalion (MMB), approved by Headquarters,

Department of the Army, to support the force commander on the ground.1In 2005, the 61st MMB

(Provisional), the first of its type, deployed in support of Operation Iraqi Freedom (OIF) 05-07 to provide

levels I and II area medical support, ground evacuation, dental, optometry, combat and operational stress

control, veterinary services, and preventive medicine.

While deployed during OIF 05-07, the 61st MMB commander employed 5 preventive medicine medical

detachments across the entire Iraqi Theater of Operations: the 898th Medical Detachment, 485th Medical

Detachment, 255th Medical Detachment, 223rd Medical Detachment, and 903rd Medical Detachment. The

number of medical detachments assigned to an MMB is situational and based upon the operational

requirements of the combatant commander on the ground. The 61st MMB commander faced a unique

challenge in evaluating mission success for the individual medical detachments, as each possessed slightly

different capabilities as well as number and diversity of inspections covered within their respective area of

responsibility. This article describes an extensive matrix, developed by the medical detachment

commanders, to measure mission success and provide a useful tool for the MMB commander.
42 Army Medical Department Journal

 Provide assistance and subject matter expertise in

the control of excessive occupational and

environmental health (OEH) exposures to such

hazards as noise, toxic industrial materials, and

climatic extremes.

 Provide assistance to command surgeons in the

evaluation of

 Elements of the medical threat,

 Risk to the force associated with identified

elements of the medical threat, and

 Integration of the medical threat into

planning for and executing force health

protection operations.

 Establish a medical and OEH surveillance system

which encompasses predeployment medical

screening (develop a medical baseline),

deployment and surveillance while in the

operational area, medical screening prior to

redeployment, and follow-up medical assessments

upon return to home station.

 Educate troops in disease and nonbattle injury

prevention measures, including those measures

used to reduce risks from chemical, biological,

radiological, and nuclear agents/weapons.

 Train unit field sanitation teams.

 Provide technical consultation on selection and

development of bivouac sites, cantonment areas,

refugee camps, and enemy prisoner of war/

detainee compounds.

 Conduct field water vulnerability assessments.

 Provide professional and technical advice to

commanders at all levels on measures to reduce

noneffectiveness from disease and nonbattle

injury.

 Report deployment health surveillance and

readiness statistics and environmental health data,

as required.

 Survey operational environments to detect and

identify health hazards and formulate means for

minimizing their effects.

 Investigate disease outbreaks and recommend

control measures.

 Provide assistance in reducing noise hazards in

rest and recuperation areas to nonstressful levels.

The broad scope of responsibilities presented a

challenge for each individual medical detachment to

measure mission success and prompted the

development of the medical detachment preventive

medicine matrix.

DEVELOPMENT

The 5 commanders of the 61st MMB preventive

medicine medical detachments reviewed several draft

matrices. The drafts included lists of all performed

inspections and consultations and the assignment of

weighted values to specific tasks. The assignment of

weighted values and total completed inspections were

quickly recognized as inaccurate metrics because of

fluctuations in mission set, number of inspections

based on the number of facilities, consultations, etc,

within each detachment’s area of responsibility. A

hypothetical example: Detachment A has 20 Army/Air

Force Exchange Service food service establishments to

inspect within its area of responsibility per month,

while Detachment B has 10. A measurement of

Detachment A against Detachment B based on the

number of inspections performed is not informative.

Therefore, the initial preventive medicine weekly

report developed by the 30th Medical Brigade Sanitary

Engineer was modified and expanded significantly to

fully capture and measure weekly mission success and

timeliness of completion. The preventive medicine

matrix was developed in a spreadsheet format using

Microsoft Excel®. The first table in the preventive

medicine matrix workbook is a summation spreadsheet

that provides an overview specific to the reporting

preventive medicine detachment. The first page of the

preventive medicine matrix workbook contains unit

information: personnel status; logistic status relative to

mission essential equipment; a list of supported base

camps, forward operating bases, and contingency

operating bases; the date last inspected; the number of

routine preventive medicine inspections; and

occupational and environmental health surveillance

(OEHS) and deployed environmental surveillance

program (DESP) inspections. The overall preventive

medicine risk assessment is based on 6 derivative type

inspections which are included within the routine

preventive medicine inspections. The overall OEHS

risk assessment is based on 2 derivative type

inspections which fall under the OEHS and DESP

Measuring Effectiveness of Deployed Medical Detachments
April – June 2007 43

inspections. The overall risk assessments are ranked

based on the number and frequency of satisfactory and

unsatisfactory inspections. The resultant action levels

are depicted by the colors green, amber, and red, as

illustrated in Figure 1. The color green reflects all

satisfactory ratings, amber represents minor

deficiencies, and red is used for any water sample

positive for bacteriological/chemical contaminants,

any health/environmental issue that poses an

immediate or near-term imminent health threat to

personnel, or a failed dining facility at that particular

base camp or forward operating base. The remainder

of the summation sheet includes information regarding

disease outbreak investigations, training provided, and

future operations.

The subsequent spreadsheets within the preventive

medicine matrix workbook allow the MMB

Figure 2. Example from Preventive Medicine Matrix Workbook section for the Waste

Management category to illustrate derivative inspections that comprise the number reported on

the summation sheet.

*Multinational Force–West. The report sheet is for inspections at camps and facilities within that area of

responsibility. The 485th Medical Detachment was responsible for inspections within MNF-W.

†

Preventive Maintenance Checks and Services.

Hazardous

Material

Hazardous

Waste

Regulated

Medical

Waste

Waste Water

Email

Consults

Telephone

Consults

Walk-in

Consults

Equipment

PM

C

S

†

Total Waste

Inspections

Total Consults

& PM

C

S

†

Grand FOB or

Camp Totals

Forward

Operating

Base or

Camp

As

Needed

As

Needed

As

Needed

As

Needed

As

Needed

As

Needed

As

Needed

As

Needed Monthly Monthly Monthly

MNF-W*

Camp 1 1 1 2 0 2

Camp 2 0 0 0

Camp 3 1 1 1 2 1 3

MNF-W*

Camp 1 6/7/06 BCT-155†5/27/06 0 0 0 0 2 0 0 0 0

Camp 2 6/15/06 MAW‡2/27/06 0 0 0 0 0 0 0 0 0

Camp 3 6/15/06 MAW‡0 0 0 0 3 0 0 0 0

Food

Sanitation

General

Sanitation

Field

Water Tests

Bottled

Water Tests

Waste

Disposal

Pest Management

Surveillance

&

Control

Overall PM

Risk Assessment

Occupational

Health Studies

Environmental

or Workplace

Noise

DESP

Overall OEH

S

Risk Assessment

OEHS Incident

Response & DESP Routine PVNTMED Inspections

Base Camp or Forward Operating Base Status

(Any Amber or Red Readiness Categories Require Comments)

Base

Camp or

FOB

Date of last FOB

visit by reporting unit

Echelon II

Support Unit

Date of last

known FOB visit by

Echelon II unit

Figure 1. Example of section from Preventive Medicine Matrix Workbook summation sheet

showing categories of preventive medicine inspections and risk assessments.

*Multinational Force–West. The summation sheet is for inspections at camps within that area of responsibility.

The 485th Medical Detachment was responsible for inspections within MNF-W.

†

Brigade Combat Team 155

‡Marine Aircraft Wing.
44 Army Medical Department Journal

commander to examine the specific data from the

derivative inspections which are presented in the

summation spreadsheet. Each of the derivative

inspection types are further broken down into several

categories, each of which has a column on the

spreadsheet. The inspection types and number of

categories (in parentheses) include Food (10), General

(12), Water (13), Waste Management (8), Vector (21),

Epidemiology (8), Industrial Hygiene (8), DESP (10),

Consultations (3), Training (10), and Movement (3).

Figure 2 is an example of the derivative inspection

sheet for waste management.

CAPABILITIES

The medical detachment preventive medicine matrix is

a tool for measuring mission success of an individual

unit and provides the MMB commander with a

snapshot of each unit’s workload and accomplishment.

In addition, the data contained in each unit’s matrix is

submitted to the next higher echelon of the preventive

medicine support staff within the medical chain of

command, oftentimes a medical brigade which will

ultimately provide data to the US Army Center for

Health Promotion and Preventive Medicine. Members

of the brigade preventive medicine staff use the

information to identify trends, provide

recommendations, and provide information to the

theater surgeon as warranted. The benefits of this

reporting matrix include:

 Consolidation of reported data.

 Immediate accessibility to detailed information, a

numerical presentation of the overall preventive

medicine mission set.

 Analysis tool for the MMB commander which can

be used on a monthly, quarterly, biannual, or

deployed basis to track workload trends.

 Mission success and achieved performance is

measured against the individual unit itself with

respect to preventive medicine coverage and AOR.

Future improvements to enhance this matrix may

include recording the amount of hours/manpower

associated with each mission in addition to designing

appropriate weighted values that reflect the impact on

the at risk population.

Some may argue that this assessment matrix is similar

to the “fox guarding the hen house,” but disease and

nonbattle injuries are a sure indicator of the success, or

lack thereof, a unit achieves in its preventive medicine

mission.

CONCLUSIONS

The preventive medicine matrix proved to be an

excellent tool, not only for the 61st MMB commander

to measure mission success, but also for use by each

individual medical detachment commander in support

of OIF 05-07. With appropriate modifications, the

matrix can be tailored to other deployments,

contingencies, and garrison environments to reflect the

mission set of an individual unit. The preventive

medicine reporting matrix is under evaluation for

inclusion in the Army’s new MMB Field Manual.

ACKNOWLEDGEMENT

We thank the following dedicated professionals for

their assistance in the preparation of this article:

 LTC Scott Wright for providing the initial baseline

preventive medicine reporting format.

 LTC William B. Grimes, Commander, 61st MMB for

critical review and editorial comment.

For assistance with the initial matrix format during the

OIF 05-07 rotation:

 MAJ James T. Flanagan, Jr, Commander, 223rd

Medical Detachment

 CPT Darryl A. Forest, Commander, 255th Medical

Detachment

 CPT Charles B. Raymond, Commander, 903rd

Medical Detachment

 MAJ James J. Meckel, Commander, 898th Medical

Detachment

 CPT Lewis Long, Executive Officer, 223rd Medical

Detachment

Measuring Effectiveness of Deployed Medical Detachments
April – June 2007 45

REFERENCES

1. Academy of Health Sciences Update, Volume FY06,

Issue 2, February 2006. Available at: http://

www.cs.amedd.army.mil.

2. Field Manual 4-02.17: Preventive Medicine Services.

Washington, DC: US Dept of the Army; 28 August

2000.

3. Technical Guide 248, Guide for Deployed Preventive

Medicine Personnel on Health Risk Assessment.

Aberdeen Proving Ground, MD: US Army Center for

Health Promotion and Preventive Medicine. 2001.

Available at: http://chppm-www.apgea.army.mil/

documents/tg/techguid/ttg248.pdf.

4. Sames WJ, Delk TC, Lyons PJ. Field preventive

medicine: challenges for the future. Army Med Dept

J. April–June 2006:40-45.

AUTHORS

LTC Schleich is the Executive Officer and Chief,

Entomological Sciences Division, USACHPPM-West,

Fort Lewis, Washington. Previously, she was the

Commander of the 898th Medical Detachment,

Baghdad, Iraq.

MAJ Carder is the Commander of the 485th Medical

Detachment, Fort Polk, Louisiana. Previously, MAJ

Carder simultaneously served as both the 485th Medical

Detachment Commander and was the Environmental

Science Officer for the 61st MMB, Balad, Iraq.

Crest of the

61st Multifunctional

Medical Battalion
46 Army Medical Department Journal

The primary focus of vector control operations in

support of Operation Iraqi Freedom is protection of the

Warfighter and government real property and materiel.

Vector control responsibilities focus on the search for

and suppression of arthropod and rodentborne disease

vectors, entomological surveys and investigations, and

pesticide application using military and contractor pest

management capabilities. To understand the

complexity of vector control operations in Iraq, one

must understand the levels of Army preventive

medicine support. The first level is the company-sized

unit’s field sanitation team, composed of 2 Soldiers

that have attended a 40-hour team training course on

all aspects of basic field sanitation. This small team

has very limited surveillance and control capabilities,

and only provides support within a company’s

immediate area. The second level is the brigade and

division’s organic preventive medicine personnel and

equipment. Brigade combat teams (BCT) are staffed

with an Environmental Science and Engineering

Officer (ESEO) and a few Preventive Medicine

Specialists. This small team supports the base camps

occupied by the BCT’s subordinate companies. They

have limited vector surveillance and control

capabilities, but are able to identify problems and

request assistance when necessary. Division level

preventive medicine has a senior ESEO who provides

assistance to the BCT ESEOs and coordinates with

other nondivision preventive medicine assets in

theater. The third level is the medical detachments that

provide area support within a specified area (eg,

northern Iraq) and report to the medical task force. The

medical detachments have a military entomologist and

more vector surveillance and control capabilities. The

entomologist provides advice and recommendations on

all aspects of pest surveillance and control measures

within their area of responsibility. In addition, there is

a senior entomologist located at the medical task force

headquarters who provides guidance on vector

surveillance and control within the theater, and

coordinates efforts when needed.

Adding to the complexity of the situation is the reality

that vector control is only one aspect of the overall

preventive medicine mission. Preventive medicine

personnel at all levels are also responsible for the

inspection of food service facilities, including AAFES

food concessions, monitoring water supplies, testing

bottled water, vector surveillance, noise surveillance,

sanitation inspections, investigations of food or water

borne illness outbreak, and the provision of other

industrial hygiene, occupational, or environmental

health surveillance activities as required. Initially,

preventive medicine personnel were the only ones

conducting both pest surveillance and control

measures. A pest control contractor was hired as the

theater matured. Pest control activities are now

performed at most camps by either a full or part-time

DoD or state certified vector control contractor

employee. The contractor provides all the pesticides,

application equipment, and certified personnel in

accordance with the requirements specified in the

contract. Their pest controllers work in close

coordination with their local preventive medicine

personnel to identify problems, conduct surveillance,

look for integrated pest management options, and

implement appropriate control measures.

As camps have grown, so have vector surveillance and

control efforts. In most camps, personnel are now

sleeping, eating, and working in climate controlled

buildings, thereby reducing the number of arthropod

bites. Control efforts have expanded to meet the new

demands of the more permanent facility environment,

Challenges of Effective Vector Control:

Operation Iraqi Freedom 05–07

LTC Jamie A. Blow, MS, USA

CPT Darryl A. Forest, MS, USA

CPT Lewis S. Long, MS, USA

MAJ James J. Meckel, MS, USA

CPT Charles B. Raymond, MS, USA

MAJ Mark C. Carder, MS, USA
April – June 2007 47

and the expectations of the deployed personnel. Fly

and rodent control and nuisance pest issues (ants,

spiders, etc) have become larger issues as the camps

have become semipermanent and personnel are less

tolerant of pests. Surveillance for mosquitoes and sand

flies continues to be an important mission due to the

threat of malaria and leishmaniasis transmission. The

use of ultra low volume (ULV) applications of

pesticides continues to be a primary control method for

mosquitoes and sand flies, although mosquito

larvacides and application of residual pesticides to

resting sites are also used. Also, the efficacy of one

type of commercial insect trap was evaluated in some

locations. Feral animals are a constant problem in our

camps, and control, including bird control, continues

to be an ongoing issue. As we use existing structures,

the birds resident in them are causing concerns about

personnel health.

MOSQUITO AND SAND FLY SURVEILLANCE AT

VICTORY BASE COMPLEX

Victory Base Complex (VBC) is composed of several

base camps located around the perimeter of the

Baghdad International Airport. The 898th Medical

Detachment was responsible for devising and

sustaining one of the largest and most comprehensive

surveillance initiatives to date during a deployment

operation. Under the guidance of their commander, the

Soldiers of the unit diligently set, maintained, and

retrieved 30 Centers for Disease Control and

Prevention light traps within the perimeter of the VBC.

Over 10,700 specimens were collected, identified, and

processed from 1 April through 30 September 2006.

All trap catches were sorted, and mosquitoes and sand

flies identified to genera. The resulting distribution by

genus is illustrated in Figure 1.

Each trap catch for a single night was handled as a

discrete set throughout the collection, processing,

shipment, and pathogen detection process. Each trap

catch was sorted into male mosquitoes, female

mosquitoes, and sand flies. Sand flies, both male and

female, from a single trap catch were sorted into pools

of no greater than 100, each of which was then placed

in a vial with approximately 1 ml of 100% ethyl

alcohol. Female mosquitoes from a single trap catch

were sorted to genus (ie, Anopheles, Culex, Aedes) and

placed in 2 ml vials with no preservative (no more than

10 specimens per vial). All samples were labeled and

processed for pathogen testing in accordance with the

US Army Center for Health Promotion and Preventive

Medicine (USACHPPM)-North and Multinational

Coalition-Iraq established protocols, then shipped to

the USACHPPM-North for malaria, leishmaniasis, and

West Nile virus pathogen detection. Remarkably, of

the 10,700 specimens tested, there were no positive

identifications.

The 898th Medical Detachment fostered a close

working relationship with the VBC vector control

personnel while conducting entomological operations.

The initial action threshold was determined to be 25

mosquitoes and/or 15 sand flies in a single light trap in

‡

† Other (4%) Sergentomyia (6%)

†

Phlebotomus (23%)

*Aedes (29%)

*Culex (38%)

Figure 1. Breakdown of the 10,700+ mosquitoes and

sand flies caught in light traps at Victory Base Complex,

Iraq between 1 April and 30 September 2006.

*mosquitoes

†

sand flies

‡mosquitoes: Uranotaenia (4), Culiseta (194), Anopheles (17)

Light traps were emplaced in the late afternoon with

sensors set to activate at dusk for routine surveillance.
48 Army Medical Department Journal

a single night. This

initial action threshold

was based on limited

historical information

and personal knowledge

of both the entomologist

and vector control

personnel. The threshold

could be subsequently

adjusted higher or lower

based on trap collection

numbers, collection of

sand flies or mosquitoes

that tested positive for

malaria, leishmaniasis,

or West Nile virus, and

customer complaints.

When the action

threshold established for

a trap site was reached,

a plan was devised in

coordination with vector

control supervisors

involved residual pesticide application to potential

resting sites and ULV application to the area of the

trap site that required treatment. Typically, after a late

night ULV application, the trap numbers were

noticeably lower for the next week. As the season

progressed, temperatures increased and rain tapered

off, with resulting decreases in mosquito trap numbers

and increases in sand fly populations, as anticipated.

Figure 2 depicts the total numbers of mosquitoes and

sand flies, per collection, from traps located around

VBC from the start of the mosquito season in early

April until the end of the season the end of October.

The greatest challenge of operating a comprehensive

surveillance system on VBC was balancing the

manpower requirements of the daily mission of

sanitation, environmental and vector surveillance with

the need to respond promptly to emerging situations.

The preventive medicine specialists always managed

to balance all the missions while providing the best

support possible to personnel.

The surveillance data is currently being analyzed by

individual light trap location. The data among the light

trap locations will be compared in an attempt to

determine if there are indicators for specific areas

within the VBC which may be prone to harbor

arthropods of military importance.

MOSQUITO MAGNETS®

Balad Airbase, also called Logistic Support Area

(LSA) Anaconda, is surrounded by an irrigation canal

fed by the Tigris River. Although the canal is a

steadily flowing body of water, it has many areas of

stagnated and/or still pools where many aquatic plants

can grow up to 8 feet. This tall dense vegetation along

the shores of the canal make an ideal breeding site for

many blood-feeding flies and is located in very close

proximity to thousands of deployed personnel. The

255th Medical Detachment had the monumental task

of protecting the base personnel from this threat and

worked closely with the supervisor of the contractor

vector control operations on LSA Anaconda.

Due to the extensive breeding grounds just outside the

base, the use of ULV pesticides had been substantial in

previous years. In an effort to reduce ULV pesticide

application, the contractor purchased approximately 50

Mosquito Magnets* in 2003 to use as a control

measure. The Mosquito Magnet works by producing

the very same characteristics (CO2, heat, moisture) that

a mammalian host would emit. In order to reproduce,

female mosquitoes must find a suitable host to obtain a

blood meal. They have finely tuned sensors that aid

Challenges of Effective Vector Control: Operation Iraqi Freedom 05–07

0

200

400

600

800

1000

1200

Mosquitoes

Sand Flies

25 April 4 May 17 May 6 June 24 July 31 August 28 September

1 May 11 May 25 May 26 June 6 August 15 September 15 October

2 April-18 April

Number Collected

Figure 2. Chronological depiction of the numbers of mosquitoes and sand flies gathered

from traps located around the Victory Base Complex, from the start of the mosquito season

in early April until the end of the season in late October. (2006 data)

*American Biophysics Corp, 140 Frenchtown Road, North

Kingstown, Rhode Island 02852
April – June 2007 49

them in finding a host by

detecting carbon dioxide,

w a r mt h , c e r t a i n p l a n t

chemicals, and sometimes even

sweat (moisture) chemicals.1

Using these sensors, mosquitoes

found an abundance of prime

blood sources among all the

personnel located at Balad

Airbase.

The Mosquito Magnet produces

CO2 by burning propane gas,

which contains carbon and

hydrogen, producing carbon

dioxide and water vapor.

However, the newer models of

t h e M o s q u i t o M a g n e t

incorporate an interesting twist

on the burning process. Instead

of a flame, the propane is burned catalytically, using

the same idea as that used in the catalytic converter on

a car. The propane flows to the catalyst—a set of

ceramic beads or a ceramic grid coated with platinum.

The catalyst converts the propane directly to heat,

carbon dioxide, and moisture without actually needing

a flame. The advantage of this system is that you can

catalyze very small quantities of propane over a long

period of time without having to worry about the flame

ever going out. In addition, there are no worries about

other gases, like carbon monoxide or nitrogen oxides,

being produced by the flame. The lack of a flame also

reduces the risk of fire. By itself, the CO2 was found to

be inadequate, so a cartridge that contains either

octenol (a generic molecule that simulates plant

chemicals) or Lurex* (a proprietary mixture that

simulates sweat chemicals) was added. These

chemicals act as strong attractants for different types

of mosquitoes. Lurex-type chemicals work best on the

Asian tiger mosquitoes, while octenol works best on

mosquitoes which are native to the United States. By

mixing the chemical attractant with the carbon dioxide

and moisture, then emitting the warm mixture into the

surrounding air, the trap creates a plume of gas that

mosquitoes find irresistible. They will fly upwind to

follow the plume to its source. When the mosquitoes

get to the mosquito magnet, they encounter a vacuum

created by a fan and are sucked into a net bag, where

they dehydrate and die.

The contractor had started the

Mosquito Magnet control

program in 2004 with mixed

results. However, in 2005, they

increased the number of devices

and improved the placement

based on 2004 data. The

numbers were incredible; over

1.3 million mosquitoes and

600,000 sand flies were caught

between April–Nov 2005. In

2006, the contractor and the

255th Medical Detachment

continued the mosquito/sand fly

control program. First, they

initiated an aggressive larval

control program on the interior

of LSA Anaconda. This was

done by using both Altosid†

briquets, Altosid liquid, and methoprene mosquito

dunks in storm drains, unused sewer lines, and areas of

standing water. Additionally, the number of Mosquito

Magnets was increased inside the fence line along the

perimeter of LSA Anaconda and their spacing was

modified so they were approximately one acre apart.

This was done in an attempt to overlap the magnets’

attracting range to ensure maximum coverage. The

2006 results were outstanding, approximately 1.5

million mosquitoes and 800,000 sand flies were

†Wellmark, International, 1501 E. Woodfield Road,

Schaumburg, Illinois 60173

*American Biophysics Corp, 140 Frenchtown Road, North

Kingstown, Rhode Island 02852

Some of the insects captured by the Mosquito Magnet®

traps emplaced around LSA Anaconda.

The Mosquito Magnet® uses propane to

produce CO2 and heat to attract insect

vectors which are caught in the vacuum and

deposited in the collection bag.
50 Army Medical Department Journal

trapped, and complaints were almost nonexistent.

Anecdotal evidence* indicated that the strategically

placed Mosquito Magnets, in conjunction with an

aggressive larvacide program, appeared to

significantly reduce the number of blood-feeding

diptera on LSA Anaconda.

ULV OPERATIONS

The ULV sprayer is the primary weapon utilized to

suppress adult sand fly and mosquito populations in

Iraq. However, without the insecticide, the ULV would

be useless. Pesticides are hazardous materials

(HAZMAT) and shipping them halfway around the

world is not an easy endeavor. The first major

complication is that special training and certification

are required in order to containerize, load, and ship the

pesticides. There are specific requirements for

documenting the HAZMAT being shipped which

include material safety data sheets, declaration

documentation, spill response and contingency plans,

safety requirements, and load plans. The

documentation is complicated and the volume is

staggering. Units are required to have HAZMAT

handlers and certified personnel in order to expedite

the material transport process. However, the process is

worth the effort once the insecticide arrives and vector

suppression operations begin.

The second major complication is the sheer volume of

pesticides required and the different restrictions of

shipping classes. As a basic planning factor,

preventive medicine personnel should plan for 8 weeks

of sustained operations before resupply. This is the

factor recommended if the theater of operations is not

developed logistically. Obviously, less may be

required based upon the intelligence gathering from

the battle space prior to deployment. It should also be

noted that certain classes of insecticides cannot be

shipped in the same container due to reactivity.

Another factor to consider is that clothing, tools, and

field gear should not be shipped with insecticides.

These factors will increase container requirements, as

well as tracking considerations for those containers.

A third complicating factor is that the lead acid

batteries required to run the ULV sprayer most

commonly used in Iraq by US forces, the Beecomist

15MP†are considered HAZMAT.

Once in theater, ULV sprayer maintenance is required

on regular intervals and will require more vigilance

and extensive attention to detail. Two areas of

particular concern are static build up and battery

charging. In hot dry climates where electrical devices

are used, static electricity can become an issue if

equipment is not properly grounded. This is especially

true for ULV sprayers mounted in trailers which are

subsequently towed by HMMWVs‡during pest control

operations. Attention must also be given to battery

maintenance and charging. Regular use of a voltmeter

to check the vehicle alternator output is recommended

to ensure the vehicle batteries are being adequately

charged. A check of the onboard ULV sprayer battery

prior to and after operation is also recommended to

ensure it is not depleted. Finally, environmental

conditions must be taken into consideration. Dusty,

hot, and windy operating environments require that the

ULV sprayers be dusted and/or rinsed after each

mission to ensure maximum equipment operating life.

Although the topics discussed here are not the result of

an epiphany and seem painfully obvious, if they are

not followed, the mission will not be accomplished.

These comments are based on the experiences of

several preventive medicine detachment commanders

since the beginning of operations in Iraq in 2003.

ANIMAL CONTROL

Not only do feral and wild animals pose the danger of

animal bites and potential disease (rabies)

transmission, but perhaps more importantly for

Soldiers in deployed environments, they can act as

reservoirs for various vector-borne diseases (eg,

leishmaniasis). Therefore, animal control should be

part of any comprehensive preventive medicine plan

intended to protect US troops and preserve combat

power.

The contractor does the vast majority of animal

trapping on camps throughout the Iraqi theater of

operation, but is prohibited, by contract, from

euthanizing captured animals. When available, US

Challenges of Effective Vector Control: Operation Iraqi Freedom 05–07

†Clarke Mosquito Control, 110 E. Irving Park Road,

Roselle, Illinois 60712

‡High mobility multipurpose wheeled vehicles

*The vector control supervisor at LSA Anaconda related that

complaints and requests for mosquito and/or sand fly

control were averaging 16 to 18 a month prior to the

Mosquito Magnet control program. Once the program was

in place and fully operational, the number of complaints fell

considerably to 3 or 4 a month, and those were primarily

from temporary housing areas for personnel awaiting

redeployment or assignment to permanent quarters.
April – June 2007 51

military veterinary

personnel perform the

required euthanasia,

however, they are not

present on all camps and

the 903rd Medical

Detachment personnel

assumed the euthanasia

mission. Several forms of

e u t h a n a s i a w e r e

authorized in theater

based on guidance from

the theater veterinarian.

The preferred method of

control was through the

use of euthanasia drugs.

Nonveterinary personnel received training in

euthanasia procedures and handling and accountability

of euthanasia drugs. Once trained and approved by a

veterinarian, they were provided with a supply of

ketamine and sodium pentobarbital (which were

treated as controlled substances). In the absence of

personnel trained in administering euthanasia drugs,

the use of kinetic means was also authorized and

continued to be used for large, potentially dangerous

animals, as that method was judged safer than

attempting to hold and close with the larger stronger

animals. The same personnel handled all euthanasia

duties during the deployment, and were responsible for

the humane elimination of nearly 200 animals at Camp

Echo alone.

Not all animals captured by the contractor required

euthanasia. Wild animals, if healthy, were generally

released outside the

compound. After the

presumably unpleasant

experience of spending

the night in a cage, and

the appearance of humans

the following morning,

wild animals were seldom

r e c a p t u r e d . T h e s e

included native foxes,

sand cats, African pygmy

h e d g e h o g s , a n d

occasionally large birds

such as black francolins.

Healthy feral dogs and

cats, upon first capture,

were marked by a spot of

orange paint on the flank

or tail, and released

outside the camp. If

marked animals were

recaptured a second or

third time, they were

deemed inveterate pests

and, for the safety of camp

personnel, humanely

euthanized. To reduce the

potential spread of illness

and/or parasites to either

camp personnel or native

animals, ill or unhealthy

animals were euthanized

upon initial capture.

Complete control is not always desirable for some

species. For example, intensive control efforts by the

contractor and the 903rd Medical Detachment virtually

eliminated the feral feline population at Camp Echo.

An increase in rodent and then in snake populations

over the following months was indicated by customer

complaints and visual surveys. Though anecdotal, the

situation illustrates the sometimes confounding

relationships between targeted pest species.

Presumably, the elimination of a key predator allowed

rodent and reptile populations to quickly increase and

the larger rodent populations possibly attracted (and

maintained) additional snakes in the camp perimeter.

Consequently, control measures relative to the cat

population were relaxed, and the number of cats

allowed to increase to a level deemed adequate for

natural rodent control, and subsequent control efforts

were aimed at maintaining

the population at that

arbitrary level.

Bats discovered in

bunkers at Camp Echo

presented a special

problem. First, although

the presence of bats in

structures is generally

undesirable, like feral cats,

these flying mammals

perform a valuable and

beneficial function. Many

species of bats are

insectivorous and hunt at

dusk and during the

evening hours, when most

Native wild animals that were occasionally captured

included small-to-medium-sized predators such as this fox.

A sand cat communicates displeasure at its temporary

captivity. Most captured native wild animals, including this

cat, were released outside of the perimeter.
52 Army Medical Department Journal

flying blood-feeding insects are active. A single bat

can consume 400 to 1,200 mosquitoes and other

insects in an hour. Few natural predators are more

effective at reducing night-flying insect populations.2

Also, at least 5 species are listed on the “Iraq Red List”

as protected or threatened in Iraq: the Greater

Horseshoe Bat (Rhinolophus ferrumequinum), the

Mediterranean Horseshoe Bat (R. Euryale), Mehely’s

Horseshoe Bat (R. mehelyi), the Long-fingered Bat

(Myotis capaccinii), and the Sind Bat (Eptesicus

nasutus). Therefore, to conserve valuable predators

and avoid the difficulties inherent in attempts by

nonexperts to differentiate between protected and

unprotected species, nonlethal control of bat

populations was pursued. The most practical, and

humane, approach was to block available openings in

vacated buildings and bunkers after the bats left for

their nightly feeding forays to prevent their return. If

the openings were blocked while bats were inside, they

would starve, producing environmental hazards in the

forms of carcasses that are difficult to recover.

Parasites would then leave recently-deceased bats and

seek the nearest warm-bodied host. In addition, the

contractor constructed bat boxes which were installed

at suitable locations around the camp to provide

alternative roosting sites, and possibly attract

additional bats.

While there is little health hazard associated with freeliving healthy bats, many personnel expressed a

distinct fear or distaste of bats, particularly if

encountered inside living and working areas. In

addition, bats are commonly associated with rabies by

the general public, even though the best available

evidence indicates that less than 1% of all bats are

infected with the virus.3 Bat-transmitted rabies is very

rare, less than one case per year in the United States.

Public education efforts can alleviate some of these

concerns.

Animal control is an integral part of the overall

preventive medicine responsibility. Flexibility,

adaptability, and the willingness to “see the bigger

picture” are key components of feral and wild animal

control in deployed situations. The operating

environment may be considerably different from what

preventive medicine units are accustomed to (even

from deployment to deployment), and unexpected

missions may be incurred. Euthanization of feral and

sometimes wild animals is a necessary if often

unpalatable mission, and, if veterinary units are not

available, it is a mission that logically falls on the

preventive medicine personnel. The personnel that

perform the euthanasia should be volunteers (many

find this task abhorrent, objectionable, and/or

stressful), and receive training from veterinary

personnel in proper procedures for humane euthanasia.

There are strict guidelines for storage, accounting for

usage, and monthly inventory of any euthanizing drugs

maintained by preventive medicine personnel. If a

firearm is used, additional ammunition may be

required as well as proper accounting for expended

rounds. Finally, it is important to keep in perspective

the fact that animal control is not synonymous with

euthanasia. Healthy wild animals should generally be

released (if practical), and preventive medicine

personnel should educate themselves on any protected

wild species in their area of operations. It may be

preferable to permit some species of feral animals to

remain at some (arbitrary) population level in order to

help control even less desirable pests, as was the case

with cats and bats.

BIRD CONTROL

An often overlooked aspect of animal control efforts

during deployments is bird control. Birds pose little

problem when tents are the primary form of housing or

work areas because of the lack of established roosting/

feeding habitats. Bird control problems in these

situations are normally limited to birds feeding on

trash. As a theater matures, existing hard stand

buildings are utilized, bringing with them attendant

bird problems. Pigeons are the primary bird pest in

Iraq, although sparrows and other birds also contribute

to the problem. Pigeons roost on building ledges and

roofs, coating the exteriors with feces. Due to poor

construction, birds can readily gain access to building

attics. Most rooftops are flat, providing excellent

roosting sites for birds.

Forward Operating Base (FOB) Spiecher had one of

the most significant bird problems in theater due to the

large number of damaged buildings. Open air

warehouses, hangars, and abandoned/damaged

buildings provided ample roosting sites. Personnel and

equipment stored in these buildings were often

contaminated by feces and bothered by noise from the

large populations. Exclusion of the birds from the

buildings was impossible due to the numerous

openings. Building renovations were often limited to

Challenges of Effective Vector Control: Operation Iraqi Freedom 05–07
April – June 2007 53

repairing rooms and

ceilings to make them

usable, but the exterior

structures were not sealed

and birds continued to use

the buildings. The 223rd

Medical Detachment

provided support to camps

located in northern Iraq,

and dealt with the bird

control problem at FOB

Speicher by persistently

removing suitable habitat.

This resulted in the

decline of the population

t o s m a l l e r , m o r e

manageable populations.

Razing of other roosting

sites resulted in further

d i sp e rsi o n of th e

population, mainly to the

hangars.

Bird exclusion measures that we would often use

elsewhere were not feasible in Iraq, due to the cost and

lack of materials. Bird spikes on ledges, window sills,

and other roosting sites were costly and required

significant manpower to install. Bird netting was not

practical because of the large areas that required

coverage to reduce access. Further, the birds were not

readily startled by loud noises because of the almost

constant noise around the base.

Avicides were authorized for use, but only on a limited

basis due to limited efficacy and complaints about

dead and dying birds on base. Any report of a dead or

dying bird immediately caused concern about avian

influenza. The use of live traps was considered,

however, such measures would introduce the problem

of disposition of the captured birds. Removal from the

building and release would only mean they would

return immediately if the building was not sealed.

Contractor personnel where not authorized to kill the

captured birds, so, as with other feral animals, it would

have been incumbent on preventive medicine

personnel to euthanize them. We lacked a CO2

chamber and the removal of individual birds from the

traps to inject them was not considered a viable option.

A few pellet guns were used to shoot pigeons to scare

them away, but with only limited results. As with the

other methods, shooting

pigeons would scare them

away for a time, but they

returned in force. This

method also required

extensive coordination

and was often not feasible

in areas where personnel

lived and worked. Pigeons

are difficult to control

even on the best of days,

but pigeon control in Iraq

is a constant problem

compounded by the threat

of avian influenza.

Vector control in Iraq

presented many unique

and difficult challenges.

The military preventive

medicine team worked closely with the contractor

vector control personnel to do an outstanding job of

searching for and identifying new and innovative

approaches to problems. Through their efforts,

Warfighters are protected from vectorborne diseases

and environmental hazards that are so detrimental to

the performance of their primary mission.

REFERENCES

1. Sutherland DJ, Crans WJ. Mosquitoes in Your Life.

Rutgers University. The New Jersey Agriculture

Experiment Station Publication SA220-5M-86.

Available at: http://www-rci.rutgers.edu/~insects/

moslife.htm.

2. State of Michigan. Emerging disease issues:

biological mosquito control. Available at: http://

www.michigan.gov/emergingdiseases/0,1607,7-186-

25805_25824-75797--,00.html. Accessed 2 April

2007.

3. Organization for Bat Conservation, Cranbrook

Institute of Science. Bats and rabies. Available at:

h t t p : / / w w w . b a t c o n s e r v a t i o n . o r g / c o n t e n t /

Batsrabies.html. Accessed 2 April 2007.

AUTHORS

LTC Blow is the Brigade Entomologist, 30th Medical

Brigade, Heidelberg, Germany. Previously, she was the

Pest Management Consultant, Multinational CoalitionIraq, with the TF-30 Medical Brigade in Baghdad, Iraq.

One of the numerous damaged buildings at Forward

Operating Base Spiecher that was infested with birds.

Portions of the interior of this building were being

renovated for use. Numerous openings made exclusion

of birds impossible.
54 Army Medical Department Journal

Challenges of Effective Vector Control: Operation Iraqi Freedom 05–07

CPT Forest is an Entomology Project Officer, USACHPPM, Aberdeen Proving Ground, Maryland. Previously he was

the Commander, 255th Medical Detachment, Grafenwoer, Germany, and twice deployed to Iraq.

CPT Lewis is the Executive Officer, 223rd Medical Detachment, Ft. Carson, Colorado.

MAJ Meckel is an Entomological Project Officer, USACHPPM-West, Fort Lewis Washington. Previously, he was the

Commander, 898th Medical Detachment, Fort Lawton, Washington, during the detachment’s deployment to OIF 05-07.

CPT Raymond is the Commander, 903rd Medical Detachment, Beloit, Wisconsin. He was the Commander during the

unit’s deployment in support of OIF 05–07.

MAJ Carder is the Commander, 485th Medical Detachment, Fort Polk, Louisiana. Previously, he was the

Environmental Science Officer, 61st Multifunctional Medical Brigade, Balad, Iraq.

Using DoD Insect Repellent System as a Personal

Protective Measure Against Disease Vectors

Throughout the course of military history, more casualties have resulted from disease and nonbattle injuries than from

wounds inflicted by the enemy. The bites of insects and ticks transmit many of the disease-causing germs that give our

military the most trouble. Don’t let yourself be pestered by arthropods, or worse, become a victim of an arthropod-borne

disease. These diseases can take you out of the action, make you miserably sick, or even kill you. The diseases and the

creatures that transmit them are as much of a threat during routine training exercises or humanitarian/disaster assistance

operations as during actual combat.

The DoD Insect Repellent System is available for use by all personnel to prevent arthropod-borne diseases, such as

malaria, leishmaniasis, scrub typhus, West Nile virus, and Lyme disease. When used properly, the DoD Insect Repellent

System will prevent disease, pain, and the annoyance caused by bites of insects such as mosquitoes, sand flies, and other

arthropods such as ticks and chiggers. The following procedures for the repellent system will ensure maximum

protection for you while performing routine training exercises or actual missions in areas where vector (insect)-borne

diseases are common:

1. Permethrin on clothing. This can be accomplished in any one of four ways. You can use the Permethrin

impregnation kit known as the Individual Dynamic Absorption (IDA) Kit (NSN 6840-01-345-0237). One kit treats one

entire uniform, and the treatment lasts for approximately 52 washes (generally considered the combat life of the

uniform). If the IDA kit is not available, use the aerosol spray can (NSN 6840-01-278-1336). One application of

approximately 3⁄4-can lasts 4 to 6 washes. You can also use a 2-gallon, pump sprayer for permethrin application to many

uniforms at the same time. This method must be applied by properly trained personnel who protect themselves from the

spray with a respirator. You will not be exposed to as much permethrin because the chemical binds with the cloth after it

dries. Another recently approved method is to have uniforms (BDU, DCU, or ACU) factory treated. The factory

treatment method results in the same chemical concentration as both the IDA kit and the 2-gal sprayer method. Factory

treatment is a big advantage because it is more convenient for the individual and the unit, as well as providing a uniform

that retains its repellency for the life of the uniform. If a unit contracts to have their uniforms treated, the uniforms will

be returned with a label indicating that they were treated with permethrin. The new ACUs are made of the same fabric as

the old BDUs and DCUs, so the ACU treatment is the same. DO NOT dry clean a permethrin treated uniform, as drycleaning solvents completely remove the permethrin, rendering the treatment ineffective. However, a dry-cleaned

uniform can be retreated.

2. Deet on exposed skin. Apply a thin coat of the current standard military skin repellent. This product was carefully

developed to minimize the amount of active ingredient (35%) and maximize the duration of protection by incorporating

the active ingredient into a sustained-release, polymer formulation known as the extended duration topical insect and

arthropod repellent (EDTIAR) (NSN 6840-01-284-3982). Apply it to all exposed skin except areas close to the eyes and

mouth. Be sure to follow label directions when applying this or any other repellent. One application lasts up to 12 hours,

depending on the climate.
April – June 2007 55

3. Properly wear the uniform. Wear the sleeves rolled down and close all openings on your clothing that might

provide access to insects. Tuck pants into your boots and undershirt into your pants. The uniform should be loose and not

tight fitting so that insects, particularly mosquitoes, cannot bite through the cloth into your skin. Check your clothing

routinely for insects and ticks, and use the buddy system to inspect areas of the uniform that you can’t easily see.

4. Treat bednet. Some insects such as sand flies are smaller and can fit through the mesh of the net. Treat your bednet

with permethrin in a well-ventilated area before you bed down. A self-supporting popup bednet is now available (NSN

3740-01-516-4415 [olive drab] and NSN 3740-01-518-7310 [coyote brown]). The new popup bednets are factory treated

with permethrin and do not require poles or a separate frame.

5. Malaria pills. There are drugs, known as chemoprophylaxis, which can be taken to prevent malaria. Some of these

drugs can make a person feel ill, especially when they are first used. Be sure to use only the drugs that are prescribed

because an effective drug in one part of the world is useless in another. If you think you are having bad side effects

(upset stomach, disturbed sleep, rashes, vision impairment, etc) from chemoprophylaxis, tell a physician as soon as

possible.

The DOD Insect Repellent System is critical to the Army’s Medical Regiment motto to “Conserve the Fighting

Strength.” It is a mission essential task located in STP-21-1-SMCT; Soldier’s Manual of Common Task Testing, Skill

Level 1 dated 11 Oct 2005. The system is a DoD Policy that every Soldier, Airman, Marine, and Corpsman need to

strictly follow.

Additional information on personal protective measures can be found in the Armed Forces Pest Management Board’s

Technical Guide 36, Personal Protective Measures Against Insects and Other Arthropods of Military Significance,

which can be downloaded from http://www.afpmb.org/pubs/tims/tims.htm; in the US Army Center for Health Promotion

and Preventive Medicine fact sheet on the DoD Insect Repellent System (http://chppm-www.apgea.army.mil/documents/

DODInsectRepellentSys.pdf); and in the Army Medical Department Center and School deployment training portal at

http://www.cs.amedd.army.mil/deployment2.aspx#.

For further information, contact: COL Debboun (mustapha.debboun@amedd.army.mil [210-221-7649]) and SSG(P)

Vincent (andrea.vincent@amedd.army.mil [210-221-6801]), Medical Zoology Branch, Dept of Preventive Health

Services, Academy of Health Sciences, AMEDD Center and School, Fort Sam Houston, Texas.

1 2 3

It’s DoD

Policy

It’s a basic

training

task

It’s critical

for your

health

Courtesy of the Entomological Sciences Program, US Army Center for Health

Promotion and Preventive Medicine, Aberdeen Proving Ground, Maryland
56 Army Medical Department Journal

INTRODUCTION

Although US military operations in Afghanistan have

been conducted for more than 5 years as part of

Operation Enduring Freedom (OEF), the challenges in

providing preventive medicine support are not widely

recognized by the majority of US military medical

personnel. The nature of the climate, terrain,

infrastructure, and mission dictated that provision of

preventive medicine support was not always according

to doctrine.

Terrain and Climate

Afghanistan, located in south central Asia, is 647,500

km2(250,000 sq miles) in area, which is slightly

smaller than Texas.1 This landlocked country is

dominated by the rugged Hindu Kush Mountains, with

plains in the north and southwestern portions and

elevations ranging from 258 m (846 ft) to 7,458 m

(24,469 ft). Although some US forward operating

bases (FOBs) are located at an elevation of 500 m

(1,640 ft) above sea level, most are situated above an

elevation of 1,500 m (4,921 ft), with some FOBs at

elevations approaching 2,750 m (9,022 ft). Higher

elevations generally lead to colder temperatures and an

increase in cold weather injuries. Altitude sickness is

another concern for troops deployed to these high

elevation areas.

The climate in Afghanistan is typically dry with hot

summers and cold winters. Areas near the Pakistan

border are influenced by monsoonal weather patterns

that bring significant amounts of rain in short periods

of time. The areas of southeastern Afghanistan

surrounding Jalalabad and Khowst are classified as a

Subtropical Steppe climate.2Summer temperatures in

Jalalabad reach 46°C (115°F) with high humidity, and

winter temperatures normally remain above freezing.

Winter temperatures below freezing at Kabul are due

mainly to the elevation of 1,791 m (5,876 ft). Many of

the FOBs have a climate similar to Kabul because of

their high elevations.

Transportation

Transportation infrastructure is limited throughout the

country. Only 8,231 km (5,000 mi) of paved roads

exist in Afghanistan1and most of those are located

near Kabul and a few other large cities. The lack of

roads combined with the rugged terrain resulted in an

almost total dependence on air transportation for

movement of military forces between FOBs. Some

locations, such as Bagram Airfield, Kandahar Airfield,

FOB Salerno near Khowst, and Jalalabad Airfield have

runways capable of supporting C-130 aircraft.

However, most locations are only accessible by rotary

wing aircraft, primarily CH-47 Chinook and UH-60

Blackhawk helicopters. The demand for air transport

was high and flights to outlying FOBs were limited to

one or two per week. Besides the numbers of

personnel vying for transport, a significant amount of

space was allocated to mail, equipment, and supplies.

Flight operations at higher elevations also reduced the

amount of personnel and cargo that the helicopters

could carry.

Preventive Medicine Assets in Theater

The dispersed and isolated nature of approximately

18,000 US and Coalition Forces mandated a larger

preventive medicine presence than doctrinally

specified. The 71st and 480th Medical Detachments

(Preventive Medicine) provided support in theater and

were task organized under Task Force Strength

(comprised mainly of the 249th General Hospital). The

71st Medical Detachment supported Bagram Airfield

and the Regional Command (RC) East, based in FOB

Salerno. The 480th Medical Detachment supported RC

South, based at Kandahar Airfield, and a base at

Karshi-Khanabad, Uzbekistan. Two Brigade Combat

Teams (BCT) were the primary elements of each RC:

Preventive Medicine Support in Afghanistan

During Operation Enduring Freedom VI

MAJ Christopher A. Gellasch, MS, USA

CPT Lesly C. Calix, MS, USA
April – June 2007 57

the 1st Brigade, 82nd Airborne Division in RC East

and the 173rd Airborne Brigade in RC South. Each

BCT had its own Environmental Science and

Engineering Officer and one or two Preventive

Medicine Specialists (68S). The Medical Detachment

and BCT preventive medicine personnel worked

together to provide area support within each RC. The

technical reporting chain for all preventive medicine

assets in theater went through the Combined Joint

Task Force-76 (CJTF-76) Surgeon Cell’s Force Health

Protection Officer. No medical brigade or other higher

echelon medical unit was present in Afghanistan. The

higher headquarters to CJTF-76, Combined Forces

Command-Afghanistan in Kabul, did not have a

Surgeon Cell. Reporting of preventive medicine issues

went from CJTF-76 to the Coalition Forces Land

Component Command.

SUPPORT TO LARGER BASES

Three bases in Afghanistan (Figure 1), Bagram

Airfield, Kandahar Airfield, and FOB Salerno were

much larger than the others and had populations

between 1,500 and 10,000 personnel. The larger bases

required a significant amount of man-hours to conduct

all required inspections and surveys as they were

transportation, logistics, and service hubs with many

garrison-type operations. Contractors were responsible

for operating dining facilities (DFACs), potable water

production, waste disposal, vector control, laundry,

and other base operations. Since these locations were

transportation hubs, they were ideal locations for

preventive medicine units to use as bases of

operations. Bagram Airfield is so large that it was

divided into approximately 20 smaller base camps,

each requiring a separate monthly base camp

inspection. The base camps included the hospital

compound, engineer task force area, contractor

housing, and many others.

Food and Water

Personnel ate most of their meals at the DFACs, but

there were also Army and Air Force Exchange Service

food concessionaires on each base. The largest base

was Bagram Airfield with 7 DFACs and 9 food

concessionaires. The food concessionaires consisted

mostly of fast food chains familiar to Soldiers

(Subway, Burger King, Diary Queen, etc) but were run

primarily by third country nationals not accustomed to

US standards of food service sanitation. Consequently,

several facilities were closed after preventive medicine

inspections found serious deficiencies (eg, poor

sanitation, expired food) and many had repeat

closures. The contractor-operated DFACs, several of

which were managed by retired US military food

service personnel, had relatively few violations.

Contractor run potable water operations used

groundwater from large, deep wells as the primary

source. Water quality was good and chlorine residuals

at the source were kept between 3 ppm and 5 ppm, and

was normally above 3 ppm for water at the point of

use. Although there was a low health

risk from this water, bottled water was

the primary source of drinking water.

Weekly testing for chlorine residual,

pH, and coliform bacteria was

conducted at sites throughout the bases.

Due to a lack of water distribution

infrastructure at some bases, potable

water tanker trucks were used to

transport water to shower points,

latrines, DFACs, and other sites. The

trucks were inspected quarterly by

preventive medicine Soldiers.

Solid Waste and Wastewater

A significant amount of solid waste and

wastewater was generated at these

bases. Contractor-operated burn pits

were the primary means of solid waste

disposal, but they were inefficient and

did not completely burn the waste. The

Figure 1. Locations of Army preventive medicine resources at the beginning

of OEF VI.

FOB Salerno

71st Medical

Detachment (-)

1st BDE 82nd Airborne Di v

Bagram Airfield

71st Medical

Detachment (-)

CJTF-76 Headquarters

Kandahar Airfield

480th Medical

Detachment (-)

173rd Airborne Brigade

Karshi-Khanabad

480th Medical

Detachment (-)

FOB Salerno

71st Medical

Detachment (-)

Karshi-Khanabad

480th Medical

Detachment (-)

Kandahar Airfield

480th Medical

Detachment (-)

Bagram Airfield

71st Medical

Detachment (-)
58 Army Medical Department Journal

burning created a large plume of smoke that was an

irritant if inhaled. Efforts by the CJTF-76 Engineers

(J7), Surgeon, and preventive medicine to have

incinerators installed for general trash disposal were

unsuccessful. No recycling of metal, glass, or paper in

the municipal waste stream was undertaken, although

the J7 Environmental Officer attempted to find a

contractor to initiate a recycling program. Regulated

medical waste was taken to a contractor-operated

incinerator at Bagram Airfield for disposal.

Wastewater disposal at Bagram Airfield consisted of

dumping untreated gray water from showers, laundry,

and DFACs into a stream that flowed off the

installation. The black water from latrines was taken

off-site by a local contractor, but upon investigation,

no one could be found that knew exactly where the

black water was being disposed. At both Kandahar

Airfield and FOB Salerno, large settling basins were

used to treat wastewater, but the efficacy of these

structures was questionable and they served as

breeding sites for Culex spp mosquitoes.

Vector Surveillance

The vector control mission (including spraying) had

been assumed by the contractor, but the vector

surveillance mission was still performed by preventive

medicine personnel. Centers for Disease Control and

Prevention (CDC) miniature light traps were used to

conduct mosquito and sand fly surveillance during the

deployment. Traps were set up 2 or 3 times a week,

depending on available personnel and

threat level. Surveillance was conducted

during the summer months with

variation between bases due to

e l e va t i o n a n d a ve r a ge d a i l y

temperatures. The collection data from

FOB Salerno is presented in Figure 2.

The majority of insects were collected

from mid-June to mid-July, when

temperatures were highest. Malaria is

endemic in Afghanistan and species of

Anopheles mosquitoes, a vector of

malaria, are predominant in the east and

south regions.3 The most common cause

of malaria in theater was Plasmodium

vivax with a smaller number of P.

falciparum cases. CJTF-76 policy

directed all Soldiers in theater to take a

chemoprophylaxis, typically doxycycline or

mefloquine, during deployment. However,

noncompliance with the chemoprophylaxis policy was

found in every instance of the more than 40 cases of

malaria during 2005. Sand flies are a vector of

leishmaniasis, however, the risk level for this disease

was low in the southern and eastern portions of the

country. Rodents and house flies were the most

common pests found throughout the theater.

SUPPORT TO FORWARD OPERATING BASES

In contrast to the larger bases, many of the FOBs had

little or no contractor support, and most DFACs were

staffed by military food service specialists. In some

cases, there were several smaller camps present within

Preventive Medicine Support in Afghanistan During Operation Enduring Freedom VI

Light trap installation at a forward operating base

0

20

40

60

80

100

120

23-27May

31May-Jun3

6-9 Jun

13-18Jun21-23Jun

28Jun-Jul1

6-9Jul

13-16Jul19-22Jul30-31Jul

1-6Aug

9-10Aug

Culex spp.

Sand flies

Anopheles spp.

No. of insects Figure 2. Insect collection data from FOB Salerno, 23 May to

10 August 2005.

Culex spp.

Sand flies

Anopheles spp.

Number of Insects
April – June 2007 59

the FOB (eg, Special Forces, Provincial

Reconstruction Team, infantry company) with some

duplication of base operations in each camp.

Concept of Support and Limitations

During the previous rotation, only the 172nd Medical

Detachment (Preventive Medicine) was in theater and

FOBs were only visited once per quarter. With 2

detachments (the 71st and the 480th) present for OEF

VI, the decision was made to visit FOBs every 4 to 6

weeks, with a goal of monthly visits. To illustrate how

this process worked, the plan of support to portions of

RC East from Bagram Airfield is discussed in the

following paragraphs.

The limiting factors in providing support to FOBs

were personnel, transportation, and preventive

medicine equipment. In order to keep enough

personnel at Bagram Airfield to conduct missions on

the installation, only one preventive medicine

specialist rather than a team of 2 or 3 Soldiers was able

to travel to each FOB. Many of the Soldiers in the 71st

Medical Detachment were recent graduates of

Advanced Individual Training with limited experience.

These junior Soldiers were required to fly to an FOB,

conduct all inspections, recommend corrections, and

provide any other support as needed without any direct

supervision. With overlap due to flight availability, at

any given time, 2 Soldiers were at FOBs while 2

Soldiers were at Bagram Airfield conducting missions.

The typical FOB mission required 2 or 3 days to

complete but flights to some FOBs arrived only once

every 8 days. This resulted in junior Soldiers

remaining at an FOB for several additional days with

neither a mission nor noncommissioned officer

supervision. Some proactive Soldiers spent the extra

time applying preventive medicine principles and

looking for additional ways to help the FOB mayor

improve living conditions.

Equipment presented another challenge in the support

of FOBs. The normal medical equipment sets used by

a team in a medical detachment are contained in

medical chests and fill an M1114 HMMWV.* Due to

space restrictions on aircraft, the preventive medicine

specialist visiting an FOB was limited to a personal

bag (rucksack or duffel bag) plus one footlocker or

similar-sized container for equipment. This required

some creativity to maintain capability while meeting

space requirements. Typically, preventive medicine

specialists would carry the following:

 Binder with forms

 Water Testing

Hach† DR/890 Colorimeter

Millipore Incubator

Colilert media and bottles

LaMotte Kit or test strips

 Food Sanitation

Copy of TB MED 530 4

Food service Cl test paper

Food Thermometers

 Entomology

One CDC Light Trap

Rodent sticky traps

Fly strips

Mosquito larvacide dunks

Instead of using the standard Hach DREL 2400 water

quality analysis laboratory, a Hach DR/890 Portable

Colorimeter was substituted. This saved a substantial

amount of space while retaining most of the capability

required to conduct onsite drinking water analysis. The

standard gray Millipore Field Incubator‡used to

incubate samples for the presence or absence of

coliform bacteria was essential on FOB missions, but

required almost half of the space allotted. Initially, a

few of the older model incubators were used since they

are much smaller, but they soon stopped functioning

and could not be repaired. Only limited entomology

equipment and no industrial hygiene equipment was

part of the standard kit. If a need for additional

*High Mobility Multipurpose Wheeled Vehicle

†Hach Company, Loveland, Colorado 80539, 800-227-4224

‡Millipore Inc., Billerica, MA 01821, 978-715-4321

Hach DREL 2400 Complete Water Quality Lab
60 Army Medical Department Journal

equipment was recognized

during a visit, the preventive

medicine specialist would

bring it on the next month’s

mission.

Food and Water

The quality of sanitation at the

military dining facilities at

FOBs was variable. In

general, larger FOBs had

higher-ranking supervision at

the DFAC and better

compliance with food service

sanitation standards. Common

deficiencies at FOB DFACs included improper food

holding temperatures and poor sanitation practices.4

Poorly maintained or malfunctioning equipment such

as steam tables or refrigerators could not be repaired or

replaced quickly. Most food was transported to FOBs

via local national trucks over Afghanistan’s primitive

road system. The frozen and refrigerated food often

arrived at the FOB above the acceptable temperatures

or was clearly allowed to thaw and then refreeze. This

resulted in an increased risk of foodborne illness to US

and Coalition troops.

Although bottled water was used for drinking, well

water was utilized for personal hygiene, laundry, and

washing dishes at the DFAC. In general, wells were

not properly constructed, did not have a sanitary seal,

and were contaminated with coliform bacteria. Some

wells did have chlorine injectors but most did not

function. The only locations with a consistent chlorine

residual in the water supply were those in which

personnel (normally medics) manually added calcium

hypochlorite to storage tanks and tested chlorine

residual on a daily basis. During FOB visits,

preventive medicine specialists provided assistance by

ensuring that water tank chlorination was conducted

by trained personnel and that a supply of calcium

hypochlorite and chlorine test strips was on hand.

Solid Waste

Solid waste was burned at most FOBs, although the

effectiveness ranged from moderate to poor. At some

locations, waste was dumped outside the FOB

perimeter and not burned immediately. Groups of local

nationals would rummage through the waste looking

for useful items and subsequently spread the trash over

a large area. Other locations would pour fuel on trash

piles and ignite them without ensuring proper

combustion. Although the term “burn pit” was

normally used, high water tables in some areas

prevented excavating more than a few feet below

ground level and burned trash was not always covered

with soil. Most solid waste disposal areas became

magnets for rodents, house flies, and stray dogs.

Vector Surveillance and Control

Vector surveillance data was valuable for efficient

control. Contractor personnel applied chemical control

only following a recommendation by a military

entomologist. Mosquito breeding sites were identified

and larvae controlled by applying Altosid or Bacillus

thuringiensis briquettes.5Sand fly and Anopheles

mosquito specimens were sent to the Biosystematics

Unit of the Walter Reed Army Institute of Research

and the US Army Center for Health Promotion and

Preventive Medicine (USACHPPM)-North,

respectively, to be tested. House fly infestations were

widely problematic, particularly around the DFACs.

Sanitation practices were instituted and then

supplemented with fly bait and fly strips such as

Quikstrike.*Integrated pest management practices

used throughout the year of deployment significantly

reduced the use of pesticides.

Uniform Treatment

The proper chemical treatment of uniforms, as

mandated by Department of Defense directives, is

imperative for the prevention of vectorborne diseases.

Soldiers need greater awareness and training in

uniform treatment procedures before deploying. The

imminent threat of diseases such as leishmaniasis and

malaria made the treatment of uniforms in theater a

priority for many units that were not able to do so prior

to deploying. Preventive medicine personnel treated

uniforms at many FOBs where troops did not have

spray equipment or permethrin.5

Environmental Sampling

Soil and water samples were collected periodically in

support of the Army Deployment Occupational and

Environmental Health Risk Management Program.

Since water at FOBs was not treated (with the

exception of some chlorination), raw water sampling

was required at each well. Two or three wells were in

Preventive Medicine Support in Afghanistan During Operation Enduring Freedom VI

Hach DR/890

Portable Colorimeter

*Do-It-Yourself Pest Control, Inc., Atlanta, Georgia 30341
April – June 2007 61

use at many FOBs, which required a large cooler for

each sample. Normally, an Environmental Science and

Engineering Officer (ESEO) accompanied a

preventive medicine specialist to an FOB during a

normally scheduled visit in order to collect these

samples. As mentioned earlier, the logistics of

bringing extra equipment to an FOB was problematic.

In addition, after the raw water samples were collected

they had to be maintained at 4°C, and during the

summer months ice packs only kept samples chilled

for a limited time. Some analytes have short holding

times and there were challenges getting water samples

from a FOB to a main base, such as Bagram Airfield,

and then to USACHPPM for laboratory analysis. It

was difficult to move samples from remote locations to

a USACHPPM laboratory within a 14-day holding

time.

OTHER PREVENTIVE MEDICINE MISSIONS

Closure of Karshi-Khanabad

The airbase at Karshi-Khanabad (K2), Uzbekistan, was

used primarily as a logistics hub for equipment and

supplies flowing into Afghanistan. The preventive

medicine team at K2 consisted of an ESEO, and 2

preventive medicine specialists from the 480th

Medical Detachment. The routine mission to provide

preventive medicine support changed in July 2005

when the Government of Uzbekistan ordered US

forces to vacate K2 within 6 months. The rapid

drawdown and closure of the airbase presented some

challenges that were handled by preventive medicine

personnel, including the discovery of a 20-foot long

shipping container that had been accumulating

regulated medical waste (RMW) for more than 3

years. No inventory existed and the Level II clinic

personnel had been adding red bags of RMW to the

container on a regular basis. The ESEO had to quickly

determine the proper way to categorize and dispose of

all of the RMW. A local contractor was found that

could properly handle and incinerate the contents of

the shipping container. This saved the US government

the cost of shipping the container of RMW to

Germany for disposal. Another major issue related to

closure activities involved proper disposal of a large

amount of hazardous waste and hazardous materials.

An Army Reserve Officer that works for the State of

Missouri dealing with hazardous waste issues in his

civilian job was the ESEO at K2. His civilian

experience made him an invaluable asset to the K2

mayor cell and prevented a potentially serious issue

with disposal of hazardous waste and materials.

Earthquake Support in Pakistan

On 8 October, 2005, a 7.6 magnitude earthquake

struck northern Pakistan, killing more than 86,000

people, leaving more than 4 million people homeless,

and causing massive destruction.6 A task force

comprised mostly of aviation units from CJTF-76

rapidly deployed from Afghanistan to Qasim Airfield

near Islamabad, Pakistan, to provide humanitarian

relief. No preventive medicine personnel were

authorized to accompany the initial group into

Pakistan. One week later, the CJTF-76 headquarters

received numerous reports that US Soldiers in Pakistan

suffered from foodborne illness, poor sanitary

conditions, and a large number of mosquito bites. At

that point, the Commander of the 71st Medical

A preventive medicine specialist treats uniforms with

the clothing repellent Permethrin

Preparing to conduct raw water sampling at a forward

operating base
62 Army Medical Department Journal

Detachment was dispatched to Pakistan to direct

efforts to improve the situation. Although the mission

was initially focused on correcting existing problems,

preventive medicine measures were also quickly

implemented to reduce the disease and nonbattle injury

rate. Working with the task force engineer, a

semipermanent base camp for use by the aviation task

force was designed and a food service contractor was

selected. After one week, a Navy Forward Deployable

Preventive Medicine Unit arrived and assumed the

mission at Qasim.

Malaria and Leishmaniasis Investigations

In September 2005, a Soldier contracted P. falciparum

malaria in Paktika province, Afghanistan. Falciparum

malaria is the most serious malarial infection and may

cause coagulation defects, shock, renal and liver

failure, pulmonary and cerebral edema, coma, and

death. The Soldier was evacuated by air to the level III

treatment facility at Bagram Airfield, then to the

Landstuhl Regional Medical Center, Germany, and

eventually to the Walter Reed Army Medical Center.

The Soldier survived, but suffered permanent liver

damage.

An Army Regulation 15-6 investigation7conducted by

the Executive Officer of the 71st Medical Detachment

revealed that the Soldier contracted malaria

individually as the result of a combination of factors.

He did not take his malaria prophylactic or use any

other personal protective measures to reduce the risk

of contracting malaria. Personal protective measures

include chemoprophylaxis, permethrin treated

uniforms, proper wearing of uniforms, use of military

DEET skin cream and mosquito bed nets. A

combination of all of these preventive measures could

have protected him from malaria. The chain of

command failed to ensure that malaria medication was

part of the precombat inspections and checks.

LESSONS LEARNED

Decentralized Preventive Medicine Operations

With the initial split-based operations used by

preventive medicine in the early part of the

deployment, most of the larger FOBs received a

monthly assistance visit. However, some of the smaller

FOBs and fire bases could only be reached by irregular

flights or ground convoys from a larger FOB.

Attempts to coordinate visits to these smaller FOBs

regularly failed due to changing convoy schedules or

the inability to coordinate flights with convoys. The

alternative was to have a Soldier on the ground for 16

days to accomplish 4 days worth of work.

The solution in RC East was the reorganization of

preventive medicine personnel—the 82nd Airborne

Division organic preventive medicine assets covered

FOB Salerno and teams of 2 Soldiers from the 71st

Medical Detachment and their equipment were

forward positioned at the battalion-level FOBs. This

allowed greater integration with the maneuver units

and allowed one preventive medicine specialist to be

available to accompany a convoy or flight to the

smaller outlying FOBs. Although having a forward

presence resulted in many benefits, a lack of

equipment resulted in limited capability and/or

portability for some teams. Teams usually consisted of

2 junior enlisted Soldiers that had minimal supervision

by a preventive medicine noncommissioned officer

(NCO) for months at a time. It also lowered morale for

Soldiers that covered only the Bagram Airfield

mission and no longer had the opportunity to travel to

FOBs. A plan was developed to rotate Soldiers at

Bagram Airfield and the FOBs every 3 to 4 months to

mitigate these issues.

Field Sanitation Teams

Based on unit reports and observations in the field,

most company-sized units in theater did not have

functioning Field Sanitation Teams. Army Regulation

40-5 requires that “Company-sized units will establish

and employ manned, trained, and equipped unit field

sanitation teams (FSTs).”8 When questioned about the

status of their FSTs, many units replied that they had

ordered the required equipment before deployment,

but it never arrived. If Soldiers in the FST had

received the 40-hour FST training course, they did not

use that knowledge in the field. One example: during

the Pakistan earthquake support mission, a Sergeant in

the aviation task force mentioned that he attended an

FST class taught by the 71st Medical Detachment a

few months prior to the earthquake. This NCO had the

knowledge to correct many of the sanitation problems

negatively impacting the mission at his location. He

chose not to take action or inform his chain of

command of the corrective actions that were needed.

As a result, an ESEO was required to deploy to

Pakistan and correct these problems.

Preventive Medicine Support in Afghanistan During Operation Enduring Freedom VI
April – June 2007 63

The importance of the FST must be stressed to units

during predeployment training and field sanitation

should be incorporated into training scenarios. The

71st Medical Detachment has worked with observer/

controllers at the Joint Multinational Training Center

(JMTC) (formerly the Combat Maneuver Training

Center) in Hohenfels, Germany, to have units

construct latrines, determine the wet bulb globe

temperature, and perform other FST functions during

training and predeployment rotations at the JMTC.

Clinical Preventive Medicine

During OEF VI there were adequate numbers of

ESEOs, medical entomologists, preventive medicine

specialists, and NCOs to handle most problems

requiring their skills sets. However, no clinical

preventive medicine expertise was present at any of

the level II or level III medical treatment facilities.

Issues such as tuberculosis and hepatitis policies for

local national and third country national workers on

base, pandemic influenza, sexually transmitted

diseases, and tracking of reportable medical events

belong in the purview of preventive medicine

physicians and Army Public Health Nurses (APHN).

According to Hollandsworth et al,9the role of the

APHN (formerly Army Community Health Nurse) is

expanding to cover these topics in deployed settings.

There are now authorizations for APHNs in the

combat support hospitals, but none were deployed in

OEF VI or the following rotation. These clinical

preventive medicine specialists must be present in

deployed settings to ensure the proper mix of skill sets

is available to maximize Force Health Protection.

Water Well Construction

In the summer of 2005, while conducting an

assessment of water supplies used by US and Coalition

Forces, several organizations were contacted to

determine the number and location of wells at each

FOB. No one within CJTF-76 had a comprehensive

census of wells at each location, and planning for raw

water sampling was difficult. Further, at each FOB no

information related to the construction, depth, or

geology of the well sites existed. Wells were typically

constructed by local contractors at the request of the

FOB mayor, and higher headquarters was not

informed. Most wells were not constructed to US

standards and frequently became contaminated with

coliform bacteria.

To correct this situation, preventive medicine

personnel worked with the J7 Environmental Officer

in an attempt to bring in US military well drilling

teams to construct new wells at FOBs. Although water

well drilling units exist in the Army, Navy, and Air

Force,10 none were available for deployment to

Afghanistan. All Army well drilling units have been

moved to the Reserve components and their equipment

is aging and in need of replacement. In order to ensure

US troops are receiving water from properly

constructed wells that minimize the risk of

contamination, military well drilling units should be

deployed to construct wells at FOBs.11 In an effort to

construct wells to US standards, a well specification

guide template was developed by preventive medicine

personnel working in conjunction with the Army

Corps of Engineers. The guide can be used by FOB

mayors when hiring local contractors for well

construction.

Environmental Sample Analysis

Soil, water, and particulate air samples comprised the

bulk of media collected and sent out of theater for

analysis. The logistics of collecting and shipping

samples posed multiple problems. Some samples

shipped by commercial carriers were left sitting at the

point of departure for days, and it could take weeks for

samples to arrive at the laboratory. The most reliable

method of shipping samples was the US Air Force

medical evacuation flights from Bagram Airfield to

Ramstein Airbase, Germany. A patient escort would

maintain accountability for the samples during the

flight to Ramstein and subsequent trip to the nearby

Landstuhl Regional Medical Center (LRMC). Once at

LRMC, the patient escort would call the contact

numbers provided for the USACHPPM-Europe to

arrange pickup. The limitation to this procedure was

that evacuation flights were not regularly scheduled,

and not all flights went directly from Bagram Airfield

to Germany. In some cases, a week would elapse

between flights. A solution to the problem of having

samples quickly analyzed would be the deployment of

an Area Medical Laboratory (AML) to the US Central

Command Area of Responsibility. Neither of the 2

AMLs has deployed since their formation in 2004,

even though they have the capability to perform most,

if not all, analyses required by the Army Deployment

Occupational and Environmental Health Risk

Management Program.12 At a minimum, one AML

should be deployed to Kuwait to support units

deployed in both Afghanistan and Iraq.
64 Army Medical Department Journal

Preventive Medicine Support in Afghanistan During Operation Enduring Freedom VI

CONCLUSION

The climate and terrain of Afghanistan combined with

transportation limitations complicated the preventive

medicine mission during OEF VI. The keys to success

were providing the maximum amount of support given

the limitations, and always remaining flexible. A wide

range of preventive medicine support was required,

and knowledge of which in-theater personnel had

expertise in industrial hygiene, drinking water,

hazardous waste, and other areas was critical to

ensuring the proper person was consulted for a

particular mission. On several occasions, missions

occurred that were outside the normal areas of

responsibility for a preventive medicine unit.

Flexibility and the ability to think outside the box were

important to success. When determining the proper

mix of medical support required for any large scale

deployment, it is very important to include clinical

preventive medicine personnel.

REFERENCES

1. The CIA World Factbook: Afghanistan. December 19,

2006. Available at https://www.cia.gov/cia/

publications/factbook/geos/af.html.

2. Palka EJ, ed. Afghanistan: A Regional Geography.

West Point, NY: United States Military Academy;

2001.

3. Rowland M, Mohammed N, Rehman H, et al.

Anopheline vectors and malaria transmission in eastern

Afghanistan. Trans R Soc Trop Med Hyg. 2002;96:620-

626.

4. TB MED 530, Technical Bulletin Occupational and

Environmental Health Food Sanitation. Washington

DC: US Dept of the Army; October 30, 2002.

5. Armed Forces Pest Management Board. Contingency

Pesticide List. Available at http://www.afpmb.org/pubs.

6. US Geological Survey Earthquake Hazards Program

Website. Available at http://earthquake.usgs.gov/

eqcenter/eqinthenews/2005/usdyae.

7. Army Regulation 15-6: Procedures for Investigating

Officers and Boards of Officers. Washington, DC: US

Dept of the Army; October 2, 2006.

8. Army Regulation 40-5: Preventive Medicine.

Washington DC: US Dept of the Army; July 22,

2005:para 1-7.

9. Hollandsworth JE, Hall TI, Hart CM. Community

health nursing in the Army: past present, and future.

Army Med Dept J. July–September 2005:21-24.

10. Scarbrough T, Lang P. Military water-well drilling.

Engineer; July-September 2001:4-9.

11. Gellasch CA. Groundwater: past, present, and future

uses in military operations. In: Caldwell DR, Ehlen J,

Harmon RS, eds. Studies in Military Geology and

Geography. Dordrecht, The Netherlands: Kluwer

Academic Publishers; 2004:307-319.

12. Taylor PW, Gordon SW, Hall TL, Kimm GL, Tyner

SD, Van Horn GT. Force health protection through

laboratory analysis and health risk assessment. Army

Med Dept J. April–June 2006:66-72.

AUTHORS

MAJ Gellasch is the Chief, Environmental Health

Engineering Division, US Army Center for Health

Promotion and Preventive Medicine-West, Fort Lewis,

Washington. From 2003 to 2006, he was the

Commander, 71st Medical Detachment which deployed

to Afghanistan from April 2005 to April 2006.

CPT Calix is the Executive Officer, 71st Medical

Detachment, Grafenwoehr, Germany. She was also the

Detachment Executive Officer during the unit’s

deployment to Afghanistan from April 2005 to April

2006.
April – June 2007 65

INTRODUCTION

On October 8, 2005, a magnitude 7.6 earthquake

struck the Pakistani-controlled region of Kashmir. The

quake was centered near the city of Muzaffarabad, but

the damage was widespread. The affected population

was spread over an area of 30,000 km2, most of which

was inaccessible. The final death toll was estimated to

be 86,000 people, but the exact figure may never be

known. Population data for many locations were

incomplete or inaccurate before the quake, and it is

thus impossible to know who perished or who simply

moved away. Similarly, the figure of 3.5 million

people left homeless will remain an estimate. Initial

damage estimates conducted from the air were also

low, and it was not until responders walked the ground

that the true magnitude of the destruction was realized.

Structures collapsed internally, leaving the roof largely

intact but crushing all inhabitants. Consequently, the

structures appeared intact from the air, but the ground

truth was quite different. The multinational response to

assist the people of Kashmir was tremendous. The

United Nations (UN), the World Health Organization,

military forces from several nations (including Austria

and Australia), the US Department of State, and

numerous nongovernmental organizations converged

on the affected area to provide varying types and

levels of aid.

RESPONSE BACKGROUND

The US military immediately responded with

helicopters from Afghanistan (relocated into Pakistan)

which airlifted supplies to remote villages and brought

out the wounded. This was followed by the formation

of the Disaster Assistance Center Pakistan (DACPAK)

on October 10. This Navy-led task force (TF) was

headquartered in the capital city of Islamabad and had

command and control of all US military assets

responding to the disaster. Under DACPAK was the

212th Mobile Army Surgical Hospital (MASH), the

command element of Medical TF 212, operating out of

Muzaffarabad. The main body of the MASH arrived at

Muzaffarabad on October 25. The preventive medicine

section of Medical TF 212 consisted of personnel from

the US Army Center for Health Promotion and

Preventive Medicine–Europe (USACHPPMEUR), the

133rd Medical Detachment, the 100th Medical

Detachment Veterinary Services, and the Navy

Environmental and Preventive Medicine Unit 7. The

specialties represented by the team included

entomology, environmental science, epidemiology,

food inspection, infectious diseases, preventive

medicine, and public health. The preventive medicine

team ultimately included 12 personnel, but due to

personnel shifts, no more than 10 personnel were

assigned to the team at any time. There were only 7

personnel on the team during 75% of the deployment.

PREDEPLOYMENT SUPPORT

Prior to deployment, the preventive medicine team

provided medical threat consultation to the task force

leadership. It was initially unclear into which area of

Kashmir the MASH would deploy, and threats

imposed by a variety of environments had to be

evaluated. Deploying personnel were briefed on high

altitude operations, cold weather operations, rabies,

communicable diseases endemic in the area, hygiene

and sanitation, malaria prevention and prophylaxis,

pre- and postdeployment medical requirements (eg,

vaccination), and other standard predeployment topics.

Since health threat data indicated a very high risk of

rabies in Pakistan, we elected to follow a selective

vaccination strategy, vaccinating only those at highest

risk for exposure on and off base—the preventive

medicine team. The team also evaluated the malaria

threat based upon geographical, climatic, and historical

Preventive Medicine Support to

Operation Lifeline: Pakistan 2005

CPT E. Owen Price, MS, USA

LTC David F. West, MS, USA

MAJ James D. Mancuso, MC, USA
66 Army Medical Department Journal

data and suggested that the low risk of malaria did not

make chemoprophylaxis necessary. However, the

MASH command elected to remain consistent with US

Central Command (USCENTCOM) policy and

required chemoprophylaxis throughout the duration of

the deployment.

BASE CAMP SUPPORT

Following deployment, the preventive medicine team

was initially tasked with a base support role and was

responsible for the initial setup of the task force base

camp, as well as support to the aircraft refueling point

located at the Muzaffarabad airport. This included the

proper placement of latrines, drainage for showers and

laundry facilities, trash disposal sites, and design of the

hospital’s medical waste disposal system. The MASH

deployed with wooden latrine boxes that were

intended to be used with metal barrels for collection

and burning of waste. The barrels did not arrive with

the boxes, however, and replacement barrels had to be

purchased from the local economy. Burning of waste

was not a long term solution, as Pakistani guards

expressed a dislike for the smoke and MASH

personnel expressed a dislike for burning waste. The

boxes were modified for use as deep pit latrines and

pits were dug by the Naval Mobile Construction

Battalion 74, colocated with the MASH on the base

camp.

Proper disposal of regulated medical waste was a

problem for other hospitals in the city, and a safe and

reliable system had to be in place before the MASH

began receiving patients. The task fell to the

preventive medicine section, and a burn and bury plan

was developed. Small, forklift-movable containers

were installed near the hospital, and a large pit was

constructed separate from the regular waste pit.

Complete incineration was assured for each load of

waste. The system worked efficiently and a visiting

health team from the UN stated that it was the model

for other facilities struggling to cope with the growing

quantities of medical waste.

As the camps became better established, the preventive

medicine team took on a maintenance role. Base camp

assessments were conducted on a weekly basis with

recommendations provided to the company level

commander for action. Areas of focus included

drainage, noise levels, proper waste disposal, living

space within sleep tents, condition of latrines, quality

of water produced by the camp’s reverse osmosis

water purification unit, and any other areas of concern

Preventive Medicine Support to Operation Lifeline: Pakistan 2005

Preventive Medicine Support Major Events

Earthquake,

8 Oct 2005

Oct 05

Feb 06 Jan 06

Nov 05 Dec 05

USACHPPMEUR

Notified for Possible

Deployment (9 Oct)

Deployment (22 Oct)

Arrived in

Muzaffarabad

(24 Oct)

Arrival of NEPMU -7

Personnel (22 Nov) Departure of

NEPMU -7 Personnel

(18 Dec)

Final Outreach

Mission (11 Feb)

First Outreach

Mission (12 Nov)

Departed Muzaffarabad

(16 Feb)

Arrived in Ramstein ,

Germany (21 Feb)

US Navy Construction

Battalion Arrived in

Muzaffarabad (27 Oct)

Opening of

Contracted Dining

Hall, Spike in DNBI

(24 NOV)

US Navy Construction

Battalion Redeploys

(13 Feb)

TIMELINE

PREVENTIVE MEDICINE SUPPORT OF OPERATION LIFELINE

The team was ready for deployment within 24 hours.

The delay between notification and deployment was

due to limited availability of air lift assets.
April – June 2007 67

identified during the inspection. The camp assessments

also included water testing and an inspection of the

dining facility. Responsibility for correcting many of

the issues fell to the task force’s field sanitation team,

which was trained and supervised by the preventive

medicine section. Vector control operations were

limited to filth fly control involving residual

treatments of latrine boxes and placement of bait

stations. Food service sanitation inspections became a

critical mission as the task force moved away from

meals-ready-to-eat to contracted meal service. The

team’s food inspector became a valuable asset. Failure

to use approved food sources and low holding

temperatures were the most common infractions, but

there was a general deficit in sanitary food service

techniques. The preventive medicine section provided

a food service course to the contracted dining facility

workers and managers, and the instances of minor

violations dropped considerably.

The preventive medicine team also conducted baseline

environmental sampling. Concerns were raised about

the ever-present cloud of dust over the city, and

sampling was conducted to assess the risks posed by

particulate matter less than 10 μm in diameter. Surface

soil sampling was conducted upon arrival and just

prior to redeployment, both at the MASH base camp

and at the aviation refueling point (located at the

Muzaffarabad airport), so that any environmental

changes caused by the US presence could be

evaluated. A deployment screening kit was used to

evaluate water used for cooking and hygiene.

In addition to supporting the MASH and the refueling

point, the preventive medicine team provided support

to personnel based at the military airbase in Islamabad,

and to personnel temporarily assigned to the US

Embassy in Islamabad. Food service sanitation

inspections were conducted at the embassy, at 3

houses where catered food was provided to US

personnel, and at the dining facility at the military air

base at Qasim. Gastrointestinal illness investigations

were also conducted when the number of cases

increased beyond baseline rates, which happened twice

at the military air base. These investigations were

conducted in collaboration with the Australian Armed

Forces, as they also suffered gastrointestinal illness

above the baseline rates.

PATIENT TRACKING

A key component of the base support mission, and one

that continued throughout the deployment, was the

tracking of disease and nonbattle injury (DNBI) for

both US and Pakistani patients seen at the MASH.

Within a deployed medical facility, the Composite

Health Care System II–Theater (CHCS II-T) is used to

track patient data. Although USCENTCOM policy

mandates the use of CHCS II-T in deployed locations,

the system was not available to the MASH at the time

of deployment. Consequently, the MASH used the

Joint Patient Tracking Application (JPTA). There are

several differences between the systems, two of which

directly impacted DNBI tracking during the mission.

In CHCS II-T, the physician enters patient data into

the system at the time of the consultation. Data are

thus recorded immediately with little chance for error.

In JPTA, however, data are input by patient

administration technicians at a later time with paper

medical records as a reference. This resulted in data of

varying quality and frequent coding errors. For

example, a patient would identify knee pain as a chief

complaint, and the physician would record the visit as

a musculoskeletal or overuse injury. The technician

coding the visit, however, would code the visit by the

chief complaint as “TB of the knee,” which is a

diagnosis of Tuberculosis of the knee. These errors in

coding may have been caused by technician

unfamiliarity and difficulties in adapting to the system.

Additionally, some patient visits were not recorded at

all, either through unfamiliarity with the JPTA tool or

through lost paperwork. Documents were often lost in

paperwork piles or within the paperwork given to the

patients themselves. These difficulties highlight the

rapidly changing nature of DNBI surveillance tools, as

well as the need for constant vigilance and careful
68 Army Medical Department Journal

monitoring of the data to ensure data

completeness and quality.

Another difference between the 2

systems is the link to the Joint

Medical Workstation (JMEWS), the

classified system used to compile

patient data among the various

military services. There is a link

between CHCS II-T and JMEWS

which updates automatically, but

this is not true of JPTA. Data from

JPTA must be manually entered into

JMEWS, a process involving access

to a secret level computer terminal

and enough time to make the

entries. The bottom line is that an all

encompassing system for patient

data entry and tracking does not

exist. Each system has positives and

negatives, and the process of

capturing surveillance data is still

evolving.

Patient data tracking allowed the team to observe

trends among TF personnel, and this view adequately

complemented information collected during camp

inspections. This multifront approach allowed the team

to focus its efforts on areas of concern and resolve

many issues before they became problems. The

average DNBI rate among US military at Camp

Resolute was 6.4% (range: < 2% to > 10%). As shown

in Figure 1, gastrointestinal illness represented the

greatest number of sick call visits. When an increase in

gastrointestinal illness was noted

among MASH personnel, the team’s

epidemiologist was able to conduct

a thorough investigation which

included patient interviews.

Possible sources of infection were

eliminated through increased dining

facility inspections and water

monitoring, as well as the

identification of commonalities

among patients. All cases were

nonbloody and nontoxic, and

several stool samples were

submitted to local laboratories for

culture to confirm the absence of

bacterial pathogens. All results were

negative, and the presence of a

Norwalk-like virus was considered

likely. Occurrences of such viruses

are not atypical of such

deployments.1

Analysis of Pakistani patient data

presents an interesting view of how

Preventive Medicine Support to Operation Lifeline: Pakistan 2005

Pakistani DNBI--Task Force 212

0

200

400

600

800

1000

1200

1400

1600

1800

23-Oct-05

6-Nov-05

20-Nov-05

4-Dec-05

18-Dec-05

1-Jan-06

15-Jan-0629-Jan-06

Week of

Nu

m

ber of visits (#)

Dermatologic--All

GI - Infectious

Heat/Cold Injuries

Injury, Other

Respiratory-All

Fever, Unexplained

Total DNBI

Figure 2. Nature of Pakistani civilian DNBI complaints presenting at the

MASH during Operation Lifeline.

Pakistani DNBI–Task Force 212

Week of

Figure 2. Nature of Pakistani civilian DNBI complaints presenting at

the MASH during Operation Lifeline.

USPersonnelDNBI

TaskForce 212

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

23-Oct-05

6-Nov-05

20-Nov-05

4-Dec-05

18-Dec-05

1-Jan-06

15-Jan-0629-Jan-06

Week of (SundaytoSaturday)

Rate

of visits

Resp

Injury

AcuteGI

Heat/cold

Psych

Total

Figure 1. Nature of US military personnel DNBI complaints presenting

at Camp Resolute during Operation Lifeline.

US Personnel DNBI

Task Force 212

Week of (Sunday to Saturday)

Figure 1. Nature of US military personnel DNBI complaints presenting

at Camp Resolute during Operation Lifeline.
April – June 2007 69

patient care changed from the onset of the relief effort

through the course of the MASH’s operations in

Pakistan. It was expected that the MASH would see

primarily traumatic injuries, but this was true only at

the beginning. The DNBI data, shown in Figure 2,

reflects a transition from traumatic primary effects into

secondary and tertiary effects, and then a transition

towards care of routine and chronic illnesses not

necessarily associated with the earthquake.

COMMUNICABLE DISEASES

Related to tracking host nation patient data was the

investigation of communicable disease outbreaks.

These diseases, rare in the United States, included

outbreaks of measles, tetanus, diphtheria,

meningococcus, and scabies. There were many

challenges associated with tracking down these

outbreaks, some due to the chaos following the

earthquake, others inherent in the way population data

and vital statistics were kept historically. The

earthquake itself isolated many remote villages,

making them accessible only by air or by long hikes

over difficult terrain. Even if villages could be

reached, patient home of record information was often

inaccurate or villagers were not familiar with everyone

in their own village. In one instance, the preventive

medicine team traveled by air to the village of Sarli

Satchel to vaccinate contacts of a diphtheria patient,

only to be told the patient did not live in that village.

The team hiked to a second village to be told that the

patient did, in fact, live in the first village.

Other problems included a lack of communication

between the various relief agencies. Often a team

would trace an outbreak to a village but arrive to find

one or more relief agencies already working there.

This unnecessary expenditure of time and resources

could have been prevented if good communications

channels had been established from the onset. It is

difficult to know whether these outbreaks were

occurring in greater frequency due to the earthquake

and the crowded conditions common in camps for

internally displaced persons (IDP). The accuracy of

historical data is questionable at best, but it indicates

many of these diseases—measles, diphtheria, hepatitis,

tetanus, and many others—were occurring at the same

levels as experienced prior to the quake.

As patients arrived at the MASH suffering from these

communicable diseases, the need for isolation facilities

grew, as did the number of questions the preventive

medicine team received concerning infection control.

No ideal setup for the isolation of patients with

contagious respiratory illnesses existed, but a

makeshift isolation cell was built using plastic sheets.

The lack of isolation facilities within the MASH

highlights commonalities with combat support

hospitals in Iraq and Afghanistan and the need to

better address infection control issues in deployed

theaters.2 This is particularly true in light of the

Acinetobacter issues seen in both theaters.3

Intestinal parasites were also common, and the

preventive medicine team answered questions about

the likelihood of parasites being spread to other

patients or to providers. Similarly, providers sought

advice on protection from scabies as the condition

became essentially ubiquitous among earthquake

victims. Basic concerns, such as latrine usage by

patients and family members, became an infection

concern when it was discovered that the traditional

style of latrine utilized by US forces was unfamiliar to

most Pakistanis. The MASH deployed with several

box-style latrines equipped with seats, but a squat-style

latrine was far more common in Pakistan, and many

patients and family members were simply unable to

use the latrines. Some were so unwilling to use them

that they urinated in hospital hallways and defecated

near the latrine boxes. The situation was remedied by

the purchase of several squat-style latrine plates and

the Navy’s modification of the box latrines to

accommodate the plates.

OUTREACH PROGRAM

Once the base camp was stabilized, the preventive

medicine team began looking for more opportunities to

leave the camp and work within the city of

Muzaffarabad and beyond. These opportunities came

first in the form of support to IDP camps as the team’s

involvement with the United Nations Children’s Fund

(UNICEF) water and sanitation cluster. The team did

not have the capability to dig latrines or supply water,

but it could provide technical support through sanitary

inspections and the testing of drinking water.

Inspections were documented on a standardized

UNICEF form, and feedback was provided directly to

UNICEF. Resources and materials could then be

directed to where they were most needed. The team
70 Army Medical Department Journal

had very limited ability to directly enact change within

the camps and could often only make

recommendations to UNICEF or camp managers. The

recommendations were not always implemented.

The largest component of the preventive medicine

mission was one that started out on a small scale and

grew to be one of the MASH’s highest-visibility

missions. When a vaccination initiative was

undertaken by the local government and UNICEF, the

preventive medicine team offered to assist in reaching

the program’s goal of vaccinating 800,000 children

against measles over a 2-week period. Numerous

nongovernment organizations (NGOs) also supported

this effort. When the initial drive ended, the preventive

medicine team continued providing vaccinations

within and beyond Muzaffarabad. The continuation of

the program was possible in part because it was a very

small logistical burden for the MASH. All vaccines

and supplies were provided by UNICEF to the

Pakistani Ministry of Health (MOH), as well as NGOs

and other relief organizations, including the US

military. In addition to measles, the team provided

vaccinations against diphtheria, tetanus, and polio, and

Vitamin A to reduce the effect of measles. Personnel

challenges included a training deficit as traditionally

nonclinical occupational specialties (entomologists,

preventive medicine technicians, and food inspectors)

required training before vaccines could be given. The

high tempo of the mission and large geographical area

covered also meant the team was continually on the

go, but medical and nursing personnel assets from

within the MASH were used to augment the preventive

medicine team.

The vaccination program became the MASH’s

Medical Outreach Program as it incorporated nutrition

and wellbeing surveys and the water and sanitation

inspections. By the time the outreach program ended,

the team had given 16,205 vaccinations to 6,050

people in more than 50 villages, schools, and IDP

camps in the Muzaffarabad area. The population wellbeing program (11 camps visited, 316 patient contacts)

resulted in an accurate and timely description of the

health status of the IDP population in Muzaffarabad.

The MOH for the Muzaffarabad District incorporated

the water and sanitation assessments to develop a

district-wide needs assessment that was briefed to the

military chief of the medical effort in the region. In

addition to medical tasks, the team also distributed

approximately 200 boxes of clothing, blankets, and

toys donated by the American people, and raised funds

to purchase books for a local school. The outreach

program may have had the biggest long-term health

benefit to the people living in the affected area of any

of the US-led relief programs. The health benefits of

the vaccinations will be felt for decades, and the

team’s frequent personal contacts with Pakistanis gave

the US a personal face, which resulted in a strong

positive impact on Pakistani-US relations.

LIAISON EFFORTS

The outreach program was not a standalone effort,

however, and the preventive medicine team worked

closely with several organizations through the course

of the mission. The closest and most important

relationship was with the host nation’s military.

Pakistani military and police forces provided all

security for the outreach program and its team

members. They were also very familiar with regional

roads, and many provided valuable translation

assistance. Collaboration with the Pakistani Army

Medical Department was essential, and the medical

personnel provided information on remote locations

that were not receiving aid. They coordinated

helicopter transportation to many areas, and they

possessed a wealth of knowledge on the prevalence of

communicable diseases and vaccination coverage.

Similarly, liaison efforts with the World Health

Organization (WHO) epidemiology cell kept the team

abreast of disease outbreaks and provided an avenue

through which diagnostic samples could be routed.

Additionally, the WHO collected all patient

information from area hospitals and closely tracked

emerging issues, providing direct feedback to relief

organizations.

The preventive medicine team also maintained a close

relationship with UNICEF, attending both the health

and water/sanitation cluster meetings on a regular

basis. The cluster concept was introduced by the UN

for earthquake relief operations, and reviews were

mixed. The intent of the concept was to appoint a lead

agency within each relief sector and to improve

coordination between relief agencies. In Pakistan, 10

clusters were established that focused on health,

emergency shelter, water and sanitation, logistics,

camp management, protection, food and nutrition,

information technology and communications,

education, and reconstruction. The concept was strong,

as it allowed the focus of resources and technical

Preventive Medicine Support to Operation Lifeline: Pakistan 2005
April – June 2007 71

specialties. Unfortunately, individuals appointed to

lead the clusters often lacked the experience, technical

knowledge, or leadership skills to effectively conduct

the meetings. As a result, priorities were often

incorrectly set, and communications among relief

agencies were poor.

Working relationships with other militaries and NGOs

varied by group. The outreach team maintained a

partnership with the Austrian armed forces which

maintained a reverse osmosis water purification unit

and delivered water to most of the IDP camps within

Muzaffarabad. The outreach team worked within the

camps to verify water sanitation while the Austrians

worked to purify water and establish a delivery system

that ensured a safe product from purification to

delivery. Encounters with Cuban hospitals were tense,

and several NGOs chose to distance themselves from

any military activities. For example, a team member

took a photograph of himself near a Medecins Sans

Frontieres (MSF) sign, and an organization member

became very upset. He proclaimed that MSF is only

successful because it has no affiliations with

governments and militaries, and to have a photo with

an MSF sign and a US military member could be

detrimental to their credibility. Other groups

welcomed the sanitary inspections, technical advice,

and water testing capabilities the outreach team

brought, as they either lacked those capabilities or

appreciated the opportunity to focus on other areas.

The preventive medicine team, US State Department,

and the US Agency for International Development

(USAID) worked well together in the majority of

cases, but the relationships could have been improved.

The preventive medicine team was limited in its ability

to leave the MASH base camp early in relief

operations, which may have influenced USAID’s view

of the team as a useful resource. Additionally, the high

turnover rate among USAID personnel (teams rotated

approximately every month) made it difficult to form

contacts and establish good relationships. Whatever

the reason, the preventive medicine team enjoyed a hot

and cold relationship with these agencies that could

definitely be improved during future operations.

It would be of value to establish a strong relationship

between the military and USAID before the next

disaster occurs. Most importantly, a single point of

contact should be established within each organization

that could facilitate better interaction and

communication. Pre-event training that incorporates

both Department of Defense and USAID personnel

would allow better interaction among organizations

during the next relief operation, and a more structured

use of available resources. The MASH’s medical

outreach team undoubtedly demonstrated that military

preventive medicine does have a role to play in

disaster response, within which they can be a very

effective tool.

The MASH also retained a close relationship with the

media, and the outreach team was included in the

coverage. Some reporters proved hostile, others were

precisely the opposite. Overall, the coverage was

positive, and stories appearing in local papers were

valuable in improving the image of the US military

presence. Media presence was not always a benefit,

however, as schedule matching between the media and

visiting dignitaries sometimes led to the rescheduling

of outreach missions. A change in plan was easy

enough for the team, but the local people often

traveled great distances to have their children

vaccinated. A change in the date meant either waiting

in the area for the next opportunity or returning to their

villages without vaccination.

MISSION CHALLENGES

The outreach mission had to overcome the challenges

of security and transport in order to be successful. All

US personnel were entirely dependent upon the

Punjabi Rangers or the Elite National Police for

security, both within the compound and while out on

missions. The outreach team relied on them to provide

convoy security, traffic control, crowd control, and

even translation assistance when needed. As with any

force, some members were very attentive while others

were not. Security was a nonnegotiable requirement in

the eyes of the host nation, but escorts were not always

available or were not always ready on time. This

sometimes resulted in the cancellation, or at least a

delay, of missions. As mentioned earlier, any such

occurrence was always a huge disappointment for the

local population.

Road conditions throughout the region posed an

obstacle to transport, as well as creating unpredictable

and often dangerous traveling conditions. While roads

within Muzaffarabad remained largely intact, virtually

all roads outside the city suffered damage. The main

roads into the Neelum and Jellum river valleys were
72 Army Medical Department Journal

impassible for the first month of relief efforts, and later

were only marginally passable. For the first 2 months,

the outreach team used 3 M998 HMMWVs* to

negotiate the roads, but they were simply too wide and

too heavy to be safe on the loose and narrow roads that

served as the only access to remote villages. The

outreach teams changed to the use of sport utility

vehicles which considerably improved the overall

safety of outreach missions. While air travel would

have been a better means of travel in some cases, it

was not always available. Air assets were limited less

by number and more by priority, with food and supply

lifts and medical evacuations having higher priority.

CONCLUSION

The relief operation was an extremely rewarding

experience for all involved, as well as a great learning

opportunity. The 212th MASH was a proactive

organization that utilized preventive medicine assets

from the outset, allowing the team to practice

preventive rather than reactive medicine, and

encouraging outreach programs that positively affected

US relief operations. The efforts of the US task force

not only reduced the ongoing and future suffering of

those affected by the earthquake, but also made

considerable progress in reversing the negative image

of Americans held by many Kashmiris. The preventive

medicine team demonstrated that military preventive

medicine and public health has a clear mission in

disaster relief and humanitarian operations, and that it

can perform this mission well. Relationships with

other US agencies, such as USAID, should be

improved, and collaboration between agencies would

improve future relief missions. The establishment of

points of contact and conducting of dual-agency

training events prior to the next disaster would set the

stage for a streamlined US response.

ACKNOWLEDGEMENT

The success of the preventive medicine mission would

not have been possible without the diligent efforts of

each team member.

LTC West, Team Leader

MAJ Mancuso, Epidemiologist

LCDR Jobanputra, USN, Infectious Disease Physician

LT Lyons, USN, Environmental Health Officer

CPT Price, Entomologist

SFC Garcia, Team NCOIC

SGT Russell, Preventive Medicine NCO

SGT Rivera, Food Inspector

HM1 Pallesco, USN, Preventive Medicine NCO

SPC Finucane, Preventive Medicine Specialist

SPC Choate, Preventive Medicine Specialist

REFERENCES

1. Centers for Disease Control. Outbreak of acute

gastroenteritis associated with Norwalk-like viruses

among British military personnel – Afghanistan, May

2002. MMWR. 2002;51(22):477-479.

2. Schofield CM, Murray CK, Horvath EE, Cancio LC,

Kim SH, Wolf SE, Hospenthal DR. Bacteria

recovered from patients admitted to a deployed US

military hospital in Baghdad, Iraq. Mil Med.

2006;171(9):821.

3. Centers for Disease Control. Acinetobacter

baumannii infections among patients at military

medical facilities treating injured US service

members, 2002-2004. MMWR. 2004;53(45):1063-

1066.

Preventive Medicine Support to Operation Lifeline: Pakistan 2005

*High mobility multipurpose wheeled vehicle

AUTHORS

CPT Price is a medical entomologist in the Entomological Sciences Division, USACHPPMEUR, Landstuhl, Germany.

LTC West is Chief of the Entomological Sciences Division, USACHPPMEUR, Landstuhl, Germany.

MAJ Mancuso is an epidemiology fellow at the Uniformed Services University of Health Sciences, Bethesda, Maryland.
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