April – June 2006

Perspective 1

MG George W. Weightman

Prevention is the Best Way to Health 3

BG Michael B. Cates

The Evolution of Public Health Education in the US Army, 1893-1966 7

COL Stephen C. Craig, MC, USA

The Evolving Role of Environmental Science Officers and 18

Environmental Engineers in the Medical Service Corps

COL John J. Ciesla, MS, USA

Army Epidemiology and Health Surveillance 22

COL Bruno Petruccelli, MC, USA; Dr. Joseph Knapik, ScD

Vector Control and Pest Management 31

LTC Mustapha Debboun, MS, USA, et al

Field Preventive Medicine: Challenges for the Future 40

LTC William J. Sames, MS, USA, et al

Deployment Occupational and Environmental Health Risk Management 46

COL Robert R. Eng, MS; USA; COL (Ret) Curtis W. Pearson, MSC, USAF

Deployment Occupational and Environmental Health Surveillance: 50

Enhancing the War Fighter’s Force Health Protection and Readiness

Jeffrey S. Kirkpatrick; LTC Christine Moser, MS, USA; Brad E. Hutchens, PE

Making the Modern Army Public Health Nurse: 61

Establishing Essential Service Skills

MAJ James A. Madson, MS, USA; LTC Bryan J. Alsip, MC, USA

Force Health Protection Through Laboratory Analysis 66

and Health Risk Assessment

MAJ Patterson W. Taylor, MS, USA, et al

Bullis Fever: A Fleeting Epidemic of Unknown Etiology 73

LTC Michael J, Zapor, MC, USA

F

O

R

C

E

H

E

A

L

T

H

P

R

O

T

E

C

T

I

O

N

A

N

D

P

R

E

V

E

N

T

I

V

E

M

E

D

I

C

I

N

E
LTG Kevin C. Kiley

The Army Surgeon General

Commander, US Army Medical Command

MG George W. Weightman

Commanding General

US Army Medical Department Center and School

April – June 2006 The Army Medical Department Center & School PB 8-06-4/5/6

0608803

PETER J. SCHOOMAKER

General, United States Army

Chief of Staff

DISTRIBUTION: Special

Administrative Assistant to the

Secretary of the Army

By Order of the Secretary of the Army:

Official:

JOYCE E. MORROW

Online issues of the AMEDD Journal are available at https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1

A Professional Publication

of the AMEDD Community

The Army Medical Department Journal [ISSN 1524-0436] is published quarterly for

The Surgeon General by the US Army Medical Department Center & School, ATTN:

MCCS-DT, 2423 FSH-Hood ST, Fort Sam Houston, TX 78234-5078.

CORRESPONDENCE: Manuscripts, photographs, official unit requests to receive

copies, and unit address changes or deletions should be sent to the Journal at the

above address. Telephone: (210) 221-6301, DSN 471-6301

DISCLAIMER: The Journal presents clinical and nonclinical professional information

to expand knowledge of domestic & international military medical issues and

technological advances; promote collaborative partnerships among Services,

components, Corps, and specialties; convey clinical and health service support

information; and provide a peer-reviewed, high quality, print medium to encourage

dialogue concerning healthcare initiatives.

Views expressed are those of the author(s) and do not necessarily reflect official US

Army or US Army Medical Department positions, nor does the content change or

supersede information in other Army Publications. The Journal reserves the right to edit

all material submitted for publication (see inside back cover).

CONTENT: Content of this publication is not copyright protected. Material may be

reprinted if credit is given to the author(s).

OFFICIAL DISTRIBUTION: This publication is targeted to US Army Medical

Department units and organizations, and other members of the medical community

worldwide.
April – June 2006 1

Perspective

Major General George W. Weightman

This will be my last issue to review as the

Commanding General, Army Medical Department

Center and School and Fort Sam Houston and I want

to thank all of the readers and contributors for their

interest and intellectual rigor in making this Journal a

more relevant and respected publication over the last

two years. The breadth and depth of the issues we have

covered have been indicative of how complex the

AMEDD has become as we constantly strive to

support the Warfighter. All of us at the Center and

School appreciate your support and I encourage you to

continue to conduct and report on your research as we

all do our very best to broaden the knowledge base of

all of our Warrior Medics. The AMEDD Journal is an

important venue to help us all understand the “big

picture” as well as brush up on our own specialties.

I think you will find this edition of the AMEDD

Journal particularly useful and informational. This

issue’s focus is on Preventive Medicine and I’m sure

you will all find that the articles will expose you to

areas of this specialty which you were not familiar

with. What makes this topic particularly relevant as we

find ourselves in our fifth year of the Global War on

Terrorism is what a tremendous impact our preventive

medicine initiatives are making, and how they have

drastically changed the epidemiology of the casualties

we are seeing in just a few years of intensive effort.

This issue is kicked off by a capstone article on

preventive medicine by BG Michael Cates, the

Commanding General of the US Army Center for

Health Promotion and Preventive Medicine. With

“Prevention is the Best Way to Health,” BG Cates

gives us a brief look at the history and background of

military preventive medicine, notes the current status,

and offers up several considerations for future

endeavors. He reminds us that 97% of our nation’s

healthcare dollars are spent on restorative care while

only 3% are designated for government preventive

medicine programs. Our Disease and Nonbattle Injury

hospitalization rates for Operations Iraqi Freedom and

Enduring Freedom are less than 10% of what they

were in World War II and Korea. This is a great

overview and easy read.

“The Evolution of Public Health Education in the US

Army, 1893-1966” by COL Stephen Craig traces the

preventive medicine residency program and how it

paralleled civilian public health education. Of

particular note is that we learn that in 1893 Surgeon

General BG George Sternberg established the Army

Medical School in Washington, DC with an emphasis

on public health. This same school evolved into our

modern day Walter Reed Army Institute of Research.

Finally, he documents well the persistent conflicts

between Preventive and Clinical Medicine through the

last 100+ years.

“The Evolving Role of Environmental Science

Officers and Environmental Engineers in the Medical

Service Corps” by COL John Ciesla helps all of us

understand how both specialties evolved and how they

differ in their academic preparation, backgrounds, and

primary focus. He notes the present increased demand

for both specialties as we get more concerned about

Soldier exposure to environmental toxins. The great

news is that there is a continued strong demand for

both in the new Army formations being created under

Transformation.
2 Army Medical Department Journal

“Army Epidemiology and Health Surveillance” by

COL Bruno Petruccelli and Dr Joe Knapik starts by

defining both concepts and then proceeds with a brief

history of both. The authors remind us that the Army is

the Executive Agent for all the Department of Defense

for health surveillance, and does a great job telling us

how we’re using such tools as DOEHRS* and GEIS†

to accomplish today’s very complex and sophisticated

battlefield surveillance mission.

“Vector Control and Pest Management” by LTC

Debboun et al provides us with an overview of the

relevance, scope, and agencies involved in DoD

Vector Control and Pest management. He gives us all a

timely reminder that the cornerstone of these programs

is personal protective measures.

“Field Preventive Medicine: Challenges for the

Future” by LTC Sames et al gives us a brief

description of the manning available to accomplish

operational field sanitation, from individual soldiers, to

Field Sanitation Teams, to the multiple AMEDD

specialists available. He points out several drawbacks

of the current manning/training and points out a few

future challenges to improve our present systems.

“Deployment Occupational and Environmental Health

Risk Management” by COL Robert Eng and COL (ret)

Curtis Pearson, starts by giving us a brief history of the

Deployment Occupational and Environmental Health

Risk Management program and then further describes

several existing and planned initiatives. Interestingly,

they point out that this initiative grew out of our

deficiencies in dealing with the issues from our

veterans returning from Operation Desert Storm.

“Deployment Occupational and Environmental Health

Surveillance: Enhancing the War Fighter’s Force

Health Protection and Readiness” by Jeffrey

Kirkpatrick et al basically lays out the three programs

which comprise the Directorate of Health Risk

Management. These include 1) the Global Threat

Assessment Program which identifies and assesses

deployment Occupation and Environmental hazards

and threats worldwide. 2) The Deployment

Environmental Surveillance Program which provides

commanders reach-back capability for environment

and occupational issues, informs them of present

health risks associated with their occupations and

environment, and gives them actual exposure data. 3)

The Deployment Data Archive and Policy Integration

Program is the information technology system which

captures and archives occupational and environmental

health (OEH) data and helps with integration of OEH

into the DOTMLPF‡ model methodology.

“Making the Modern Army Public Health Nurse:

Establishing Essential Service Skills” by MAJ James

Madison and LTC Bryan Alsip traces the evolution of

the Community Health Nurse from their original focus

on assisting new parents adjust to family life, to being

responsible for many community programs, to their

current professional training and assignments in the

increased responsibilities of a public health official. In

recognition of their new skills and responsibilities,

their title has been changed Public Health Nurse.

“Force Health Protection Through Laboratory

Analysis and Health Risk Assessment” by MAJ

Patterson Taylor et al describes the unique capabilities

of the 1st and 9th Area Medical Labs, which are the

only Army deployable labs with a robust analytical

capability to provide health hazard surveillance with a

remarkable short response time.

Finally, “Bullis Fever: A Fleeting Epidemic of

Unknown Etiology”, by LTC Michael Zapor is a

medical “Who Dun It?” mystery about an unknown

pathogen which sickened over 1,000 soldiers right here

at Camp Bullis from 1941-1944. Although a vector

was identified, the pathogen was never proven.

Thanks for your continued support of our AMEDD

Journal. I ask that you help me in welcoming the new

commander, MG Russ Czerw, with the next edition.

*Defense Occupational and Environmental Health Readiness System

†Global Emerging Infections Surveillance and Response System

‡Doctrine, Organization, Training, Materiel, Leadership and Education, Personnel and Facilities
April – June 2006 3

Health is an essential element of military

readiness, and prevention is and always

will be the best way to health. Preventing

diseases and conditions that threaten the

health of the warfighter is more

operationally sound since it maximizes

available manpower. It is more beneficial

to the Soldier, from a well-being

perspective, to stay healthy and avoid all

that the hospital has to offer, such as long

waiting room times, diagnostics, and

treatment. When considering healthcare

costs, both short-term and long-term,

prevention again wins out. In an ideal

world, the military would be able to

minimize disease and nonbattle injuries

(DNBI), through prevention and health

promotion, while optimizing the

restorative medicine resources and

applying them toward those diseases and

conditions that are not readily

preventable, especially combat injuries.

This article takes a brief look at military preventive

medicine, its background, its current status, and some

future considerations for its use in improving the

health of our warfighters.

Currently, in our nation, approximately 97% of our

medical costs are focused on the “restorative” aspect

of health care or “fixing” our medical problems. The

other 3% goes to governmental public health

expenditures.1 Military health expenses are similar.

Over the past century, applying the appropriate levels

of proactive and responsive approaches to health care

seems to have worked well. Figure 1 shows the

dramatic decrease in both DNBI and battle injuries

(BI), using hospitalization rates, during various wars

and conflicts from World War II, through Operations

Enduring Freedom and Iraqi Freedom (OEF/OIF),

including Operations Desert Shield and Desert Storm

(ODS/S). The rates for Operations Enduring Freedom

and Iraqi Freedom are approximately one-tenth that of

World War II and the Korean Conflict. However, the

proportion of hospitalizations for DNBI compared to

BI has not changed significantly and is actually almost

the same or higher now than during the conflicts in

Korea and Vietnam, as shown in Figure 2. In other

words, while Army medicine has dramatically

improved overall, the Army is still forced to dedicate a

tremendous amount of resources to DNBI. The Army

must do a better job of prevention, ultimately requiring

a larger investment than the current 3%.

Leadership clearly recognizes the value of prevention.

The recent Department of Defense (DoD) Quadrennial

Defense Review Report (6 February 2006), states: “It is

the Department’s goal to have a lifetime relationship

with the entire Department of Defense family which

maximizes prevention, wellness and personal choices,

and responsibility.”3 The DoD Force Health

Protection Capstone Document adds: “Medical assets

must be configured to support health promotion, health

Prevention is the Best Way to Health

BG Michael B. Cates, VC, USA

BG Cates is the Commanding General, US Army Center for Health Promotion and Preventive Medicine,

Aberdeen Proving Ground, Maryland, and the Functional Proponent, US Army Preventive Medicine.

WWII Korea Vietnam ODS/S OEF/OIF

Figure 1. Decrease in DNBI and BI during US conflicts.

2,

*

*Statistics for OEF/OIF were obtained from the US Transportation

Command Regulating, Command and Control Evacuation System

(TRAC2ES)
4 Army Medical Department Journal

hazard assessment, implementation of

countermeasures and the provision of

essential care of the injured and ill in

theater and their rapid evacuation to

definitive medical care outside of theater

of operations. Force Health Protection

supports service members with a full

spectrum of health services that (1)

emphasize fitness, preparedness, and

preventive medicine; (2) improve the

monitoring and surveillance of forces in

military operations; (3) enhance Soldiers’

and Commanders’ awareness of health

threats before they can affect the force;

and (4) support the healthcare needs of

the fighting forces and their families

across the continuum of medical

services.”4 DoD Directive 6200.4 directs

all members of the Active Components

and the selected Reserve Components to

be physically and mentally fit.

Commanders, supervisors, individual

service members, and our health system

have been given the responsibility to

“promote, improve, conserve, and restore the physical

and mental well being of members of the Army Forces

across the full range of military activities and

operations.”5Specific verbiage regarding prevention

includes its requirements for all service components to

“promote and sustain a healthy and fit force, prevent

injury and illness, [and] protect the force from health

hazards.”5

The Army’s “bible” for these preventive measures is

Army Regulation 40-5, in which preventive medicine

is described as “the anticipation, prediction,

identification, surveillance, evaluation, prevention, and

control of diseases and injuries.”6 The regulation also

delineates 9 major functional areas of support to

military personnel and their families, in garrison and

deployed settings, throughout the world. What is key

to this publication is that responsibilities for preventive

medicine are given to a wide variety of people, from 3

different assistant secretaries of the Army, to 4

primary deputy chiefs of staff, The Surgeon General,

major commands, regional medical commands,

military treatment facilities, veterinarians, dentists,

commanders at all levels, installation commanders,

leaders, supervisors, and individuals.6 Dr. Craig

Llewellyn, in the Textbook of Military Medicine...,

7

talks of the far-reaching scope of preventive medicine

throughout the entire military force. He says the

“promotion and preservation of health and the

prevention of illness and injury can rarely be

accomplished solely through medical channels.”

What we call preventive medicine encompasses a very

broad spectrum of identifying, assessing, and

mitigating health risks to our personnel. Because the

Army deploys globally, those health risks are spread

out geographically as well as culturally. In today’s

world of easy, quick transportation, one country’s

endemic diseases can become an outbreak in another

country’s populace almost overnight. Public health in

one country clearly influences public health in many

other countries. Laurie Garrett, in Betrayal of Trust,

the Collapse of Global Public Health, agrees, saying

“Public Health needs to be—must be—global

prevention.”8 With the stresses and operational tempo

of our military deployments, it is imperative to

recognize the potential for exposures to unusual

diseases and environmental conditions. Also, lifestyle,

nutrition, vehicles, weapons and equipment, and

disease vectors all have potential impact on the

Soldier’s health. The proactive approach toward

minimizing the negative effects of these health impacts

is critical, not only to the individual Soldiers but also

to their units, our nation, and our nation’s healthcare

system. There are multiple examples of preventive

medicine successes and failures throughout our

Figure 2. Proportion of hospitalizations for DNBI and BI from WWII to

Operations Enduring Freedom and Iraqi Freedom.

2,

*

*Statistics for OEF/OIF were obtained from the US Transportation

Command Regulating, Command and Control Evacuation System

(TRAC2ES)

WWII Korea Vietnam ODS/S OEF/OIF
April – June 2006 5

military history. The Textbook of Military Medicine

names many successes, including yellow fever in Cuba

and skin disease in Vietnam. Failures include British

dealings with typhoid fever in the Second Boer War

and with malaria in World War I, and the US

involvement with heat and cold injuries in World War

II. It should be noted that all were heavily influenced

by command emphasis on prevention, or the lack

thereof.7

In today’s world, there are emerging or reemerging

diseases, such as tuberculosis, malaria, Acinetobacter

infections, leishmaniasis, and E.coli O157:H7

infections; zoonotic diseases associated with the

animals of the various regions; chronic diseases, many

of which are related to nutrition and other lifestyle

choices, such as heart disease, lung cancer, diabetes,

etc; and illnesses related to exposure to toxic industrial

chemicals, toxic industrial materials, and pesticides.

Our Soldiers deploy to locations with threatening

environmental conditions, where the soil, air, water,

and food, in many cases, pose far different threats than

most areas of the US. Our military personnel use

weaponry, vehicles, and other equipment that present

inherent risks to hearing, vision, and other organ

functions. Occupational and environmental exposures

go beyond just the deployed setting; the garrisons, and

their buildings, roads, property, and waterways can be

dangerous as well. Natural and man-made disasters on

our own soil and in other nations have presented their

own form of health threats and, accordingly, the need

for public health-related interventions.

The Army Medical Department (AMEDD) preventive

medicine team encompasses a wide range of expertise

in a myriad of locations, with the ability and flexibility

to provide local support while maintaining the ability

to project wherever and whenever the need arises. The

Proponency Office for Preventive Medicine is

responsible for policy making and oversight in the

Office of The Surgeon General. The US Army Center

for Health Promotion and Preventive Medicine

provides the operational foundation for Army military

public health, preventive medicine and health

promotion. The Center is globally positioned, with

capabilities which are easily projected when needed.

Smaller but fully functional capabilities are found with

individual officers and enlisted Soldiers assigned to

brigade combat teams, preventive medicine

detachments assigned to medical brigades and medical

commands, the two area medical laboratories, and the

preventive medicine departments found at the Army

military treatment facilities. From local installation

support (such as industrial hygiene, immunizations and

occupational health services) to the projected support

provided by deployed individuals, detachments, and

Special Medical Augmentation Response Teams–

Preventive Medicine to Iraq and Afghanistan, the

Center’s entire team does a lot with relatively few

resources. After Hurricane Katrina hit the southern US

coast, military preventive medicine personnel were

deployed quickly. When the earthquake hit Pakistan in

2005 and the US Army sent medical personnel to help,

preventive medicine experts were an important and

visible part of the humanitarian assistance operation.

When there were potential outbreaks of hepatitis C in

El Paso, meningococcal disease in Europe, or

tuberculosis in Afghanistan, preventive medicine

experts were on the scene to determine the cause of the

disease and the potential health threats to personnel.

Health promotion initiatives continue to be an integral

part of preventive medicine to drive down injuries,

tobacco use, and alcohol abuse while enhancing

nutrition and overall fitness. We are part of the

continuing surveillance of occupational and

environmental health threats to our military personnel,

both in deployed and garrison settings, providing

broad-ranging, very effective, globally committed

preventive medicine capabilities, with constrained

resources.

At the national level, there has been a renewed focus

on health promotion and prevention, as evidenced by

the Healthy People 2010 initiative by the Department

of Health and Human Services. This initiative has set

out to “identify the most significant preventable threats

to our health and to establish national goals to reduce

those threats.” Certain statistics justify this effort:

Heart disease and stroke account for 40% of all US

deaths each year, 64% of US adults are obese or

overweight, and 31 million have asthma.9 Diabetes

now affects 20.8 million Americans, 7% of our

population and a 6.3% increase since 2002.10 Like the

military, the US as a whole spends an inordinate

amount on health care—15% of the gross domestic

product in 2003, the highest of any member country of

the Organisation for Economic Cooperation and

Development (OECD). The US spends over $5,600

per capita on total health care, more than twice the

OECD average; despite that, there are indications we

are no healthier than other developed countries.11
6 Army Medical Department Journal

As the Army moves forward, our deployments are

longer and more dispersed throughout the world.

Therefore, environmental exposures will increase in

diversity as well as intensity. The AMEDD preventive

medicine teams must keep up their vigilance of

medical and environmental surveillance,

communicating quickly and effectively when

necessary to correct deficiencies and have a positive

impact on the health of individual Soldiers or units.

Health promotion efforts must continue to be

aggressive. Similar to our civilian counterparts, the

military has to contend with many of the heath risks

associated with lifestyle choices, such as tobacco use,

poor nutrition, and alcohol abuse. Among male

Soldiers age 18 to 25, 48% use tobacco. Over 27% of

our military personnel, age 26 to 34, are overweight

(with body mass index as the indicator), and over 40%

of our Soldiers engage in “binge drinking” (that is, 5

or more drinks at one occasion at least once in 30

days).12 These statistics present short-term and longterm implications, impacting not only individuals but

also entire units, our military as a whole, and our

military healthcare system. In the future, medical

technology will help us do a better job of identifying,

assessing, and mitigating health risks, and, hopefully,

leaders at all levels will become actively engaged in

promoting better prevention and the overall medical

readiness of their Soldiers.

Just as preventive maintenance is a crucial aspect of

the logistics community, drastically improving the

availability, workability, and durability of our

equipment and vehicles, preventive medicine is crucial

to our most important resource—our people. Fixing

something much more inefficient than sustaining,

maintaining and improving it; this directly applies to

our health. Maintaining and even improving a

Soldier’s health is a much more appropriate, wiser use

of resources than waiting until that Soldier becomes

sick or is hospitalized. The more we prevent diseases

and improve poor environmental conditions, the more

resources will be available to apply to those things we

cannot prevent. Prevention efforts have been and still

are effective, invaluable pieces of the medical health

system. And 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 health of our personnel.

REFERENCES

1. Honore PA, Amy BW. Public health finance:

advancing a field of study through public health

systems research. J Public Health Manage Pract.

2005;11(6):571-573.

2. Jones BH, Perotta DM, Canham-Chervak ML, Nee

MA, Brundage JF. Injuries in the military: a review

and commentary focused on prevention. Am J Prev

Med. 2000;18(3 Suppl):71-84.

3. Quadrennial Defense Review Report. Washington,

DC: US Dept of Defense. February 6, 2006.

Available at: http://www.defenselink.mil/pubs/pdfs/

QDR20060203.pdf.

4. Force Health Protection Capstone Document. Falls

Church, VA: US Dept of Defense, Office of the

Assistant Secretary of Defense (Health Affairs),

TRICARE Management Activity; 2004. Available at:

http://www.ha.osd.mil/forcehealth/library/main.html.

5. DoD Directive 6200.4: Force Health Protection

(FHP). Washington, DC: US Dept of Defense;

October 9, 1994.

6. Army Regulation 40-5: Preventive Medicine.

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

2005.

7. Textbook of Military Medicine: Military Preventive

Medicine, Mobilization and Deployment.

Washington, DC: US Dept of the Army, Office of

The Surgeon General, Borden Institute; 2003.

8. Garrett L. Betrayal of Trust: The Collapse of Global

Public Health. 1st ed. New York, NY: Hyperion;

2000.

9. Healthy People 2010: The Cornerstone for

Prevention. Washington, DC: US Dept of Health and

Human Services, Office of Disease Prevention and

Health Promotion; 2005. Available at: http://

www.healthypeople.gov/document.

10. National Diabetes Fact Sheet. Washington, DC: US

Dept of Health and Human Services, Centers for

Disease Control and Prevention; 2005. Available at

http://www.cdc.gov/Diabetes/pubs/estimates05.htm.

11. OECD Health Data 2005: How Does the United

States Compare. Organisation for Economic

Cooperation and Development; June 2005. Available

a t h t t p : / / w w w . o e c d . o r g /

dataoecd/15/23/34970246.pdf.

12. Bray R, Hourani L, Rae K, et al. 2002 DoD Survey of

Health Related Behavior Among Military Personnel:

Final Report. Research Triangle Park, NC: US Dept

of Defense, Research Triangle Institute; 2003.
April – June 2006 7

The Army Preventive Medicine Residency is now

officially 47 years old. Firmly established, accredited,

and respected, its graduates sit for their boards with

their civilian contemporaries, become Fellows of the

American College of Preventive Medicine, and pursue

careers in public health practice, education,

administration, and research, the same as their civilian

colleagues. It was not always the case. The

development of civilian preventive medicine/public

health education and acceptance progressed over a

rocky road of professional animosity while its military

counterpart, by virtue of necessity, evolved on a

smoother path. Although preventive medicine, as an

accredited residency, was a latecomer to Army

graduate medical education, as a continuous,

systematic course of instruction, it is the oldest

postgraduate medical training program in the military.

This article traces the evolution of that training and

how it paralleled civilian public health education.

The idea of a graduate Army medical school was first

proposed by Surgeon General William A. Hammond

in 1862. A progressive thinker, he had already created

an Army museum for pathological research and

ordered the preparation of a medical history of the war

of the rebellion.1(pp179-180) Hammond felt there was a

better way for physicians to learn the art of military

medicine and surgery than by trial and error while on

campaign. He envisioned an Army medical school that

would, in Major John Brinton’s words,

...teach [the surgeons] how soldiers should be looked

after in health, on marches, in camp, how they should

be treated when sick or wounded, how cared for in

hospitals or in the field, and how properly

transported.1(pp257-258)

There was little money to support this educational

venture. Therefore, Hammond established a classroom

and a couple of laboratories in the rooms beneath the

main hall of the Army Medical Museum which was

housed in the old Riggs Bank building in Washington.

Only Secretary of War Edwin M. Stanton’s approval

was needed to begin classes in the fall of 1863.

Regrettably, Hammond had clashed with the Secretary

of War early in his tenure and had been removed as

Surgeon General the previous summer. When Acting

Surgeon General Joseph K. Barnes showed Stanton the

school, the Secretary of War inquired, “Are these

lectures to be given in the evenings?” The acting

surgeon general replied in the affirmative, to which

Stanton thundered “They will go to the theatre and

neglect their duties. It shan’t be!”1(p259) This seed of an

idea did not die, but rather went into dormancy waiting

for a new champion and a more agreeable time.

That time came in the spring of 1893. The Gilded Age

was receding and the tide of the Progressive Era was

beginning to roll in. On that tide came a very different

age as social, economic, technological, and scientific

changes indelibly altered the American way of life.

Bacteriology, developed by Koch, Pasteur, and others,

and the nascent science

of immunology were

establishing a foundation

for public health practice

t h a t w a s b e i n g

effectively applied by

innovative physicians in

state and metropolitan

p u b l i c h e a l t h

departments.2In the

A r m y M e d i c a l

Department, George

Miller Sternberg was

selected as Surgeon

General over 10 senior

officers. A career

officer, experienced

military campaigner, and

medical educator, he was an internationally known and

respected bacteriologist and sanitarian.3(pp6,13,60,94),4,5 To

his supporters he was the personification of this new

medical science.

On June 24, 1893, just a little over three weeks from

the time he took office, Sternberg resurrected

The Evolution of Public Health

Education in the US Army, 1893-1966

COL Stephen C. Craig, MC, USA

BG George Sternberg

Army Surgeon General

1893–1902
8 Army Medical Department Journal

Hammond’s idea, by establishing the Army Medical

School (AMS) in available space at the Army Medical

Museum and Library. The permanent faculty was

composed of medical officers stationed in Washington,

DC. COL Charles H. Alden became president of the

faculty and lectured on the duties of medical officers.

COL William H. Forwood taught military surgery, and

military hygiene was taught by MAJ John S. Billings.

MAJ Charles Smart lectured on military medicine and

directed the chemical laboratory, and CPT Walter

Reed lectured in bacteriology and was secretary of the

faculty. CPT Julian M. Cabell was brought in to assist

Forwood and teach Hospital Corps drill on Saturdays

at Fort Myer, Virginia.6(pp21,23)

In a note sent to the Secretary of War, Sternberg was

very clear about the purpose of the school:

There is no need to teach medicine and surgery to

graduates of our medical colleges, but there are certain

duties of an Army medical officer — which the college

course has not prepared them — which are more

important than the clinical treatment of individual cases

of disease and injury....A special education is needful

to prepare a military man to undertake the protection of

the public health. The course at the army medical

school will prepare him to cope with the questions of

practical sanitation that will be presented to him at

every turn in his military career.7

Indeed, Sternberg considered preventive medicine and

public health as the foundation for military medical

practice, and teaching these principles to be the

primary function of the school. He also sought to

prepare them for their roles as military officers and

modern physicians. If medical officers were to be

effective in garrison and on the battlefield, it was

imperative that they learn to function and

communicate in a military framework. Sternberg

expected a number of these students to rise to

command hospitals in the future where success

depended upon a thorough understanding of hospital

administration, logistics, and military law.

Furthermore, the modern medical officer had a

responsibility to maintain educational currency, pursue

practical research at every opportunity, and share his

results with his colleagues.8

Courses in military surgery, medicine, and hygiene,

the duties of medical officers in war and peace,

military law, and medical jurisprudence were

developed. Laboratory

instruction in sanitary

microscopy, pathological

histology, bacteriology,

and urinology was

provided.6(pp26-29,32-33)

Establishing a modern

professional commitment

to lifelong learning,

however, would only

begin with classroom and

laboratory instruction

and mentorship. Its

realization would depend

upon an officer’s interest

in research and a

continuing example from

the school. Sternberg

enlarged and modernized

the Medical Museum

Laboratory, not only for the benefit of the students, but

also to expand its mission to include modern

investigative research. In the execution of this

endeavor he relied heavily upon CPT Walter Reed and

Dr. James Carroll. Reed, who became Sternberg’s alter

ego in the laboratory and on numerous field

assignments, and Carroll began conducting

experiments into the value of cresol as a disinfectant,

smallpox, and, later, yellow fever. Epidemiological

field investigations were conducted as required.9-13

The school got off to a fine start, graduating its first

class in 1894. It graduated three more classes, and

began awarding the Hoff medal for academic

excellence in 1898, before the War with Spain closed

the school for three years.6(p24),14,15 When the war

ended, America had a new empire, rife with endemic

First Army Medical School

Graduating Class, 1894.

Standing left to right:

TS Bratton, AS Porter, DC

Howard, WH Wilson;

Seated: WW Quinton

Army Medical Museum and Library at 7th and B Streets,

SW, Washington DC. BG Sternberg established the

Army Medical School in this building in June 1893.
April – June 2006 9

diseases, in which Sternberg saw not only challenges

for the Medical Department, but also opportunities for

it to advance medical science. Public health would

play a major and interdependent role in accomplishing

the nation building goals of the McKinley

administration. Boards of health were created which

directed sanitation and large scale smallpox

immunization programs. In November 1899, Assistant

Surgeon General Bailey K. Ashford, with only basic

laboratory equipment and techniques acquired at the

AMS, demonstrated that Puerto Rican anemia was due

to the hookworm, Necator americanus.*

In January 1900 Sternberg sponsored a Board for the

Study of Tropical Diseases in the Philippines.16(p531)

The organizational format of the formal board was

known and understood by the Army, and Sternberg

had applied this format to the typhoid fever

investigation conducted by Reed, Victor C. Vaughn,

and Edward O. Shakespeare during the war.13

Sternberg told Secretary of War Elihu Root that

It was my desire that this [Tropical Disease] board

should be given all the appliances and assistance

necessary for conducting their researches and every

opportunity for obtaining access to cases and making

autopsies, etc. In my letter of instruction to the chief

surgeon I stated that the members of the board...while

pursuing their general investigations...could make

blood examinations and bacteriological researches for

the purpose of clinical diagnosis as well as with a view

to the promotion of our knowledge of infectious

disease.16(p531)

Sternberg also created the Yellow Fever Board in

Cuba a few months later with a similar intent.16(p532)

While these boards focused on diseases most

commonly encountered by soldiers, and certainly

provided immediate diagnostic assistance to clinicians,

his instructions defined a larger, more autonomous and

permanent goal: the establishment of a productive,

enduring research capability in the US Army Medical

Department. By the time Sternberg retired in June

1902, the medical school, laboratory, and tropical

disease boards provided a firm foundation for the

integration and management of public health education

and research science within the Army.3(p237) He had

produced the first post graduate, schoolhouse trained

preventive medicine officers.

Academic motivation among the student officers was a

problem, however. Reed recognized this fact and

commented about the first class: “Although no

member of the class has exhibited any special

enthusiasm for the work pursued in this laboratory, all

have acquitted themselves to my satisfaction.”6(p31)

COL Alden identified the root cause for this lack of

incentive when he stated

The rank of the student officers is already fixed before

they enter the school, and is not affected by their

proficiency at the school....It is very desirable that the

future rank of those student officers who have entered

the service just before the session should be determined

by the combined results of the examination for entrance

into the corps and their work at the school.6(p24)

Between 1902 and 1907, Army Medical Service

courses were made more robust. The academic session

was lengthened to eight months duration, military

medicine became military and tropical medicine, and

three new courses were added: operative surgery,

ophthalmology,optometry, and radiology.17(p12),18(p121)

To gain more control over medical officer candidates,

commissions were not awarded until after the officer

had successfully completed all courses with a score of

80% or better.17(p13),19

Class size, however, was on the decline. In his annual

report for 1907, Surgeon General Robert M. O’Reilly

commented

Obviously, the army medical service has lost much of

its attraction for the bright young graduates from our

best medical schools, and unless a remedy is soon

supplied, by suitable legislation, it will be impossible to

fill vacancies in the medical corps without lowering the

present standard of examination, a resort which, if

adopted, would leave us distinctly outclassed by the

medical corps of the armies of all other civilized

countries.18(p122)

The pay was low and promotions were slow in the

Medical Department. O’Reilly was grappling with a

perennial problem that Sternberg had never solved,

and his successors still worry about on a regular basis

— how to obtain and keep medical officers in uniform.

Secretary of War Root and his successor, William

Taft, agreed with the surgeon general that sufficient

numbers of medical officers had to be trained in

peacetime to be available in a crisis. In 1904, O’Reilly

drafted a bill to increase the efficiency and enlarge the

Medical Department. Although congress did not act on

it until April 1908, when they did, a number of

significant changes occurred. The legislation created

*References 16(pp 610, 681, 699-700, 701, 723-724) 123 new medical officer vacancies, relieved slow
10 Army Medical Department Journal

promotions by requiring examinations for promotion

from major to lieutenant colonel, increased pay,

allowed physicians to moonlight only if it did not

interfere with Army duties nor require an off-post

office, and created the Medical Reserve Corps, the

Army’s first reserve corps.20(pp321-22) The AMS noted

an immediate increase in class size and two years later

moved into larger quarters in the old Builders

Exchange on 13th Street, NW.21(p133),22(p132)

In the decade from 1908 to 1917, military medical

education and research, and the Army Medical Service

overall began the slow metamorphosis into the form

recognized today as the Walter Reed Army Institute of

Research. Frederick Russell, who developed an

effective typhoid vaccine in 1908 that was tested on

the staff and students and made mandatory in the

Army and Navy in 1911, served on the faculty, as did

Percy Ashburn and Charles Craig.20(p348),22(p131),23

Ashburn and Craig were fresh from the Philippines

where they had conducted original research on plague,

dengue, and malaria. Edward Vedder, who

solved the problem of infantile beri-beri in

those islands by supplementing breast milk

with an extract of rice polishings, taught

bacteriology.24,25(p162) Carl Darnall, who

developed a practical field apparatus for

chlorinating water in 1910, taught

chemistry.22(p131) William Lyster, who gave

us clean water using calcium hypocholorite

in a canvas bag in 1913, served for a time

as the military hygiene instructor.25(p162)

These young officers were Sternberg’s

disciples, dedicated to military medical

education, research, and mentoring.

Valery Havard and Percy Ashburn each

published handbooks on military hygiene

in 1909 to update Munson’s comprehensive

work from 1901. In 1915 the first

postgraduate course in preventive medicine

was offered to more senior officers.* To the Hoff

Medal was added the Sternberg Medal for excellence

in bacteriology and serum therapy. Sternberg awarded

the first one himself in 1913.28

However, the commandant of the school, COL

William H. Arthur, lamented in 1916 that

...too much time is given up to laboratory work and not

enough attention paid to sanitary tactics. While the

laboratory work is very important, it is not strictly

military, and the students have no opportunity of

learning to care for themselves in camp, the details of

camp sanitation, and the general duties of medical

officers in the field.27(p200)

However, this too was part of the ongoing

metamorphosis.

Army Inspector General Ernest Garlington commented

in 1910 that medical officers required more training in

“campaign work.” A year later the Field Service and

Correspondence School for Medical Officers was

created at Fort Leavenworth under the direction of

MAJ Edward Munson to instruct Regular and National

Guard physicians in staff, field, and administrative

duties.20(p324) But there was no longer any room at the

AMS for such training. The school moved once again

in 1917, this time to offices vacated by the Department

of Commerce on Louisiana Avenue, just in time to

absorb the massive influx of physicians who would put

their skills to immediate use with the American

Expeditionary Forces in France, and a variety of other

wartime responsibilities. Training courses expanded

and were set up at a variety of posts. Three hundred

officers were trained in five sessions and over 200

other reserve officers received refresher courses and

preparation for overseas movement. Large numbers of

enlisted laboratory and x-ray technicians were trained,

an orthopedic section was established to give

instruction in orthopedic theory and practice, and 750

physical examinations — for appointment and

promotion in the Reserve Corps — were performed

each month. Eighteen million doses of typhoid vaccine

*References 21(p 136), 26(p 171), 28(p 198) were produced and shipped, and oil suspension

Offices vacated by the Department of Commerce on Louisiana Avenue

became the home of the Army Medical School in 1917
April – June 2006 11

vaccines for dysentery, pneumococcal pneumonia,

meningitis, streptococcal infections, and cholera were

developed and tested in the laboratory.29,30

In the late fall of 1917, Surgeon General William C.

Gorgas led a team, consisting of COL Deane Howard

and reserve officers COL William Welch and MAJ

Victor Vaughn, on an inspection tour of a number of

southern and western mobilization and training camps.

There was a growing concern that the amount of

measles, mumps, meningitis, and pneumonia at these

camps was excessive. They determined that the

Sanitary Inspectors at these camps needed assistance

in the form of trained epidemiologists who would

conduct surveillance, evaluate the examinations of

incoming and outgoing soldiers, recommend control

measures, educate medical officers on communicable

diseases, and report routinely to the Surgeon General’s

Office. Gorgas issued orders to this effect in January

1918.31 Epidemiologists became an integral part of the

robust preventive medicine teams that served stateside,

particularly during the Influenza Pandemic, in Europe

during the war, and in the post-war occupation of the

Rhineland.

Civilian public health education was also developing

in the early part of the twentieth century, and its

evolution provides some interesting contrasts to events

occurring in the Army. According to Welch, Sternberg

had created America’s first school of public health at

the AMS,32 but it is a little known fact that Sternberg

also assisted in creating one of the first civilian schools

of public health, where he also served as faculty

president. A joint venture of the Georgetown and

Columbian University Medical departments, the

Washington Post Graduate Medical School opened its

doors in January 1903. It gave special attention to

preventive medicine, tropical diseases, and laboratory

work in bacteriology and sanitary chemistry, as these

subjects would be extremely valuable to general

practitioners, specialists, and health officers in the

government service. Thirteen months later, the

President and University Council of Columbian

University, soon to be George Washington University,

presented a petition to the Board of Trustees for the

establishment of a graduate Department of Public

Health which offered Masters and Doctorate of Public

Health degrees. Sternberg accepted the Dean’s chair

for the department and continued to teach classes in

hygiene and preventive medicine.33,34,35,36

The prominent growth of bacteriology and

immunology, emergence of state boards of health, the

continuing urbanization of the country and resulting

sanitary problems, and the need for properly trained

professionals to deal with these issues was a powerful

stimulus for the establishment of other postgraduate

programs. In 1906 William Sedgwick was teaching

principles of public health practice at the

Massachusetts Institute of Technology.* By 1912 his

program had joined with that of Milton Rosenau at

Harvard. Their School for Health Officers offered a

Certificate in Public Health and a doctorate. Public

health training programs were established by Victor C.

Vaughn at the University of Michigan in 1912,

Alexander Abbott at the University of Pennsylvania in

1914, C. E-A. Winslow at Yale the following year, and

a School of Public Health opened at Johns Hopkins

University in 1918.† However, standard course work,

such as sanitary engineering and legislation, sanitary

surveys, and inspections of consumable animal

products, took the physician outside the realm of

traditional medical education and practice. The public

health doctor also had to embrace a broad range of coequal colleagues as public health professionals.

Sedgwick’s program began with nonphysicians, and

by the time Hopkins opened, applicants included

sanitary engineers, chemists, epidemiologists, nurses,

and social workers.37(pp148-149) As the schools matured,

their advocates hoped that public health and preventive

medicine would become part of clinical training in all

medical schools.37(p183) However, many physicians

were simply not interested in public health training,

and physician dominance in the field diminished

during the interwar years. Public Health Officer jobs

were low paying, lacked the excitement of curative

medicine, were frequently given to physicians without

specialized training, and therefore offered little

incentive for bright young physicians.37(pp184,189-190)

Furthermore, this was the era when specialization

began to grow — residency programs doubled

between 1934 and 1940 — and with that growth came

the complexities of standardized training, licensing,

and regulation. General practitioners saw their

autonomy and scope of practice diminish with the

arrival of each new specialist.‡ When that specialist

worked for the public health he also bore the stigma of

“state medicine.” Governmental influence in the

delivery of health care, such as the Sheppard-Towner

Act of 1921 which gave federal monies to states for

mother and child health maintenance, threatened to

*References 37(pp 150-183), 38(p 194)

†References 37(pp 151-152), 38(p 253), 39

‡References 40(pp149-153, 155, 258)
12 Army Medical Department Journal

alter traditional fee-for-service practices and physician

autonomy.* Public Health Department efforts to

control infectious diseases were interpreted by local

practitioners as unfair state competition, and the

profession of public health became increasingly at

odds with clinical medicine. While the indifferent, and

often blatantly hostile, established medical community

pushed preventive medicine farther away from the

clinical realm and precluded its incorporation into

medical school and hospital training, the Army

Medical Department (AMEDD) pursued a different

approach.

In September 1923, the Army Medical Service (AMS)

began moving into Building 40 on the Walter Reed

campus, and became part of the Army Medical Center

which was established the same month.41(p247)

Consisting of Walter Reed General Hospital, which

had opened in 1909, and the Army Medical, Nursing,

Veterinary, and Dental

Schools, the medical center

represented the culmination

of Army Medical Department

efforts to secure suitable

facilities for furthering the

medical education system of

the Army in the national

capital area. The medical

center concept improved and

strengthened the relationship

of the medical school with the

other schools and the

hospital.41(p246) A considerable

amount of hospital radiographic and laboratory work

was done at the school, more time was given to

clinical work, and closer contact was maintained with

hospital cases. Directors at the school were given

consultancies in the hospital and house officers were

made instructors in the school. In addition to the basic

preventive medicine course and postgraduate

roentgenology course, the school now offered a 14

week postgraduate session in preventive medicine

which included instruction in bacteriology, personal

hygiene, protozoology, immunology, epidemiology,

helminthology, entomology, chemistry, and vital

statistics.41(pp247-48),42 In 1928 preventive medicine

achieved departmental status when it became part of

the Department of Laboratories, Preventive Medicine,

and Clinical Pathology.43 Three years later, two new

wings were added to the school to accommodate its

growth. Four years after that the Army Medical,

Dental, and Veterinary Schools(the Army School of

Nursing had closed in January 1933) were renamed the

Medical Department Professional Service School.44

In 1936 Surgeon General Charles Reynolds recognized

the need for a strong preventive medicine service in

wartime.45(p177) A member of the AMS faculty 30 years

before and Deputy Chief Surgeon in the American

Expeditionary Forces in 1917, Reynolds had a keen

appreciation for the specialty, and commented “The

most valuable contributions of the Medical

Department of the Army have been in the field of

preventive medicine. The dividends from intelligent

service in the future will be no less.”45(p179) To direct

the Preventive Medicine Service, later the Preventive

Medicine Division, in the Office of the Surgeon

General, he brought in COL James S. Simmons. One

of the few officers to hold a doctorate in public health,

Simmons had a distinguished career in infectious

disease research at the AMS, had been president of the

medical research boards in the Philippines and Canal

Zone, and was an acknowledged authority on

malaria.45(pp178-79) In late 1939 the US began to

mobilize for war. Simmons, with only a small cadre of

trained public health officers, successfully co-opted a

wide range of national resources, such as the US

Public Health Service, National Research Council, and

Rockefeller Foundation, to train the large numbers of

physicians required to preserve the health of an

expanded Army. The Board for the Investigation and

Control of Influenza and Other Epidemic Diseases in

the Army, established in 1940 and now known as the

Armed Forces Epidemiological Board, consisted of

distinguished civilian scientists and Medical

Department officers who worked in coordination with

their respective research facilities to solve major

disease problems affecting the Army. Short courses in *References 37(p 185), 40(pp 136-137, 143)
April – June 2006 13

sanitation and hygiene, which taught methods to

preclude and interrupt respiratory, venereal, and

vector-borne diseases, were developed as they had

been in 1917–18. For officers assigned to the tropics

and adjacent areas, the AMS initiated a four-week,

malaria and dysentery intensive course that was

lengthened to eight weeks after Pearl Harbor.

Although classes began with 20 to 30 officers, by 1943

each session was graduating 100 officers.* Naturally,

Simmons recognized the school could not possibly

educate the nearly 40,000 Army medical officers on

duty that year. With the aid of the National Research

Council, he began building a pool of trained civilian

physicians by having medical schools and teaching

hospitals provide tropical medicine courses to their

senior students and interns.47(pp11-14)

Field training in malaria control also received close

attention. Instruction was conducted for selected

medical and sanitary officers in Florida and along the

Pan-American Highway being constructed by Army

Engineers from Panama to Mexico.47(pp19-20) Malaria

was proving to be the bane of commanders in the

southwest Pacific. Forces on Guadalcanal and the

Buna Islands were saturated with it. When General

MacArthur was briefed after the Buna fight in January

1943 that 72% of the combined force was sick—60%

with malaria—he commented to his malaria

consultant,

Doctor, this will be a long war if for every division I

have facing the enemy, I must count on a second

division in hospital with malaria and a third division

convalescing from this debilitating disease.46(p2)

In response to the malaria crisis in the Pacific, an

Army School of Malariology was established in the

Canal Zone to provide training and advanced

instruction to medical and sanitary officers and

enlisted technicians, who made up special vector

control teams. All of these efforts, plus intensive troop

education and the introduction of Atabrine for malaria

chemoprophylaxis, brought malaria under control in

endemic areas during the last year of the war.47(pp21-25)

By 1945, the strife between public health and clinical

medicine of the interwar years had left America with

too few trained public health physicians.48 Determined

to enlarge their ranks, leaders in public health

recognized and embraced the fact that medical

specialization was the only way to expand and gain

credibility and acceptance within the profession,

whether civilian or military. During the war the

government, by giving higher rank and pay and larger

responsibilities to certified specialists, had

acknowledged their superior professional status.40(pp279-

280),49 While the number of residencies continued to

grow through the 1940s, specialty boards sought

quality control by requiring at least three years of postinternship training and working in conjunction with

the residency inspection system conducted by the

American Medical Association Council on Medical

Education.40(p258)

To achieve the professional status and prestige so long

desired, the American Public Health Association and

the American Medical Association (AMA) came

together in 1948 to create the American Board of

Preventive Medicine and Public Health and begin to

define training standards and establish residency

programs.40(p330) After completion of internship,

preventive medicine residents completed one year of

graduate study leading to a masters in public health

followed by two years of academic and field training

in an approved preventive medicine program.50 By

1951, public health departments in 12 states had

approved pubic health residency programs of three

years duration.51 Although originally intended to

generate public health specialists, subspecialties in the

field soon followed, aviation medicine was added in

1953 and occupational medicine in 1955.40(pp330-331)

While the civilian community wrestled with these

educational issues, events were transpiring in the

AMEDD that would culminate in the establishment of

a formal Army Preventive Medicine Residency

Program.

During the tenure of Surgeon General Raymond Bliss,

Army hospitals began offering residency training

programs to career officers. Health education and

preventive medicine programs were expanded as were

laboratories, and the AMS continued to produce

preventive medicine officers.52(pp118,120-21) The war in

Korea emphasized again the need for these welltrained specialists. Lessons in cold injury prevention

from WWII had to be re-learned by commanders,53 a

temperate strain of Plasmodium vivax — which liked

to hide in the liver for months — put a new

complication in malaria chemoprophylaxis and

treatment until primaquine was developed and issued

in 1951,54,55 and on the peninsula US forces also got

their first introduction to the hanta virus.56

*References 46(p 48), 47(pp 11-12, 16-17)
14 Army Medical Department Journal

By the early 1950s, the Military Preventive Medicine

Course offered at the recently renamed Army Medical

Department Research and Graduate School was 11

months long.57 While a steady supply of well trained

preventive medicine officers was needed, recruiting

into this specialty was difficult. With this in mind,

Surgeon General Bliss proposed that the school be

given Masters of Public Health (MPH) and Masters of

Science degree granting authority, and his successor,

George Armstrong, took the action to Congress. These

efforts failed, but the gauntlet was taken up by

Surgeon General Silas B. Hays in 1956.57 Early in his

tenure the Professional Service School was renamed

the Walter Reed Army Institute of Research (WRAIR)

and the American Board of Preventive Medicine

declared the Military Preventive Medicine Course

equivalent to a civilian MPH program. The board also

retroactively approved granting MPH degrees to the

WRAIR classes of 1954 and 1955.57 However,

attempts to secure these degrees by affiliating with

either Johns Hopkins or George Washington

University were rejected by those institutions.57

Therefore, Hays presented the degree granting bill to

Congress once again in February 1957 stating “The

proposed legislation would recognize the

responsibility placed on this institute and would

provide it with the status commensurate with its

activities.” He noted the recognition given by the

American Board of Preventive Medicine and that there

was precedent for the proposed legislation, in that the

Navy Postgraduate School and the Air Force Institute

of Technology both had degree granting authority.57(p3)

However, Dr. Arthur S. Adams, President of the

American Council on Education, who spoke for

leaders in higher education, testified that it was not in

the public interest for any federal agency to be given

such authority, and, thereby, essentially defeated the

bill.58

Surgeon General Hays abandoned his efforts to obtain

degree granting authority for WRAIR in September

and discontinued the 11-month Military Preventive

Medicine Course after the 1957-58 session. From that

point on, preventive medicine residents took their

MPH training at civilian institutions and completed the

last two years of academic and field training

requirements by performing them concurrently in a

one year course at designated Army medical

facilities.59,60(pp613-614)

Beginning in 1958, the military preventive medicine

residency consisted of a three-month course in

advanced military preventive medicine at WRAIR and

one year at residency programs established at the Fort

Dix Health Center and First US Army Preventive

Medicine Division in New Jersey, under the

directorship of COL George R. Carpenter and at the

hospital at Fort Ord and the Presidio in California

under COL G. L. Orth. Plans were also developed for

an Army Occupational Medicine Residency Program

at the Army Environmental Health Laboratory,

Edgewood, Maryland.60(p613),61

On June 1, 1959 Leonard D. Heaton began a long and

distinguished career as the Army’s 31st Surgeon

General. Heaton had a high regard for preventive

medicine, and recognized that it was more than a

specialty within itself, but one that “permeated the

realms of other disciplines,” and as such was a crucial

link in maintaining the strength of the Army.52(pp1,16)

The Army began to grow in the early 1960s. The Cold

War heated up in Berlin in 1961, left the city divided

and stimulated a buildup of US forces in Europe. A

year later Soviet missiles in Cuba put all services on

high alert and reinforced the need for a rapidly

responsive military force. During this time also, civic

action programs conducted by Army Special Forces

units in Southeast Asia and Latin America were

increasing.62(ppiii,58,62),63 These activities were

preventive medicine intensive, but attracting young

officers into the specialty remained problematic.

Through intensified recruiting the Surgeon General

began to fill the preventive medicine ranks. While the

AMEDD depended heavily on short course trained

preventive medicine officers, a third residency

program at Fort Bragg was approved by the AMA in

1962, and a fourth program at WRAIR two years

later.62(p58),64

The initiation of the WRAIR program in 1964

coincided temporally with President Johnson’s

announcement of the Gulf of Tonkin resolutions and

the major buildup of forces in Vietnam that began in

early 1965. A Preventive Medicine Division, Office of

the Surgeon, US Army, Republic of Vietnam was

organized to advise the command on the incidence,

prevalence, and epidemiological aspects of diseases

which were likely to impact combat operations.

Indeed, in this conflict, preventive medicine was in the

van of the deployment.65(p108)

In 1973, MG Spurgeon Neel wrote

One of the most striking achievements of military

medicine in Vietnam was the rapid and effective
April – June 2006 15

establishment of a preventive medicine program that

blunted the impact of disease on combat operations. In

World War II, preventive medicine programs in the Far

East did not begin to make inroads upon disease

incidence until 1945....In Korea the delay was less, but

still considerable. In Vietnam, however, effective

disease control programs were introduced in 1965

and...maintained throughout the stress of the troop

buildup.65(p32)

Neel was technically correct, but his preventive

medicine efforts in Vietnam were materially assisted

by medical technologies and logistical capabilities that

were not available as America entered the Second

World War or Korea. What had not changed, however,

and it is a shame that MG Neel did not point it out,

were the essentials of postgraduate training in

preventive medicine and public health and the ability

of the WRAIR to expand to meet mission demands.

Although accredited residency programs changed the

form of this education, the basics had been taught and

practiced in the Army for three quarters of a century

and through five wars.

Surgeon General Sternberg did not call his graduate

students “residents,” but in reality that is exactly what

they were. With a little brushing up on current

therapeutic practices and modern field sanitation and

hygiene technologies, the Army Medical School class

of 1894 would have been just as comfortable in the

jungles of Vietnam, the mountains of Afghanistan, or

the deserts of Iraq as the graduates of today.

REFERENCES

1. Brinton J. Personal Memoirs of John H. Brinton,

Civil War Surgeon, 1861-1865. New York: Neale

Pub. Co; 1914. Reprint. Carbondale, IL: Southern

Illinois University Press; 1996.

2. Duffy J. History of Public Health in New York City,

1866-1966. New York: Russell Sage Foundation;

1974:92-102.

3. Sternberg M. George Miller Sternberg. Chicago:

AMA; 1920.

4. Eggerth AH. The History of the Hoagland

Laboratory. New York: publisher undetermined;

1960:45-48.

5. Gossel P. Institutional growth and the fate of

bacteriology at Johns Hopkins, 1886–1923. Paper

presented to the Johns Hopkins University

Department of Science, Medicine, and Technology;

September 28, 2000; Baltimore, MD:79.

6. Annual Report of the Army Surgeon General, 1894.

Washington, DC: US War Dept; 1894.

The Walter Reed Institute of Research, circa 1971
16 Army Medical Department Journal

7. Annual Report of the Army Surgeon General, 1893.

Washington, DC: US War Dept; 1893:15.

8. Sternberg GM. The function of the Army Medical

School. Am Med. April 1902;547-551:547-551.

9. Reed W. The germicidal value of Trikresol.

Proceedings, Association of Military Surgeons of the

United States. St. Louis, MO: Buxton and Skinner

Stationery Co, 1894;199-208.

10. Sternberg GM, Reed W. Report on immunity against

vaccination conferred upon the monkey by the use of

the serum of the vaccinated calf and monkey. Trans

Asso Am Phys. 1895;10:57-69.

11. Reed W, Carroll J. Bacillus icteroides and bacillus

cholerae suis—a preliminary note. Med News April 29,

1899;74:513-514.

12. Reed W, Carroll J, Agramonte A, Lazear J. The

etiology of yellow fever: a preliminary note. Phil Med

J. October 27, 1900;6:790-796.

13. Reed W, Vaughn VC, Shakespeare EO. Origin and

Spread of Typhoid Fever in U. S. Military Camps

During the Spanish War of 1898 [abstract].

Washington, DC: US War Dept; 1900.

14. Annual Report of the Army Surgeon General, 1899,

Washington, DC: US War Dept; 1899:19.

15. Annual Report of the Army Surgeon General, 1902.

Washington, DC: US War Dept; 1902:14-15.

16. Annual Report of the Army Surgeon General, 1900.

Washington, DC: US War Dept; 1900.

17. Annual Report of the Army Surgeon General, 1904.

Washington, DC: US War Dept; 1904.

18. Annual Report of the Army Surgeon General, 1907.

Washington, DC: US War Dept; 1907.

19. Annual Report of the Army Surgeon General, 1905.

Washington, DC: US War Dept; 1905:134.

20. Gillett M. The Army Medical Department, 1865-1917.

Washington, DC: US Dept of the Army, Center for

Military History; 1995.

21. Annual Report of the Army Surgeon General, 1909.

Washington, DC: US War Dept; 1909.

22. Annual Report of the Army Surgeon General, 1910.

Washington, DC: US War Dept; 1910.

23. Annual Report of the Army Surgeon General, 1908.

Washington, DC: US War Dept; 1908:105.

24. Vedder E. Beri-Beri. New York: Willliam Wood & Co;

1913.

25. Annual Report of the Army Surgeon General, 1914.

Washington, DC: US War Dept; 1914.

26. Munson E. Military Hygiene. New York: William

Wood & Co.; 1901:171.

27. Annual Report of the Army Surgeon General, 1915.

Washington, DC: US War Dept; 1915.

28. Annual Report of the Army Surgeon General, 1916.

Washington, DC: US War Dept; 1916.

29. Annual Report of the Army Surgeon General, 1917.

Washington, DC: US War Dept; 1917:298-301.

30. Annual Report of the Army Surgeon General, 1918.

Washington, DC: US War Dept; 1918:438-443:68-70.

31. Chamberlain WL, Weed FW. Sanitation. Washington,

DC: US War Dept; 1926. The Medical Department in

the World War; vol 6.

32. Hume EE. Victories of Army Medicine. Philadelphia,

PA: JB Lippincott Co.; 1943.

33. Circular of Information, Georgetown University School

of Medicine, 1903-04. Washington DC: Georgetown

University Archives:19.

34. Sternberg GM. Preventive medicine. Popular Science

Monthly. February 1903;62:348-358.

35. Record of the Board of Trustees, Columbian University,

June 18, 1902-May 26, 1910. Washington, DC: Gelman

Library Archives, George Washington University: 169-

171, 174, 242, 419.

36. Opening Session Monday. Washington Evening Star.

January 10, 1903.

37. Fee E, Acheson RM, eds. A History of Education in

Public Health. New York: Oxford University Press;

1991.

38. Duffy J. The Sanitarians, A History of Public Health,

Urbana, IL: University of Chicago Press; 1992.

39. Rosen G. A History of Public Health. New York: MD

Publications; 1958:253.

40. Stevens R. American Medicine and Public Interest, 2nd

ed. Los Angeles, CA: University of California Press;

1998.

41. Annual Report of the Army Surgeon General, 1924.

Washington, DC: US War Dept; 1924.

42. Annual Report of the Army Surgeon General, 1923.

Washington, DC: US War Dept; 1923:257.

43. Annual Report of the Army Surgeon General, 1929.

Washington, DC: US War Dept; 1929:310.

44. History of the Army Medical Department Research and

Graduate School [unpublished]. Washington, DC:

Archives of the Walter Reed Army Institute of

Research:21.

45. Bayne-Jones S. The Evolution of Preventive Medicine

in the United States Army, 1607-1939. Washington,

DC: US Dept of the Army; 1968.
April – June 2006 17

46. Coates JB. Communicable Diseases: Malaria.

Washington, DC: US Dept of the Army; 1963.

Preventive Medicine in World War II; vol 6.

47. Anderson RS. Special Fields. Washington, DC:

US Dept of the Army; 1969. Preventive Medicine in

World War II; vol 9.

48. Hume JC. Development of residency training in

preventive medicine. JAMA. 1966;198;No. 3:270-274.

49. Ludmerer KM. Time to Heal. New York: Oxford

University Press; 1999:181-192.

50. Whayne TF. Preventive medicine in medical schools.

Arch Env Health. 1961;3:308-314.

51. Approved internships and residencies. JAMA.

September 29, 1951;147:442.

52. Engelman RC, ed. A Decade of Progress: The United

States Army Medical Department, 1959-1969.

Washington, DC: US Dept of the Army; 1971.

53. Whayne TF, DeBakey ME. Cold Injury, Ground Type;

Medical Department of the United States Army in

World War II. Washington, DC: US Dept of the Army;

1958:ix.

54. Marshall IH. Malaria in Korea. Recent Advances in

Medicine and Surgery. Vol 2. Washington, DC: Army

Medical Service Graduate School, Walter Reed Army

Medical Center; 1954.

55. Dilorenzo A, Marx RL, Alving AS. Korean vivax

malaria. Am J Trop Med & Hyg. 1953;2:984-984.

56. Mayer CF. Epidemic hemorrhagic fever of the Far East,

or endemic nephroso-nephritis. Milit Surg. April

1952:276-284.

57. Degree Granting Activities for WRAIR. RG112, E421

Box 59, National Archives and Records Administration.

58. Meeting Minutes, 5 Mar 1957. Degree Granting

Activities for WRAIR. RG112, E421, Box 52, National

Archives and Records Administration.

59. Annual History, Preventive Medicine Division, 1957,

39-40. Annual Reports of Divisions of SGO, 1947-1974.

RG112, E1018, Box 10, National Archives and Records

Administration.

60. Approved Residencies and Fellowships, JAMA.

1958;168:613.

61. Annual Report of the Army Surgeon General, 1958.

Washington, DC: US Dept of the Army; 1958:38.

62. Annual Report of the Army Surgeon General, 1962.

Washington, DC: US Dept of the Army; 1962.

63. Annual Report of the Army Surgeon General, 1963.

Washington, DC: US Dept of the Army; 1963:28.

64. Annual Report of the Army Surgeon General, 1966.

Washington, DC: US Dept of the Army; 1966:115.

65. Neel S. Medical Support of the U. S. Army in Vietnam,

1965-1970. Washington, DC: US Dept of the Army;

1973.

AUTHOR

COL Craig is the AMEDD Consultant in Medical Corps

History. He is a professor at the Uniformed Services

University of the Health Sciences in Bethesda, Maryland

where he is the Course Supervisor for the MS-I course in

Military Medicine. COL Craig is a member of the Editorial

Review Board of the AMEDD Journal.

COL ADAMS JOINS THE AMEDD JOURNAL EDITORIAL REVIEW BOARD

The AMEDD Journal welcomes COL George L. Adams, MS, USA

as a member of the Editorial Review Board. COL Adams is the

Senior Assistant to the Chief, Medical Service Corps,

AMEDD Center & School, Fort Sam Houston, Texas.

COL Adams joins the board replacing COL George J. Dydek, MS,

USA. COL Dydek has been a member of the Board since January,

2000. We thank COL Dydek for his dedication to the high standards

and professional quality of this publication, and his years of service

and support to our mission.

The Editors
18 Army Medical Department Journal

Over the past 25 years, Environmental Science

Officers (Area of Concentration [AOC] 72D) and

Environmental Engineers (AOC 72E) have played an

increasingly vital role in what has become known as

force health protection. The Army has historically

recognized the importance of environmental and

occupational health services as the preeminent tools to

“conserve the fighting strength” of Soldiers (and

civilians), whether these personnel are deployed

operationally or working and training on myriad

installations around the world. This has remained true

even as the Army has changed to adapt from the

requirements of the Cold War to meet the challenges

of the Global War on Terrorism. However, it is my

observation that the roles and missions of 72D and

72E officers have not only evolved, but have also

grown so close to one another that they are virtually

indistinguishable.

Environmental Science Officers (ESOs) and

Environmental Engineers are both concerned with that

portion of the public health spectrum known as

environmental health. Broadly defined, environmental

health and protection refers to protection against

environmental factors which may adversely impact

human health or the ecological balances essential to

long-term human and environmental quality, whether

in the natural or man-made environment.1 Although

complementary to each other, 72D and 72E officers

differ in their academic backgrounds and primary

focus. Environmental engineers possess undergraduate

degrees in civil, mechanical, or environmental

engineering, and are traditionally concerned with the

construction, maintenance, and development of water

and wastewater systems, air pollution control

measures, and solid waste management systems, all of

which play important roles in the maintenance of

public health. On the other hand, ESOs have

traditionally earned undergraduate degrees in the

biological or physical sciences and are concerned with

the implementation and execution of programs for

drinking water quality surveillance; applied food

service sanitation, housing sanitation, pest control,

disease surveillance, and general environmental

quality. Both ESOs and environmental engineers can

find themselves engaged in providing industrial

hygiene support to installation occupational health

programs, as well as monitoring for the presence and

extent of toxic industrial materials/compounds in the

surrounding air, soil, and water. While the

contributions of these specialties to the Army and the

Army Medical Department (AMEDD) have never

been more important, it is interesting to note that the

relative proportion of engineers and ESOs within the

Medical Service Corps has changed dramatically along

with the Army’s expectation of what these officers

must deliver in the way of support to deployed forces.

ORIGIN OF SANITARY/ENVIRONMENTAL

ENGINEERS AND ENVIRONMENTAL SCIENCE

OFFICERS

Environmental engineers (until recently known as

sanitary engineers) have served in the Army since the

First World War. In June 1917, then Surgeon General

William Gorgas created the US Army Sanitary Corps

which enrolled newly commissioned officers with

“special skills in sanitation, sanitary engineering, in

bacteriology, or other sciences related to sanitation and

preventive medicine, or who possess other knowledge

of special advantage to the Medical Department."2 The

first officer appointed in the new Sanitary Corps was

an engineer by the name of William Wrightson who

had served with Gorgas in Panama during the

construction of the Panama Canal. By November

1918, sanitary engineers numbered 213 and comprised

7.5% of entire Sanitary Corps. Sanitary/Environmental

engineers have been with the AMEDD ever since that

time, providing sanitary/public health support and

industrial hygiene services around the world and in

every major conflict and contingency throughout the

20th century. In 1961 there were 99 Sanitary

The Evolving Role of Environmental

Science Officers and Environmental

Engineers in the Medical Service Corps

COL John J. Ciesla, MS, USA
April – June 2006 19

Engineers on active duty, a number that remained

fairly steady for the next 20 years (94 were serving

with the Medical Service Corps in 1982).3(apndx K,L)

Environmental Science Officers are a more recent

development. In November 1968, the first 7 sanitarians

(later called environmental science officers) deployed

to Vietnam. Praised by both the US Army Vietnam

(USARV) Surgeon and USARV Sanitary Engineer,

these officers were judged more effective at the

division level for day-to-day preventive medicine

activities than the Medical Corps preventive medicine

officers they replaced.4,5 By 1972 the number of ESOs

serving in the Medical Service Corps had risen to 90;

and by 1982 this number had risen further still to 143.

By 1994 the aggregate number of ESOs and Sanitary

Engineers totaled 240, although ESOs outnumbered

engineers by about 2 to 1.3(apndx M) In 2006, there are

197 ESOs and 54 Environmental/Sanitary Engineers

on active duty in the Medical Service Corps.6

CHANGING ROLES AND MISSIONS

Prior to 1985, the tendency was to assign

environmental engineers to scientific/technical

organizations within the AMEDD, such as the US

Army Environmental Hygiene Agency or the 10th

Medical Laboratory. These engineers also provided

support as staff officers at the Department of the Army

level or Office of The Surgeon General, as well as at

major subordinate commands such as HSC (Health

Services Command, the precursor to the Medical

Command). They also served as instructors and

combat developers with the AMEDD Center &

School. Although environmental engineers were rarely

directly involved in the construction of water and

wastewater plants or sanitary landfills (because the

Army increasingly privatized these activities), they

nonetheless continued to advise on or perform

professional and scientific work utilizing engineering

practices to protect Soldiers’ health, and support Army

environmental protection and preservation efforts.

Duties could also include the assessment of existing

and proposed weapons systems, equipment, clothing,

training devices, and materiel systems. Engineers with

training and experience in industrial hygiene provided

invaluable assessments of workplace health and safety

in support of the Army Occupational Health Program.

At this same time, ESOs were primarily assigned at

installation level to the MEDDAC (Medical

Department activity) Preventive Medicine Services to

serve as the Chief of Environmental Health. Just as

they had done in 1968 in Vietnam, ESOs consistently

demonstrated their flexibility and adaptability in

directing environmental health programs that included

drinking water surveillance, food service facility

inspections, support for child care center and housing

sanitation, pest control, and industrial hygiene surveys.

In the absence of a preventive medicine physician,

these 72D officers could also find themselves pressed

into service as the Chief of Preventive Medicine.

Alternatively, ESOs could also find themselves

assigned to Table of Organization & Equipment

(TO&E) preventive medicine positions as the division

ESO, commander of a preventive medicine

detachment, special forces group ESO, or staff ESO at

a Medical Group or Brigade. Like their 72E

counterparts, ESOs also were assigned to the AMEDD

Center & School as both instructors and combat

developers.

Around 1985, an increasing number of environmental

engineers expressed a desire to serve in field (TO&E)

units. Consequently, engineers were assigned to 72D

positions at Army divisions, special forces groups, and

preventive medicine detachments. At this same time,

ESOs were increasingly assigned to those positions

that, although previously reserved for 72E officers,

were no longer determined to strictly require an

engineer or engineering expertise. Consequently, 72D

and 72E officers became increasingly interchangeable

for all but a relative handful of TO&E or Table of

Distribution and Allowances (TDA) assignments. This

situation remains unchanged today.

While expectations on what constitutes installation

environmental health and environmental quality

support has not changed over the past 25 years (and is

still spelled out in Army Regulation 40-5 and its

supporting documents7), it is noteworthy that the

understanding of what constitutes the mission for

TO&E preventive medicine organizations providing

operational support to deployed forces has been

revolutionized. Prior to the first Gulf War in 1991,

field preventive medicine support was considered

important but not particularly challenging from a

technical standpoint. For example, field water

surveillance was largely limited to coliform bacteria

determinations, testing chlorine residuals, and

performing a relatively limited suite of inorganic

chemical tests. Environmental surveillance was usually

limited to what was directly observed during sanitary
20 Army Medical Department Journal

surveys, and with the introduction of hermeticallysealed field rations such as MREs (Meal, Ready-toEat) and T-Rations, there was less to be concerned

about from an applied foodservice sanitation

standpoint. Industrial hygiene surveys were ordinarily

limited to measurements of carbon monoxide. Even

entomological surveillance techniques were

rudimentary.

However, the 1991 Gulf War and resulting oil well

fires produced a dramatic increase in concern about

Soldier exposure to industrial chemicals and toxic

materials during deployments. As a result, ESOs and

environmental engineers assigned to TO&E preventive

medicine units are now expected to perform

environmental contaminant risk assessments which are

then incorporated into commanders’ risk management

activities. Beginning with the deployment of US armed

forces to Bosnia in 1996, new protocols for what

would become known as Deployment Occupational

and Environmental Health Surveillance (OEHS) would

require 72D and 72E officers to perform analysis of

the air, soil, and water supplies at every major base

camp or forward operating base. These analyses would

exceed in scope and complexity what is routinely

accomplished at Army posts around the world—and in

most US municipalities. This trend has continued

because US troops increasingly make use of former

Soviet bases and infrastructure or encounter thirdworld environmental conditions that increase the

potential for exposure to toxic industrial compounds

and chemicals. From 1996 to the present, wherever US

ground forces were employed, ESOs and

environmental engineers assigned to TO&E units

collaborated with their colleagues from the US Army

Center for Health Promotion and Preventive Medicine

(USACHPPM) to produce detailed OEHS assessments

of major base camps and forward operating sites in

Macedonia, Kosovo, Uzbekistan, Afghanistan,

Kuwait, and Iraq, as well as other locations of

operational interest around the world. Although classic

field sanitation and hygiene missions remain important

(as underscored during the early phases of Operations

Enduring Freedom and Iraqi Freedom), this new

demand for OEHS support requires equipment, tactics

and techniques that are just as technically challenging

as that required to provide industrial hygiene and

environmental health support at any permanent

installation. It has produced new challenges for the

AMEDD in how it trains and employs ESOs and

environmental engineers. OEHS and force health

protection requirements have also made the presence

of a 72D/E officer on the staff of most combatant

commands (Central Command, Southern Command,

etc.) more important than ever.

ARMY TRANSFORMATION

The value placed on the support provided by 72D/E

officers has been unambiguously reinforced by the

new modular organizations developed to support Army

Transformation. Beginning in 2004, each new brigade

combat team has a 72D assigned, as does each division

headquarters. This brings the total number of ESOs

within a division to four, a dramatic increase from the

single officer assigned in the past. Additionally, every

army and corps headquarters may have up to three

72D officers assigned to its main and operational

command posts. Add to these positions new

authorizations for both company-grade and field-grade

72D/E officers at every proposed medical deployment

support command, medical support command (MSC),

multifunctional medical battalion, sustainment

command, military police battalion, and civil affairs
April – June 2006 21

brigade, and the result is a 4-fold increase in the

number of 72D TO&E authorizations within the

Active Component. In 2007, the 197 active ESO

authorizations are almost evenly divided between TDA

and TO&E positions at every grade level, something

which will facilitate the career development of ESOs

and environmental engineers by permitting officers to

rotate back and forth between operational and

institutional assignments throughout their careers.

THE FUTURE OF ESOS AND

ENVIRONMENTAL ENGINEERS

ESOs and environmental engineers will continue to

serve as valuable members of the AMEDD team and

make a direct contribution to force health protection.

The future is undeniably bright. But even with a

growing demand for 72D/E officers, several issues

remain to be addressed in the next few years:

 The Medical Service Corps will need to determine

how many 72D and 72E officers it needs as a

component of its total budgeted end strength. In

1980, there were approximately 245 ESOs and

environmental engineers on active duty providing

support to a 780,000 Soldier Army. In 2006, more

than 275 72D/E officers serve in an Army almost

one-third smaller, and based upon projections, the

number of authorizations for 72D officers in the

TO&E force will continue to grow to support

Army Transformation. At what point will the MSC

decide that it has all the ESOs that it can afford in

lieu of other operational requirements?

 Since ESOs exceed the number of environmental

engineers by almost 3 to 1, and the 2 AOCs are

interchangeable in most assignments, is

maintaining 2 separate AOCs for ESOs and

engineers still viable? Would an additional skill

identifier for engineers be a better means to

identify this valuable skill set for the MSC?

 Which positions within the AMEDD absolutely

require the skills of an engineer and should be

designated as such? Are 72E engineers at risk of

becoming civilianized because of their currently

low representation in the TO&E force?

Approximately 10% of 72E positions are TO&E

versus approximately 50% of ESO positions.

 Which TDA positions within MEDCOM will

provide the best technical and professional

opportunities for 72D/E officers? Is an assignment

to USACHPPM better than an assignment to a

MEDDAC? Should some MEDDAC ESO

positions be converted under current military-tocivilian initiatives in order to provide better

developmental opportunities for junior officers

elsewhere?

These and other questions will be discussed in the next

few years by the senior leadership of the Medical

Service Corps in collaboration with the company- and

field-grade ESOs and environmental engineers

currently serving around the world. Regardless of the

outcome of these deliberations, the future for MSC

environmental science officers and environmental

engineers will continue to be exciting and full of

enormous potential for personal and professional

development. With the increased emphasis by the

Army on force health protection in a global

environment, these officers will continue to play an

indispensable role in the AMEDD’s mission to

“protect the fighting strength.”

REFERENCES

1. Definition of Environmental Health adopted by the

National Association of Environmental Health

(NEHA), April 1996. Available at: http://

www.neha.org/position_papers/def_env_health.html.

2. War Department General Order No. 80. Washington,

DC: US War Dept; 30 June 1917.

3. Ginn RVN. The History of the U. S. Army Medical

Service Corps. Washington, DC: US Army Center of

Military History; 1997.

4. Jennings HB. Sanitarians. Presented at Senior Officer

Debrief, US Army Vietnam: 25 June 1969.

5. Smith JJ. Office of The Army Surgeon General

Lessons Learned: 23 October 1968.

6. AOC 72D/E Inventory Data. Washington, DC: US

Army Human Resources Command; April 2006.

7. Army Regulation 40-5: Preventive Medicine.

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

2005.

AUTHOR

COL Ciesla is the Environmental Science and Engineering

Consultant to The Army Surgeon General
22 Army Medical Department Journal

INTRODUCTION

Epidemiology is the study of patterns and risk factors

for disease and injury occurrence in populations with

the intent to determine approaches to mitigate adverse

health outcomes and prevent future morbidity and

mortality. Health surveillance is the routine and

systematic collection, analysis, interpretation, and

reporting of population-based data for the purposes of

detecting, characterizing, and countering threats to the

health, fitness, and well being of populations. In

military settings, epidemiology and surveillance are

required to maintain healthy, fit, and operationally

effective forces and to ensure their health and safety

during both training and real-world missions. Public

health practitioners use epidemiology and surveillance

to serve populations in the same way that medical care

providers use clinical diagnosis and screening to serve

individual patients. Figure 1 compares individual care

and population medicine with regard to the scientific

problem-solving process. Figure 2 shows how

epidemiology and surveillance function in the broader

scheme of continuous public health assessment and

intervention.

HISTORICAL PERSPECTIVE

Just as combat casualty care and the treatment of acute

diseases for which deployed troops are at high risk

have evolved with each major US military engagement

through history, so too have epidemiological tools and

procedures. The earliest Medical Department

regulation that attempted to tie the monitoring of

scientific data to predicting disease occurrence in

populations was published in 1826. It required

physicians to maintain meteorological records. The

Army Surgeon General at that time was Joseph Lovell,

who also initiated the use of physical standards for

soldier recruitment and mass vaccination (against

smallpox) of new recruits based on their history of

prior vaccination or disease. In 1874, War Department

General Orders No. 125 substantially strengthened

hygiene requirements at military posts, stations, and

camps. In particular, the Monthly Sanitary Report was

Army Epidemiology and Health

Surveillance

COL Bruno Petruccelli, MC, USA

Joseph Knapik, ScD

Figure 1. Comparison of individual care (clinician) and population medicine (epidemiologist)

practitioner functions with regard to steps in the scientific problem-solving process.

Scientific Problem Solving Process

Practitioner Database Assessment Hypothesis

Testing Action

Clinician

History

Physical

Exam

Differential

Diagnosis

Diagnostic

Studies Treatment

Epidemiologist

Surveillance

Descriptive

Epidemiology

Inference Analytical

Epidemiology

Community

Intervention
April – June 2006 23

established—a precursor of local command health

reports and, centrally, today’s Medical Surveillance

Monthly Report.* Twenty years later, Surgeon General

George Sternberg established a graduate institution

preparing physicians to become Army medical

officers: The Army Medical School, precursor of the

Walter Reed Army Institute of Research. It was here

that the earliest epidemiological field investigations of

military importance were launched, including those

directed by the famous Typhoid and Yellow Fever

Boards in which Walter Reed played a central role.2

Later, World War II raised the need for 2 relatively

small but important US military public health entities:

the Board for the Investigation and Control of

Influenza and Other Epidemic Diseases in the Army

(which today is named the Armed Forces

Epidemiology Board), and the Army Industrial

Hygiene Laboratory (which today is the much larger

US Army Center for Health Promotion and Preventive

Medicine).

SURVEILLANCE AND ANALYSIS

There are 2 broad surveillance procedure categories,

active and passive. In simple terms, active surveillance

requires either the data collector or the reporter to be

“on the lookout” for events of public health interest

*Available at: http://www.amsa.army.mil and to record or transmit the relevant data as part of an

Hazards Exposures

Risk Factors

Outcomes Countermeasures

Epidemiology

and Basic

Investigation/

Research

Intervention

Research

Step 1

Environment

Host

Action and

Prevention

Medical

Surveillance

Primary

Databases

Death

Hospitalization

Disability

Outpatient

Performance Report to

Decision Makers,

Policy Makers,

Action Agencies

OCCURRENCE DETECTION RESPONSE

Step 2

Step 3

Step 4

Step 5

Agent INJURY or

DISEASE

Epidemiology

and Basic

Investigation/

Research

Intervention

Research

Step 1

Environment

Host

Action and

Prevention

Medical

Surveillance

Primary

Databases

Death

Hospitalization

Disability

Outpatient

Performance Report to

Decision Makers,

Policy Makers,

Action Agencies

OCCURRENCE DETECTION RESPONSE

Step 2

Step 3

Step 4

Step 5

Agent INJURY or

DISEASE

Steps 1-5 = Steps of the Public Health

Step 1. Identification of problems

Step 2. Determination of causes

Step 3. Determination of what works

to prevent the problem

Step 4. Implementation of programs

Step 5. Monitoring/surveillance and evaluation

of program/strategy effectiveness

The Risk Management

Step 1. Identify hazards

Step 2. Assess hazards

Step 3. Develop controls and

make decisions

Step 4. Implement controls

Step 5. Supervise and evaluate

Figure 2. The relationship of epidemiology and surveillance in the broader scheme of continuous

public health assessment and intervention.1
24 Army Medical Department Journal

exerted effort. Examples include local preventive

medicine personnel regularly searching records or

querying databases to find clinical outcomes of

interest, or clinical personnel at sentinel sites sending

reports because they are participating in an organized

surveillance program. Passive surveillance occurs in

the background, in that either the reporter is making no

special effort to transmit data for public health

purposes (eg, the data are being collected for billing or

other purposes anyway) or the agency collecting,

archiving, and analyzing data of interest relies on the

independent knowledge and effort of reporters to feed

such data, simply because it is the appropriate thing for

such reporters to do (eg, clinician or microbiologist

originated reportable disease communication). Factors

that dictate whether or not a particular condition

should be reportable include preventability (eg,

interruptible transmission, available vaccine, and

proven safety procedures that may require renewed

command emphasis), outbreak potential, possible

offensive use of the causative agent, and the degree to

which the condition is known to be very rare or

eliminated—either globally or in a particular

geographic area.

The base of reporting varies both by location within

the healthcare system (clinic versus laboratory) and by

military setting (deployment versus garrison). The

underlying events or conditions of interest are either

exposure- or outcome-based. Exposure-based events or

conditions are from the general or immediate (eg,

occupational) environment, or they are imposed

directly on individuals (eg, vaccinations). Outcomebased events are either diseases or injuries, though at

the tissue level these are usually one and the same,

hence the generic meaning of disease surveillance. The

data themselves represent episodic events of interest

(eg, reportable conditions) or complete capture of all

healthcare encounters. Grouping or categorization of

data can occur at either the site where reports are

generated (eg, disease and nonbattle injury reports) or

the archiving center (eg, for analysis or [automatically]

using modern syndromic surveillance* programs).

The Army is the executive agent for health

surveillance. The US Army Center for Health

Promotion and Preventive Medicine (CHPPM)

oversees the collection, archiving, and analysis of

health surveillance data to execute this mission.

CHPPM’s Army Medical Surveillance Activity

manages the Defense Medical Surveillance System

(Figure 3) which archives health-relevant data that are

linked directly to military personnel and which, in

turn, is also linkable to the Department of Defense

Serum Repository (DoDSR). CHPPM’s Deployment

Environmental Surveillance Program performs

functions linked directly to specific geographic and

workplace environments such as field testing, data

monitoring, and creating and maintaining archives of

the results of laboratory analysis of environmental

samples (eg, air, soil, water). Knowledge of the health

risks from occupational and environmental exposures

can benefit field commanders and unit surgeons to

assess the medical threat and determine appropriate

countermeasures. CHPPM has also managed the

design, development, implementation, integration, and

support activities for the Defense Occupational &

Environmental Health Readiness System (DOEHRS),

which is currently being fielded.† The DOEHRS will

help integrate force health protection information by

providing automated support for the military health

system industrial hygienists, environmental health

specialists, audiologists responsible for hearing

conservation, and other preventive and occupational

medicine personnel. The goal is to have a repository of

retrievable and analyzable records containing a history

of individual worker (especially troop) exposures in

both garrison and deployed settings.

The Global Emerging Infections Surveillance and

Response System (DoD-GEIS), for which the Army is

also executive agent, oversees the conduct of focused,

microbiological surveillance activities at various DoD

laboratories worldwide, and at the public health

centers of the Air Force, Army, and Navy. While its

central organization is still relatively small, the DoDGEIS taps a broad network of collaborating experts

and laboratories to provide emerging infectious disease

consultation; identify vulnerabilities in surveillance,

response, and infrastructure; and assist DoD partners

to develop projects and implement programs that

mitigate emerging infection threats. Another Army

executive agency with surveillance-related activities is

the Armed Forces Institute of Pathology, within which

the Office of the Armed Forces Medical Examiner

maintains a database documenting occurrences and

causes of deaths of US military personnel worldwide.

*Syndromic surveillance – The tracking of categories of

outpatient clinical presentations from multiple geographic

sites to reveal trends requiring further investigation of

possible epidemics or attacks with weapons of mass

destruction, or to characterize such trends over time. †

See related article on page 46.
April – June 2006 25
26 Army Medical Department Journal

The Office of the Assistant Secretary of Defense for

Health Affairs (ASD-HA), through the Deputy ASD

for Force Health Protection, is overseeing a process of

improved networking among these various entities, as

well as an actual integration of centralized archiving,

analysis, and reporting functions to establish what may

become an Armed Forces Health Surveillance Center.

The Army Medical Department (AMEDD) would then

manage a truly multi-Service organization with

enhanced capability. In the meantime, some of the

staff of the ASD-HA are themselves directly managing

contracts to maintain specific surveillance functions

that evolved very quickly since the attacks of

September 11, 2001, and the associated recognition of

the increased threat of weapons of mass destruction,

particularly biological agents. In particular, a secure

environment with robust web based access was

required to receive disease and nonbattle injury

(DNBI) data in near real time from the rather complex

Central Command areas of operation; and a dedicated

server was required for operation of daily, worldwide

syndromic surveillance. To meet these requirements,

respectively, the Joint Medical Work Station and the

Electronic Surveillance System for Early Notification

of Community-based Events were developed and are

currently operated at Health Affairs collocated offices.

Disease and nonbattle injury surveillance has evolved

substantially over the years. For most of the 20th

century, diseases and injuries treated at corps or

theater level hospitals allowed command surgeons to

monitor trends that might require special intervention.

Over the last 25 years the practice of including

nonhospital encounters in DNBI surveillance has

strengthened the ability to intervene early when

particular disease or injury trends demand attention.

The first Bright Star exercise in Egypt took place two

years after the 1978 Camp David Accords, and became

a biennial event in 1983. Battalion-level DNBI

surveillance was among the many procedures piloted

and refined during Bright Star iterations. DNBI

categories became standardized at Joint Chiefs of Staff

level and include, among other broad but relatively

sensitive groupings, gastrointestinal, respiratory,

febrile, dermatological, psychological, and causestratified traumatic injuries.

It should be mentioned that a number of registries and

special studies support the epidemiology and

surveillance mission, and vice versa. The DoDSR

currently houses nearly 40 million serum specimens in

large walk-in freezers, and continues to grow by

approximately 2.3 million specimens per year. This

rich repository is an invaluable resource to address

important questions, such as those exemplified by the

list in Figure 4. One example of a rich data registry is

the Joint Theater Trauma Registry, which is supported

by the US Army Research Institute of Surgical

Research and the Center for AMEDD Strategic Studies

at Fort Sam Houston, Texas. Another example is the

Total Army Injury and Health Outcomes Database

maintained by the US Army Research Institute of

Environmental Medicine at Natick, Massachusetts.

Finally, effective analysis requires denominators, and

thus feeds from personnel data systems such as the

Defense Manpower Data Center in Monterrey, CA.

INVESTIGATION

Problems that have a real or potential impact on

groups of people or an entire population typically

come to the attention of public health leaders either

because epidemiologists monitoring events from a

central location see a trend that is not visible at any

single location, or because clinicians at a particular

location note a local trend or individual case that

warrants an alert. The level of response, in terms of

both chain of command and number of required

consultants, is usually dictated by the predictable

breadth of potential health impact and the perceptions

of leaders and the public. The immediacy of response

is dictated by the level of alarm aroused by the severity

 Susceptibility of measles and rubella among US Army

recruits

 Leishmaniasis serology in Gulf War veterans

 Persistence of antibody to Japanese encephalitis

vaccine

 Sero-prevalence of hepatitis A, B, and C in recruit

applicants

 Hantavirus in military personnel from four corners area

 Hepatitis C in orthopedic surgeons and dentists

 Risk of late HIV sero-conversion in US soldiers

 Serologic evaluation for mycoplasma in Gulf War

veterans

 PSA levels and PSA velocity and the risk of prostate

cancer

 Prevalence of West Nile Virus in NY military applicants

 Hepatitis C prevalence and incidence in US service

members

Figure 4. Selection of previous studies using the

DoD Serum Repository
April – June 2006 27

of a particular disease, or how quickly a disease or

injury problem affects an increasing number of people,

which in turn is usually determined by the frequency

and latency of adverse health outcomes.

Just as disease, injury, and adverse exposure

surveillance occurs both locally and centrally, so too

does the investigation of unusual diseases of

immediate public health importance and diseases and

injuries occurring at a higher-than-expected incidence.

This is one of the many roles of unit or installation

preventive medicine personnel. In a manner similar to

clinical consultation, assistance from higher levels in

the medical chain comes into play when additional

expertise is needed or when there are competing tasks

occupying local manpower. Figure 5 shows the levels

of PM consultation in a typical garrison setting, and

also implies interorganizational coordination and

communication that may occur in response to an

outbreak, including civilian liaison activities. For

many years Epidemiological Consultations (EPICON)

were executed from the Walter Reed Army Institute of

Research (WRAIR). When the Army Environmental

Hygiene Agency transformed to become the CHPPM

in 1994, a number of new missions were added to

consolidate central support to operational and garrison

units in several preventive medicine arenas, including

epidemiology and health promotion. The Current

Operations section of the CHPPM now receives US

Army Medical Command (MEDCOM) orders and

requests to investigate outbreaks, clusters, and

sentinels. Still, teams are task organized such that

CHPPM frequently partners with the WRAIR and

other US Army Medical Research and Material

Command organizations, as well as other MEDCOM

subordinate commands. EPICONs are comparable to

Epi-Aids conducted by the Centers for Disease Control

and Prevention (CDC), and, in a similar manner,

EPICONs use military preventive medicine residents,

just as Epi-Aids utilize Epidemic Intelligence Service

officers and CDC preventive medicine residents. This

enhances the intellectual approach to problem solving

while also providing hands-on teaching, and is no

different from clinical case management in hospitalbased graduate medical education programs. The

concept and procedures of an EPICON already existed

when Special Medical Augmentation Response Teams

were established within the Army Medical

Department. Under a new concept a SMART-PM

(EPI)* deployment is synonymous with EPICON.

INTERVENTION

Public health interventions in military settings are not

very different from those in the civilian context, and

may target small groups of contacts, a community at

large, or an entire population. Familiar examples

include the use of immunizations, chemoprophylaxis,

isolation, quarantine, active case finding and

aggressive treatment. Other equally important kinds of

intervention include risk communication, health

education, equipment redesign, environmental controls

and reengineering, new and enforced safety

procedures, and new policies, guidelines, procedures,

regulations, or laws. The general medical literature

frequently includes papers describing population-level

interventions, but most of these are disease related.

Since measures aimed at reducing the incidence of

trauma are more concentrated in specialty journals, the

following paragraphs briefly discuss military injury

prevention to illustrate how interventions can derive

from surveillance and epidemiological investigations.

An example of an intervention involving military

equipment was the use of a specialized ankle brace to

reduce the incidence of ankle injuries during airborne

operations. Surveys of injuries incurred during

airborne operations suggest that 30% to 60% involve

the ankle.3-7 The sports medicine literature suggested

that fewer ankle injuries occurred among athletes

wearing ankle braces.6,9 A specialized parachute ankle

brace that fit outside the combat boot and is easily

donned and doffed with Velcro straps was developed.

A randomized study of airborne trainees showed that

during jump operations, those wearing this brace had

fewer inversion ankle sprains compared to those who

did not (0.6 versus 3.8 injuries per 1000 jumps,

p=0.04).10 Later, a 3-year surveillance of ankle injuries

in a US Army Airborne Ranger Battalion showed that

those wearing the ankle brace had significantly fewer

ankle injuries compared to those not wearing the brace

(1.5 versus 4.5 injuries/1000 jumps, p<0.01).11 Ankle

braces were discontinued in 2001 because of the cost

and unsubstantiated anecdotal suggestions that they

were causing other types of injuries. A study was

conducted using a surveillance database that

demonstrated that the odds of hospitalization for an

ankle injury was 2.2 (95%CI=1.8–2.8) times higher in

*Special Medical Augmentation Response Team-Preventive

Medicine (Epidemiological)
28 Army Medical Department Journal Figure 5. The levels of vertical and lateral coordination in preventive medicine consultation in response to an outbreak. Schematic demonstrates actions in a typical garrison setting, with representations of the interorganizational coordination and communication that may occur, including civilian liaison activities. (Chart courtesy of LTC Robert Mott, Walter Reed Army Institute of Research.) Key to Acronyms *Centers for Disease Control and Prevention; †US Army Center for Health Promotion and Preventive Medicine, Epidemiology and Disease Surveillance Directorate; ‡Office of the Surgeon General, Proponency Office for Preventive Medicine; §Army Medical Surveillance Activity; ║Medical Operations; ¶Public Affairs Officer; #Medical Department Activity; **Liaison Officer; ††Morale, Welfare, Recreation
April – June 2006 29

the period before the brace was used and 1.7 (95%

CI=1.2–2.2) times higher after the brace was

discontinued. The brace is now being reintegrated into

Army airborne units as a result of advocacy efforts by

the Defense Safety Oversight Council.

An example of an intervention that involved physical

training was conducted during the 9-week basic

combat training (BCT) cycle.12 Previous studies

suggested that reducing running mileage could reduce

injuries without reducing aerobic training

effects,13,14and cross training with a wide variety of

exercises has been recommended to reduce injuries.15

A new training program, incorporating these and other

injury reduction principles was developed by the Army

Physical Fitness School. A phase-in of this program in

BCT allowed a comparison of 2 battalions. One

battalion (n=1284) ran only 17 miles and performed a

wide variety of cross training exercises that included

calisthenics, dumbbell drills, movement drills, interval

training, long-distance running, and end-of-training

stretching. Another battalion (n=1296) conducted the

usual BCT physical training program consisting of 38

miles of running and a limited variety of exercises.

Men and women in the usual BCT program were at 1.6

and 1.5 (respectively) times higher risk of injury than

those in the reduced running and increased cross

training program. Improvements in 2-mile run times

were almost identical in the 2 groups. Despite the

success of the program, concern was expressed by the

Army leadership because of the cost and logistics

associated with the dumbbell portion of the program

and potential problems with some of the exercises.

Army leadership also thought that the Army field

manual on physical training16 contained many of the

necessary principles for enhancing fitness and

reducing injuries, but inadequately presented how

these principles should be applied in BCT. A new BCT

physical training program was developed by the

Fitness School to take these considerations into

account and a second project was undertaken.17 One

battalion (Battalion A, n=829) implemented the

revised physical training program and was compared

to another battalion (Battalion B, n=1138) that

implemented a traditional BCT physical training

program. At the end of the 9-week BCT cycle, injury

surveillance data showed that men and women in

Battalion B were1.6 (95% CI=1.2-2.0) and 1.5 (95%

CI=1.2-1.8) times more likely to be injured compared

to Battalion A men and women, respectively. APFT

failures were also higher in Battalion B than in

Battalion A (1.7% vs. 3.3%, p=0.03). These studies

demonstrated that injuries could be considerably

reduced and fitness improvement maintained by

specific training modifications and that surveillance

data could be used to compare groups. In 2003, the

commander of the Army Accessions Command

mandated the new physical training program for all

basic combat training.

CONCLUSION

In the civilian world, population medicine and clinical

medicine began to drift apart a hundred years ago, just

a few decades after the germ theory began to

revolutionize medicine as a whole. While ironic, this is

not surprising. The means to combat disease grew out

of research laboratories working in parallel to develop

both “weapons of mass protection” (vaccines) and

“guns” (pharmaceuticals for individual treatment). The

latter gave such power to physicians who treat the sick

that the isolation of public health departments from

hospitals and private clinics was inevitable, given the

way health care evolved in American society. It would

seem that the managed care and health maintenance

revolution should have brought mass prevention and

individual care back together, but with beneficiaries

moving among so many competing organizations (both

insurers and employers), a parallel focus on entire,

covered populations is not economical. There are

exceptions in the armamentarium, such as childhood

vaccines, but in those cases the need to comply with

state laws is often the primary driver. While the

Military Health System struggles with similar issues of

cost when considering the majority of beneficiaries at

any point in time, the active duty sector in particular is

a workforce for which health protection serves both

the corporate customer (commanders) and the

beneficiary. Still, the focus is on prevention of shortlatency conditions such as acute infections, acute

environmental illnesses (eg, due to hot and cold

weather conditions), and trauma—and even for these

the process of “target acquisition” for those who man

the big guns remains unacceptably slow. As

information technology continues to advance, and

epidemiological tools integrate with the tools that

facilitate clinical care, the border between population

and individual care is beginning to fade. Like the

elegant feedback mechanisms that characterize human

physiology itself, information systems will permit a

“population health and safety equilibrium,” and, just as

with individual access to care, the Armed Services of

the United States are leading the way.
30 Army Medical Department Journal

REFERENCES

1. Jones BH. Injuries in the Military. Am J Prev Med.

2000;18(35):71-84.

2. Bayne-Jones S. The Evolution of Preventive Medicine

in the United States Army, 1607-1939. Washington,

DC: US Dept of the Army; 1968.

3. Kirby N. Parachuting injuries. Proc R Soc Med.

1974;67:17-21.

4. Davison D. A review of parachuting injuries. Injury.

1990;21:314-316.

5. Amamilo SC, Samuel AW, Hesketh KT, Moynihan

FJ. A prospective study of parachute injuries in

civilians. J Bone Joint Surg. 1987;69B:17-19.

6. Lowden IMR, Wetherill MH. Parachute injuries

during training decents. Injury. 1989;20:257-264.

7. Craig SC, Morgan J. Parachuting injury surveillance,

Fort Bragg, North Carolina, May 1993 to December

1994. Mil Med. 1997;162:162-164.

8. Rovere GD, Clarke TJ, Yates CS, Burley K.

Retrospective comparison of taping and ankle

stabilizers in preventing ankle injuries. Am J Sports

Med. 1988;16:228-233.

9. Sharpe S, Knapik J, Jones B. Ankle braces effectively

reduce recurrence of ankle sprains in female soccer

players. J Athlet Training. 1997;32:21-24.

10. Amoroso PJ, Ryan JB, Bickley B, Leitschuh P,

Taylor DC, Jones BH. Braced for impact: reducing

paratrooper's ankle sprains using outside-the-boot

braces. J Trauma. 1998;45:575-580.

11. Shumacher JT, Creedon JF, Pope RW. The

effectiveness of the parachutist ankle brace in

reducing ankle injuries in an airborne ranger

battalion. Mil Med. 2000;165:944-948.

12. Knapik JJ, Hauret K, Bednarek JM, et al. The Victory

Fitness Program. Influence of the US Army's

emerging physical fitness doctrine on fitness and

injuries in Basic Combat Training. Aberdeen Proving

Ground, MD: US Army Center for Health Promotion

and Preventive Medicine; 2001. 12-MA-5762-01.

13. Trank TV, Ryman DH, Minagawa RY, Trone DW,

Shaffer RA. Running mileage, movement mileage,

and fitness in male US Navy recruits. Med Sci Sports

Exerc. 2001;33:1033-1038.

14. Shaffer RA. Musculoskeletal Injury Project. Paper

presented at: 43rd Annual Meeting of the American

College of Sports Medicine, 1996; Cincinnati, OH.

15. Stamford B. Cross-training: giving yourself a wholebody workout. Phys Sports Med. 1996;24(9):15-16.

16. Field Manual 21-20: Physical Fitness Training.

Washington, DC: US Dept of the Army; 1992.

17. Knapik JJ, Darakjy S, Scott S, et al. Evaluation of

two Army fitness programs: the TRADOC

Standardized Physical Training Program for Basic

Combat Training and the Fitness Assessment

Program. Aberdeen Proving Ground, MD: US Army

Center for Health Promotion and Preventive

Medicine; 2004. 12-HF-5772B-04.

AUTHORS

COL Petruccelli is Director, Epidemiology & Disease

Surveillance, US Army Center for Health Promotion and

Preventive Medicine, Aberdeen Proving Ground,

Maryland.

Dr Knapik is a Research Physiologist with the Directorate

of Epidemiology and Disease Surveillance, US Army

Center for Health Promotion and Preventive Medicine,

Aberdeen Proving Ground, Maryland.
April – June 2006 31

INTRODUCTION

The first discovery of an arthropod-borne pathogen

was in 1893, and it was quickly followed by notable

successes in the prevention of yellow fever and

malaria through mosquito control. Despite continual

progress in the technology of vector control during the

last century, US military forces remain vulnerable to

many serious diseases caused by pathogens transmitted

by mosquitoes, ticks, and other arthropods that cause

considerable morbidity and mortality. The hundreds of

recently-returning veterans from Iraq and Afghanistan

who had contracted cutaneous leishmaniasis

transmitted by sand flies is a testimony to this fact.1

Other recent military operations have also been

negatively impacted by arthropod-borne infections. In

September 2003, when 290 Marines went ashore in

Liberia as military advisors to oversee a civil

transition, 80 contracted malaria (28% attack rate).2

Malaria remains a significant threat on the Korean

peninsula and elsewhere throughout Asia. Japanese

encephalitis is one of approximately 100 viruses

spread by insects and ticks and is a significant threat to

US forces in the Pacific region. These are but a few

examples of how arthropod-borne disease

prevention is a top priority for force health

protection of the Army. In addition to vectorborne and zoonotic diseases, biological threats

during deployments include biting and

stinging arthropods (fire ants, mites/chiggers,

scorpions, etc.); vertebrate animals (rodents,

bats, snakes, etc.); and poisonous plants (e.g.,

poison oak and poison sumac). Biting and

stinging arthropods can degrade mission

readiness and combat effectiveness even

when they do not transmit disease. These

arthropods can cause casualties ranging in

severity from secondary infections to death

from allergic reaction. Annoyance from

persistent pests, itching bites, and loss of

sleep can also erode morale.

Whether engaged in combat operations, or deployed in

support of peacekeeping or humanitarian relief,

commanders throughout the Army are concerned about

vector-borne diseases and pest threats that can

adversely affect the health of their troops and

compromise the success of the mission. Medical

entomologists, as members of the preventive medicine

team, work to minimize these threats by applying safe

pest control where it is most needed. During

deployments, this mission becomes focused on issues

that affect the health of Soldiers and their ability to

accomplish their mission. Pathogens transmitted by

such vectors as mosquitoes, ticks, and mites are the

primary concern because outbreaks of associated

diseases can occur suddenly and affect the deployed

unit. The Department of Defense (DoD) and

Department of the Army recognize that vector control

to protect the health and lives of personnel must be

balanced with the risks associated with the use of

pesticides. Thus, the US Army has taken many steps to

reduce the chances of unnecessary exposure of its

personnel to pesticides through a sustained emphasis

on the use of personal protective equipment, integrated

pest management practices, the use of safer pesticides,

Vector Control and Pest Management

LTC Mustapha Debboun, MS, USA

COL Leon Robert, MS, USA

MAJ Lisa O’Brien, MS, USA

COL Richard Johnson, MS, USA

COL Stephen Berté, MS, USA

Mosquitoes

Lice

Sand flies Fleas

Tsetse flies

Chigger Mites

Ticks
32 Army Medical Department Journal

better recordkeeping, and maintenance of a certified

pesticide applicator training program.

The Army’s constant goal is full spectrum dominance

(to defeat any adversary and control any situation

across the range of military operations) over the threat

of arthropod-borne diseases and direct injury. The

Army does this by forming partnerships with industry

and supporting academic research to develop improved

(more efficacious and cost effective) surveillance and

control techniques and equipment, as well as by

identifying and implementing the use of off-the-shelf

technologies. The Army also strives to attract and

retain high-quality military and civilian personnel to

initiate, implement, and support these efforts.

Achievement of full spectrum dominance requires

investment in the development of new military

capabilities, which will lead to multidimensional

protection against harmful arthropods and the diseases

they transmit. The purpose of this article is to describe

current methodologies and future developments for

vector control and pest management in the US Army.

ENTOMOLOGY JOINT/MULTIAGENCY EFFORT

Military vector control and pest management programs

not only must prevent or control pests and disease

vectors that adversely impact readiness or military

operations, but must also prevent structure, materiel, or

property damage. This is a huge joint/multiagency

effort that extends far beyond protecting deployed

service members from blood-feeding arthropods. Each

of the military components has its own military and

civilian pest management personnel employed to

counter the threat. The pest management effort is

guided by applicable Executive Orders, Federal, State,

and local statutory and regulatory requirements in the

US. Overseas, US legal requirements as well as

international agreements, Status of Forces agreements,

Final Governing Standards issued for host nations, and

criteria in the Overseas Environmental Baseline

Guidance Document must be followed. The DoD

requires that its personnel follow the strictest policies,

including Environmental Protection Agency (EPA)

regulations, relevant to the area in which an operation

is occurring, even though an operation may be outside

the jurisdiction of EPA. An important exception is

possible in case of need. The Command Entomologist

of an operation can authorize the use of unregistered

pesticides (such as those locally purchased) or the use

of registered pesticides in sites not on the label.

The Armed Forces Pest Management Board (AFPMB)

is the tri-Service organization which monitors and

guides this international effort, recommending policy

for the DoD. Military and civilian members of the

armed forces actively participate in the joint policy

development process. Advisors from other federal

agencies such as the EPA, the Centers for Disease

Control and Prevention (CDC), the US Dept of

Agriculture (USDA), US Dept of Homeland Security,

and others provide valuable advice during the process.

The AFPMB works with the military services, the

Joint Staff (principally the J-4, Medical Readiness

Division) and the combatant commands to ensure DoD

policy is effective in meeting the threat to personnel,

real property, and materiel. Through an Army

entomologist assigned as Contingency Liaison Officer,

the AFPMB ensures that deploying and deployed

entomologists have the tools to complete the mission.

In cases where the tools do not exist or are no longer

effective, research aimed at developing new

technologies or methodologies is necessary. This

requirement led to a new research program that began

in October 2003, the Deployed Warfighter Research

Program Against Insects that Carry Diseases of

Military Importance, or DWFP. The goal of the DWFP

is to develop new public health insecticides and

formulations, personal protection systems, and

application equipment for vector control. New

insecticides or formulations developed under this

program will require EPA registration to ensure the

level of chemical safety that Americans expect.

The Defense Pest Management Information Analysis

Center (DPMIAC), a subdirectorate of the AFPMB,

analyzes open source pest management literature

(refereed publications, trade journals, etc.) to provide

information on pest issues for deployments and DoD

installations. An Army entomologist assigned to

DPMIAC ensures that information products (Technical

Guides, Disease Vector Ecology Profiles, and

literature searches) meet the requirements of Army

customers around the world. Information relevant for

deployments is provided to the Armed Forces Medical

Intelligence Center (AFMIC) for integration with their

data. AFMIC then produces intelligence products such

as the AFMIC Medical Environmental Disease

Intelligence and Countermeasures (MEDIC) CD,

Infectious Disease Risk Assessments, and others. The

US Army Veterinary Command often collaborates on

management issues involving vertebrate pests such as

feral animals and rabies control.
April – June 2006 33

The U.S. Army Center for Health Promotion and

Preventive Medicine (USACHPPM) also has an

important Entomological Sciences Program (ESP)

with a mission to maximize the ability for US Army

units and installations to protect the Soldier from the

health threat posed by vector-borne disease and

medically important pests and to minimize the adverse

effects of pesticides. For example, under the direction

and leadership of ESP, the West Nile virus (WNV)

Surveillance Program was a good example of a

multiagency effort in pest management. Following the

emergence of WNV in the US in the late summer of

1999, the Army Surgeon General directed the creation

and implementation of a WNV Surveillance and

Control Program for Army installations. Through

collaboration with the CDC, state and local health

departments, the US Army Center for Health

Promotion and Preventive Medicine (USACHPPM),

the US Army Veterinary Command, and others,

military installations were able to use mosquito

surveillance and control, dead bird surveillance, and

human case monitoring to minimize the risk of WNV

to personnel on Army installations. Navy, Marine, and

Air Force installations conducted similar programs

with mutual interactions on pest management-related

issues discussed by an ad hoc WNV committee of the

AFPMB.

PERSONAL PROTECTION

Vector-borne diseases and associated discomfort

caused by biting arthropods can be largely prevented

with proper use of personal protective measures

(PPMs) by individual Soldiers. Personal protective

measures include arthropod repellents, clothing

impregnants, and equipment and techniques which,

when appropriately applied, will preserve the fighting

strength of the troops.

History and Military Significance

Of 80 diseases of military importance, over two-thirds

are caused by pathogens transmitted by arthropods.3In

addition, arthropods can inflict severe physical,

psychological, and economic stresses that threaten the

military mission. For example, arthropod bites can be

painfully distracting and can lead to secondary

infections, dermatitis, or allergic reactions. During the

Vietnam conflict, the irritation caused by blister

beetles (family Meloidae) was a major source of

casualties in some locations. In the recent military

actions, pest control was necessary to stop an outbreak

of dermatitis caused by a different kind of beetle

(Paederus rove beetles) in Pakistan. If there is one

lesson to be learned from the medical management of

disease casualties from all past wars, it is that, during

peacetime we should prepare our response to any

vector-borne diseases we could encounter during

future operations. Due to the lack of effective vaccines

or chemoprophylaxis for many vector-borne diseases,

proper use of PPMs may provide the only available

protection from arthropod-borne diseases. Proper use of

PPMs by all Soldiers at risk of vector-borne diseases is

critical for reducing the occurrence of disease or

nonbattle injuries in current conflicts.

Repellents are one commonly used form of PPM. They

provide the commander with a quick and inexpensive

measure to protect the force in any military situation,

no matter how quickly the unit is called into action.

They can be applied effectively to prevent any

arthropod-borne disease, whether or not surveillance

has identified the pathogen. Repellents are often the

only means of protection against arthropod-borne

diseases in combat environments when vector control

measures are not possible or when the speed of military

developments prevents the use of chemoprophylaxis or

vaccines. In addition, commanders will be able to

minimize incidence of any vector-borne disease,

providing a tactical advantage against an unprotected

enemy force which does not have the benefit of an

effective, long-lasting arthropod repellent.

Topical Repellents

The US military has been a major customer for the

development of repellents beginning in 1942 when it

was recognized that arthropod-borne disease was an

important source of casualties during World War II.

This program produced a series of active ingredients.

The current military repellent, N,N-diethyl-3-methylbenzamide (deet), was first marketed commercially in

1956. Early formulations were effective, but had

drawbacks — the application lasted for only 1 or 2

hours in warm and humid conditions, felt very oily on

the skin, had an objectionable odor, and was a strong

plasticizer (it dissolved some kinds of plastics).4 As a

result, troops did not like to use it, and most did not.

Over 62% of 1,500 Soldiers who responded to a

questionnaire urged the Army to get a better

repellent. In 1990, the standard military topical

arthropod repellent was changed to a sustained-release,

polymer formulation containing 35% deet and dubbed

the Extended Duration Topical Insect and Arthropod
34 Army Medical Department Journal

Repellent (EDTIAR). This product was developed by

the DoD in collaboration with the 3M Corporation

following extensive testing of experimental products

by the Letterman Army Institute of Research.

The search for better repellents is still going on. In

1999, the Department of the Army approved a Science

and Technology Objective (STO) for development of a

new topical standard military insect repellent in

collaboration with the USDA’s Chemicals Affecting

Insect Behavior Laboratory in Beltsville, MD. To

support this work, the Department of Entomology at

the Walter Reed Army Institute of Research (WRAIR)

developed new methods—new statistics, computer

modeling of repellent activity,5in vivo testing,6and in

vitro testing7—for repellent evaluation that expanded

on the excellent work at USDA. The STO was

completed in 2005, producing a new candidate active

ingredient, (1S,2’S)-methylpiperidinyl-3-cyclohexene1-carboxamide (SS220) in new formulations that are

easier to use than the EDTIAR.

In addition to the development of new repellent

chemistries, a new formulation of deet was developed.

In order to provide Soldiers and Marines in a tactical

environment with more convenient protection from

biting arthropods, the WRAIR Repellent Program

collaborated with Iguana LLC to produce a new,

improved formulation of camouflage face paint insect

repellent with 30% deet.

The objective in the evaluation of any repellent test is

how it performs in the field. With 5 overseas

laboratories (Armed Forces Research Institute of

Medical Sciences, Bangkok, Thailand; US Army

Medical Research Unit-Kenya, Nairobi; Naval

Medical Research Center Detachment, Lima, Peru;

Naval Medical Research Unit-3, Cairo, Egypt; and

Naval Medical Research Unit 2, Jakarta, Indonesia)

and collaboration with the Australian Army Malaria

Institute, the US military is in an excellent position to

test repellents against vectors of many disease causing

pathogens.

Repellents

Many of the pathogens of military importance are

vectored by ticks, chigger mites, fleas, and body lice.

All of these vectors have close contact to clothing when

they bite, making the development of repellents to be

applied to clothing a logical development.

An effective clothing repellent based on the synthetic

pyrethroid, permethrin was fielded in 1991 and is still

in use today as the standard military clothing

repellent.4 Currently, military personnel use

permethrin to repel and kill arthropods that land on

many kinds of treated surfaces, including field

uniforms, tents, bed nets, and helmet covers.

Clothing and Equipment

Although often neglected, one of the most practical

means of reducing arthropod bites is the proper

wearing of the BDU/ACU (battle dress uniform/Army

combat uniform). Most arthropods cannot bite through

the BDU/ACU material unless it is tightly stretched

against the skin. Therefore, Soldiers must wear loosely

fitted uniforms and minimize the amount of bare skin

that is exposed to blood-sucking arthropods.4

Field observations on the relationship between

clothing and localization of cutaneous

leishmaniasis lesions (at the site of a sand fly

bite) have confirmed the importance of proper

clothing wear in personal protection.8

Mosquito Bed Net

The mosquito bed net is a finely woven, nylon

canopy that can be used with the folding cot,

hammock, steel bed, or shelter half-tent. For

all applications, the bed net must be supported

and tucked in to prevent contact with the

occupant’s body while sleeping to prevent

mosquitoes and other biting arthropods from

biting through the mesh. Standard military

permethrin and insecticide space spray (2% dAerosol Spray Can

2-Gallon Sprayer

Factory-treated

IDA Kit

Four (4) Military Products

NOTE: All repellents are Class III stock items.
April – June 2006 35

phenothrin) can be sprayed on the mesh or on insects

that are trapped inside the net. Details are in the

Armed Forces Pest Management Board’s (AFPMB)

Technical Guide 36.

4

The new Self-Supporting Low-Profile Bed Net can be

carried inside the backpack or between the backpack

and frame. It has a built-in frame designed for single

step, "pop-up" assembly. Permethrin-impregnated tight

weave mesh provides increased protection against very

small biting arthropods such as sand flies. The bed net

may be used directly on the ground. Infrared signature,

forest camouflage pattern and carrying capacity are

compatible with military requirements. Thus, the new

bed net is less visible to the enemy, lighter in weight (2

lbs), and easier to set up and take down than the older

bed net.

DoD Insect Repellent System

The DoD Insect Repellent System is available

for use by all leaders and troops to prevent

arthropod-borne pathogens that cause diseases

such as malaria, leishmaniasis, scrub typhus,

West Nile fever, 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 system

consists of three components—permethrin on

uniforms (and bed nets), deet on exposed

skin, and proper wear of the uniform—and is

critical to the Army Medical Regiment’s

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.

This system is a DoD Policy that every

Soldier, Sailor, Airman, and Marine, need to

strictly follow. Details are in the AFPMB

Technical Guide 364and in the USACHPPM

fact sheet on the DoD Insect Repellent

System9and at the Army Medical Department

Center and School deployment training

portal.10

Immunizations and Chemoprophylaxis

Both immunizations and chemoprophylactic

measures are considered personal protective

measures although they are not controlled by

the individual Soldier. Chemoprophylaxis is

available for some of the protozoan (malaria)

and bacterial (scrub typhus) pathogens transmitted by

arthropods. Vaccines are routinely available for only a

few of the viral pathogens (yellow fever virus,

Japanese encephalitis virus) and are available on an

experimental use protocol for a few others

(Venezuelan equine encephalitis virus, Rift Valley

fever virus). Even when appropriate chemoprophylaxis

or vaccination is available for the disease of greatest

concern, their use entails considerable medical

management. When risk is unknown or considered to

be low, personal protection may be the appropriate

strategy for prevention. Therefore, the proper use of

other personal protective measures described earlier

offer the most practical means of interrupting and

preventing arthropod-borne disease transmission.

? OD Green (Camouflage) NSN 3740-01-516-4415

? Coyote Brown NSN 3740-01-518-7310

Light-weight, self-supporting, POP-UP bed net

The pop-up bed net is

factory-treated with

permethrin and has much

finer mesh than the

standard military bed net.

1 2 3

It’s DoD

Policy

It’s a basic

training

task

It’s critical

for your

health
36 Army Medical Department Journal

In summary, there are 3 required components for

effective personal protection. First, the measure itself

must be efficacious when properly used. Second, the

development and continual maintenance of a welldefined education program is of paramount

importance. Every enlisted Soldier, every officer, and

especially every commander must be informed about

the importance of personal protective measures for

reducing the occurrence of disease caused by

arthropod-borne pathogens. Field sanitation teams at

the company level can serve the commander by

educating Soldiers and ensuring adequate personal

protective supplies are maintained and used properly.

Finally, enforcement of PPM is sometimes appropriate

to assure individual compliance. Discipline in using

proven personal protective measures must be

reinforced through command emphasis and

involvement.

The individual Soldier is the most important element in

any combat system. Protection of his/her health is

absolutely critical to maintenance of a high state of

combat readiness. Medical advisors have the job of

supporting the commander by providing sound

technical advice and training in the prevention of

arthropod-borne diseases. Thus, it is imperative that

DoD leaders at all levels understand and endorse the

need and the use of these personal protective measures.

SURVEILLANCE

Disease vector and pest surveillance is designed to:

1. measure the relative population levels of known

pests to determine when and where to begin

specific management techniques;

2. detect invasions of new and potentially

important vectors and pests;

3. detect breeding sites that can be eliminated; and

4. measure the effectiveness of previous

management efforts.

The Army has 2 major groups involved in pest

surveillance and management. One group primarily

researches medical aspects of arthropod-borne

pathogens, conducts medical personnel training in

these diseases, and provides pest management in

contingency operations. The other group is the

facilities engineering element responsible for

protecting property and materiel subject to pest

infestation or destruction, including most pest

management operations at DoD installations.

Cooperation between these two elements is essential to

ensure complete, efficient protection of DoD

personnel, property, and material.

Prevention of vector-borne diseases through timely

surveillance and subsequent integrated pest

management (IPM) relies on effective decisionmaking. Decision-making tools include protocols for

deciding the need for some management action based

on an assessment of the pest population and its

potential for the transmission of vector-borne disease

to humans. Monitoring and use of action thresholds

are standard practice in military preventive medicine.

These protocols (also known as control decision rules)

consist of standardized procedures for assessing the

density of pest populations and an action threshold, in

this case the lowest population density above an

acceptable baseline value that will cause nuisance and/

or disease. Thus, carefully planned surveillance plays a

critical role in assessing vector-borne disease threats

because the information gained can influence decisions

on the use of medical preventive interventions, such as

chemoprophylaxis, and pesticide usage. One recent

example of a success in this area was the role mosquito

and malaria parasite surveillance played to help shape

an improved theater malaria chemoprophylaxis

program for Operations Iraqi Freedom (OIF) and

Enduring Freedom. Malaria chemoprophylaxis was

substantially reduced in areas with no active

transmission, thus lowering costs, limiting logistics

concerns, and diminishing undesirable side effects of

chemoprophylactic drugs.

Flying insect vectors of disease such as mosquitoes

and sand flies currently pose the greatest threat to

deployed armed forces. Standardized flying insect

trapping programs use CDC light traps (small, battery

operated traps with flashlight-like bulbs and often

supplemented with dry ice as an attractant) during the

hours of darkness. Collected mosquitoes can be tested

immediately in the field using the VecTest®kit

(Microgenics Corp., Fremont, CA, 800-232-3342) and

results are obtained within 15 minutes. The VecTest®

is an antigen panel assay that uses a rapid detection

dipstick designed to specifically test for presence of

malaria parasites in mosquitoes. The test kit employs a

wicking dipstick assay that detects Plasmodium

falciparum and P. vivax (variants 210 & 247) in pools

of up to 10 anopheline mosquitoes. The Malaria

VecTest® Kit uses specific monoclonal antibodies

targeting the circumsporozoite antigens found on the
April – June 2006 37

surface of the Plasmodium parasites. This innovative,

effective, and inexpensive test was developed

cooperatively by WRAIR and Medical Analysis

Systems, Inc.

During the early stages of OIF, Soldier complaints of

sand fly bites were high, as was the risk of contracting

leishmaniasis. Army entomologists working at Tallil

Air Base in 2003 collected over 21,000 female

phlebotomine sand flies and sent them to WRAIR

where they were tested for the presence of leishmania

parasites using fluorogenic PCR (polymerase chain

reaction) assay.11 These entomologists quickly

calculated that the minimum field infection rate was

1.58%. By mapping out the temporal and geographic

distribution of all sand flies and infected sand flies, the

team was able to focus control efforts in areas that

were at highest risk for leishmaniasis. A diverse team

of US Army, Air Force, and Navy entomologists,

along with colleagues from various coalition forces

(British, Italian, Dutch, and Korean), and pest control

contractors implemented an aggressive leishmaniasis

control plan.

Accurate vector identification and knowledge of vector

biology are essential for arthropod-borne disease risk

assessment and for development of appropriate

strategies for vector suppression, arthropod-borne

disease reduction, and vaccine and drug development.

There are hundreds of species with varying capabilities

of transmitting diseases, depending on factors such as

physiological compatibility with the disease organism,

host species preference, and feeding times and

locations. Potential vectors must be identified at least

to the species level to provide the most useful

information. Insect identification is greatly assisted

through the reach back capabilities provided by the

Walter Reed Biosystematics Unit, part of the WRAIR,

located at the Museum Support Center of the

Smithsonian Institution in Suitland, MD. This unique

national resource provides online mosquito and sand

fly identification keys, laboratory and field protocols,

high-resolution images of mosquito morphology, and

many other online products to assist military

entomologists deployed around the world to correctly

and quickly identify arthropod vectors of disease.

New and innovative surveillance techniques are

currently being developed by military entomologists.

The WRAIR, in partnership with the American

Biophysics Corp., is currently evaluating new and

innovative insect surveillance tools and control

devices. Entomologists at WRAIR and the Uniformed

Services University of the Health Sciences are

developing remote sensing capabilities that can be

applied in disease vector surveillance. We have all

become accustomed to the "birds-eye" view of the

earth provided by photographs and images acquired

from aircraft as well as from manned and unmanned

spacecraft. It is this birds-eye view that military

entomologists plan to exploit to collect more

informative and predictive insect surveillance data.

CONTROL

The DoD pest management community is firmly

committed to the principles of IPM as stated in DoD

Instruction 4150.7.

12 Integrated pest management

describes many approaches to pest control including

non-chemical activities such as sanitation, habitat

modification, and development of surveillance

programs to specifically target pest locations and

activity times. Use of IPM must not compromise the

effectiveness of control and must be tailored to best

address the specific needs of each pest or disease

vector problem. The Army recognizes that pesticides

are indispensable management tools, and takes

seriously the responsibility for their safe and effective

use. As part of any IPM program, when choosing to

use chemical control tools, pest managers are directed

to select the least hazardous pesticides that will still

provide acceptable results. For example, pesticides in

the organophosphate and carbamate chemical classes

are still used if specific conditions warrant, but

effective substitutes such as newer generation

pyrethrins or insect growth regulators are preferred

choices. In addition, since the DoD Measures of Merit

were instituted over a decade ago with the one stated

goal of a 50% reduction in pesticide use by the year

2000, the entire existing pesticide list has been

carefully evaluated and updated. When possible, lower

application rate pesticides were substituted for higher

rate products and lower toxicity chemicals were added

to the inventory. This, in addition to a DoD culture that

emphasizes IPM, has enabled the DoD to achieve a

61% reduction in pesticide use by 2006. since the

program inception, while still maintaining appropriate

levels of pest and disease vector control. The DoD has

exceeded all its pesticide use reduction goals, and will

continue to focus on further reductions wherever

possible.

The Defense Logistic Agency regularly updates the

national stock list to reflect this goal. However, this

effort succeeds only as new, effective, and less toxic

active ingredients are developed and registered for use
38 Army Medical Department Journal

by the EPA, a slow and extremely costly endeavor for

pesticide manufacturers. When such products are

brought to the market, the AFPMB makes every effort

to evaluate their potential for use by DoD components

and to add them as needed to the stock list. Examples

that appear on the current stock list include insect

growth regulators, such as fenoxycarb and

methoprene, and microbial pesticides, such as Bacillus

thuringiensis and spinosad. Members of the AFPMB

are also periodically approached by vendors

attempting to sell products to the DoD which they

label as “natural” or otherwise having low/no toxicity.

Unfortunately, in most of these cases, the data

supporting these products is either insufficient or

nonexistent, particularly if the product does not require

EPA registration. Nevertheless, if these products meet

the military’s rigorous efficacy requirements, they

could be supported by professional pest managers and

added to the national stock list.

Use of less toxic and more effective pesticides is

obviously advantageous to the DoD Pest Management

Program to protect human health and the environment.

Pest management professionals in the DoD also

recognize the need to maintain a sufficiently diverse

inventory of pesticides to delay the onset of resistance,

which makes certain pesticides ineffective and

threatens the military’s ability to prevent diseases. To

address these issues, DoD pest management

professionals, in conjunction with representatives from

the CDC, National Institutes of Health, US Agency for

International Development, USDA, private industry,

and professional pest control organizations, actively

seek more effective and less toxic or environmentally

hazardous pesticides that will still meet diverse

military pest management needs. This group of

concerned stakeholders and pesticide users recognizes

the fact that some pesticides are being removed from

the inventory not only due to concerns about human

exposures and environmental safety, but also due to

development of resistance to insecticides and lack of

economic incentives to develop and maintain products

used for disease vector control. The group is currently

identifying strategies to promote and support the

development of much-needed new products.

The DoD views careful screening and selection of the

pesticides authorized for use as one crucial component

of any effective IPM program. Another crucial

component is the type of pest management equipment

and methodology used in applying pesticides. In

addition to using the most effective and efficient

commercially produced pesticide application

equipment, the military services conduct research,

either intramurally or collaboratively, with USDA to

develop new or improve existing pesticide application

technologies for increasing efficacy of pesticide

dispersal, and/or reducing the amount of pesticide

needed for effective control. The DWFP supplies

competitive funding specifically for research relating

to pesticide technologies. Of particular promise is

current military research on the integration of global

positioning systems, new high-pressure systems for C130 aircraft aerial pesticide application, and the

evaluation of unmanned aerial vehicles for pesticide

application in hard-to-reach or dangerous areas. The

AFPMB Pesticide and Equipment Committees take the

lead on identifying and recommending new products

and equipment for inclusion on the national stock list.

This process supports the ongoing efforts within the

DoD to provide effective pest and vector control in the

safest possible manner.

SUMMARY

Entomological hazards, including vector-borne

diseases, stinging and biting arthropods, and harmful

animals and plants remain a significant threat to US

military forces both at home and abroad. Military

entomologists continue to use safe, effective,

established methods of surveillance and control while

continuing to develop new, innovative, safer, and more

effective methods. This is due in large part to the

synergy that results from joint efforts between the

Army, Air Force, and Navy through the continued

coordination of the AFPMB. Partnering with other

government agencies (USDA), industry, and

universities has also stimulated the development and

implementation of new and more effective

technologies that can be quickly delivered to field

forces. All of these activities are continually bringing

military entomology closer to the goal of full spectrum

dominance over harmful arthropods and noxious

animals and plants that otherwise would cause US

forces to suffer morbidity and mortality.

ACKNOWLEDGMENT

The authors thank Dr Ed Evans and Sandy Evans from

the Entomological Sciences Program at USACHPPM

for providing photos and editorial support, and COL

(Ret) Daniel Strickman, Dr Rich Robbins, and Zia

Mehr for helpful comments and review of this article.
April – June 2006 39

REFERENCES

1. Aronson N, Ananthakrishman M, Bernstein W, et al.

Update: Cutaneous leishmaniasis in U.S. military

personnel–Southwest/Central Asia, 2002–2004. JAMA.

2004;291:2188.

2. US Navy Environmental Health Center. Malaria

outbreak among members of JTF Liberia Consensus

Conference Report. 2003. Available online at: http://

www-nehc.med.navy.mil/downloads/prevmed/

JFTMalaria.pdf.

3. Handbook of Diseases of Military Importance.

Washington, DC: US Dept of Defense, Defense

Intelligence Agency; 1982.

4. Technical Guide No. 36, Personal Protective Measures

Against Insects and Other Arthropods of Military

Significance. Washington, DC: US Dept of Defense,

Armed Forces Pest Management Board; 1996.

Available online at: http://www.afpmb.org/coweb/

guidance_targets/ppms/TG36/TG36.htm

5. Ma D, Bhattacharjee AK, Gupta RK, Carle JM.

Predicting mosquito repellent potency of n.n-diethyl-mtoluamide (DEET) analogs from molecular electronic

properties. Am J Trop Med Hyg. 1999;60:1-6.

6. Klun J, Debboun M. A new module for quantitative

evaluation of repellent efficacy using human subjects. J

Med Entomol. 2000;37:177-181.

7. Klun J, Kramer M, Debboun M. A new in vitro

bioassay system for discovery of novel human-use

mosquito repellents. J Am Mosq Cont Assoc.

2005;21:64-70.

8. Dedet JP, Esterre P, Pradinaud R. Individual clothing

prophylaxisof cutaneous leishmaniasis in the

Amazonian area. Trans Royal Soc Trop Med Hyg.

1987;81:748

9. US Army Center for Health Promotion & Preventive

Medicine. DoD insect repellent system. Available at:

http://chppm-www.apgea.army.mil/documents/

DoDInsectRepellentSys.pdf

10. US Army Medical Command Center & School.

Deployment relevant web sites. Available at: http://

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

11. Berte SB. US Army entomology support to deployed

forces. Amer Entomol. 2005; 51;No. 4:208-217.

12. DoD Instruction 4150.7, DoD Pest Management

Program. Washington, DC: US Dept of Defense; April

22, 1996.

AUTHORS

LTC Debboun is the Chief of Medical Zoology Branch and

Deputy Chief of the Department of Preventive Health

Services, Academy of Health Sciences, US Army Medical

Department Center & School, Fort Sam Houston, Texas.

COL Leon Robert is an Associate Professor, Department of

Chemistry and Life Science, US Military Academy, West

Point, New York.

MAJ O’Brien is the Chief, Defense Pest Management

Information Analysis Center, Armed Forces Pest

Management Board, Washington, DC.

COL Johnson is the Director, Armed Forces Pest

Management Board, Office of the Deputy Under Secretary

of Defense (Installations and Environment), Washington,

DC.

COL Berte, a former Medical Entomology Consultant to the

Surgeon General of the Army, now serves as the Joint

Project Manager of the Chemical Biological Medical

Systems Project Management Office, Fort Detrick,

Maryland.

Aedes albopictus (Asian Tiger Mosquito) Phlebotomus papatasi (Sand Fly)
40 Army Medical Department Journal

Field Preventive Medicine refers to all actions that

provide commanders with a fit and healthy deployable

force, sustain the health and fitness of the force during

a military operation, and prevent casualties caused by

disease and nonbattle injury (DNBI). Preventing or

reducing DNBI allows the warfighter to focus

manpower and resources on mission accomplishment

and allows medical assets to focus on treating combat

related injuries. Actions that affect Field Preventive

Medicine occur prior to, during, and after deployment,

and involve command responsibility, unit leadership

standards and enforcement, individual actions, unit

level support through the Field Sanitation Team (FLD

SAN TM), and direct and general support from

preventive medicine personnel. These first 4

components—commander, unit leaders, individual

Soldiers, FLD SAN TM—are the primary resources

for maintaining the health of the command and

preventing DNBI. The Army Medical Department,

through its preventive medicine personnel, provides

supporting services as a resource for the commander’s

health program.

PERSONNEL RESPONSIBILITIES

Commanders

The commander is the authority for actions that occur

within the unit and is, therefore, responsible for the

health and welfare of the unit, and thereby the

prevention of DNBI. The commander provides the

time, training, resources, and emphasis needed to

implement a DNBI prevention program. The

commander sets the standards, leads by example, and

ensures the establishment of devices or practices that

promote unit or collective Preventive Medicine

Measures (PMM). These include latrines, hand

washing stations, shaving areas, showers, arthropod

and rodent control, and food and water sanitation and

quality issues. The commander is responsible for

ensuring that FLD SAN TM supplies are on-hand and

taken with the unit when it deploys.

Unit Leaders

Unit leaders must support the command’s health

program and ensure that all unit members adhere to

command policies and procedures. Unit leaders must

be knowledgeable on health issues and the application

of PMM, which are the methods used to prevent and

mitigate DNBI.

Soldiers

Soldiers at all levels are responsible for implementing

individual PMM. These individual tasks may be very

basic, eg, hand washing, bathing, changing socks, and

brushing teeth. Or they may be more complex, eg,

using insect repellents and consuming food and water

only from approved sources. Utilizing PMM takes

time and resources, but primarily discipline. Most

Soldiers know how to implement the majority of

PMM, but may not do it because of the perceived

inconvenience.

Field Sanitation Teams

To assist the command in mitigation of DNBI through

the use of unit-level PMM, each company sized unit is

required, per Army Regulation 40-5,

1

to establish and

equip a two-person FLD SAN TM. This team is

composed of one noncommissioned officer and one

junior enlisted. For units assigned a unit health care

specialist (ie, medic), the health care specialist should

be one of these members. Personnel selected for this

additional duty must be highly capable individuals,

possess above average leadership skills, and should be

expected to stay with the unit for at least 6 months

after being trained. Preventive medicine personnel

certify each team member through a 40-hour course on

field sanitation. This certification should take place

Field Preventive Medicine: Challenges

for the Future

LTC William J. Sames, MS, USA

LTC Thomas C. Delk, MS, USA

MAJ Paul J. Lyons, MS, USA

Note: The doctrine of field preventive medicine services discussed in this paper is delineated in Department of the Army

Field Manual 4-02.17, Preventive Medicine Services.
April – June 2006 41

while in garrison, but preventive medicine personnel

can provide the required training while deployed.

Field Sanitation Teams employ the information

contained in Field Manual (FM) 4-25.12,

2

and FM 21-

10.

3 Currently these manuals are being revised and

combined into one comprehensive document.* The

FLD SAN TM monitors the use of individual and unit

PMM, and provides guidance and direction on the

construction of unit level devices for implementing

PMM. The information gathered, along with their

recommendations for enhancing individual and unit

PMM, is reported to the commander and unit leaders.

As necessary, the commander decides on a course of

action for correcting or enhancing PMM, and unit

leaders implement this plan. If a work detail is

required to implement the action, the FLD SAN TM

should provide guidance and monitor the activity to

ensure that it is being properly implemented.

Army Medical Department

The Army Medical Department (AMEDD) supports

this command program by providing field preventive

medicine service support from 5 medical functional

areas: preventive medicine services, veterinary

services, preventive dentistry, combat and operational

stress control, and preventive laboratory services. The

AMEDD also conducts field preventive medicine

research and development for each of these functional

areas to further assist the command in the mitigation of

DNBI.

PREVENTIVE MEDICINE SERVICES

The services provided by preventive medicine

personnel are the most diverse and constitute the bulk

of applied field preventive medicine (see FM 4-

02.174). These services are provided by officers from 8

Areas of Concentration: Preventive Medicine Officer

(60C), Occupational Medicine Officer (60D), Public

Health Nurse (66B), Nuclear Medical Science Officer

(72A), Entomologist (72B), Audiologist (72C),

Environmental Science Officer (72D), and Sanitary

Engineer (72E). These services are also provided by 3

enlisted Military Occupational Specialties: Preventive

Medicine Specialist (68S [formerly 91S]), Health

Physics Specialist (68SN4), and Ear, Nose, and Throat

Technician (68WP2). In deployed situations, the 68S,

72D, and 72B are the primary personnel who interact

with units to resolve field preventive medicine issues.

Other preventive medicine personnel are represented

on the staff of various medical and nonmedical units.

Preventive medicine personnel support units in

medical surveillance, as well as occupational and

environmental health surveillance. This support is

accomplished through analyzing DNBI data, unit

inspections for compliance with PMM, disease

surveillance, area vector and disease suppression,

health risk communication, technical consultations,

food service sanitation inspections, water quality

monitoring, pest management services, retrograde

operations inspections, hearing and vision

conservation, industrial hygiene surveys, field

sanitation practices, environmental sampling for short

and long-term health risk exposures, community health

services, and radiological safety.

Preventive medicine personnel are located throughout

the battlefield, and must be deployed during early

operations. Some, such as the Preventive Medicine

Section in the brigade combat team’s medical

company, are organic to units and provide direct

support. This section is currently composed of a 72D

and a 68S. Others provide staff support and are found

in Preventive Medicine Sections or the Surgeon Cells

of command and control organizations. Preventive

medicine personnel are also found in Military Police

battalions (Internment/Resettlement), Special Forces

groups, Civil Affairs battalions/brigades, Armored

Cavalry regiments, Engineer units, and some

Quartermaster battalions.

Medical Detachments (Preventive Medicine) are 13-

member units that provide direct support to units that

do not have organic preventive medicine personnel,

and general support to units that have organic

preventive medicine personnel. The Medical

Detachments are attached to multifunctional medical

battalions (MMB), operate on an area basis, and have

the capability to provide expanded services (especially

pest management services) to supported units.

VETERINARY SERVICES

Veterinary services include the surveillance and testing

of food and water sources to ensure the safety and

quality of food, ice, and bottled water (see FM 4-

02.185). Veterinary personnel establish and provide a

list of approved food, ice, and bottled water sources to

the theater commander and staff for dissemination to

subordinate units, and they provide health services to * The comprehensive document will be FM 4-25.10: Field

Sanitation Team and Preventive Medicine Measures
42 Army Medical Department Journal

military working dogs (MWDs). Veterinary personnel

are seldom found at lower echelons on the battlefield,

but primarily interact with quartermaster units,

preventive medicine units, and units that have MWDs.

Veterinary units will also be assigned to the MMB.

PREVENTIVE DENTAL SERVICES

Preventive dental services primarily involve individual

PMM such as regular dental hygiene (brushing,

flossing). FM 4-02.19 delineates doctrine for dental

operations.6 Dentists also provide preventive support

through annual dental exams and cleanings (including

preventive measures such as fluoride treatments), and

will provide consultations on how to properly brush

and floss teeth and gums. Deployed dental units can

provide in-theater treatment and preventive services,

normally with a high return to duty rate.7 To further

assist with preventive dental health, dentists look for

strategies that maintain an individual’s dental health

that are effective, easy to use, and require no

additional action on the part of the Soldier. For

example, the military dental community has succeeded

in having Xylitol chewing gum added to the field

rations, Meal, Ready to Eat (MREs).8 Xylitol is a

naturally occurring sugar alcohol that kills the bacteria

that causes cavities. Adding Xylitol to MREs assists in

the prevention of tooth decay and is a no-effort benefit

to those Soldiers who chew this gum.

COMBAT/OPERATIONAL STRESS CONTROL

Deployed Soldiers are subjected to a multitude of

issues that may that lead to suicide, fratricide, a

significant reduction in work performance, or other

disruptive behavior. These issues include preexisting

conditions that are corrected by medications;

separation from a spouse, a significant other, or other

family members; fear of the unknown combat

situation; stress from boredom, overwork, lack of

sleep, seeing peers killed or maimed, and experiencing

other war conditions; and other personality disorders.

Preventing behavioral issues in deployed Soldiers is

the role of combat and operational stress control

personnel (see FM 4-02.519) located in Combat and

Operational Stress Control Detachments. These

detachments are attached to MMBs and provide

contact teams to their supported units. These contact

teams have the capability to interview Soldiers,

evaluate the stress issues within a command, provide

guidance on the prevention of disruptive behavior to

the individual for specific issues or to the commander

for unit issues, and, if necessary, provide some

rehabilitatory or reconstitution services.

PREVENTIVE LABORATORY SERVICES

Preventive laboratory services are those services that

support the field preventive medicine effort by testing

clinical or environmental samples for infectious agents

or hazardous materials. The information from these

services are used as part of the DNBI analysis process

and as diagnostics for understanding surveillance data.

These services are located within the Area Medical

Laboratory or outside theater in regional or continental

United States support laboratories.

INDIVIDUAL MEDICAL READINESS

Personnel are screened prior to entry into military

service to prevent entry of recruits that have a

preexisting medical condition which would hinder

their performance, or disrupt or burden other military

personnel. For those in the service, periodic medical

exams or tests (periodic health assessments,

deployment limiting conditions, dental readiness,

immunization status, readiness laboratory studies,

individual medical equipment, hearing readiness, and

vision readiness) are required. These individual

medical readiness data are entered into the Medical

Protection System via the internet and allow medical

personnel to assess each Soldier, and prevent or treat a

condition in advance of deployment. This in turn

serves to maintain individual health, unit integrity,

morale, and saves deployment activities for warfighter

issues. Commanders assist this process by ensuring

that their Soldiers complete these periodic

requirements.

DISEASE AND NONBATTLE INJURIES:

PREVENTIVE MEDICINE MEASURES AND

SOLDIERS

Even with the best preventive medicine practices in

place, some DNBI will occur. This DNBI may

fluctuate. However, over time a fairly stable rate of

DNBI—a baseline—may be established. Ideally, this

baseline should be the same in both nondeployed and

deployed settings. If the measured DNBI exceeds the

expected baseline or an established threshold,

preventive medicine personnel investigate the issue,

look for a potential break in PMM, and implement the

means to mitigate the DNBI. Within the body of

preventive medicine knowledge, much is already
April – June 2006 43

known on the prevention of the majority of militarily

and medically important DNBI. Unfortunately, DNBIs

are based upon laws of probability, and it is not always

clear that a specific action yields a direct consequence.

Hence, Soldiers who do not practice effective PMM

may not have DNBI, while Soldiers who practice

PMM may have some DNBI. This may cause a sense

of security when PMM are not followed and no DNBI

occurs. Conversely, it may cause Soldiers to mistrust

recommended PMM and rely on home-remedies or

recommendations from peers when they practice PMM

but DNBI occurs. Both situations may cause Soldiers

to stray from using PMM as they perceive PMM as

being ineffective or to have no added value. However,

unit leaders must understand that the PMM is not at

fault, but that there is a break somewhere in the

implementation of the PMM or the disease process that

is preventing or allowing the DNBI. Preventive

medicine personnel are trained in locating these

breaks, can explain why DNBI situations exist or do

not exist, and can assist the command with correcting

the issue. In some cases, the PMM may have a side

effect on the Soldier, and to avoid the side effect the

Soldier may avoid implementing the PMM. An

example of this situation was the administration of

chloroquine as a chemoprophylaxis for malaria.

Soldiers often had gastrointestinal pain for several

days after taking the weekly dose of chloroquine.

Soldiers did not like this side effect and would avoid

taking the once-a-week medication. Unit leaders

countered this by having Soldiers line up in formation

and observe each Soldier swallow the pill. Preventive

medicine measures must be sustained on a routine to

periodic basis, which is costly in time and resources to

the Soldier and unit. The multitude of tasks that must

be completed daily in a field situation to maintain

Soldier and unit health can appear enormous. Many of

these tasks are expected in garrison (bathe, brush and

floss, wash hands after using the latrine and before

eating, put on clean clothes, change your socks and

underwear daily, etc.), but in the field they can become

an inconvenience and, without command emphasis,

resourcing, and enforcement, Soldiers may neglect

these basic hygiene practices. For Soldiers who take

prescribed medications to counter behavioral health

issues, the loss of these medications or arriving in

theater with an insufficient supply can be disruptive to

the unit. To mitigate this issue during Operation Iraqi

Freedom, the Army authorized unit medical personnel

to carry and issue psychotropic medications. Soldiers

may also develop a “we’re tough” or a “we don’t need

to wash our hands or take showers on a regular basis”

attitude. Soldiers may also risk eating or drinking from

unapproved sources. Both of these can lead to

significant DNBI, and overcoming them is a leadership

and training issue. Theater policies designed to gain

support of the local population or to overcome cultural

differences may encourage Soldiers to interact with the

local population and consume their food and water in

the traditional host nation manner. Since this food and

water may not have been handled, prepared, stored, or

served using military standards, the Soldiers may be

exposed to a local bacterial or viral fauna to which

they are susceptible, resulting in increased DNBI.

Commanders must consider the health-related

implications of these policies as they conduct their risk

assessments.

CURRENT PREVENTIVE MEDICINE ISSUES

Currently there are a number of issues that must be

addressed to improve the effectiveness of preventive

medicine services and protect the health of

warfighters. Three significant issues are:

1. The current brigade combat team (BCT)

organizational structure places 2 initial entry-level

personnel (a 72D and a 68S) in the BCT medical

company’s Preventive Medicine Section. These

Soldiers are the warfighter’s most forward-deployed

preventive medicine professionals in theater, therefore,

they are the first line of “technical” defense in the BCT

commander’s battle against DNBI. Unfortunately,

these personnel lack the technical and tactical

experience to fully accomplish this important mission.

Unlike many of the Army’s areas of concentration

(AOC)/Military Occupational Specialties (MOS)

which “grow” their junior ranks in field assignments,

the preventive medicine personnel are expected to

have the level of knowledge, experience, and

professional bearing found in personnel who have

been in the military for several years. These

professionals are not only expected to interact with

Soldiers and the FLD SAN TM, but they also interact

directly with commanders and senior NCOs. We

propose correcting this situation by replacing the

BCT’s junior 68S (68S10) with a more senior

specialist (68S30). This action would provide the

knowledge, experience, and professional bearing

required to successfully interact with Soldiers and unit

leaders, resulting in increased mission success. The

68S10s should first be grown in other assignments

where they would have noncommissioned officer

supervision and mentorship.
44 Army Medical Department Journal

2. Preventive medicine units are equipped with a

variety of highly specialized, low density equipment to

conduct their mission. Identifying and resourcing these

equipment items present significant challenges: they

are expensive, they usually require specialized and

routine maintenance, they may require specialized

operation and maintenance training, and technological

advances may make these items obsolete 3 to 5 years

after procurement. Also, although the Medical

Equipment Set cyclic review process requires Combat

Developers to review and update these items every 3

years (as a minimum), due to resourcing constraints

units may not actually see these items for another 2 to

3 years after the review process. As an interim

solution, the US Army Center for Health Promotion

and Preventive Medicine (USACHPPM) has provided

valuable assistance to field preventive units by

procuring, maintaining, providing technical training,

and temporarily issuing specialized, low-density

equipment to these units in support of military

operations. Examples include air particulate samplers

and combination photoionization detectors/multigas

analyzers provided to preventive medicine units

deployed to the Balkans, Southwest Asia, and other

parts of the world to conduct their occupational and

environmental health surveillance missions. Perhaps

the procurement, maintenance, training, and fielding of

low density, high technology preventive medicine

support equipment should be further explored as a core

USACHPPM mission, and the organization should be

adequately resourced to provide this service.

3. Preventive medicine units are theoretically

designed (i.e., staffed and equipped) to provide a

variety of services depending on their preventive

medicine support capability level. The two-person

BCT Preventive Medicine Section provides direct and

basic (Level II) support to its brigade, while the 13-

person Medical Detachment (Preventive Medicine)

provides general area and slightly more advanced

(Level III) support to units (to include BCTs) at the

corps level. The Area Medical Laboratory (AML), on

the other hand, is designed to provide theater-wide,

more technically advanced (Level IV) support to these

units. However, other than containing more personnel

and increased pest management capabilities, the

Preventive Medicine Detachment does not provide

significantly different services than the BCT

Preventive Medicine Section. Although the AML can

provide other services, the unit may not be properly

organized to deploy in a modular (and timely) manner

to maximize its operational footprint while minimizing

its logistical footprint. Therefore, the Army may need

a Level III+ or perhaps a Level IV preventive

medicine unit to provide these additional services in a

modular manner. This unit may perhaps be assigned

personnel from each 72-series AOC and be equipped

with more advanced surveillance equipment, such as

direct-reading toxic material analyzers, to provide

more robust DNBI surveillance and control services.

In fact, this unit may possibly be configured much like

the US Navy’s modular Forward-Deployed Preventive

Medicine Unit.

FIELD PREVENTIVE MEDICINE STRATEGIES

AND FUTURE PROSPECTS

Future field preventive medicine strategies are

complex, and multiple parameters must be met to

provide optimal results. These strategies must meet a

balance between warfighter mission requirements,

political requirements, and support requirements, with

the ultimate focus on issues that would provide the

greatest benefit to the warfighter in terms of reduced

DNBI. The following sections identify some of these

future field preventive medicine strategies and

prospects:

1. Warfighters focus on mission accomplishment;

therefore, efforts to reduce nonmission requirements

are warranted. Future preventive medicine strategies

for the warfighter must focus on essential capabilities

that will result in warfighter mission accomplishment

with minimal support requirements. Ideally, these

solutions must be easy to use or require little or no

effort from the Soldier or unit leaders, have high

Soldier acceptance levels, be highly effective, have no

or only minor side effects, be given or accomplished in

advance or after a deployment, and require little

planning, training, or resources to implement.

2. Materiel solutions must also focus on providing

increased capabilities, while at the same time reducing

equipment weight and volume. Efforts must be taken

to consolidate 2 or more capabilities into a single,

portable, lightweight, and easy to operate and maintain

equipment item whenever possible. An example of this

effort is RAE Systems’ (3775 North First Street, San

Jose, CA 95134, 408-952-8200) consolidation of a

standalone photoionization detector (capable of

detecting volatile organic compounds and other

ionizable gases and vapors) with a standalone multigas

analyzer (capable of measuring explosive gases and

vapors, oxygen content, as well as carbon monoxide
April – June 2006 45

and other toxic gases) in the design of the Multi-RAE

Plus® Multiple Gas Monitor.

3. Political requirements, such as the health

surveillance requirements mandated by Presidential

Review Directive-5,10 must be met. These

requirements focus on the entire spectrum of medical

support and require the warfighter and medical

personnel to document medical treatment and

preventive measures, as well as exposures to known

hazards and environmental conditions. These hazards

must be anticipated, identified, measured, assessed,

and correlated to locations and Soldiers exposed.

These data must then be linked to individual electronic

health records for future review and use by medical

personnel. This is an enormous task, and processes to

efficiently collect, analyze, and correlate these data are

needed. Roles and responsibilities must be established

to ensure that the correct data are collected and to

eliminate any duplication of effort. Materiel solutions

are also needed to more effectively collect and assess

health hazard exposure information, and creative

information management solutions are required for

data entry, correlation, archiving, and retrieval.

4. A number of medical research programs are already

established to improve future field preventive

medicine capabilities. Programs such as the Military

Infectious Disease Research Program (MIDRP) and

the Military Operational Medicine Program focus on

preventing and treating disease, protecting warfighters’

physical and mental health, enhancing their

performance, and providing force health status. Each

program will establish a set of parameters that will

provide the best possible solution for the warfighter.

For example, vaccines are a major research focus in

the MIDRP. These meet warfighter requirements by

preventing DNBI, and they can usually be

administered prior to deployment to protect the

warfighter against a particular disease. Additional

vaccine parameters that will benefit the both the

warfighter and the Army may include vaccines that

provide protection soon after the initial vaccination;

require only one dose to provide a high level of

protection with no boosters, or a long time between

boosters; are highly effective; have no or only minor

side effects; are given in advance of a deployment; and

require little planning and logistical support to

implement. Furthermore, these vaccines should be low

cost, have a long shelf life, are easily manufactured,

easy to apply (oral or inhaled), easy to store, and have

low dose regimens.

CONCLUSIONS

Army field preventive medicine must have command

emphasis from the top down to include planning

considerations, training emphasis, and adequate

resourcing. Mechanisms are in place to support current

and future field preventive medicine through doctrine,

organization, and materiel processes, with each to be

modified as new knowledge and technology improve

or change the implementation of PMM.

REFERENCES

1. Army Regulation 40-5: Preventive Medicine.

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

2005.

2. Field Manual 4-25.12: Unit Field Sanitation Team.

Washington, DC: US Dept of the Army; 25 January

2002.

3. Field Manual 21-10: Field Hygiene and Sanitation.

Washington, DC: US Dept of the Army; 21 June

2000.

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

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

2000.

5. Field Manual 4-02.18: Veterinary Services, Tactics,

Techniques, and Procedures. Washington, DC: US

Dept of the Army; 30 December 2004.

6. Field Manual 4-02.19: Dental Service Support in a

Theater of Operations. Washington, DC: US Dept of

the Army; 1 March 2001.

7. Jones TK. Army dental service support in a theater of

operations. AMEDD J. 2006;Jan–Mar:5-9.

8. Scott AE Jr. Xylitol chewing gum: a recommended

addition to the MRE package. Army Med Dept J.

2006;Jan–Mar:56-58.

9. Field Manual 4-02.51: Combat Stress Control in a

Theater of Operations. Washington, DC: US Dept of

the Army; 29 September 1994.

10. Presidential Review Directive-5 (PRD-5) A National

Obligation-Improving the Health of Our Military,

Veterans, and Their Families issued in August 1998.

Available at: http://fas.org/irp/offdocs/prd-5-

report.htm.

AUTHORS

LTC Sames, LTC Delk, and MAJ Lyons are all members of

Force Protection Branch, Directorate of Combat and

Doctrine Development, US Army Medical Department

Center & School, Fort Sam Houston, Texas.
46 Army Medical Department Journal

It is the Army’s responsibility to ensure that Soldiers

are protected during deployments (both domestic and

overseas) against any hazards or threat agents, and to

document potential or actual exposures to these

harmful threat agents. The documentation database

will allow health care providers to better treat and

manage Soldiers if an illness occurs after deployment,

or even after separation from the military. The record

is permanent and always available to the Soldier. The

Deployment Occupational and Environmental Health

Risk Management (DOEHRM) Program will greatly

assist in dealing with postconflict illnesses which have

occurred following US major military engagements.

This article presents a brief history of the DOEHRM

program and existing or planned initiatives for

program enhancement.

In the 1991 Gulf War, the number of coalition

casualties was significantly low from an historical

perspective. However, neither service personnel nor

the American public were prepared to deal with

significant health issues among returning veterans. Of

particular impact were those veterans whose symptoms

and conditions were not easily diagnosed or treated.

To complicate matters, the military services soon

became aware of 3 serious shortcomings;

1. the inability to track specific daily locations for

deployed personnel and units, making it

extremely difficult to cross reference locations

with potentially dangerous occupational and

environmental health exposures,

2. the health risk communications process was

deficient, and

3. the lack of formal pre- and postdeployment

screening processes (Note: screenings have since

been implemented).

Deployment Occupational and

Environmental Health Risk Management

COL Robert R. Eng, MS, USA

COL (Ret) Curtis W. Pearson, MSC, USAF
April – June 2006 47

Several of the postwar health concerns centered on

veterans’ illnesses, mortality, hospitalizations, and

reproductive outcome issues. For example, why were

some veterans ill with unexplainable symptoms and

were untreatable as well, leaving practitioners unable

to explain diagnosis, prognosis and long term recovery

issues to them? What were the acute, chronic, or

delayed health relationships among pesticide

exposures, vaccinations and antidotes, air/soil/water

pollutants, chemical and biological warfare agents,

stress, depleted uranium, and others? What exactly

happened within a 50 km radius of Khamisiyah, Iraq

when it was destroyed by coalition forces? What about

potential exposures at other locations? Were veterans

who deployed more likely to become ill and/or

hospitalized versus those veterans who had not

deployed? And what about birth defects among

children born to Gulf War veterans—did the war

experiences have anything to do with that?

To address the shortcomings during subsequent

deployments, the Presidential Advisory Committee

Army DOEHRM policy objectives:

1. Protect Army personnel, including Dept of the Army civilians and Army contractors, from potential

and actual exposures on the battlefield. These exposures include chemical, biological, radiological,

and nuclear (CBRN) warfare agents; endemic communicable diseases; food, water, and vector borne

diseases; ionizing and nonionizing radiation; combat and operational stress; heat, cold, and altitude

extremes; environmental and occupational hazards; toxic industrial materials and other physical

agents.

2. Reduce occupational and environmental hazard potential and actual exposures during Army

operations to as low as practicable to minimize acute, chronic, and delayed health effects within the

context of mission parameters and Army risk management (RM) principles.

3. Make informed risk decisions regarding occupational and environmental health (OEH) threats

during Army operations, using the RM process to manage such threats and minimize total risk to

Army personnel.

4. Ensure that commanders are aware of and consider acute, chronic, and delayed health risks

associated with occupational and environmental potential and actual exposures during all phases of

Army operations and activities.

5. Comply with federal, state, local or host nation statutes, regulations, directives, and guidance

governing OEH except for uniquely military equipment, systems, and operations while in garrison

or during training exercises.

6. During deployments, comply with US, Army-unique, or host nation OEH standards, whichever are

more restrictive.

7. Implement health surveillance and readiness programs during Army operations.

8. Collect, document, evaluate, report, and archive OEH sampling data from Army operations,

integrating all relevant OEH data with potential and actual exposures and exposure scenarios to

individual Army personnel, in their longitudinal health records.

9. Ensure necessary healthcare intervention and followup for potentially exposed Army personnel.

10. Deploy in such a way that DOEHRM supports modular and interoperable joint forces capabilities

provided by the services.

11. Communicate OEH risks from military operations to all Army personnel and share OEH risk

management lessons learned during unit rotations.

12. Provide commanders with the capabilities and tools for conducting RM assessments and

communicating risks.

13. Provide access to all needed intelligence sources, deployable computer systems with environmental

exposure data, unit locations, and movement information.
48 Army Medical Department Journal

(PAC) on Gulf War Veterans’ Illnesses was

established. In its final report issued on Dec 31, 1996,

the PAC recommended that the National Science and

Technology Council (NSTC) develop an interagency

plan to address health preparedness for, and

readjustment of, veterans and their families after future

conflicts and related military missions. The NSTC

recommendation resulted in Presidential Review

Directive-5 (PRD-5), A National ObligationImproving the Health of Our Military, Veterans, and

Their Families issued in August 1998.* The Deputy

Assistant Secretary of the Army (Environment, Safety

and Occupational Health) (DASA[ESOH]) directed

implementation of the recommendations contained in

PRD-5 in the memorandum Force Health Protection:

Occupational and Environmental Health Threats dated

27 June 2001.

With encouragement and support from the Army

Surgeon General, LTG James Peake, the Army Deputy

Chief of Staff (DCS), G-3/5/7 took the lead

responsibilities for implementation. The program was

renamed Deployment Occupational and Environmental

Health Risk Management to better describe the intent

of the DASA(ESOH) memo. As part of the program, a

governing Army regulation in the 11 series is in final

staffing as the source document for DOEHRM. The 11

series (Army Programs) of regulations was chosen as

the appropriate location for the DOEHRM regulation

since it represents much more than a medical issue.

DOEHRM is an Army issue to be executed by

commanders and the Army leadership.

In addition to the impending Army regulation, an

implementation plan for DOEHRM has been authored,

directing numerous organizations within the Army to

incorporate DOEHRM into their respective areas of

responsibility. With finalization of the DOEHRM

regulation and publication of the implementation plan,

major commands (MACOMs) and Special Staff will

be tasked to author their own implementation plans

and identify requirements for the program. The DCS,

G-3/5/7 will then assemble and validate all MACOM

requirements as identified in the MACOM and Special

Staff implementation plans, and staff DOEHRM

through the Program Objective Memorandum process

for implementation throughout the Army.

With the guidance as provided by the Army regulation

and the specific instructions of the DOEHRM

implementation plan, MACOMs and Army staff

offices will be responsible for DOEHRM integration

into their respective areas of responsibility. For

example, the following are representative lead

responsibilities of several major Army organizations:

1. The DCS, G-3/5/7 will

 ensure all relevant Army publications are

modified to include DOEHRM;

 review modified tables of organization and

equipment to ensure DOEHRM equipment

requirements are properly included;

 integrate the DOEHRM implementation plan

with current and future CBRN and high

explosive surveillance and bioanalysis systems;

 identify, track and review DOEHRM issues,

resolution and assessments.

2. The Training and Doctrine Command will

 develop and publish DOEHRM doctrine in

accordance with doctrine, organization,

training, materiel, leadership, personnel, and

facility (DOTMLPF) domains;

 develop consistent operational guidance that

allows appropriate personnel to assist

commanders in managing risks from

deployment occupational and environmental

health hazards and incorporating same into the

Army DOTMLPF process;

 as DOEHRM requirements are identified,

*Available at: http://fas.org/irp/offdocs/prd-5-report.htm. examine force structure to ensure said
April – June 2006 49

requirements are defined and addressed by

appropriate organizations;

 review current training practices to ensure

appropriate risk is being communicated to those

having DOEHRM responsibilities;

 develop exportable leader and Soldier training

packets on sustainment DOEHRM training for

all components after doctrine is approved;

 develop unit/organization training programs.

3. The DCS, G1 will

 review and identify modifications to or

expansion of Chapter 7 (Medical and Dental) of

the Department of the Army Personnel Policy

Guidance for Contingency Operations in

Support of GWOT* (global war on terror) to

accommodate DOEHRM;

 review and/or develop personnel policies to

support integration and direct access of daily

personnel and unit location cross-referenced

data in DOEHRM information management/

information technology (IM/IT) systems in

coordination and linkage with other IM/IT

systems.

4. The Medical Command will

 develop, improve, and disseminate criteria and

guidance to include, but not be limited to,

chemical, biological, radiological, nuclear, high

explosive, physical, entomological, combat and

operational stress health risks, endemic

diseases, and preventive measures throughout

the range of exposure levels for acute, chronic,

and delayed health effects;

 examine medical technology transition projects

and processes for potential DOEHRM

applicability and priority;

 conduct reviews of existing medical research

and development programs to determine

DOEHRM applicability and opportunities for

integration.

5. The Combat Readiness Center (CRC) will

integrate the DOEHRM implementation plan with

the CRC strategic plan and into RM doctrine.

6. Forces Command will incorporate procedures in

the DOEHRM implementation plan into all

mission training plans and deployment training

exercises for both line and medical units.

Other MACOMs and staff offices have additional

responsibilities outlined in the implementation plan.

The Surgeon General is confident that, under the

leadership of the Deputy Chief of Staff, G-3/5/7, the

DOEHRM program will enable commanders to better

manage their war-fighting responsibilities and, at the

same time minimize harmful occupational and

environmental health threat exposures to the Soldier,

Dept of the Army civilian, and Army contractor.

AUTHORS

COL Eng is the Director, Proponency Office for Preventive

Medicine-San Antonio (POPM-SA) at Headquarters, US

Army Medical Command, Fort Sam Houston, Texas.

COL (Ret) Pearson is employed by the Battelle Memorial

Institute as the Senior Technical Consultant to POPM-SA at

Headquarters, US Army Medical Command, Fort Sam

Houston, Texas
50 Army Medical Department Journal

In 1996, the US Army Center for Health Promotion

and Preventive Medicine (USACHPPM) formed the

Deployment Environmental Surveillance Program

(DESP). This program was formed to fulfill the

USACHPPM role as the Department of Defense

(DoD) executive agent for deployment occupational

and environmental health (OEH) surveillance

measures, databases, data analysis, and support items.

The program greatly assisted in implementation of

preventive medicine lessons learned following the

1991 Gulf War by focusing deployment OEH

surveillance measures and archive data, reports, and

assessments. An overview of USACHPPM

deployment support of major US military deployments

since 1991 is presented in Figure 1.

At the behest of the Army Surgeon General, the

Directorate of Health Risk Management (DHRM) was

formed in 2001 to enhance the readiness of the US

Army. The DESP and two existing USACHPPM

programs were realigned under the DHRM. The

Directorate is staffed by professional scientists,

engineers, and technicians who provide a wide variety

of services supporting health risk management. These

services enable the Army and DoD leadership to

incorporate informed risk management decisions into

all Army and DoD activities.

The DESP workload expanded exponentially with the

increased operational tempo of the worldwide

deployment of forces for Operations Enduring

Freedom and Iraqi Freedom, and the global war on

terrorism. This expansion included USACHPPM’s

designation as the DoD repository for archives of

deployment OEH surveillance data. In addition, the

increased workload included deployment OEH

surveillance training and coordination with the Army,

Navy, Air Force, and Marine Corps, and collaboration

with Coalition Forces.

USACHPPM restructured the DESP in 2004 to

enhance the mission focus on warfighters’ readiness,

support the USACHPPM strategic vision, and respond

to the increased workload of worldwide deployments.

The restructuring added 2 new programs under the

Directorate of Health Risk Management, appropriately

named the Global Threat Assessment Program and the

Deployment Data Archive and Policy Integration

Program. The DESP was maintained for current

deployment OEH surveillance support measures. The

3 programs provide comprehensive deployment OEH

surveillance measures (Figure 2) and preventive

medicine support as outlined in DoD and Joint Chiefs

of Staff (JCS) surveillance requirements.

The 3 restructured DHRM programs ensure timely

comprehensive deployment OEH surveillance support

to their broad customer base, which includes deployed

preventive medicine units of the Army, Navy, and Air

Force; Combatant Commands (COCOM); Component

Commands; Joint Task Forces (JTF); DoD;

Departments of the Army, Navy, and Air Force;

Department of Veteran Affairs; Joint Staff (J4-Health

Service Support Division); Office of the Assistant

Secretary of Defense for Health Affairs; Office of the

Deputy Under Secretary of Defense, Installations and

Environment; and the Army Surgeon General.

Deployment Occupational and

Environmental Health Surveillance:

Enhancing the Warfighter’s Force

Health Protection and Readiness

Jeffrey S. Kirkpatrick

LTC Christine Moser, MS, USA

Brad E. Hutchens, PE

NOTE: The remainder of this article is organized into three major sections detailing the Global Threat Assessment Program,

the Deployment Environmental Surveillance Program, and the Deployment Data Archive and Policy Integration Program

respectively. The references and author information for all sections are consolidated at the end of the article.
April – June 2006 51

OVERVIEW

The Global Threat Assessment Program (GTAP) was

preceded by the Global Threat Assessment Team,

which functioned from September 2003 through

September 2004. Prior to that (1996 to 2002),

predeployment OEH functions were performed

exclusively under the DESP.

The GTAP was created to identify and assess

deployment OEH hazards and threats for worldwide

COCOM, Component Command, Joint Task Force,

and the military services’ priority deployment areas,

both existing and planned. These assessments are used

by the OEH surveillance activities that support the

intelligence preparation of the environment during

operational planning.

The GTAP works with US intelligence activities,

including the Defense Intelligence Agency’s Armed

Forces Medical Intelligence Center, the National

Geospatial-Intelligence Agency, the Army’s National

Ground Intelligence Center, and other domestic and

overseas resources to obtain pertinent intelligence data

and other products to support the USACHPPM

mission.

1991 1993 1995 1997 1999 2001 2003 2005

1992 1994 1996 1998 2000 2002 2004

Operation Desert Storm

(Kuwait Oil Well Fires)

Operation Vigilant Warrior

(Kuwait)

Operation Joint Endeavor (Bosnia)

Operation Allied Force/Joint Guardian

(Kosovo)

Operation Desert

Thunder (Kuwait)

Operation Enduring Freedom

Operation Iraqi Freedom

JTF Katrina

Figure 1. Overview of major US military deployments since 1991 for which USACHPPM provided deployment

occupational and environmental health surveillance measures .

GLOBAL THREAT ASSESSMENT PROGRAM

Jeffrey S. Kirkpatrick
52 Army Medical Department Journal

The GTAP coordinates with theater customers to

ensure that all predeployment (phase I) OEH

surveillance products are expeditiously requested,

produced, and disseminated. GTAP production

priorities are based on the following ongoing DoD

campaigns and missions:

 Global War on Terrorism

 Operation Iraqi Freedom

 Operation Enduring Freedom

 Theater transformation

 Peacekeeping/humanitarian missions

In addition, any products that are required to support a

USACHPPM-based mission (eg, special medical

augmentation response team – preventive medicine)

are integrated with and managed against current

production priorities. Finally, all products are

coordinated with and validated by the requesting

agency, activity, or unit, including COCOM,

Component Command, and/or the military service.

The GTAP produces comprehensive, all-source (ie,

information derived from all intelligence disciplines,

including human, signal, imagery, and open sources)

technical assessments of deployment hazards and

threats to deployed and deploying US armed forces.

Normally classified, the deployment hazards and

threats in an assessment include:

 industrial chemicals

 historical contamination

 radiation

 infectious disease

 entomological risks

 weapons of mass destruction

(chemical, biological, radiological, nuclear)

 unexploded ordnance

 specific threats identified by requirements

(eg, oil infrastructure sabotage)

Both specific hazard and threat operational risk

management (ORM) estimates and an integrated

deployment based ORM estimate are generated using

methods and procedures outlined in USACHPPM

Technical Guides 230 and 248.

1,2

The GTAP develops pertinent

input and subsections (tabs)

for the medical services

annex (Annex Q) of COCOM

and Component Command

operations plans. A recent

example: tabs dealing with

oil sabotage developed for

the USCENTCOM Surgeon

in support of operational

planning for Operation Iraqi

Freedom.

In addition to its forecasting

and planning responsibilities,

the GTAP develops and

coordinates deployment OEH

surveillance sample summary

assessments for current

military operations. The

assessments help update the

operational risk management

estimates based on collected

and analyzed deployment

samples and assist in refining

•Assess and Select

operating sites and base

camps

•Establish OEH R isk

Levels

•OPLAN Preparation

•En su re risk control

measure s are working

•Document exposures to

acute and chron ic health

risks

•Va lidate OEH Risks

•Document all

deployment related

exposures and health

risks

•Archive and Maintain

for future assessments

•Epidemiology Work

initial days to weeks > 30 days

PHASE II MOBILIZATION PHASE III CONFLICT PHASE IV POST- DEPLOYMENT

•OEHS Equ ipment a nd Media Resupply

•An alytical Support

•OEHS Operatio nal R isk Assessm ents

•In cident Respon se

•D ata Archiving

•OEHS Equipment Redeployment

•Consolidated Data Reporting

•Reassess OEH Threat

•Data Archiving

PHASE I PRE-DEPLOYMENT

•Identify, assess and

control exposures

OEH risks

•Obtaining OEHS

Info & Intelligence

•Operations Plan

(OPLAN) Input

G

o

als

Environmental He alth Site Assessment

Environmental Baseline Survey (EBS)

R outine OEHS

EBS Camp Closure

OEH S Ex posure Summa ry

Pre- and During-Deployment OEHS Assessments

•OEH / Intelligence

Preparation of

Environment (IPE)

Threat Assessment

•OEHS Equipment/

Training

A

ctio

n

s

GTAP

DDAPI

DESP

Identify, Assess, Control, Communicate DOEHS Risks

Figure 2. Tasks and goals of the deployment OEH surveillance process by

phase, including the timeline of involvement of the Global Threat Assessment

Program, the Deployment Environmental Surveillance Program, and the

Deployment Data Archive and Policy Integration Program.
April – June 2006 53

information on deployment hazards and threats for

current and future use. The GTAP also maintains and

populates the USACHPPM classified website and

interactive map server on the SIPRNET (secure

internet protocol router network).

ACTIVITIES

As illustrated in Figure 1, from 1996 to 2002 the

DESP produced and disseminated numerous

predeployment OEH products in support of the

planning and execution of military operations and

exercises in Europe—including Bosnia and Kosovo—

and southwest, central, and southeast Asia. OEH

products supported Operation Enduring Freedom/Joint

Forge (Bosnia); Operation Allied Force/Joint Guardian

(Kosovo); Operation Southern Watch (Kuwait, Saudi

Arabia); and Operation Enduring Freedom

(Afghanistan, Pakistan, Uzbekistan, Kyrgyzstan,

Philippines).

Since early 2003, the GTAP has provided

predeployment support to COCOM, Component

Commands, Joint Task Forces, various DoD

secretariats, and deploying armed forces in accordance

with DoD directives and JCS guidelines. The support

efforts provided the deploying forces with pertinent

deployment OEH surveillance assessments and

information on known and potential health threats,

risks, and enhanced sampling requirements for main

operating bases, forward operating sites, cooperative

security locations, and other known and planned

locations of military interest. Commanders and staff

sections (surgeon, intelligence, engineer, planners,

operations, preventive medicine) use the assessments

and information to plan and implement comprehensive

force health protection for deploying forces. When

needed, the GTAP ensures that all appropriate security

classification measures are identified and coordinated

with all concerned organizations.

The GTAP supports other government and allied

organizations with predeployment OEH information.

These organizations include the Office of the Deputy

Under Secretary of Defense (Installations &

Environment); the Department of State; and coalition

partners (ie, Australia, Canada, and the United

Kingdom).

The GTAP continues to support the worldwide

military deployment operations for the global war on

terrorism. Currently, the US Special Operations

Command is the lead COCOM in the prosecution of

this major, long term commitment. The 5 major

geographic combatant commands are identifying

known and potential locations of interest in their

respective areas of responsibility. This includes

planning for overseas bases, personnel, infrastructure,

and equipment to better position US forces to

strengthen allied and partner nation relationships to

defeat terrorism and meet future challenges.

Concurrent with ongoing worldwide deployment

planning and operations, DoD is actively engaged in

global posture efforts, which focus on the restructuring

of the US global defense posture. GTAP supports the

DoD Integrated Global Presence and Basing Strategy

which outlines the long term, comprehensive,

integrated overseas strategy. In all, the locations will

be identified as a cooperative security location (a hostnation facility with little or no permanent US

presence), a forward operating site (an expandable

host-nation site with limited US military support

presence and possibly prepositioned equipment), or a

main operating base (an enduring strategic base

established in friendly territory with permanently

stationed combat forces, command and control

structures, and family support facilities). The GTAP

will produce phase I assessments or deployment OEH

surveillance summary assessments for identified sites

as tasked.

Domestically, the US Northern Command

(USNORTHCOM), established in 2002, is heavily

involved with homeland defense efforts, providing

military assistance to civil authorities (including

consequence management operations), and

maintaining theater security cooperation within their

area of responsibility (mainly Canada and Mexico).

The Hurricane Katrina response (2005) by DoD’s Joint

Task Force Katrina (under USNORTHCOM)

highlighted the need for development, expansion, and

integration of more comprehensive force (and public)

health protection items in planning activities.

Finally, as discussed in detail in an accompanying

article (page 46), the Department of the Army’s

Deployment Occupational and Environmental Health

Risk Management (DOEHRM) program policy has 13

major elements that enable commanders to better

manage their responsibilities to minimize both known

and potential deployment OEH exposures to Soldiers,
54 Army Medical Department Journal

Department of the Army (DA) civilians, and Army

contractors. The first major element identified in this

policy is the protection of Army personnel, including

DA civilians and Army contractors, from potential and

actual exposures on the battlefield. In addition, the

policy also discusses the use of operational risk

management practices and ensuring that commanders

are aware of and consider acute, chronic, and delayed

health risks associated with occupational and

environmental potential and actual exposures during

all phases of Army operations and activities. The

current efforts of the GTAP are in line with the overall

intent of this policy. However, not all identified

elements are in complete compliance, and additional

resourcing efforts are necessary to realize the

comprehensive intent of the DOEHRM policy.

Acknowledgement: Mumtaz Ali, Louis G. Boomsma, Mari Robinette-Deasel, Suhale M. Fathimulla,

Farhana Lotlikar, and Sherri C. Whiteman contributed in the preparation of this section.

DEPLOYMENT ENVIRONMENTAL SURVEILLANCE PROGRAM

LTC Christine Moser, MC,USA

The Deployment Environmental Surveillance Program

(DESP) provides coordination of technical

consultative “reach-back” assistance concerning

deployment occupational and environmental health

(OEH) surveillance issues, operational risk

management estimate assessments, and coordination of

sample collection equipment. These efforts supply

commanders and decision makers with pertinent

deployment OEH surveillance information needed to

detect, assess, and counter threats and hazards as part

of the Comprehensive Military Medical Surveillance

Program required by the DoD.3

The existing DESP mission supports the Army

Deployment Occupational and Environmental Health

Risk Management (DOEHRM) program (see

accompanying article, page 46) by championing the

collection, documentation, evaluation, and reporting of

OEH sampling data in the standard operational risk

management (ORM) principle format. The DESP

informs commanders and decision makers, through

their respective preventive medicine personnel, of the

health risks associated with occupational and

environmental potential and actual exposures during

all phases of Army operations and activities. Armed

with this OEH operational risk estimate, commanders

can make informed decisions about properly

mitigating the OEH risks while balancing the

operational requirements of the mission.

The DESP provides coordination of technical

consultative reach-back assistance concerning

deployment OEH issues, sample collection equipment,

media, and shipping coordination. Each discrete

sampling event is interpreted and synthesized into a

deployment OEH risk characterization report by

utilizing the operational risk management model. The

report assists commanders and preventive medicine

professionals with identification, reduction, and

prevention of potential OEH hazards. DESP personnel

provide training assistance with regard to OEH-unique

equipment and the ORM process.

The DESP is the central point of contact to coordinate

and answer deployment OEH questions from

personnel in both predeployment and deployed phases.

DESP personnel collaborate with the technical experts

within USACHPPM or other organizations as

necessary to link customers with the correct answers,

or the technical experts best suited to provide the

answers.

Currently, the Army preventive medicine assets

assigned to brigade combat teams, division

headquarters, special forces groups, and preventive

medicine detachments do not possess the type of

equipment required to perform extensive ambient air,

water, or soil sampling as part of their organic military

authorized equipment. The US Central Command

(USCENTCOM) developed an operating concept for

theater force health protection of joint and

interoperable preventive medicine support. Under that

concept, the Air Force Expeditionary Medical Support

units and Preventive Medicine Teams, the Navy

Forward Deployed Preventive Medicine Units, and

Marine Expeditionary Forces perform the OEH
April – June 2006 55

surveillance mission. Table 1 presents the variety of

deployment sampling equipment, media, and

administrative accessories supplied to the tri-Sservice

preventive medicine assets by DESP.

Additionally, the DESP supplies sampling media and

supplies including preservatives, gloves, coolers, small

tools, barometers, thermometers, etc. Although many

preventive medicine units possess global positioning

systems (GPS), DESP provides GPS equipment that is

dedicated to tracking the location of air, water, and soil

samples for future geospatial mapping. DESP

personnel can also assist with developing a sitespecific sampling plan.

As detailed in Table 2, between May 1991 and April

2006, the DESP provided worldwide equipment and

lab analysis interpretation of approximately 17,000

deployment samples. It should be noted that although

the USCENTCOM theater of operations sample

numbers are themselves robust, DESP OEH

surveillance responsibilities extend to the European

Command, the Pacific Command, the Southern

Command, USNORTHCOM, and the Army Special

Forces Command. For example, between 1999 and

2006, a total of 120 air, water, and soil samples were

collected from the Dominican Republic, El Salvador,

Honduras, Nicaragua, Dominica, Guatemala, Guyana,

Haiti, and Panama.

The deployment OEH risk assessment reports for the

samples listed in Table 2 are created using the

operational risk management doctrine included in

Army Field Manual 100-144and the relatively

conservative (protective) assumptions and methods

contained in the USACHPPM Technical Guide 2301to

facilitate decision-making that can minimize the

likelihood of significant risks. The DESP facilitates

integration of medical threats into mission risk

assessments as described in the USACHPPM

Technical Guide 248.

2

DESP supplies sandfly and mosquito surveillance

equipment and media to the tri-Service preventive

medicine resources involved in Operations Iraqi

Freedom and Enduring Freedom. Mosquito and

sandfly surveillance is performed by USACHPPM

laboratories to analyze vectors that significantly

impact readiness by transmitting disease (malaria and

lieshmaniasis, respectively), analyze specimens for

infectivity of the organism, and impact the outcome of

the operational chemoprophylaxis policy.

Tri-Service preventive medicine personnel typically

perform the air, water, soil, and vector surveillance

functions in deployed settings. However, the

USACHPPM can deploy a Special Medical

Augmentation Response Team – Preventive Medicine

(SMART–PM) upon

request and validation by

the corresponding

component command

surgeon’s office for an

identified deployment

O E H s u r ve i ll a n ce

mi s s i on re q uir in g

subject matter expertise,

i n t e n s e t i m e

c o m m i t m e n t , a n d

dedicated focus. The

scope of the team’s

expertise is tailored to

meet the mission

requirements. The DESP

c i v i l i a n O E H

surveillance subject

Table 1. Equipment, Media, and Accessories Supplied by

the Deployment Environmental Surveillance Program

Equipment Intended Parameters

Deployment soil kits Metals, pesticides,

polychlorinated biphenyls,

herbicides, semi-volatile organic

compounds (SVOCs)

Deployment water kits Metals, volatile organic

compounds (VOCs), pesticides,

inorganics, radionuclides

Airmetrics® Mini-Vol

Particulate Sampler

Particulate matter with a

diameter less than 50 μm,10

μm, and 2.5 μm and heavy

metals

SKC®pumps VOCs

SUMMA® Canisters VOCs

PS-1 high volume

ambient air sampler

Dioxins, furans, SVOCs,

pesticides, Polycylic aromatic

hydrocarbons

Air sampling in Kuwait
56 Army Medical Department Journal

Table 2. Deployment Occupational and Environmental Health Surveillance Samples for the period

May 1991 Through April 2006

Operation or

Exercise

Time

Period

Deployment

Samples Geographic Area (Type Samples)

Desert Storm 1991 5,000 Kuwait and Saudi Arabia; Kuwait Oil Well Fires (air, soil,

industrial hygiene)

Southern Watch 1992–2002 650 Kuwait, Qatar, Saudi Arabia (air, water, soil, industrial

hygiene, bulk, asbestos)

Vigilant Warrior 1994 125 Kuwait, Saudi Arabia (air, water, soil, industrial hygiene)

Desert Focus 1996 250 Saudi Arabia (air, water, soil, industrial hygiene, asbestos)

Joint Endeavor

Joint Forge

1996–2005 2,250 Bosnia (air, soil, water)

Desert Thunder 1998 225 Kuwait (air, water, soil)

Allied Force 1999 25 Albania, Macedonia (water, noise)

Joint Guardian 1999–2005 840 Kosovo (air, soil, water, other)

Native Atlas 1999 100 Kuwait (air, soil, industrial hygiene)

Eastern Castle 2000 25 Jordan (soil)

New Horizons 1999–2006 120 Dominican Republic, El Salvador, Honduras, Nicaragua,

Dominica, Guatemala, Guyana, Haiti, Panama (air, water,

soil)

Joint Interagency

Task Force

(Drug Interdiction)

1999–2006 131 Colombia, Ecuador, El Salvador, Netherland Antilles,

Antigua, Belize, Bolivia, Costa Rica, Guatemala,

Nicaragua, Panama, Peru (air, water, soil)

Tradewinds 1999–2006 19 Antigua and Barbuda, Barbados, Dominican Republic,

Ecuador, Jamaica, St Kitts and Nevis (water, soil)

Joint Task Force

Bravo

1999–2006 125 Soto Cano Air Base, Honduras (air, water, soil)

Enduring Freedom 2001–2006 1,590 Afghanistan, Pakistan, Uzbekistan, Kuwait, Philippines,

Cuba, Ethiopia, Kenya, Kyrgyzstan, Pakistan, Saudi

Arabia, Uganda, Uzbekistan (air, water, soil, industrial

hygiene)

Iraqi Freedom 2003–2006 5,503 Iraq, Kuwait, UAE, Qatar (air, water, soil, industrial

hygiene)

Joint Task Force

Katrina/Rita

2005 164 Louisiana, Mississippi (air, water, soil)

Total 17,142
April – June 2006 57

matter experts have often

augmented the SMART–

PMs, including recent

missions to Afghanistan,

El Salvador, Haiti,

Hurricane Katrina, Iraq,

Kosovo, Kuwait, and

Uzbekistan.

I n p o r t i o n s o f

USCENTCOM’s area of

r e s p o n s i b i l i t y ,

c o n c e n t r a t i o n s o f

airborne particulate

matter less than 10 μm

i n d i a m e t e r a r e

predominantly at levels much higher than normally

encountered in the United States. The primary source

of this particulate appears to be windblown dust and

sand. Not enough information is currently known

about the chemical and physical characteristics to

determine whether short- or long-term health effects

could be expected from exposure to these high

particulate concentrations. Therefore, DESP partnered

with the National Oceanic and Atmospheric

Administration, Natural Environmental Test Office,*

USCENTCOM, and the Desert Research Institute

(DRI) for a year-long study to better distinguish the

particulate matter by both physical (size, shape,

geomorphology) and chemical (metals, elements,

carbon ratios, silica content) characterization. The DRI

will compare this data to existing desert research data

from Operation Desert Storm (1991) and other US and

worldwide locations.

For deployment locations requiring more intensive,

continuous surveillance, the Mobile Ambient Air

Monitoring Station provides continuous surveillance

of US Environmental Protection Agency criteria

pollutants, including carbon monoxide, sulfur dioxide,

nitrogen oxides, ozone and particulate matter less than

10 μm in diameter. This suite of equipment transmits

near-real-time data over the internet, allowing

remotely located DESP personnel to compile

operational risk management estimates. DESP and Air

Quality Program

personnel provide

periodic onsite

s e r v i c e i n

deployment settings

to train personnel,

install upgraded

e q u i p m e n t ,

reposition the station

to a new location,

and establish realtime deployment

OEH surveillance

data connectivity.

C u r r e n t l y, o n e

station is located in a

U S C E N T C O M

operating location. Other stations are available for

deployment as required.

In summary, the ongoing DESP mission remains

operationally relevant by augmenting tactical

preventive medicine assets with deployment OEH

surveillance-unique collection equipment, shipping,

lab analysis coordination, and interpretation. The

subsequent OEH ORM estimate upholds the Army

DOEHRM program, in which commanders make

informed decisions about identification of deployment

OEH health hazards and risk mitigation measures.

Armed with this knowledge, decision makers can

successfully execute their operational mission while

protecting the health of deployed forces during the

entire spectrum of the military operations.

Acknowledgement: John Kolivosky, Chris Weir, and James Sheehy contributed in the preparation of this

section.

*Activity of the US Army Developmental Test Command

(http://www.dtc.army.mil/capabilities/enviro.html)

Water sampling in Iraq Mobile Ambient Air

Monitoring Station in Kuwait

Soil sampling during deployment in

Louisiana (Joint Task Force Katrina)
58 Army Medical Department Journal

Prior to the reorganization of the Deployment

Environmental Surveillance Program (DESP) in 2004,

information technology development and policy

integration were the responsibility of DESP. As a part

of the restructuring, the Deployment Data Archiving

And Policy Integration (DDAPI) Program was

established to develop an information technology

system capable of capturing and archiving

occupational and environmental health (OEH) data, as

part of a Comprehensive Military Medical

Surveillance Program. This program, illustrated

schematically in Figure 3, is mandated by Department

of Defense (DoD) directives, Department of the Army

Policy, and Joint Staff Memorandum to ensure the

effective analysis and dissemination of data. The

DDAPI is responsible as an agent of the Army to

“Provide for the assembling and archiving of all DoD

deployment and environmental health surveillance

data and reports.” as required by DoD directive.4(p5)

In addition, the DDAPI Program is responsible for

integrating OEH into Army Preventive Medicine

through the Doctrine, Organization, Training,

Logistics, Materiel, Personnel and Facilities model,

with primary emphasis on the Doctrine, Training and

Materiel aspects.

To meet this responsibility, the DDAPI, in

coordination with the Defense Occupational and

Environmental Health Readiness System (DOEHRS)

has developed the Occupational and Environmental

Health Data Portal (OEH-DP).5 The OEH-DP is a

password protected internet site that allows registered

users to submit and retrieve documents and other

electronic files associated with OEH activities.

In addition to maintaining the OEH-DP, the DDAPI

Program is responsible for developing an information

technology system to capture, process, analyze,

interpret, and report all OEH data. Examples of this

data include, but are not limited to, environmental

samples (air, water, soil), entomological data,

sanitation surveys, and waste management surveys. To

accomplish this, DoD is expanding the current

capabilities of DOEHRS Industrial Hygiene

(DOEHRS-IH) to capture and manage the types of

data outlined above. The DDAPI, in conjunction wit

the other armed services, is developing the system

requirements needed to expand the capability of

DOEHRS-IH. The goal is to have a single system for

environmental and occupational health surveillance

data for both deployment and garrison conditions.

The DOEHRS-IH is only one part of comprehensive

medical surveillance and will be linked to other

military health systems such as the Armed Forces

Health Longitudinal Technology Application.6 These

systems will work together to provided a longitudinal

health record for all military personnel from the time

they enter military service until they separate.

In addition, the DDAPI is assisting in the development

and integration of doctrine, training, and material

requirements for OEH for the Army. The program,

along with the Navy and Air Force, worked to develop

ASTM E2318-03,

7 which standardizes the process to

evaluate sites used by US military personnel. The

DDAPI is the proponent for US Army Center for

Health Promotion and Preventive Medicine

(USACHPPM) Technical Guides 230 and 248.

1,2

The DDAPI provides OEH training to a wide variety

of DoD agencies and personnel. The training includes

sampling techniques, operational risk management,

entomological surveillance, radiation protection, risk

communication, and situational training exercises. The

training is conducted using a wide variety of

USACHPPM subject matter experts and is coordinated

with other agencies and armed services for consistency

across the Department of the Army and DoD.

DEPLOYMENT DATA ARCHIVING AND POLICY INTEGRATION

Brad E. Hutchens

Health Surveillance

Medical

Surveillanc e

Comprehensive

Military Health

Surveillance

Occupational and

Environmental

Health Surveillance

Figure 3. The Comprehensive

Military Health Surveillance Program
April – June 2006 59

Material solutions are developed to assist preventive

medicine personnel in the collection of OEH samples.

The DDAPI personnel are constantly investigating

commercial-off-the-shelf equipment that can provide

more effective and efficient ways to acquire OEH data.

Also, existing sampling methods are reengineered to

meet the needs of a deployed military force by making

existing equipment and sampling media lighter,

smaller, simpler to operate, and more rugged.

Examples of this include the deployment water and

soil sampling kits (Figures 4 and 5) and the

Deployment Environmental Surveillance Backpack

(Figure 6).

DDAPI personnel also participate in several DoD and

international work groups. This participation allows

technology to be leveraged across the DoD and the

international community, bringing together OEH

surveillance data from throughout the Armed Services

and International coalitional partners.

As discussed in detail in an accompanying article

(page 46), the Department of the Army’s Deployment

Occupational and Environmental Health Risk

Management program policy has 13 major elements

that enable commanders to better manage their

responsibilities to minimize both known and potential

deployment OEH exposures to Soldiers, Department

of the Army civilians, and Army contractors. All of the

elements require OEH data to be captured, processed,

analyzed, interpreted, and reported, which is the

mission of the DDAPI program.

Acknowledgement: Wilbert Moultrie, Mark Walter,

Kenya Jones, Mary Roso, Warren Wortman and

Art Lee contributed in the preparation of this section.

REFERENCES

1. Technical Guide 230, Guide for Deployed Preventive

Medicine Personnel on Health Risk Assessment.

Version 1.3. Aberdeen Proving Ground, MD: US

Army Center for Health Promotion and Preventive

Medicine; 2003. Available at: http://chppmwww.apgea.army.mil/documents/TG/TECHGUID/

TG230.pdf.

2. 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/TG248.pdf.

3. DoD Directive 6490.2, Medical Surveillance.

Washington, DC: US Dept of Defense; 21 October,

2004.

4. Field Manual 100-14: Risk Management.

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

1998.

Figure 4. Deployment Potable Water

Sampling Kit

Figure 5. Deployment Soil Sampling Kit

Figure 6. Environmental Surveillance

Sampling Backpack
60 Army Medical Department Journal

5. US Dept of the Army. DOEHRS OEHP portal.

Available at: https://doehrswww.apgea.army.mil/

doehrs-oehs/. Registration required.

6. Office of the Assistant Secretary of Defense (Health

Affairs), US Dept of Defense. AHLTA, Global

information for quality care. Available at: http://

www.ha.osd.mil/AHLTA/.

7. 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; 2006.

AUTHORS

Jeffrey Kirkpatrick is the Program Manager, Global Threat Assessment Program, Directorate of Health Risk Management,

US Army Center for Health Promotion and Preventive Medicine, Aberdeen Proving Ground-Edgewood Area, Maryland.

LTC Moser is the Program Manager, Deployment Environmental Surveillance, Directorate of Health Risk Management, US

Army Center for Health Promotion and Preventive Medicine, Aberdeen Proving Ground-Edgewood Area, Maryland.

Brad Hutchens is the Program Manager, Deployment Data Archiving and Policy Integration Program, Directorate of Health

Risk Management, US Army Center for Health Promotion and Preventive Medicine, Aberdeen Proving Ground-Edgewood

Area, Maryland.

THE US ARMY CENTER FOR HEALTH

PROMOTION AND PREVENTIVE MEDICINE
April – June 2006 61

As times change, the defined roles for some military

occupations must also change. One field where this

has become evident is in the field of Army Public

Health Nursing, Area of Concentration (AOC)

designation 66B. The need for transformation is

apparent from the recent name change for the 66B

(Public Health Nurse), previously Community Health

Nurse. Traditionally, the role of the Army Public

Health Nurse (APHN) has been defined in terms of

program management sets. The AOC was originally

created in 1949 to run a planned program geared to

assist new parents adjust to family life, with the overall

goal of decreasing emergency room utilization. The

scope of practice quickly widened to programs

focusing on family-centered services and

communicable disease case management.1 Over time,

the AOC 66B incorporated many more programs,

including the identification or labeling as the Latent

TB Infection (LTBI) program manager, the Sexually

Transmitted Infection (STI) clinic director, the HIV/

AIDS program administrator, the health consultant to

the Child and Youth Services, or the Health Promotion

Center manager. Other more local program titles might

be In-Out Processing Center manager, Pregnant

Soldier Physical Training Program director, or the

Smallpox Vaccination coordinator. Sometimes one

might wonder if the APHN is being asked to function

as a specialty practicing nurse or as a nurse program

administrator.

The incorporation of the previously mentioned

programs as responsibilities of the AOC is not really

the issue. The APHN can certainly function in those

areas, and should maintain those duties. However, they

have found themselves pigeon-holed into those

program roles. Many of those responsibilities are not

required during deployment, or at the least in a full

time capacity. The APHN could be deployed being

completely unsure of what will be expected. This

uncertainty is understandable since much of the

previous training and job descriptions have been

geared towards running those programs.

A medical command group will naturally attempt to

optimize use of their assets in a deployed setting. In

the case of the Army Public Health Nurse, they must

consider any value that is realized when this resource

is assigned those traditional programs of the APHN in

garrison. They know there is no need for a child and

youth health consultant because there are no Child

Development Centers. They are not interested in the

establishment of an HIV/AIDS program. They

probably do not see the need for in and out processing

of Soldiers through the medical treatment facility. STI

and LTBI can be followed in the acute care setting in a

combat support hospital or a battalion aid station under

established standard operating procedures. The

environment of deployment probably explains why the

deployed APHN is often tasked to function within the

scope of the general medical-surgical nurse AOC on

the intermediate or the minimal care ward. The

command often sees that task as the most appropriate

use of a nurse in a deployed environment. However, in

making such assignments, commanders fail to fully

exploit the valuable skills of the Public Health Nurse.

The role of the APHN in the increasing involvement of

the Army in humanitarian efforts and civil-military

operations is another factor to consider in Army Public

Health Nurse training. The AOC 66B has been

proposed to fill two slots within a civil affairs (CA)

section of the Medical Deployment Support

Command. Under the responsibilities expected of the

CA section, there is little need for the APHN to

function within the traditional roles or programs of that

AOC. Instead, the Army Public Health Nurses will be

expected to apply their skills as public health officials.

It is within this evolving environment that the APHN

basic skill set must change to meet the changing needs

of the Army, but at the same time maintain

Making the Modern Army Public

Health Nurse: Establishing

Essential Service Skills

MAJ James A. Madson, MS, USA

LTC Bryan J. Alsip, MC, USA
62 Army Medical Department Journal

familiarization with the traditional programs still

expected of the APHN in garrison. To accomplish this,

it is important that we start looking at the APHN

profession, not as program managers, but as skilled

professionals that have much to bring to Preventive

Medicine, Force Health Protection, and military

operations. Recently, leadership in the APHN field has

identified the direction to take regarding the APHN

future practice.2 They have established a vision of

ready and fit Soldiers prospering in healthy military

communities. The overall goal is to realize this vision

and to align the 66B AOC with the American Nursing

Association’s (ANA) understanding of the skill sets

required by a public health nurse to accomplish the

job. For the APHN, this skill set should be used under

any number of situations, including garrison, deployed

settings, civil-military operations, and even local

emergency response conditions.

The knowledge-based skill set recognized as the base

foundation to practice as an Army Public Health Nurse

has come to be known as the APHN-Public Health

Essential Services. The 10 services are built directly

around the work of the National Public Health

Performance Standards Program.3It supports the 3

core public health functions (assessment, policy

development, and assurance) modeled by the

Association of State and Territorial Directors of

Nursing Public Health Nursing Practice Model,4 with

the intent to standardize practice according to the

ANA. The essential services, listed below, are those

that the APHN is expected to perform under any

situation requiring community-based health

interventions and public health nursing efforts:

1. Monitor health status to identify 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 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 a competent public and personal health

care workforce.

9. Evaluate effectiveness, accessibility, and quality

of personal and population-based health

services.

10. Research new insights and innovative solutions

to health problems.

To implement these skills, it is imperative that the

initial training for the Army Public Health Nurse

includes fundamental development and understanding

of these essential service expectations. Presently, to

become an Army Public Health Nurse, a Registered

Nurse is required to attend the Principles of Military

Preventive Medicine (6A−F5) course within the Army

Medical Department (AMEDD) Center and School.

Adjustments have been and continue to be made to the

skill sets training in the 6A−F5 course, especially the

nurse track phase, to accommodate this paradigm shift

in Army Public Health Nursing.

The greatest change came in 2003, when a number of

hours in the HIV/AIDS certification material were

removed from the program. Though the topic is

relevant to the 66B AOC, the depth was much greater

than necessary when viewed in light of practical

expectation of future application as an APHN.

Though 6 hours of HIV/AIDS material are still

provided, elimination of this and some other material

freed up nearly 30 hours for additional course work.

Health fairs are perfect examples of how Army

Public Health Nurses can educate and inform the

public and mobilize community partnerships.

During their training in course 6A- F5, the APHNs

are deeply immersed in the development and

presentation of a health fair which will typically

host 200 to 300 clients with 12 to 15 vendors.
April – June 2006 63

The available time is used to focus on the essential

skill sets and projected roles of the APHN in a

deployed setting. Along with introduction to some

other programs, classes that focused on developing

skills applicable to public health nursing were

incorporated into the curriculum. Training in many

skills was expanded. Classes on the Planned Approach

To Community Health and the PRECEDE/PROCEED

models5 were introduced as tools for community

assessments and setting health objectives for the

community. Conducting a community health

assessment is the primary skill that the APHN will

need. The skill set includes collection of data, analysis

of information, and determining risks and resources

within the population. The assessment establishes the

foundation of all the other APHN responsibilities. The

assessment must not only consider the health of the

population, but also recreation, education, safety, and

economics. The professional skills background in

nursing and the ability of nurses to build partnerships

and mobilize the community make the APHN

assessment different from other Preventive Medicine

assessments.

Additional courses on etiology and epidemiology on

many of the newer diseases of military importance are

now included to improve competence in this critical

area. A sample of these useful topics includes

emerging infectious diseases, such as West Nile virus,

avian influenza, and leishmaniasis. Another

contemporary issue is exposure to biological agents

and environmental hazards during deployment. It is

important that the APHN is able to discuss these issues

in the military context, and also have an awareness of

the concerns of individuals who face potential

exposure, as well as those of family members worried

about their Soldiers.

To facilitate the changing role of the APHN,

completely new material was introduced into the

curriculum. The APHN now receives 12 hours in civil

affairs, rapid health assessments, nutritional

considerations in disaster relief, preventive medicine

support in contingency operations, and PM operations

with detainees. This course material was added to help

the APHN incorporate the essential services and public

health core functions into military operations other

then war, in particular humanitarian assistance and

disaster relief. The material is there to stimulate

student thinking about the APHN role in a deployed

setting. The student must understand that although the

responsibilities during deployments are different in

many ways from those in garrison, basic skills are

applied the same way. The APHN must assess the

deployment setting for risk and potential health

concerns, and identify resources. Interventions,

programs, and policies must then be instituted to

decrease the risks and to link specific populations with

the proper programs and resources in the area of

concern. Lastly, the setting must be evaluated for the

effectiveness of efforts and changes in the community.

The population might be different, but the essential

service skill set does not change.

During the 6A- F5 course, Army Public Health

Nurses work with other Preventive Medicine

Officers on issues that today’s Soldier may face in

a deployed setting. Cross-training, thorough

investigations, and command briefings are

emphasized during the training period.

Army Public Health Nurse training often includes

understanding responsibilities not traditionally

nursing in nature. Here, two student APHNs

identify mosquitoes in an effort to manage a

notional malaria threat.
64 Army Medical Department Journal

Good presentation skills are necessary for the APHN

to inform, educate, and empower people. Public

speaking is vital to informing commanders of current

issues, instructing personnel to insure a competent

public health system, and supporting regulations. The

presentations of medical threat briefs and aggregate

health promotion education are the principal means for

the prevention of disease and nonbattle injury in the

Army. The APHN exposure to public speaking skill

development has nearly doubled with recent changes

in the nurse track of the 6A−F5 course.

Another increasing role for preventive medicine is in

homeland security and local disaster response plans.

The APHN is now given exposure to the issue and

made aware of the potential need for public health

nurse involvement in response plan development and

postevent action. They are taught this with a special

emphasis on biological threat responses,

communicable disease outbreak responses, and

preventive medicine support. Once again, in this

environment, the APHN must be able to incorporate

the essential service skills to manage the community

under any of the potential situations.

There are, of course, many previous topics in the

6A−F5 course which are still integral parts of the

training of the APHN. Some of these broad topics

include epidemiology, outbreak investigations,

occupational and radiological exposures,

environmental quality, medical entomology, data

management, and risk communication. No

modifications have specifically been made to this

material, but the nurses are challenged to see how this

material is applicable within their scope of practice,

and how it relates to the essential service skill set they

are assimilating. The APHN also participates in a

Preventive Medicine Operation and Field Training

Exercise at the end of the course. They are immersed

in a simulated deployed setting with other preventive

medicine disciplines and are expected to incorporate

their proficiency in issues that might occur in a field

environment.

The modifications to update the role of the APHN also

come at a critically vital time for the AMEDD. The

capabilities of officers in other professional AOCs

within Army Preventive Medicine are enhanced by the

deployment of the skilled APHN in the operational

setting. Whether at a combat support hospital or within

a civil affairs unit, the assessment skills of the APHN

can be invaluable to other nurses, physicians,

physician assistants, and other AOCs, including

Environmental Science Officers (ESOs),

Environmental Engineers, Audiologists, Nuclear

Medicine Science Officers, and Medical

Entomologists. Greater numbers of ESOs are now

assigned at the brigade level to enhance surveillance

capabilities within a division. The APHN can now

work hand in hand with ESOs at the brigade level and

with preventive medicine physicians who are often

assigned to the division surgeon section. This allows

the APHN to act as an effective force multiplier for

preventive medicine in this setting.

The changes in the program have been geared toward

the modernization of the Army Public Health Nurse.

The APHN brings educational expertise and

professional nursing skills into the Army Preventive

Medicine arena. Their background in the holistic

nursing process helps fuse the environmental aspects

with the individual factors associated with public

health. They understand human responses to exposures

and to the diseases that might occur. They can bridge

the gap between data availability and practical

utilization of these data. The public tends to trust the

nurse in situations where they might be reluctant to

accept words and messages from someone else.

Therefore, the Army Public Health Nurses find

themselves well placed in situations to bring public

health education, compliance, and agreement on the

focus of preventive medicine to benefit our most

important asset – the Soldier.

Public speaking as a means of informing and

educating the community and assuring

competency among other health care workers is

essential in the development of the Army Public

Health Nurse.
April – June 2006 65

REFERENCES

1. Field Manual 8-24: Community Health Nursing in

the Army. Washington, DC: US Dept of the Army; 10

March 1980.

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

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

Army Med Dept J. 2005;PB 8-05-7/8/9:21-24.

3. The Public Workforce: An Agenda for the 21st

Century. Washington, DC: US Dept of Health and

Human Services, Public Health Service; 1997. Full

report of the Public Health Function Project.

4. Association of State and Territorial Directors of

Nursing: Public Health Nursing: A Partner for

Healthy Populations. Washington, DC: American

Nurses Publishing; 2003.

5. Green L, Kreuter M. Health Promotion Planning.

2nd ed. Mountain View, CA: Mayfield Publishing

Co; 1991.

AUTHORS

MAJ Madson is the AOC 66B Program Director in the

Department of Preventive Health Services, Academy of

Health Sciences, AMEDD Center & Schools, Fort Sam

Houston, Texas.

LTC Alsip is the 6A−F5 Course Director in the

Department of Preventive Health Services, Academy of

Health Sciences, AMEDD Center & Schools, Fort Sam

Houston, Texas.

The new logo emphasizes the modern paradigm of

today’s Army Public Health Nurse as a specialty

practicing nurse, not a program manager.
66 Army Medical Department Journal

INTRODUCTION

The US Army's 1st and 9th Area Medical Laboratories

(AMLs) provide the Department of Defense (DoD)

with a Force Health Protection (FHP) capability. FHP

is a strategy using preventive health techniques and

emerging technologies in environmental surveillance

and combat medicine to protect all service members

before, during and after deployment.1 The mission of

the AML:

On order, deploy worldwide and conduct health hazard

surveillance for biological, chemical, nuclear,

radiological, occupational/environmental health, and

endemic disease threats at the theater level to protect

and sustain the health of the force across the full

spectrum of military and domestic support operations.

Through the use of sophisticated analytical

instrumentation combined with health risk assessment

by medical and scientific professionals, the AML

performs field confirmation of environmental

exposures associated with the contemporary operating

environment. The execution of this mission provides

the warfighting commander with the critical

information requirements needed to mitigate or

eliminate health threats during the operational risk

management process.

The 1st and 9th AMLs are the only deployable

laboratories in the US Army's inventory capable of

providing health hazard surveillance through a robust

analytical capability. Both AMLs are an Echelon

Above Corps level asset assigned to 44th Medical

Command and XVIII Airborne Corps. This

relationship exists primarily to provide command and

control, however, both AMLs can provide FHP

support to Army, joint, or combined forces. The AML

is authorized 43 personnel, however, only 30

personnel are required by the Modified Table of

Personnel and Equipment and are available at all

times. The 13 personnel not permanently assigned to

the unit are PROFIS (Professional Filler System)

assigned to US Army Medical Command (MEDCOM)

organizations. The organizational structure of the

AML consists of the Headquarters, Occupational/

Environmental Health, Nuclear/Biological/Chemical,

and Endemic Disease Sections. The unit personnel

represent a wide range of scientific military

occupational specialties, therefore, both the 1st and 9th

AMLs are capable of providing the comprehensive

health hazard surveillance typically associated with

MEDCOM's fixed facilities.

The home station of the AMLs is Edgewood Area,

Aberdeen Proving Ground, Maryland. This location

was chosen due to the reliance of the 1st and 9th

AMLs on MEDCOM for sustaining Soldier technical

proficiency. The AMLs draw upon the following

organizations for the scientific expertise, technical

training, assistance, and consultation:

 US Army Center for Health Promotion and

Preventative Medicine (USACHPPM),

 US Army Medical Research Institute for

Chemical Defense (USAMRICD)

 Walter Reed Army Institute for Research

(WRAIR)

Due to the proximate location to these organizations,

the AMLs can easily leverage and stay current with the

emerging technologies necessary to perform their FHP

mission.

Force Health Protection

Through Laboratory Analysis and

Health Risk Assessment

MAJ Patterson W. Taylor, MS, USA

COL Scott W. Gordon, MS, USA

MAJ Tara L. Hall, MS, USA

MAJ Gregory L. Kimm, MS, USA

CPT Stuart D. Tyner, MS, USA

CPT Gerald T. Van Horn, MS, USA
April – June 2006 67

HISTORY

The Army has activated and inactivated both the 1st

and 9th AMLs several times. Both laboratories

supported campaigns in World War II. The 1st AML

participated in investigations in North Africa and the

European Theaters of Operation. The 1st AML also

participated in campaigns of the Korean War and the

Vietnam War. The 9th AML participated in the ChinaBurma-India Theater during World War II and

participated in 15 campaigns in the Vietnam War. The

Army activated the current version of the 1st and 9th

AMLs in September 2004. The Army based both

AMLs on the structure of the 520th Theater Army

Medical Laboratory (TAML) which was inactivated on

the same day. The history of the 520th TAML is

similar to the AMLs with participation credit for

Vietnam, Bosnia, and Operation Iraqi Freedom.

Transformation of the 520th TAML to the 1st and 9th

AMLs did little to change the mission. The Army

expects both units to execute the same level of

surveillance as the 520th TAML performed in support

of Operation Iraqi Freedom. The chain of command

for both the 1st and 9th AMLs runs through the 44th

Medical Command, the XVIII Airborne Corps, and the

US Army Forces Command. The Army preserved this

chain of command during the conversion from the

520th TAML. The personnel of both units are largely

enlisted Soldiers of the 91 (now changed to 68)

military occupation specialty series and a sergeant

major is the highest ranking noncommissioned officer.

In addition to the commander, 5 officers provide

leadership to the AML. The Army equips both AMLs

with tactical equipment that enable the units to move

and survive in a tactical environment. Each AML has

organic transportation assets including 5-ton trucks,

FMTVs (Family of Medium Tactical Vehicles), and

HMMWVs (High Mobility Multipurpose Wheeled

Vehicles). The AML conducts laboratory operations in

TEMPERs (Tent, Extendable, Modular, Personnel),

and Isolation Facilities. Each AML can supply all the

power needed for its own continuous operations.

Both AMLs retained headquarters at Aberdeen

Proving Ground, the location of the former 520th

TAML’s headquarters. Since the endemic disease

section has a close relationship with US Army Medical

Research Institute for Infectious Disease

(USAMRIID), both AMLs stationed this section of

their units at Fort Detrick, Maryland. The AMLs

retained the same close relationship that the 520th

TAML established with USACHPPM, USAMRICD

and USAMRIID. Combined, these centers provide

most of the technical training needed by each AML.

These centers also provide PROFIS personnel and

controller/observers to evaluate the performance of

each AML on field exercises.

CAPABILITIES

The personnel and equipment organizational structure

of the AML places great challenges upon the AML to

perform logistical and maintenance operations. Based

upon the Modified Table of Organization and

Equipment (MTOE), the AML is approximately 35%

mobile. If and when called upon to provide support in

a theater of operation, the AML would require

transportation assets to move all assigned equipment

and personnel. Under the new MTOE following the

Medical Reengineering Initiative, the AML lost key

support military occupational specialties (MOS)

formerly available in the 520th TAML. The most

significant losses were the Supply Sergeant (MOS

92Y20), Utilities Equipment Repairman (52C10), and

the Medical Equipment Repairman (91A20).

The AML Headquarters provides command and

control functions, operational planning, administrative

and logistics support to the unit. The headquarters is

staffed by the commander, executive officer, sergeant

major, medical operations officer, medical supply

sergeant, administrative specialist, wheeled vehicle

mechanic, and a cook.

Occupational and Environmental Health Section

The Occupational and Environmental Health (OEH)

Section of the AML provides comprehensive

environmental health threat assessments by conducting

air, water, soil, entomological, epidemiological, and

radiological surveillance and laboratory analyses. In

support of this mission, the OEH Section conducts

analysis in 4 areas: environmental health, industrial

hygiene, radiological assessment, and entomology.2-4

The OEH Section monitors air quality for particulate,

inorganic, and organic contaminants. The Section

employs high volume, mid volume and low volume air

sampling equipment capable of collecting particulate

samples PM-10 (Particulate Matter 10 μm), PM-2.5

(2.5 μm), TSP (Total Suspended Particulates), and

inorganics (ie, heavy metals). Sorbent tubes and

polyurethane foam sampling systems are utilized to
68 Army Medical Department Journal

collect ambient and breathing-zone samples of volatile

and semivolatile organics. The OEH Section

presumptively determines particulate samples and

sends these and inorganic samples to a laboratory in

the United States for confirmatory analysis. The NBC

Section receives the sorbent tubes collected by OEH

Soldiers and analyzes the tubes using gas

chromatography coupled with either mass selective

detector, electron capture detector (ECD) or flame

photometric detector (FPD).

The OEH Section executes comprehensive water

quality surveillance. The OEH Section conducts

inorganic analysis using ultraviolet and visible light

spectroscopy and measures most inorganic water

contaminants absorbance readings taken after addition

of applicable reagents or in conjunction with other

isolation and extraction procedures and reagent kits.

The OEH Section detects, identifies, and measures

concentrations of lead and copper in potable water

with an electrochemical device which utilizes anodic

stripping voltammetry. The method is specific for lead

and copper and is free from all known interferences

typically found in potable water. Organic analysis is

conducted using either a portable gas chromatograph/

mass spectrometer (GC/MS) or a benchtop GC/MS/

ECD/FPD. To detect bacteriological contamination in

water, the OEH Section utilizes presence/absence

techniques, membrane filtration, most probable

number, and heterotrophic plate counts. To further

identify nonfecal coliforms or other problematic

bacteria, the Section can forward collected samples to

the Endemic Disease Section for analysis.

Soil sampling and analysis for the detection of

volatiles, semivolatiles, inorganics, metals, and

biologicals is also possible. The OEH Section uses

traditional soil sampling equipment and techniques to

obtain surface and subsurface soil samples. The

Section has the capability to conduct some limited, onthe-spot colorimetric and electrochemical testing for

PCBs (polychlorinated biphenyls) and PAH

(polycyclic aromatic hydrocarbons), but most chemical

soil analysis is conducted by the NBC Section using

head-space analysis with the portable GC/MS or

solvent extraction with analysis on the benchtop GC/

MS/ECD/FPD.

The OEH Section deploys a robust radiological

surveillance capability. The Section uses numerous

high volume particulate samplers and collects filters

for radiological analysis. The Soldiers analyze these

samples and collected soil samples using multichannel

scaling spectroscopy. The Section also has a handheld

radiation spectrometer/identifier, dose-ratemeter, and

nuclide finder in addition to multiple radiac meters

with probes for measuring alpha, beta, and gamma

radiation. The Section analyzes wipe samples and

water samples using a liquid scintillation counter. The

Soldiers also employ dosimeters to manage their own

exposures as well as occupational exposures of those

working in and around radiation hazards. Further,

besides detecting, identifying, and measuring ionizing

radiation, the Section also has the capability to detect

and measure nonionizing radiation hazards.

The OEH Section conducts industrial hygiene surveys.

Using multigas electrochemical analyzers,

photoionization detectors, infrared gas analyzers, and

sampling pumps with filters and/or sorbent tubes, the

Section identifies potential chemical hazards in the

workplace. Noise meters, noise dosimeters, thermal

environment monitors, ventilation meters, and particle

counters help to characterize the physical environment

and indoor air quality. Utilizing portable GC/MS and

portable Fourier Transform Infrared Spectroscopy

technology, the OEH Section responds and

qualitatively identifies many unknown solids, liquids

and gases.

The OEH Section contributes expertise in medical

entomology, another vital discipline. The Section

collects and identifies arthropods, rodents, and

poisonous plants of military importance, and also

raises mosquito larvae for accurate species

identification or potential insecticide resistance

studies. The Section prepares and forwards specimens

to the Endemic Disease Section for real-time or

traditional polymerase chain reaction analysis to detect

and identify medically relevant vector-borne diseases.
April – June 2006 69

The OEH Section’s strength is the ability to conduct

complete worksite and ambient environment

evaluations to detect and identify the hazards present

in the full spectrum of media, air, soil, water, physical

environment, arthropods and rodents. These

comprehensive evaluations provide the data necessary

to conduct accurate and thorough environmental health

site assessments.

Nuclear Biological and Chemical Section

The capabilities of the Nuclear/Biological/Chemical

(NBC) Section include cholinesterase activity

measurement, microbial identification, GC/MS/ECD/

FPD, a mobile laboratory and telechemistry. These

capabilities allow the Section to monitor for chemical

weapons of mass destruction and a wide variety of

toxic industrial chemicals, as well as to conduct

microbial identification using an independent method

that compliments the capabilities of the Endemic

Disease Section. The NBC Section works closely with

both the OEH and Endemic Disease Sections. The

NBC Section analyzes many samples collected by the

OEH Section. Similarly, the NBC Section analyzes

microbes cultured and incubated by the Endemic

Disease Section. The technicians of the NBC Section

execute all of the capabilities in an isolation facility

(ISOFAC). The Soldiers set up the ISOFAC using an

expandable, 2-sided shelter attached to 2 sections of

TEMPER. Some of the capabilities can be executed in

the mobile laboratory mounted in a shelter unit on the

back of a M1097 HMMWV.

The NBC Section provides confirmatory analysis of

exposure to nerve agents and toxic industrial

compounds (organophosphorus pesticides) by

measuring acetylcholinesterase (AChE) activity in

Soldier blood samples. Technicians use the Test-mate

ChE Test System (EQM Research, Inc, 2814 Urwiler

Ave, Cincinnati, Ohio, 513-661-0560) to perform the

tests for AChE. The ability of the Test-mate ChE Test

System to determine AChE activity under field

conditions was evaluated several years ago by the

520th TAML in conjunction with USAMRICD. To

mimic nerve agent exposure, USAMRICD spiked

blood samples with variable amounts of soman.

Blinded to the identity of the samples, the 520th

TAML tested the samples during a field training

exercise. The technicians accurately identified all of

the samples and quantified the AChE activity.5

The NBC Section provides confirmatory analysis of

microorganisms including aerobic bacteria anaerobic

bacteria and yeasts using the MIDI Sherlock Microbial

Identification System (MIDI, Inc, 125 Sandy Drive

Newark, Delaware, 800-276-8068). The MIDI analysis

system is based on fatty acid profiles and contains

reference profiles for thousands of microorganisms.

This technique provides an identification that is

independent from other techniques used by the

Endemic Disease Section.

The NBC Section provides confirmatory analysis of

air, water, wipe, and soil samples using an Agilent

6890N GC (Agilent Technologies, Inc, 395 Page Mill

Road, Palo Alto, California, 650 752 5303). The

technicians extract water, wipe, and soil samples. Mass

spectra frequently provide a unique fingerprint

identification of chemicals. Using the retention time

and the mass spectrum, technicians can often identify a

chemical based solely on the results of GC-MS. The

other detectors, the ECD and FPD, provide analysis for

much lower concentrations of threat chemicals. The

ECD detects compounds containing halogens and

other electrons withdrawing groups at levels much

lower than the mass selective detector (MSD). The

FPD provides much greater sensitivity for compounds

containing sulfur and phosphorous than the MSD.

Soldiers of the NBC Section also conduct GC-MS with

a portable instrument called HAPSITE (Inficon, Inc,

Two Technology Place, East Syracuse, New York,

315-434-1100). Using the HAPSITE, Soldiers can

commence analysis with less than an hour setup time

The 520th TAML constructed a mobile NBC

laboratory from a shelter unit mounted on a M1097

HMMWV, equipped with a GC-MS, glovebox and

Ruggedized Advanced Pathogen Identification

Device® (Idaho Technology Inc, 390 Wakara Way,

Salt Lake City, Utah, 801 736-6354) thermal cycler.6

The M1097 HMMWV pulls a trailer with a mounted

generator that supplies all the power needed to conduct

sample preparation and GC-MS analysis. A full tank

of fuel is sufficient to power the generator in nearly a

week of continuous use. The mobile laboratory

platform gives the commander of the AML more

flexibility in responding to a volatile environment. The

AML mobile lab can conduct sample analysis more

rapidly upon arrival in an area of operations, usually

within 3 hours of arrival, and can perform initial

analysis at a remote location instead of waiting for

collected samples to arrive at the ISOFAC. The mobile

laboratory provides the commander of the AML with

the ability to test for chemical and biological agents,

endemic diseases and to monitor cholinesterase

activity in Soldiers with potential field exposures.
70 Army Medical Department Journal

Through a joint venture with USAMRICD, the AMLs

have developed the capability to conduct

telechemistry. Through a satellite link, senior scientists

at USAMRICD can control the computers that run the

AMLs gas chromatographs, conduct data analysis,

tune the MSD, troubleshoot, and even run samples.

Through a video link, USAMRICD scientists can

inspect sample preparation and identify other problems

that require visual inspection. Telechemistry provides

the AMLs in a deployed environment with

unprecedented access to scientists with years of

experience in analytical chemistry.7

Endemic Disease Section

Upon request, the Endemic Disease Section deploys

worldwide to conduct health threat surveillance for

biological warfare agents and endemic disease threats

at the theater level and provides and sustains FHP. The

Endemic Disease Section is composed of an officer-incharge (captain or major, microbiologist [MOS 71A]),

a noncommissioned officer-in-charge (staff sergeant

[91K30]), and 4 medical laboratory technicians (MOS

91K). The Section sets up its laboratory in an ISOFAC

that is nearly identical to that used by the NBC

Section. The Section is self-supporting, with the

capacity to transport tactical and technical equipment,

provide environmental control and power generation

equipment in order to complete any assigned mission.

The Endemic Disease Section relies primarily on

nucleic acid and antigen detection based technologies,

along with basic microbiological techniques in order to

detect, identify, and analyze naturally occurring

infections and biological warfare (BW) agents that

may be encountered during deployments. The Section

can also conduct laboratory diagnosis of military

relevant infectious diseases which are endemic within

the theater. However, in order to enhance the

capabilities of the section, PROFIS personnel are

assigned, including a veterinary pathologist, veterinary

microbiologist, preventative medicine physician, and

an infectious disease physician. With the PROFIS

personnel, the Section serves as the local joint task

force commander’s subject matter experts on matters

regarding infectious disease and BW agents, providing

laboratory support for in-theater infectious disease

outbreak investigations, and processing and analyzing

potentially dangerous infectious specimens.

Currently, the nucleic acid identification capabilities/

technology relies on the Ruggedized Advanced

Pathogen Identification Device (R.A.P.I.D®). The

system utilizes quantitative real-time polymerase chain

reaction technology and provides both presumptive

and confirmatory analysis of potential BW and

endemic disease agents. The system consists of the

R.A.P.I.D. analyzer, a laptop computer for

programming the analyzer, and backpack for efficient

storage and ease of transport. Associated durable

equipment consists of the nucleic acid extraction kits,

a microcentrifuge for centrifugation of 1.5 ml snap-cap

tubes, and a standard color printer. The technology is

based on the detection of a fluorescent reporter

fluorochrome attached to an internal primer that

hybridizes to the target sequence between traditional

forward and reverse primers. Presently, our BW

nucleic acid confirmatory detection capabilities are

limited to approximately 8 to 10 agents. Reagents are

selected based on the disease causing agents endemic

to a particular region and what is available through

supporting research institutions, such as USAMRIID.

For antigen detection based capabilities, the Endemic

Disease Section employs the M-Series® M1M

analyzer (BioVerisTM Corp, 16020 Industrial Drive,

Gaithersburg, Maryland 20877, 800-336-4436), an

antibody-antigen based identification system

(sandwich immunoassay) developed for the detection

of a variety of antigens/analytes from small molecules,

proteins, and microorganisms. The system is capable

of analyzing raw liquid samples such as blood, serum,

and liquid buffers from a joint biological point

detection system or biological integrated detection

system unit. The technology is based on

electrochemiluminescence. Sample preparation tags

the target to emit light when electrochemically

stimulated. Presently, BW antigen confirmatory

detection capabilities are limited to approximately 9

agents using the M1M analyzer, with expanded

capabilities using an Enzyme Linked Immunosorbent

Assay (ELISA).

The Endemic Disease Section is also capable of

providing basic laboratory support for weaponized and

endemic bacterial agents and parasitic organisms.

Limited culture capabilities include the ability to

generate ambient air, microaerophilic, and anaerobic

culture environments. Basic biochemical identification

of many human pathogens and environmental

organisms can be performed. To enhance this

capability the Dade Behring Microscan® autoSCAN®

system (Dade Behring, Inc, 1717 Deerfield Road,

Deerfield, Illinois 60015, 847-267-5300) is employed

to provide definitive identification of gram positive
April – June 2006 71

and gram negative organisms. The antimicrobial

susceptibilities of these organisms can also be

determined with the autoSCAN®. Endemic parasite

identification can be performed on fixed sample

unknowns and other sample types, such as malarial

smears and arthropod vectors. Fluorescent and light

microscopy is available for pathogen analysis through

variable staining methodologies, ie, Gram stain,

Wright/Giemsa stain, and specialized fluorochrome

stains for specific pathogens.

While in garrison and aside from technical and tactical

training exercises, the Endemic Disease Section has

had the opportunity to assist DoD as well as the local

community with the present capabilities. During AprilMay of 2005, both the 1st and 9th AMLs were tasked

by DoD to represent the Army in a multi-Service joint

exercise during the initial operational test and

evaluation of the Joint Biological Agent Identification

and Diagnostic System (JBAIDS), at Brooks Air Base

in San Antonio, Texas. The JBAIDS is a nucleic acid

based laboratory instrument system that provides

commanders with rapid and specific identification of

biological threat agents. Following a 10 day training

course, the AMLs were involved in a 10 day record

test that evaluated 4 of 8 JBAIDS systems for network

performance, survivability, interoperability, and

logistical support. In August 2005, the 9th AML

provided 5 Soldiers to assist USACHPPM for 2 weeks

at Fort AP Hill, Virginia. The Soldiers assisted in the

identification of Lone Star, Black-Legged (Deer), and

American Dog ticks and used nucleic acid based

technologies to screen for such arthropod-borne

diseases as human monocytic ehrlichia, Lyme disease,

human granulocytic ehrlichia, and Rocky Mountain

spotted fever.

DISCUSSION

Although neither AML has been deployed since

activation in September 2004, both units maintain a

high state of readiness by conducting realistic field

training exercises and maintaining a robust intramural

training program. One of the largest challenges in the

current operating environment is the maintenance of a

core of Soldiers highly trained with the requisite skills

to operate and maintain the advanced technologies

fielded by the AMLs. To this end, the AMLs invest

considerable effort in arranging mission-specific

technical training programs for individual Soldiers in

cooperation with their fixed facility partners. Through

participation in strategic working groups and scientific

conferences, AML personnel stay abreast of current

issues in Force Health Protection. Every effort is made

to update unit equipment to reflect the latest

developments in technology and provide a better

product to their customers. They also work to establish

relationships and investigate joint training

opportunities with the Army National Guard and

organizations of the other armed services that perform

similar missions. In addition to the doctrinal theater

support mission, the AMLs provide an untapped

resource of essential capabilities to support civil

authorities in homeland defense missions, consequence

management, and disaster relief operations. Ready,

relevant, and reliable, the 1st and 9th AMLs stand

prepared to assist whenever and wherever they are

needed.

REFERENCES

1. US Dept of Defense resources page. Force Health

Protection website. Available at: http://

www.ha.osd.mil/forcehealth/about/main.html.

2. Field Manual 4-02.12: Health Service Support in

Corps and Echelon Above Corps. Washington, DC:

US Dept of the Army; 2 February 2004.

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

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

2000.

4. Army Training and Evaluation Program. ARTEP 8-

668(MRI)-30-MTP: Mission Training Plan for the

Area Medical Laboratory. Washington, DC: US Dept

of the Army; 3 December 2002.

5. Taylor P, Lukey B, Clark C, Lee R, Roussel R. Field

verification of Test-mate ChE. Mil Med.

2003;168:314-319.
72 Army Medical Department Journal

6. Shippee RL. The TAML/AML concept; lessons

learned/prescription for change. Army Med Dept J.

2004;Jul–Sep:65-68.

7. Slife H, Winston J. Telechemistry, projecting

laboratory expertise to a deployed area medical

laboratory. Mil Med Tech. 2005;9.3:3-42.

AUTHORS

MAJ Taylor is the Chief, Nuclear Biological and Chemical Threat Assessment Section, 9th Area Medical Laboratory,

Edgewood Area-Aberdeen Proving Ground, Maryland.

COL Gordon is Commander, 1st Area Medical Laboratory, Edgewood Area-Aberdeen Proving Ground, Maryland.

MAJ Kimm is the Executive Officer, 1st Area Medical Laboratory, Edgewood Area-Aberdeen Proving Ground, Maryland.

MAJ Hall is the Chief, Occupational/Environmental Health Threat Assessment Section, 9th Area Medical Laboratory,

Edgewood Area-Aberdeen Proving Ground, Maryland.

CPT Van Horn is the Chief, Endemic Disease Section, 9th Area Medical Laboratory, Fort Detrick, Maryland.

CPT Tyner is the Chief, Endemic Disease Section, 1st Area Medical Laboratory, Fort Detrick, Maryland.
April – June 2006 73

SUMMARY

Between 1941 and 1944, over 1,000 troops training at

Camp Bullis, TX presented to the post hospital with

concurrent fever, rash, adenopathy, and cytopenia. In

each case, the physical examination was also notable

for numerous tick bites, suggesting an arthropod-borne

infection. The syndrome, coined “Bullis fever,” was

self-limiting, but convalescence was protracted.

Investigations implicated the Lone Star tick

(Amblyomma americanum) as vector, and an aggregate

of signs consistent with Bullis fever was reproducible

in volunteers and guinea pigs inoculated with

emulsified tick extract. However, sera from inoculated

subjects did not show cross-reactivity with known

tick- borne pathogens, and workup of a solitary case

presenting several years later was similarly

nondiagnostic. The end of the war heralded a sharp

decline in the number of troops training at Camp

Bullis and also an abrupt end to the disease bearing its

name.

Although highly speculated, the etiology of Bullis

fever was never proven, and a definitive retrospective

diagnosis is unlikely. The clinical specimens collected

during the epidemic are no longer extant. Moreover,

insecticide use, drought, and predation have decimated

the region's tick population. Six decades after the

epidemic, Bullis fever seems fated to remain

enigmatic.

INTRODUCTION

In the spring of 1941, United States Army physicians

assigned to Brooke General Hospital (presently

Brooke Army Medical Center) at Fort Sam Houston,

TX, encountered a number of “acutely ill Soldiers

suffering from (an) obscure febrile disease” which

“defied definite identification.”1Invariably, each of

these Soldiers had been training at nearby Camp Bullis

(an adjunct field site for Fort Sam Houston) in

preparation for deployment overseas. Coined “Bullis

fever,” the illness was characterized by the abrupt

onset of fever and chills, leukopenia, headache, and

lymphadenopathy. Eventually, over 1,000 cases (with

one fatality) would be diagnosed. However, a cause

was never proven and as recently as 1988 speculation

appeared in the literature about its etiology.2

CLINICAL PRESENTATION

Bullis fever typically commenced with subjective

chills and fever from 102°-105°F. Patients complained

of postorbital or occipital headache, lassitude,

prostration and, occasionally, nausea and vomiting;

and weight loss was common (20 pounds in one

patient). The fever persisted from 4 to 14 days

(average 5 days) with abrupt defervescence. However,

convalescence was protracted.3

On physical examination, patients presented with

regional or generalized lymphadenopathy and a

fleeting maculopapular rash similar to that of endemic

typhus. Moreover, multiple tick bites were commonly

evident. In severe cases, splenomegaly and

subconjunctival hemorrhage were noted. A typical

case description appeared in the medical literature in

1943:

(The patient) was admitted to the Brooke

General Hospital on June 25, 1942 complaining

of severe generalized headache of four or five

hours duration. His face was flushed as with

fever, and he appeared acutely ill. The onset of

illness was sudden with nausea, vomiting and

severe headache...He had been at Camp Bullis,

Texas, for one week, June 13 to June 20

inclusive, and had returned to Fort Sam Houston

five days prior to the onset of symptoms. While

at Camp Bullis, he suffered numerous tick and

“chigger” bites. Physical examination revealed

flushed skin and evidence of numerous insect

bites on the abdomen and the legs. Moderate

lymphadenopathy was found. Otherwise,

physical examination gave negative results.3

Bullis Fever: A Fleeting Epidemic of

Unknown Etiology

LTC Michael J. Zapor, MC, USA
74 Army Medical Department Journal

A constant finding among patients with Bullis fever

was leukopenia with associated neutropenia occurring

on or about the second or third day of symptoms. The

total white blood cell count frequently dropped to about

3,000/μl and occasionally as low as 1,750/μl. The

leukopenia gradually resolved during convalescence,

however, a relative lymphocytosis persisted beyond

discharge. Several patients had trace albuminuria and

none were anemic.3

Typically, patients with Bullis fever suffered a mild,

self-limiting, febrile illness of 7–10 days duration. In

some instances, however, the course was more severe,

characterized by debilitation and protracted

convalescence. One death occurred which was

attributed to agranulocytic angina and sepsis. In about

10% of cases, a transient rash “resembling German

measles, and at times, typhus”3appeared early in the

disease. Treatment was mostly supportive and

consisted of codeine, aspirin, ice, rest, and fluids.

THE ARMY MEDICAL DEPARTMENT RESPONSE

Faced with an epidemic of unknown etiology, the

Brooke General Hospital commander, COL George C.

Beach, petitioned the Surgeon General to dispatch

specialists for consultation. Consequently, 3 members

of the Board for the Investigation and Control of

Influenza and Other Epidemic Diseases in the Army

(Drs Kenneth E. Maxey, Norman H. Topping, and John

C. Snyder) arrived at Fort Sam Houston on 8

July,1942. After a thorough examination of the patients

and their medical records, these 3 investigators

concluded that the evidence suggested an association

with tick bites (thus garnering the tentative designation

of “tick bite fever”), however, neither the causative

agent nor the tick as vector had been proven.

Three successive papers were subsequently published

describing the syndrome and reporting the results of

preliminary laboratory investigations. One paper,

authored by 3 clinicians at Brooke General Hospital,

depicted the clinical presentation and implicated the

Lone Star tick (Amblyomma americanum) as vector.3

Another study, conducted by the Army's 8th Service

Command Laboratory, described the induction of an

illness resembling Bullis fever in animals inoculated

with clinical specimens.4In this study, a consistent

low-grade febrile reaction was observed in guinea pigs

after intra-abdominal inoculation with blood or lymph

tissue from infected patients. Biopsy specimens, taken

both from patients and inoculated guinea pigs,

demonstrated “small intracellular fuchsinophilic

granules and rods, similar in morphology to

Rickettsiae.”

However, sera from inoculated animals showed no

cross reactivity with the etiologic agents of Rocky

Mounted Spotted fever (Rickettsia rickettsii) or Q fever

(Coxiella burnetii), nor were these animals protected

against challenge with R rickettsii. A third paper, an

epidemiologic study published at about the same time,

reiterated the likelihood of A americanum as the vector

for Bullis fever.5 Collectively, these studies suggested

that Bullis fever represented a previously unknown

rickettsial illness with the Lone Star tick as likely

vector.

Pursuant to these findings, the Army scaled back the

number of troops deployed to Camp Bullis for training

with a consequent decrease in the incidence of disease.

In 1944, for example, there were 47 patients admitted

with Bullis fever to Brooke General Hospital,

compared to more than 500 cases the preceding year.1

Interestingly, 13 of these patients were treated with

penicillin without therapeutic benefit, further

implicating a rickettsial etiology.

In 1946, Army researchers from the 8th Service

Command Laboratory and Brooke General Hospital

published the results of several human challenge

experiments.6In these studies, volunteers were

inoculated with either whole blood from natural cases

of disease, whole blood from a natural case propagated

through chick embryos, or an emulsion derived from

the spleens of mice inoculated with emulsified A

americanum ticks from Camp Bullis and serially

passed through chick embryos. These researchers

found that a syndrome resembling Bullis fever could be

reproduced in humans by inoculation with either whole

blood from natural cases or with emulsified A

americanum ticks. Based on these findings, they

determined Bullis fever to be a transmissible illness

with a causative agent maintainable by serial passage.

CONSIGNED TO HISTORY

With the end of World War II, and a further reduction

in the number of troops passing through Camp Bullis,

the syndrome bearing its name became all but

forgotten. In 1949, however, a case report of Bullis

fever was published by physicians at Walter Reed

Army Hospital in Washington, DC.7 The patient, who

had trained previously at Camp Bullis, presented with
April – June 2006 75

fever, leucopenia, and lymphadenopathy. Subsequent

workup, which included complement fixation testing,

excluded American Q fever, Rocky Mountain Spotted

fever, rickettsialpox, Colorado Tick fever, lymphocytic

choriomeningitis, and mumps. Interestingly, the

patient failed to respond to sulfa drugs and penicillin

but showed clinical improvement with paraaminobenzoic acid, an agent then used in the treatment

of rickettsial diseases.

Subsequent to that case report, there was a dearth of

references to Bullis fever in the literature until 1975,

when Anigstein and Anigstein published a review of

the subject and proposed the name Rickettsia texiana

for the hitherto unnamed etiologic agent.8 More

recently, Goddard described an airman with a clinical

syndrome resembling Bullis fever and positive

serology for Ehrlichiosis canis, prompting him to

speculate that human ehrlichiosis and Bullis fever

might be the same disease.2In reply, however, Eng et

al of the Centers for Disease Control disputed this

conclusion, citing differences in clinical presentation,

hematologic parameters, histopathology, and

endemnicity.2Specifically, they noted:

1. the association of generalized lymphadenopathy

with Bullis fever and its absence in human

ehrlichiosis,

2. the neutropenia and lymphocytosis commonly

seen with Bullis fever, contrasted with the

thrombocytopenia and lymphopenia typical of

human ehrlichiosis,

3. the differing appearance of intracytoplasmic

inclusions in patients with each disease, and

4. the exclusive distribution of Bullis fever cases to

Camp Bullis, TX.

EPILOGUE

Since it was established in 1917 as a training site for

troops headed for the war in Europe, Camp Bullis has

functioned as a tactical training area for the Army, Air

Force, and Marine Corps, a prisoner of war camp, a

reception center for inductees as well as a separation

center for Soldiers upon completion of their military

service, and even as the backdrop for several motion

pictures (The Rough Riders, 1926 and Wings, 1927).

The Army maintains a small cadre of assigned

personnel, and there are several tenant units based at

Camp Bullis. However, World War II, as with other

conflicts, precipitated a massive influx of troops

training there prior to deploying overseas. Perhaps the

sudden proximity of a large human population and the

presumed tick vector set the stage for the Bullis fever

epidemic. Similarly, the abrupt disappearance of the

disease may be due to the near abandonment of the

camp at the end of the war. Moreover, there has been a

notable decline in the tick population at Camp Bullis

over the past 6 decades. This may derive from

aggressive tick eradication by the cadre, a prolonged

regional drought in the 1950s,9and the appearance in

Texas of the fire ant, a predator of ticks.10,11

However, those conditions, which set the stage for the

epidemic, may eventually recur, permitting the

reemergence of Bullis fever. As a consequence of

current and impending hostilities overseas, the tempo

of training at military installations including Camp

Bullis has intensified,12 and much of this training is

conducted in forested areas with dense underbrush,

terrain favored by the Lone Star tick. Moreover, some

researchers project resurgence in the Lone Star tick

population as a consequence of rising populations of

the mammalian host vectors (consider, for example,

the fiftyfold increase in the number of white-tailed

deer in the United States during the 20th century).13

Collectively, these variables may contribute to the

eventual recreation of those conditions which set the

stage for the emergence of Bullis fever 6 decades ago.

Until then, however, Bullis fever is consigned to

history as an intriguing diagnosis sans known etiology.

REFERENCES

1. Annual Report of the Brooke General Hospital, Fort

Sam Houston, Texas. 1942:21-24.

2. Goddard J. Was Bullis fever actually ehrlichiosis?

JAMA. 1988;260;No. 20:3006-3007.

3. Woodland JC, McDowell MM, Richards JT. Bullis

fever (Lone Star fever-tick fever). JAMA.

1943;122:1156-1160.

4. Livesay HR, Pollard M. Laboratory report on a clinical

syndrome referred to as Bullis fever. Am J Trop Med.

1943:475-479

5. Anigstein L. Bader KN. Investigations on rickettsial

diseases in Texas — preliminary report on

investigations of Bullis fever. Texas Reports on Biol &

Med. Fall;1943.

6. Pollard M, Livesay HR, Wilson DJ, Woodland JC.

“Experimental studies with Bullis fever”. Am J Trop

Med. 1946;26:379-381.
76 Army Medical Department Journal

7. Arnold WT, Van Noate HF. Bullis fever: report of a

case treated with PA-BA. Bull US Army Med Dept

1949;9:218-223.

8. Anigstein L, Anigstein D. A review of the evidence in

retrospect for a rickettsial etiology in Bullis fever. Texas

Rep Biol Med. 1975;33;No. l:203-211.

9. Heat waves and drought: legacy of a Texas summer. In:

Bomar GW, ed; Texas Weather. 1st ed. Austin, TX:

University of Texas Press, 1983:143-156.

10. Burns EC, Melancon DG. Effect of imported fire ant

(Hvmenoptera formicidae) invasion on Lone Star tick

(Acarina ixodidae) populations. J Med Entomo.

1977;14:247-249.

11. Drees B. Spread of the imported fire ant. AgNews [serial

online]. Available at: http://agnews.tamu.edu/graphics/

fireants/antspred.htm.

12. Army medic training has greater urgency. The Dallas

Morning News. December 23, 2002.

13. Childs JE, Paddock CD. The ascendancy of

Amblyomma americanum as a vector of pathogens

affecting humans in the United States. Annu Rev

Entomol. 2003;48:307-337.

AUTHOR

LTC Zapor is a staff physician of the Infectious Diseases

Service, Department of Medicine, Walter Reed Army

Medical Center Washington, DC. He is currently deployed

as the Battalion Surgeon and Infectious Diseases Consultant

with the 10th Brigade Support Battalion, 1st Brigade Combat

Team,10th Mountain Division (LI), Camp Liberty, Iraq.
SUBMISSION OF MANUSCRIPTS TO THE ARMY MEDICAL DEPARTMENT JOURNAL

The United States Army Medical Department Journal is published quarterly to expand knowledge of domestic and international 

military medical issues and technological advances; promote collaborative partnerships among the Services, components, Corps, 

and specialties; convey clinical and health service support information; and provide a professional, high quality, peer reviewed 

print medium to encourage dialogue concerning health care issues and initiatives. 

REVIEW POLICY

All manuscripts will be reviewed by the AMEDD Journal’s Editorial Review Board and, if required, forwarded to the appropriate 

subject matter expert for further review and assessment. 

IDENTIFICATION OF POTENTIAL CONFLICTS OF INTEREST

1. Related to individual authors’ commitments: Each author is responsible for the full disclosure of all financial and personal 

relationships that might bias the work or information presented in the manuscript. To prevent ambiguity, authors must state 

explicitly whether potential conflicts do or do not exist. Authors should do so in the manuscript on a conflict-of-interest 

notification section on the title page, providing additional detail, if necessary, in a cover letter that accompanies the 

manuscript. 

2. Assistance: Authors should identify Individuals who provide writing or other assistance and disclose the funding source for this 

assistance, if any. 

3. Investigators: Potential conflicts must be disclosed to study participants. Authors must clearly state whether they have done 

so in the manuscript. 

4. Related to project support: Authors should describe the role of the study sponsor, if any, in study design; collection, analysis, 

and interpretation of data; writing the report; and the decision to submit the report for publication. If the supporting source

had no such involvement, the authors should so state. 

PROTECTION OF HUMAN SUBJECTS AND ANIMALS IN RESEARCH

When reporting experiments on human subjects, authors must indicate whether the procedures followed were in accordance with 

the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki 

Declaration of 1975, as revised in 2000. If doubt exists whether the research was conducted in accordance with the Helsinki 

Declaration, the authors must explain the rationale for their approach and demonstrate that the institutional review body 

explicitly approved the doubtful aspects of the study. When reporting experiments on animals, authors should indicate whether the 

institutional and national guide for the care and use of laboratory animals was followed. 

GUIDELINES FOR MANUSCRIPT SUBMISSIONS

1. Articles should be submitted in digital format, preferably an MS Word document, either as an email attachment (with 

illustrations, etc), or by mail on CD or floppy disk accompanied by one printed copy of the manuscript. Ideally, a manuscript 

should be no longer than 24 double-spaced pages. However, exceptions will always be considered on a case-by-case basis. In 

general, 4 double-spaced MS Word pages produce a single page of 2 column text in the AMEDD Journal production format. 

2. The American Medical Association Manual of Style governs formatting in the preparation of text and references. All articles 

should conform to those guidelines as closely as possible. Abbreviations/acronyms should be limited as much as possible. 

Inclusion of a list of article acronyms and abbreviations can be very helpful in the review process and is strongly encouraged.

3. A complete list of references cited in the article must be provided with the manuscript. The following is a synopsis of the 

American Medical Association reference format: 

 Reference citations of published articles must include the authors’ surnames and initials, article title, publication title, 

year of publication, volume, and page numbers. 

 Reference citations of books must include the authors’ surnames and initials, book title, volume and/or edition if 

appropriate, place of publication, publisher, year of copyright, and specific page numbers if cited. 

 Reference citations for presentations, unpublished papers, conferences, symposia, etc, must include as much identifying 

information as possible (location, dates, presenters, sponsors, titles). 

4. Either color or black and white photographs may be submitted with the manuscript. Color produces the best print reproduction

quality, but please avoid excessive use of multiple colors and shading. Digital graphic formats (JPG, GIF, BMP) and MS Word 

photo files are preferred. Prints of photographs are acceptable. Please do not send photos embedded in PowerPoint. Images 

submitted on slides, negatives, or copies of X-ray film will not be published. For clarity, please mark the top of each 

photographic print on the back. Tape captions to the back of photos or submit them on a separate sheet. Ensure captions and 

photos are indexed to each other. Clearly indicate the desired position of each photo within the manuscript. 

5. The authors’ names, ranks or academic/certification credentials, titles or positions, current unit of assignment, and contact 

information must be included on the title page of the manuscript. 

6. Submit manuscripts to: 

EDITOR, AMEDD JOURNAL 

ATTN MCCS DT 

2419 HOOD ST STE C 

FORT SAM HOUSTON, TX 78234-7584 

DSN 471-6301 

Comm 210-221-6301 

Email: amedd.journal@amedd.army.mil