FORCE HEALTH PROTECTION 

April – June 2009 

Perspective 1

MG Russell J. Czerw 

Joint Environmental Site Assessments in Support of Global Basing 6

LTC Timothy G. Bosetti, MS, USA 

Evaluation of Exposure Incident at the Qarmat Ali Water Treatment Plant 10

Coleen Baird Weese, MD, MPH 

Cohort Case Studies on Acoustic Trauma in Operation Iraqi Freedom 14

MAJ D. Scott McIlwain, MS, USA; MAJ (Ret) Bryan Sisk, AN, USA; Melinda Hill, AuD 

Provider Resilience: The Challenge for Behavioral Health Providers 24

Assigned to Brigade Combat Teams

LTC (Ret) Larry Applewhite, MS, USA; LTC (P) Derrick Arincorayan, MS, USA 

The Unit Field Sanitation Team: A Square Peg in a Round Hole 31

LTC Timothy Bosetti, MS, USA; CPT Davin Bridges, MS, USA 

Prisoner of War Camps: Lack of a Revolution 34

LTC Jennifer Caci, MS, USA; LTC Joanne M. Cline, MS, USA 

The Reporting and Recording of Unspecified Malaria 42

in the Military, 1998–2007

LTC Joseph K. Llanos, MC, USA

Improvement of Force Health Protection Through 46

Preventive Medicine Oversight of Contractor Support

MAJ Scott A. Mower, MS, USA 

Health Sector Development in Afghanistan: The Way Forward 51

Maj Paul Brezinski, MSC, USAF; et al 

Army Transformation and Level II Preventive Medicine 58

within a Deployed Division Task Force 

MAJ Kenneth D. Spicer, MS, USA 

Control of Concealing Vegetation Along Rural Routes in Iraq 62

CPT Dennis M. Rufolo, MS, USA; MAJ Rebecca A. Zinnante, MS, USA; CPT Ryan Bible, MS, USA 

Fort Carson: An Army Hearing Program Success Story 67

CPT Leanne Cleveland, MS, USA 

Establishing a Base Camp Assessment Program for a Forward Operating Base 76

CPT Davin Bridges, MS, USA; LTC Timothy Bosetti, MS, USA 

Army Force Health Protection: Past, Present, and Future 81

E. Wayne Combs, PhD, RN 
LTG Eric B. Schoomaker

The Surgeon General

Commander, US Army Medical Command

MG Russell J. Czerw

Commanding General

US Army Medical Department Center and

School

April – June 2009 The Army Medical Department Center & School PB 8-09-4/5/6

0911102

GEORGE W. CASEY, JR

General, United States Army

Chief of Staff

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April – June 2009 1

Force health protection is a term that, on the face of it,

appears to represent a straightforward and easily

definable concept. Indeed, Army Field Manual 4-02

characterizes it as follows:

Force health protection encompasses the pillars of a

healthy and fit force, casualty prevention, and casualty

care and management.1(p1-1)

However, the old proverb, “the devil is in the details”

is nowhere more applicable than here. An examination

of each of those elements reveals the levels of

research, commitment, planning, application, and

resources that are necessary to achieve the desired

result—a healthy, fit Warrior in a sustainable, effective

fighting force.

The second element, casualty prevention, is especially

deceptive in its seeming simplicity. However, as Field

Manual 4-02 expands casualty prevention into its

components, the complexity and scope inherent in that

effort begin to emerge:

The second pillar...concerns both the enemy threat and

the medical threat....To counter the medical threat,

comprehensive medical and OEH* surveillance activities, preventive medicine measures...and field hygiene

and sanitation combined with personal protective

measures (such as the correct wear of the uniform and

the use of insect repellent, sun screen, and insect

netting) must be instituted and receive command

emphasis. These activities must be conducted continuously—during mobilization, predeployment, deployment, postdeployment, and demobilization.1(p1-2)

Of course, the factors contained in the above

description are a combination of the easily understood

and intuitively obvious, (ie, sun screen) and those that

require dedicated resources, specialized training, and

often external support (ie, medical and OEH surveillance, hygiene, and sanitation). As our understanding of the interactions (including causes and effects) of

humans and our natural and man-made environments

expands and evolves, we are still learning the true

extent and importance of those relationships.

Fortunately, research and proactive efforts in the

environmental sciences are recognized for their direct

contribution to the medical sciences, and collaboration

between the disciplines is resulting in healthier

populations where and when the knowledge has been

applied. This is yet another area where the synergistic

effect of efforts by both military and civilian resources

produces results beneficial to both general populations

and military mission accomplishment.

The articles within this issue of the AMEDD Journal

are excellent examples of the work by our military

medical professionals in various aspects of force

health protection. The subject matter runs the gamut

from field sanitation to the development of a

functioning national health care structure in

Afghanistan, with articles presenting research projects,

addressing preventive medicine programs, and looking

at the absolutely critical area of the health and wellbeing of behavioral health providers assigned to

combatant commands. This collection offers true

insight to the diversity and complexity of preventive

medicine’s contributions to force health protection,

and is another testimony to the dedicated men and

women of military healthcare who work tirelessly to

support our Warriors who must go into harm’s way.

Perspective

Major General Russell J. Czerw

*Occupational and environmental health
2 https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1

The US military has always been structured for force

projection, taking our combat capability wherever in

the world it is necessary to provide armed forces for

combat operations, combat training, or humanitarian

assistance. Of course this has been our capability for

many years, and the potential for disease in

deployment areas has been addressed since the late

1800s. However, only in the last several decades has

the potentially detrimental effects of environmental

factors on Soldiers’ health become a vital consideration in the planning and execution of deployments

and operations. LTC Timothy Bosetti’s carefully

detailed article explains the joint environmental site

assessment process that has been developed and

implemented to project and minimize potential

environmental hazards to our personnel. The assessment also allows planners to take measures to protect

the environment itself from harm resulting from the

deployment. LTC Bosetti’s article also addresses an

interesting, related, and increasingly important purpose

of environmental assessments; the documentation of

existing conditions as a baseline for answering third

party claims with regard to environmental damage.

Unfortunately, even though the initial environmental

assessment will be accurate and complete, future

environmental damage attendant to heavy combat

operations is usually unavoidable. Dr Coleen Weese

returns to the AMEDD Journal with an article

chronicling such a situation involving potential

hazardous chemical exposure to both civilian

contractors and Soldiers in Basra, Iraq, in 2003. The

article describes the incident and the correct response

of the onsite Army preventive medicine personnel in

their initial evaluation and request for a special

medical augmentation response team-preventive

medicine (SMART-PM) from the Army Center for

Health Promotion and Preventive Medicine. The team

quickly arrived and made detailed assessments of the

incident, potential health effects to individuals, and the

protective actions taken to mitigate the hazard. This

case is of particular interest because it was the subject

of congressional hearings due to a lawsuit, and was

referred to the Defense Health Board for review. Dr

Weese’s article is an excellent illustration of the

structure in place to address environmental hazards,

and the capabilities of the SMART-PM to augment

deployed preventive medicine resources when those

capabilities are insufficient to ensure the health and

safety of involved personnel.

MAJ Scott McIlwain and his coauthors have

contributed a well-researched, carefully developed

article detailing a clinical study of hearing trauma

among Soldiers involved in operations in Iraq in 2006.

The article examines current research on the

physiology of hearing trauma in detail, with particular

emphasis on the damaging noises experienced during

deployed military operations, in both combat and

noncombat situations. Those research findings are

applied to the results of cohort case studies of hearing

trauma patients in Iraq. The resulting conclusions

indicate much progress has been made in the emphasis

on hearing protection, examination, and treatment by

troop leaders and headquarters, and the recommendations are logical extensions of the methods and

techniques that have achieved such measurable

success. Their study is yet another example of the

progress and improvements military medicine

continues to make in preparing our Warriors for the

entire spectrum of hazards of the combat environment.

The July-September 2008 issue of the AMEDD

Journal focused on behavioral and mental healthcare

of our Soldiers as they face the demands and stresses

of the Global War on Terror. In one article, Boone et

al2described provider resiliency training, a program of

instruction implemented by the Army Medical Department to prepare those charged with saving lives in the

worst of environments for the stress and potential

psychological pressures they will encounter. In their

article, LTC (Ret) Larry Applewhite and LTC (P)

Derrick Arincorayan zero in on the particular stresses

and challenges faced by behavioral health providers

who accompany Army brigade combat teams into the

combat theater. In their excellent, well-researched

article, they describe the factors that affect those

providers, often subtly and without discernible

symptoms, as they work to alleviate the psychological

pain and suffering of “their” Soldiers. The article

details how the effectiveness of the behavioral healthcare providers can be adversely affected, which is only

detrimental to those whom they are supposed to help.

Further, like the traumatized combat Soldier, those

effects can be long-lasting, extending long after the

combat zone should be a distant memory. The authors

offer a series of well-reasoned recommendations for

those who create doctrine and design the structure of

expeditionary forces, as well as those practitioners

who are, or will be, directly charged with the

behavioral healthcare of our Warfighters.

Perspective

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April – June 2009 3

THE ARMY MEDICAL DEPARTMENT JOURNAL

As with most sophisticated things, preventive

medicine must sometimes be examined at the “basic”

levels to ensure that it continues to adequately address

those needs. LTC Timothy Bosetti and CPT Davin

Bridges examine the Army’s frontline of defense

against disease for deployed Soldiers, the field

sanitation team (FST). Initially instituted during World

War II, the FST are Soldiers specifically trained in

hygiene, sanitation, arthropod control, and water and

food safety. However, the authors point out that the

longstanding concept for training and employment of

the FST is not suited for the expeditionary, noncontiguous battlefield environment of today, and the

foreseeable future. They propose that FST capabilities

must be driven down to the smallest unit level, the

platoon, because those sized units are often employed

as outposts on today’s battlefield, existing without the

full range of support from the larger, parent unit. This

excellent article details the considerations inherent in

rethinking the FST concept, and the various factors

that must be addressed to meet the needs of the

modern expeditionary environment. The points made

by LTC Bosetti and CPT Bridges should be carefully

considered by those planning the changes to our force

structure and training to accommodate the lessonslearned in our current conflicts.

LTCs Jennifer Caci and Joanne Cline have contributed an article that looks at one of the unavoidable

elements of warfare, prisoners of war (POWs), from a

preventive medicine perspective. They examine

American experience with POWs throughout our

history, both as prisoners and custodians. Their indepth research reveals that one recurring element of

POW history, for both the US and other combatants, is

the failure to adequately plan for the management and

care of the prisoners that will inevitably be collected

during armed conflicts. The authors recount the

atrocious sanitation, hygiene, and healthcare situations

of POWs from the Revolutionary War through World

War II, and describe the circumstances that contributed

to the difficulties and, in some cases, criminalities that

occurred in the Global War on Terror. LTCs Caci and

Cline find that, for the most part, US forces have

adequately addressed the preventive medicine aspects

of prisoner healthcare over the last century, but

increased attention must be given to preparing those

who will manage the prisoner population, especially in

the current counterinsurgency environments of Iraq

and Afghanistan, and undoubtedly conflicts of the

future. Especially critical is the psychological

foundation that must be laid, for both the leaders and

the Soldiers charged with managing the POWs. This

article contains important information for everyone

who is or will be involved with POWs, both in and out

of the medical community.

Despite the best efforts of environmental and medical

science, malaria continues to be a deadly scourge of

many areas of the world. As such, it is a factor that

must be considered in the planning, execution, and

follow-up of all deployments into areas where it is

endemic, and especially into areas where data may be

inconclusive, but the environment is favorable to the

disease vector, the Anopheles mosquito species. Symptoms of malaria may mimic those of less serious

conditions, and therefore it may be misdiagnosed, or

suspected but not confirmed. The serious nature of

malaria mandates that all cases are reported to the

military’s central data repository for use by planners,

and for the patient’s permanent medical history. LTC

Joseph Llanos investigated cases of suspected malaria,

termed unspecified, among US military personnel

from 1998 through 2007. He grouped the cases into a

number of demographic and clinical categories, and

determined those characteristics most favorable to a

confirmable diagnosis of malaria. His detailed examination reveals some shortcomings in several areas of

diagnosis and documentation, including recognition of

malaria in initial and followup examinations, some

laboratory procedures, and especially in the documentation of the diagnostic results and followup care. LTC

Llanos’ findings and recommendations should be

carefully considered by all of us involved in patient

care, especially those patients who are, or have been,

involved in deployments.

A long-term presence in a maturing theater of

operations allows the military to establish fixed base

camps which require more sophisticated life support

services than are possible in the fluid, dynamic

environment of heavy combat operations. Large,

concentrated numbers of personnel create heavy

demands for sewage and trash disposal, pest control,

availability of food and water, and other basic sanitation and hygiene support services. These functions

are largely contracted, eliminating the need for Soldiers to be pulled from their military duties to perform

these mundane tasks. MAJ Scott Mower points out

that there are problems, however, in that contractors

are often lacking in the knowledge and understanding

necessary to perform the life support services to the
4 https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1

Perspective

standards required by our standards, and have little

basis to understand, or respect, contractual requirements. Further, those charged with contract oversight

often have little background in preventive medicine

and the environmental sciences, so problems in contract specifications, and the performance of the contractors themselves, are not recognized until serious

situations develop. The remedies for these resulting

problems are usually expensive, and always time-consuming. MAJ Mower presents a series of 10 wellreasoned, fully developed recommendations to create a

structure to ensure that preventive medicine personnel

are involved at every level of contracting for life

support services. This is an excellent presentation of

facts and recommendations that deserves the attention

of everyone working in life support services for

deployed personnel.

Air Force Maj Paul Brezinski and his team of

coauthors have contributed an important paper looking

at the state of the domestic healthcare situation in

Afghanistan and the largely uncoordinated efforts by

various entities to address the lack of care and

services. As the first sentence of the article states:

“Health sector development is a critical component of

nation-building and a cornerstone of any exit

strategy...” so it is vital for everyone involved in the

country, both foreign and Afghani, to establish a

functioning national health sector as quickly as

possible. The limited capability and organization that

does exist within the Afghanistan government is

examined, but the article concentrates on the myriad of

external resources that are present in the country,

including military, other governmental agencies, and

nongovernmental organizations. The article describes

the uncoordinated, fragmented, and often isolated

efforts of these multiple agencies, each approaching

their contribution to health sector development as they

see and understand the immediate need. However, as

the authors point out, those individual, isolated cases

of progress are unsustainable on their own, as

ultimately the external resources must leave. Each time

a pocket of such progress collapses, the credibility of

the entire national effort is undermined, and nation

building once again suffers a step back. Maj Brezinski

et al have captured the current situation succinctly and

with clarity, and have developed a scheme by which

the existing, disjointed activities can be brought into a

structure that will focus their efforts towards the goal

of someday transitioning to a functioning, self-sustaining, Afghan national health sector.

MAJ Kenneth Spicer describes his experiences as a

division environmental science and engineering officer

whose unit underwent transformation and deployed to

Iraq in September 2007. From that perspective, his

article describes the improvement in force health

protection that resulted from the transition, and he

makes additional recommendations as to how the

resulting preventive medicine services delivery can be

further improved. In his well-organized article, MAJ

Spicer relates the details of various aspects of

preventive medicine across the theater, and clearly

describes those areas that could benefit from further

adjustments in doctrine, especially with regard to some

personnel assignments. This article is an informative

update on the current situation of force health

protection services in Iraq.

In their article, CPT Dennis Rufolo and his coauthors

describe an environmental situation which lends itself

to exploitation by insurgents, often with deadly

consequences. In many areas of Iraq, dense vegetation,

in particular a type of large reed, crowd the edges of

rural roads. This vegetation provides excellent

concealment to insurgents who emplace explosive

devices, and, of course, even more effectively hide the

devices themselves. The authors describe the various

methods that US forces have employed in attempts to

eliminate the threat, but burning, cutting, and

combinations of those methods have proven to provide

temporary relief at best. More importantly, those

methods are actually counterproductive if not

performed during the correct time of the reeds’

growing cycle, and are dangerous to those who must

do the work. Therefore, commanders find that they

must commit their Soldiers to a frustratingly endless

cycle of repetitive, dangerous, difficult work. CPT

Rufolo et al have closely examined the feasibility of

using herbicides as a much more effective, longer

lasting reed control measure, which is also much safer

for the Soldiers and contractors who will perform the

applications. They have identified herbicides approved

by the Environmental Protection Agency which are

used effectively in the United States for similar control

applications. Their article describes how the

application equipment currently in common use can be

easily adapted for military use, and how application

would be performed under supervision of certified

personnel. However, this solution is not currently

available to military commanders because of a

presidential executive order (11850) issued in 1975 as

a result of heightened sensitivity to the use of

4 https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1
April – June 2009 5

THE ARMY MEDICAL DEPARTMENT JOURNAL

potentially hazardous chemicals during military

operations. Since the executive order was issued, great

strides have been made in both regulatory oversight

and the formulation of safe, effective herbicides for

civilian use, but their use by the military is still

severely restricted—the order allows no herbicide use,

period, beyond installation boundaries. CPT Rufolo et

al make a very strong case for a top-level review of the

executive order in view of state-of-the-art herbicides

and their long record of safe use in civilian applications. Their proposal should be seriously considered,

because, unfortunately, Iraq will very likely not be the

last location where our Soldiers are faced with the

deadly problem of concealing vegetation.

An article3in the April-June 2008 issue of the

AMEDD Journal described the evolution of the Army

Hearing Program, established to provide hearing loss

prevention services to Army Soldiers and civilians in

all environments, especially those of training and

operational activities. In this issue, CPT Leanne

Cleveland’s detailed, well-developed article describes

the implementation of the program at Fort Carson,

demonstrating how dedication, planning, command

support, and sheer hard work can have significant

positive results for all concerned. The Fort Carson

Hearing Program is one of the first full

implementations of the Army Hearing Program at a

large facility with an increasing Soldier population,

most of whom are involved in intensive combat

training and deployment rotations. The incorporation

of each of the 4 elements of the program is explained

in detail, with statistics to illustrate the positive results

for each area. The target population of the program at

Fort Carson is dynamic, as preparations for

deployment and units returning from deployment often

coincide. The population is also growing, as new units

arrive or are created at the post. The value of the Army

Hearing Program is thus demonstrated in the most

demanding of stateside environments, as well as its

invaluable role as a vital enhancement of the hearing

protection efforts in place in the combat theaters. CPT

Cleveland’s excellent article can serve as a guide for a

proven, working model implementation of the Army

Hearing Program.

CPT Davin Bridges and LTC Timothy Bosetti have

contributed an important article addressing the

absolute necessity, and complexity, of preventive

medicine surveillance and assessment of all troop

locations in a deployed environment, even though they

may be geographically dispersed across an area of

operations. Their article presents a logical development of the approach to the vital inspections and

data monitoring needed to reduce disease and

nonbattle injury casualties through proactive measures.

For example, data gathering is only the initial phase of

an assessment. That information must be analyzed to

identify the hazards, evaluate the potential risks they

represent, determine risk control, and communicate the

information to the forces for action. This article is a

clearly written treatment of the subject, packed with

information, tips, and recommendations for our

preventive medicine professionals on the application

of the experience and the extensive skills and

knowledge they already possess.

The limited health related information available to

investigate the health problems of Warriors returning

from the first Persian Gulf conflict in 1990 and 1991

prompted congress to mandate health evaluations of

military personnel before and after deployments, and

maintain that information. However, as Dr Wayne

Combs explains in his informative, well-documented

article, the services were slow to comply with the

requirements, and practitioners were often unaware of

their existence. Eventually, the standards, metrics, and

reporting requirements were formalized and mandated

by a DoD instruction, followed by the attendant Army

regulations. The implementation of formal, structured

quality assurance programs at both DoD and each of

the services’ medical commands has stabilized the

collection and quality of the health data for military

members throughout their careers, and civilians

involved in operations and deployments. Dr Combs’

article clearly captures the history and current situation

of the data we must have to ensure the best possible

healthcare and force health protection for our

Warriors.

REFERENCES

1. Field Manual 4-02: Force Health Protection in a

Global Environment. Washington, DC: US Dept of

the Army; February 13, 2003.

2. Boone RR, Camarillo C, Landry L, Delucia J. Army

provider resiliency training: healing the wounds “on

the inside”. Army Med Dept J. July-September

2008:57-59.

3. McIlwain DS, Cave K, Gates K, Ciliax D. Evolution

of the Army hearing program. Army Med Dept J.

April-June 2008:62-66.
6 https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1

THE OPERATIONAL ENVIRONMENT

The current operational environment is one that is

characterized by instability and persistent conflict. To

meet this challenge, the Army is transforming to

become a more expeditionary force with increased

global reach. The expeditionary capability is the ability

to promptly deploy combined arms forces worldwide

into any operational environment and operate

effectively upon arrival. Expeditionary capabilities

assure friends, allies, and foes that the United States is

able—and willing—to deploy the right combination of

Army forces to the right place at the right time.

Forward deployed units, forward positioned

capabilities, peacetime military engagement, and force

projection—from anywhere in the world—all

contribute to expeditionary capabilities.

In support of the expeditionary capability, the Army

needs forward bases and cooperative security locations. This massive effort of global restationing, repositioning, and rebasing regardless of short- or longterm positioning of forces requires an environmental

assessment to ensure that we are protecting the health

of deployed forces, protecting the environment, and

protecting the US government from third party claims.

It is critical to know the stakeholders and identify and

balance the sampling requirements to properly

document environmental conditions. Partnering is the

key to make this happen.

STAKEHOLDERS AND REQUIREMENTS

Environmental sampling is dependent upon the

perspective. But who are the stakeholders? Experience

has shown that there are typically 3 major players or

stakeholders: the engineers, the medics, and the

lawyers, as illustrated in Figure 1. The engineers are

typically involved in the real estate procurement, site

selection, site layout, and construction. The engineers

are also responsible for conducting the environmental

baseline study. Preventive medicine personnel are

responsible for conducting the environmental health

site assessment, and providing an assessment of the

site from a force health protection standpoint to

determine if there is anything at the site that could

potentially endanger Soldier health (acute or chronic).

The US Army Claims Service is involved to protect

the US government from third party environmental

claims. To accomplish this, they also conduct

environmental surveys to document environmental

conditions. Three major players, 3 different

perspectives, 3 different studies—one environmental

sample.

Knowing the stakeholders and understanding that each

has a different perspective means that the sampling

plan can be coordinated to ensure the needs of all 3

parties are addressed. This partnering can have great

benefits in the reduction of environmental sampling

costs, not to mention the integrated sampling approach

Joint Environmental Site Assessments in

Support of Global Basing

LTC Timothy G. Bosetti, MS, USA

ABSTRACT

As the US Army becomes more expeditionary and establishes forward operating bases in new locations, the

need to document environmental conditions becomes paramount in the protection of the health of deployed

service members and the US government from potential claims. The same holds true for exercises where the

US presence may only be for a week, however, the potential impacts on force health protection and

environmental claims linger for years. Balancing and synchronizing these multiple demands and requirements

can be daunting. Over the past 3 years, the US Army Center for Health Promotion and Preventive Medicine –

Europe has been working closely with the US Army Europe Deputy Chief of Staff, Engineer, and the US Army

Claims Service Europe to conduct joint environmental assessments in support of command exercises and

forward basing initiatives. The synergy and partnerships forged during this process ensure that environmental

assessments are conducted to document environmental conditions, protect human health, and protect the US

government against claims.
April – June 2009 7

that develops to ensure the different needs are met,

resulting in a more thorough assessment of the site.

Therefore, it is possible to take one sample that meets

3 different needs and perspectives.

At the action officer level, we all agree. However,

sometimes it is the command that does not understand

the importance of environmental sampling. In

conducting environmental assessments or follow-on

studies, the question is often asked: what is the

requirement for testing? For the most part, we agree

that we should do some type of baseline environmental

study. However, the amount of discovery and

sampling required is usually questioned. During an

environmental assessment, there can appear to be a

gray area, especially when it seems to fall between

contingency and installation operations; it does not

appear to be covered by either one. To bridge this gap,

the Department of the Army issued a policy

memorandum.1 The specifics of these environmental

assessments come from several different sources as

illustrated in Figure 2.

Partnering can address these different requirements

and ensure that the environmental sampling plan is

designed to meet the different perspectives. The next

step is to balance these requirements to gain efficiency

in the sampling and maximize the return on our

sampling investment.

BALANCE THE SAMPLING

The spectrum of sampling must be

considered when developing the

stakeholder requirements for environmental sampling. However, the difficult

question is how much sampling is

required? The other important question is

what are the courses of action when you

get unfavorable sample results? Also, will

additional sampling be required? Too

often, the second half of the question is

omitted. It is only after we have discovered a problem that it becomes an issue,

and we ask the question. But how do we

respond to the question? Typically, we

scramble around, develop a more detailed plan, and go back to the command

to request more time and money. This is

not a good way to approach this issue.

It is important to know the spectrum of

environmental sampling, illustrated in

Figure 3, and determine how much

sampling will be required to achieve the objectives.

This requires balancing the potential or perceived

threat against the time and resources available. The

ends of the spectrum are relatively easy to identify. If

the site is clean, we stop. If the site is extremely

contaminated, we stop. But what about the site that is

in the middle? Partnering can help consolidate

requirements to reduce duplicative sampling, but that

probably will not be enough to balance the amount of

sampling required to characterize the environmental

threat and the resources available. Therefore, you need

to look at alternative ways to characterize the site. One

way to accomplish this is through phasing the

7

AIR

SOIL WATER

Environmental

Sample

Engineer Medical

Claims

Same sample and data; different perspective and use of the data

Environmental Impact

on the Soldier

Soldier Impact on

the Environment

Environmental

Impact on the

Community /

Host Nation

Partnering ensures

that all three

different views are

addressed

Environmental Health Site Assessment

In Support of Global Basing

A Matter of Perspective

Figure 1. The primary stakeholders and their perspectives in

the environmental sampling and assessment process.

Standard Practice for Conducting Environmental Baseline Surveys: ASTM D6008-96 2

Environmental Health Site Assessment Process for Military

Deployments: ASTM E2318-03 3

Department of Defense Instruction 6490.03: Deployment Surveillance4

Joint Chiefs of Staff Memorandum MCM 008-207: Procedures

for Deployment Health Surveillance5

Army Regulation 11-35: Deployment Occupational and Environmental Health Risk Management6

Department of the Army policies

US Army Europe regulations

Figure 2. Sources for the requirements and specific

guidelines for environmental assessments.
8 https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1

sampling: “look at the site

from 30,000 feet” (broad

sampling approach), then

narrow the scope and focus

to hot spots (areas of

contamination) for more

detailed assessment.

The phased approach gives

us that opportunity and

allows us to tailor the level

of sampling effort to meet

the site conditions. This

works as long as we

communicate those goals

and objectives from the start.

Therefore, a limitation of the

environmental assessment is

that additional sampling may

be required to ensure force

health protection, to properly

document environmental

conditions, and protect

against claims.

KNOWING YOUR LIMITATIONS

The environmental health

site assessment (EHSA) is

required by Department of

Defense Instruction 6490.03 4and Joint Chiefs of Staff

memorandum MCM 0028-07. 5 The key objectives of

the EHSA are to identify exposure pathways, confirm

whether they are completed or potentially completed

through sampling, and conduct a risk assessment on

data gathered in order to determine the impact on the

deployed force.

Like the environmental

baseline study (EBS), the

EHSA is a living document

that must be updated when

conditions change: the site

will change, the plan for the

site will change, the force will

change, the mission will

change, and the truth will

change. What we thought to

be true in the early stages of

the environmental assessment

may turn out to be false or bad

assumptions. Therefore, we need to know the

limitations of the environmental assessments.

The EHSA and the EBS have limitations, the most

prominent of which are shown in Figure 4. This is

important to understand with respect to global

restationing because things move quickly, change

rapidly, and often involve multiple entities. The

key is to understand and communicate upfront

what the environmental assessments will be used

for, and assess whether further assessments are

required. Planning and funding for additional

assessments must be

programmed. Flexibility is

critical, phasing the

assessments are a tool to

accomplish this. However,

you must stay engaged in the

process and be attuned to

changes in your base

assumptions.

An example of this occurred

during an environmental

assessment for a forward

operating site in eastern

Europe. We had all 3 parties

engaged and had planned a

phase II assessment to

characterize the site. In the phase I assessment, we had

identified 2 areas that contained surface and

subsurface contamination, and recommended no

construction activities over those areas. The phase II

assessment focusing on potential groundwater

contamination was completed. Everything was going

great, a model of partnering and efficiency—or so we

thought. Within a few months

after the phase II assessment,

we learned that troop billets

were planned over the area

identified in the phase I as

contaminated. How did this

happen? The plans for the site

had changed, things had

shifted for other reasons, and

these changes were not

communicated prior to the

phase II assessment. This was

not an insurmountable task to

correct, but it did take time. It

Joint Environmental Site Assessments in Support of Global Basing

Document environmental conditions:

Site selection

Identify preexisting contamination

Historical information

Purpose

Protect Human Health

Document environmental conditions

Protect against claims

How much sampling is required?

Ends of the spectrum are more easily quantified

Synergestic and competing requirements

Balance the middle

Figure 3. Determine the extent of sampling

necessary to obtain the data required to

achieve the objectives.

Chronic Threats

Acute Threats

Environmental Sampling

How much

sampling is

required?

Environmental Baseline

Identification of Hot Spots

Environmental Claims

Health Assessment

Snapshot in time

 May not be a complete assessment

 May only identify “hot spots”

 May not contain information related to site

layout and planned activities

 Initial assessment is NOT the final assessment

The truth has a date – time group

 Facts and assumptions change over time

 Must not be a stagnant report, but rather a

living document

Not a “box check” on a list

Figure 4. Limitations inherent in the environmental health site assessment.
April – June 2009 9

THE ARMY MEDICAL DEPARTMENT JOURNAL

illustrates the limitations of the assessments and the

need to communicate, and stresses the importance of

partnering to achieve a common goal.

PARTNERING TO ACHIEVE A COMMON GOAL

Based upon the involvement of the US Army Center

for Health Promotion and Preventive Medicine –

Europe with environmental assessments, specifically

the EBS/EHSA process, we have identified the

following lessons observed over the past 3 years:

 Initial assessments are NOT the final assessment.

 The phased approach is best, and most flexible.

 There are limitations to the environmental

assessment that must be articulated.

 Conducting joint surveys and data sharing is good.

 The truth will change.

 Communication is important, especially to

articulate the purpose, goals, and objectives of the

environmental sampling and assessments.

 Partnering is critical to success.

Partnering on environmental baseline surveys is a

prudent move to ensure that environmental issues are

addressed from all perspectives. This synergy can

provide a consolidated effort, lower laboratory costs,

reduce third party claims, standardize sampling

protocols, and balance environmental sampling

requirements to ensure the protection of health and

safety through proper documentation of existing

environmental conditions.

PARTING THOUGHT

Environmental sampling is expensive, but the results

of proper discovery and documentation of existing

environmental conditions are good investments in the

protection of the Department of Defense from

environmental claims, and ensuring that our Soldiers,

Marines, Sailors, and Airmen are living and training in

places that are not going to cause adverse short- or

long-term health effects.

REFERENCES

1. Assistant Secretary of the Army for Installations and

Environment. Memorandum: Policy for

Environmental Baseline Surveys in Global

Repositioning and Closures Overseas. Washington,

DC: US Dept of the Army; June 6, 2008.

2. American Society for Testing and Materials

International. ASTM D6008-96: Standard Practice

for Conducting Environmental Baseline Surveys.

West Conshohocken, PA: American National

Standards Institute; 2005.

3. 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.

4. Department of Defense Instruction 6490.03:

Deployment Health. Washington, DC: US Dept of

Defense; August 11, 2006.

5. Office of the Chairman, Joint Chiefs of Staff.

Memorandum MCM 0028-07, Procedures for

Deployment Health Surveillance. Washington DC:

US Dept of Defense; November 2, 2007. Available

at: http://amsa.army.mil/Documents/JCS_PDFs/

MCM-0028-07.pdf.

6. Army Regulation 11-35: Deployment Occupational

and Environmental Health Risk. Washington, DC:

US Dept of the Army; May 16, 2007.

AUTHOR

LTC Bosetti is Chief, Department of Environmental

Sciences, US Army Center for Health Promotion and

Preventive Medicine – Europe, Landstuhl, Germany.
10 https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1

BACKGROUND

In 2008, employees of Kellogg, Brown, & Root, Inc,

filed a lawsuit alleging exposure to toxic chemicals

while working to restore the infrastructure in Iraq in

2003. The lawsuit prompted Congress to hold hearings

regarding the incident, and when they learned that

some National Guard members served as escorts for

the KBR employees, they inquired as to whether there

was a potential for adverse health effects among

Soldiers in these units. The United States Army Center

for Health Promotion and Preventive Medicine

(USACHPPM) provided information based on an

assessment conducted by a special medical

augmentation response team-preventive medicine

(SMART-PM) which deployed at the time of the

incident. To alleviate any questions regarding the

assessment, The Surgeon General of the Army

requested that the assessment be reviewed by the

Defense Health Board.* The review was requested to

assess the incident and the information gathered,

determine whether the information was sufficient to

assess the potential health risk, and decide whether

additional actions should be taken.

The Qarmat Ali Industrial Water Treatment Plant

located in Basra, Iraq, produced industrial water for

use in oil production, and did not produce potable

water. The site was in an urban area, enclosed by a

perimeter fence, and consisted of several structures

lacking sleeping or living quarters. It had been

ransacked and was not functional when secured by US

military forces. The site was visibly contaminated by

sodium dichromate, a corrosion suppression agent

used in the water treatment process. Sodium

dichromate is an inorganic compound containing

hexavalent chromium known to be toxic and

carcinogenic to humans and animals. Four groups

worked at Qarmat Ali during the time of concern:

Kellogg, Brown, & Root (KBR), a US based company

contracted to restore the plant to operative status; the

US Army National Guard units from Oregon, South

Carolina, and Indiana, who provided personal security

to KBR; the British military previously present at the

site to secure the area; and Iraqi civilians hired by

KBR to assist in the restoration effort.

In 2003, Army personnel were assigned to provide

security for the KBR workers restoring the industrialgrade water treatment facility at Qarmat Ali, Basra,

Iraq. In the summer of that year, contract work crews

and safety personnel identified sodium dichromate as a

potential occupational hazard in the work

environment. Several US Army Soldiers reported to

the supporting military medical facility and inquired

about the potential health risks posed to them in their

role as security detail. Concurrently, KBR initiated

containment of the contaminated site and conducted

environmental sampling. In-theater military

occupational and environmental health specialists

addressed the health concerns of the military units at a

local “town hall” meeting and requested a SMARTPM conduct an in-theatre assessment. The team

consisted of industrial hygienists, occupational

medicine physicians, and environmental scientists. The

team conducted sampling and medical evaluations for

all personnel present at that time, including the Indiana

Army National Guard Soldiers and Department of the

Army civilians.

THE OCCUPATIONAL AND ENVIRONMENTAL INCIDENT,

AND THE ROLE OF THE SMART-PM

Department of Defense Instruction 6490.03 implements policies and prescribes procedures for deployment health activities to

...control or reduce Occupational and Environmental

Health (OEH) risks, to document and link OEH

exposures with deployed personnel,...and to record

daily locations of deployed personnel.1(p1)

Evaluation of Exposure Incident at the

Qarmat Ali Water Treatment Plant

Coleen Baird Weese, MD, MPH

*The Defense Health Board is a Federal Advisory Committee to the Secretary of Defense. It provides independent

scientific advice/recommendations on matters relating to

operational programs, health policy development, health

research programs, and requirements for the treatment

and prevention of disease and injury, promotion of health

and the delivery of health care to Department of Defense

beneficiaries. Information available at http://www.

health.mil/dhb/default.cfm.
April – June 2009 11

The instruction requires a trained and equipped staff

“to provide support to conduct disease outbreak and

OEH exposure incident investigations”1(p6) and to

ensure reports and documentation are archived. The

instruction further notes that

All exposures shall be reported that are immediately

hazardous to life or health or that may significantly

increase long-term health risks (eg cancer) through

appropriate command channels.1(p6)

Likewise, Joint Chiefs of Staff Memorandum MCM

0028-07 requires preliminary hazard assessments be

conducted at sites to summarize and identify

anticipated OEH threats and hazards. This

memorandum requires

...documentation in the individual medical record...of

any significant occupational and environmental

exposures...2(pA-3)

Significant occupational and environmental exposures

are defined as

Exposures to OEH hazards that will plausibly result in

some clinically relevant adverse health outcome to

exposed individuals...2(pA-A-4)

Alternatively, routine or investigative sampling might

yield a result that exceeds guidelines and was

considered significant.

A preliminary or phase I site assessment may have

identified the contamination if there was sufficient

evidence to raise the suspicion. Alternatively, during

an occupational and environmental health assessment,

past practices, visible ground contamination, or other

findings may have led to a more detailed and specific

assessment. In this instance, visible contamination at a

worksite prompted an evaluation by the contractor, and

the Soldiers who escorted them to the site were

concerned. Their expressed concerns prompted the

request for additional assessment support through

command channels. The request for a special medical

augmentation response team was received by

USACHPPM, and a SMART-PM staffed with

personnel appropriate to the situation was formed. The

team deployed to conduct sampling to assess the risk,

and to provide medical evaluations and risk

communication.

SPECIAL MEDICAL AUGMENTATION RESPONSE

TEAM ACTIONS

Between September 30 and October 24, 2003, the

SMART-PM sampled surfaces within the water

treatment plant, the air within and outside the plant,

and the soil outside the plant. By the time the team

arrived, the contractor had contained the

contamination with an asphalt cover, and thus air

sampling did not identify any samples above the

Military Exposure Guidelines (MEGs) for air. The soil

sampling results exceeded the MEGs for soil only

outside the fence line of the plant. Prior to

encapsulation, 3 of 48 samples of air were found to

exceed the MEGs for hexavalent chromium. These

values did not exceed the Permissible Exposure

Limits, set by the Occupational Safety and Health

Administration, which define the amount to which

workers may be exposed for 40 hours a week for a

working lifetime. However, the MEGs, designed for

use on deployments, recognize that military personnel

could be exposed to contaminants in air 24 hours per

day, for periods from one to 15 years, if the sources

were continuous. As such, the MEGs are lower than

comparable workplace standards. This means that they

are more conservative, and they are also set not to be

an effect level at which adverse outcomes occur, but

are screening values that indicate a need for further

assessment. As the sampling conducted by the

SMART-PM did not produce results that exceeded any

limits, the concern for health effects was low.

However, as stated previously, these results were

obtained following encapsulation. It was known that

some samples had exceeded the long-term MEGs for

chromium. To address the potential that exposures

prior to encapsulation were higher, and may be of

concern, it was decided that medical evaluations of

those onsite should be conducted. Medical evaluations

were offered to the members of both security forces

and Department of Defense civilians. While KBR

employees performed repairs to the plant prior to

discovery and containment of the sodium dichromate

powder, security forces and civilians spent much less

time at the site. The routes of exposure of concern

were determined to be inhalation and skin contact. The

evaluations included the administration of exposure

and symptom questionnaires, and medical

examinations tailored to assess chromium exposure.

Elements in the exams included a medical history, a

general physical examination, and blood and urine

testing (whole blood chromium levels, complete blood

counts, serum chemistries, liver and renal function

tests), routine urinalysis, chest x-rays, and spirometry

testing. The medical evaluations were conducted

within 30 days of the last potential exposure at the site.

Under occupational standards, a physical examination
12 https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1

targeting the skin and respiratory system must be

conducted within 30 days of an overexposure, focusing

on the presence of characteristic lesions (“chrome

holes”) associated with hexavalent chromium

exposure. These lesions were commonly seen in

occupational groups in the US which worked with

hexavalent chromium at levels above the current

occupational limits. The specific testing for chromium,

or biomonitoring, was particularly useful in this

instance. Typically, if individuals are exposed to

metals, or solvents or many other types of substances,

they typically “clear” the body directly or are

metabolized within hours to days. For this reason,

many of the biomonitoring tests are useful only if

performed soon after exposure. When hexavalent

chromium enters the body, it is taken into red blood

cells where it remains for the life of the red blood cell,

which is 120 days. Whole blood testing, which

includes red blood cells, provided an indication of

exposures up to 4 months prior to the test, prior to

encapsulation. This testing, available at the Armed

Forces Institute of Pathology, was performed.

Less than 30% of examined individuals reported

symptoms, and the symptoms reported were

nonspecific irritation, with eye and throat irritation

being the most common. None of the individuals

exhibited classical symptoms of overexposure to

chromium. As might be expected when nonspecific

testing is performed, some individuals were identified

with minor abnormalities on urinalysis, liver function

tests, pulmonary function tests, etc, but these

abnormalities were minimal, few in number, and had

multiple potential etiologies. Abnormal findings were

not correlated with time onsite by history, and did not

support a significant exposure to hexavalent

chromium. The SMART-PM concluded that the

reported symptoms could be related to existing

personal medical conditions and desert environmentrelated exposures, such as heat, sand, dust, and wind.

Whole blood testing for total chromium was done at

the Armed Forces Institute of Pathology. Most tested

individuals had levels of total chromium below the

detection limit. Average values were not elevated

when compared with nonoccupationally exposed

general population ranges.

INCIDENT EVALUATIONS

Exposure assessment is the next step following

identification of a potential hazard. Ideally, exposure

monitoring can be conducted and compared to relevant

standards. Typically, if adequate sampling results in

levels below standards, no further action is needed. In

this instance, the initial monitoring indicated a need

for further assessment, based on exceedance of the

MEGs prior to encapsulation. As the MEGs are

conservative, they can be used as a screening guide to

direct further action. In this instance, those actions

were additional sampling, which indicated that

encapsulation had been a successful protective action.

This was complemented by physical examination and

biomonitoring, which did not indicate that significant

exposure had occurred. The findings are based upon

exposure assessment, including the identification and

quantification of exposure, and assessment of potential

risk based upon prior knowledge of dose response

relationships. Analysis of the materials/specimens

collected is affected by time between collection and

analyses (degradation), quantity of materials/specimens gathered, and most importantly, the limits of

detection. The end product of the interpretation of

findings of the above analyses is a scientificallydefensible estimate of risk for the exposed individuals

given the limitations of both measures of exposure and

response. The estimate of risk is likely to be qualitative, such as low, medium, or high, but should dictate

specific actions. These could be 1) no further action,

2) retain roster of those involved and consider passive

epidemiological surveillance, 3) retain a roster of

population at risk and conduct active epidemiological

surveillance, and 4) recommend certain screening or

other examinations at some set interval.

In this instance, estimation of the risk determined no

significant risk, and no anticipation of future health

outcomes. As such, the findings were communicated

to the individuals involved, information was placed in

their permanent medical records, and they were

instructed to note the incident on their postdeployment

health assessment form. When the Defense Health

Board evaluated this incident, they determined that the

risk assessment conducted was “timely,

comprehensive, and appropriate for the potential risk

posed to service members.”3(p1) They acknowledged

that USACHPPM

met or exceeded the standard of practice for

occupational medicine in regard to the exposure

assessment and medical evaluation conducted in 2003

for Soldiers potentially exposed to hexavalent

chromium.3(p9)

Evaluation of Exposure Incident at the Qarmat Ali Water Treatment Plant
April – June 2009 13

THE ARMY MEDICAL DEPARTMENT JOURNAL

They concluded that there was no expectation of any

future adverse health outcomes. Additionally, they

recognized that the anticipation, recognition,

evaluation, and intervention in such situations often

requires expertise beyond assets on the ground.

The actions taken to address the situation of the

potential exposure to hazardous materials at the

Quarmat Ali Water Treatment Plant are a case study of

how on-scene preventive medicine and medical

personnel correctly collaborate in the recognition,

evaluation, and response to environmental risks in a

deployed environment. Resources are available to

assist in these types of situations. As was done in this

case, deployed preventive medicine personnel and

medical personnel are strongly encouraged to seek

additional support through USACHPPM if they are

faced with an exposure incident.

REFERENCES

1. Department of Defense Instruction 6490.03: Deployment Health. Washington, DC: US Dept of Defense; August 11,

2006.

2. Office of the Chairman, Joint Chiefs of Staff. Memorandum MCM 0028-07, Procedures for Deployment Health

Surveillance. Washington, DC: US Dept of Defense; November 2, 2007. Available at: http://amsa.army.mil/Documents/JCS_PDFs/MCM-0028-07.pdf.

3. Defense Health Board. Defense Health Board Review of the US Army Center for Health Promotion and Preventive

Medicine Assessment of Sodium Dichromate Exposure at Qarmat Ali Water Treatment Plant. Falls Church, VA: US

Dept of Defense; 2008. Report DHB 2008-06.

AUTHOR

Dr Weese is Program Manager for Environmental Medicine, US Army Center for Health Promotion and Preventive

Medicine, Aberdeen Proving Ground, Maryland.
14 https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1

BACKGROUND

Hearing is a critical sensor of Soldiers that is vital to

both their survivability and lethality. When hearing

loss is present, the ability to conduct auditory tasks is

greatly diminished. Good hearing is required to

perform such tasks as localizing sound, gauging

auditory distance, identification of a sound source, and

understanding verbal orders or radio communications.

This multidimensional sense provides an indispensable

amount of information on the battlefield and can mean

the difference between life and death in combat. The

ability to distinguish the sounds of different weapons,

both friendly and enemy, is a combat-critical skill.

Poor hearing jeopardizes the unit mission and

increases the likelihood of a serious mishap due to a

Soldier’s decreased situational understanding. Verbal

communications and hand and arm signals between

dismounted Soldiers remain the primary means of

communication on the battlefield. Although technological advances have improved battlefield communication systems, these electronic advances cannot

overcome the fact that human hearing is required to

complete most communication.

Sound is often the first source of information a Soldier

has before direct contact with the enemy. Unlike visual

cues, information carried by sound comes to us from

all directions, through darkness, and over or through

many obstacles. Aggressive action produces sound the

enemy cannot hide or camouflage. The ability to hear

and recognize combat-relevant sounds is a vital

component to situational understanding and provides a

tactical advantage. Noise-induced hearing loss is a

tactical risk and threatens both individual and unit

combat effectiveness. Hearing loss due to noise

exposure usually occurs in the high frequencies. Since

speech sounds that give meaning to words (for

example, consonants such as ch, th, sh, f, and p) are

high-frequency sounds as well as the sounds that

provide the ability to determine the signature of

weapons and vehicles, high-frequency hearing loss is

particularly devastating to military operations. In the

heat of battle, many words can be mistaken—even

more so if hearing loss is present. For example; breach

and break, attack and get back, cease fire and keep

firing, stay down and go around, or right car and white

car. Figure 1 displays a spectrograph of the sentence

“get the white car.” Each speech sound from the

sentence is superimposed at the location corresponding

to its occurrence. The horizontal axis represents time

in seconds and the vertical axis represents the

frequency of the sound in Hz. The colors represent

intensity. The brighter the color, the louder the sound

is at that frequency. When the same sentence is filtered

to H3 hearing profile levels,* the decrease or absence

in intensity in the higher frequency region at the top of

the spectrograph is considerable. This is a visualization

of just how much speech cues are not audible in a

Soldier with an H3 profile.

Outside of combat, the ability to hear still matters for

safety and performance reasons. In fact, most of the

150 different enlisted jobs in the Army do not directly

involve combat. Even so, most of these jobs do require

combat deployments and have occupational hazards

such as noise and ototoxins. These auditory hazards

are compounded by 12- to 18-month deployments that

have lengthy work days, no weekends, and very little

free time away from work. The symptoms of noiseinduced hearing loss can be deceptively subtle, usually

with no obvious physical injury or wound, but the

effects can be permanent, debilitating, often untreatable, and, most importantly, preventable.

LITERATURE REVIEW

During the first year of the war in Iraq, there was an

average of one medical evacuation a day for hearing

loss (with no other concurrent injury). Medical

Cohort Case Studies on Acoustic Trauma in

Operation Iraqi Freedom

MAJ D. Scott McIlwain, MS, USA

MAJ (Ret) Bryan Sisk, AN, USA

Melinda Hill, AuD

*H3 hearing profile is defined by the US Army Standards of

Medical Fitness1as “speech reception threshold in best

ear not greater than 30 dB HL, measured with or without

hearing aid; or acute or chronic ear disease.”
April – June 2009 15

evacuations for hearing loss were sent to the audiology

clinic at Landstuhl Regional Medical Center in

Germany. McIlwain found that out of the 564 patients

seen there during this time, 65% were from blast

injuries.2Sensorineural hearing loss from friendly

forces weapons systems made up approximately 25%

of the injuries. The remaining 10% were balancerelated or conductive type hearing loss that was

predominantly unrelated to hazardous noise exposure.

As a result, a military audiologist position was

temporarily placed in Baghdad in 2004 to evaluate

acoustic trauma patients. This provided an efficient

way to determine a Soldier’s hearing ability without

the need for a lengthy and expensive medical

evacuation for a nonlife-threatening injury. Oftentimes, Soldiers are exposed to an explosion such as an

improvised explosive device or a mortar round and

have no apparent injuries, but can sense their hearing

has decreased and tinnitus is present. With no visible

injuries, the Soldiers return to their duties. This is

where the term “invisible injury” is derived.

The ability to distinguish the sounds of different

weapons, both friendly and enemy, is a skill that is

taught in the Army. If the sounds of weapons fire are

coming from the next block of buildings, knowing

whether it is enemy or friendly, small arms or

automatic weapons, small caliber or large caliber, or if

it is a rocket propelled grenade or an antitank weapon

can be critical information that determines a Soldier’s

reaction. Katzel et al found that the signature sounds

distinguishing a weapons system are primarily above 4

kHz.3 The frequencies above 4 kHz are also where

hazardous noise affects the cochlea the most, and

where the tell-tale “noise notch” occurs.4 Consequently, identification of noise signatures, communication, gauging auditory distances, and localization

are negatively affected. Studies have shown that the

ability to accomplish a unit’s mission is directly

proportional to its ability to communicate effectively.

If effective communication drops by 30%, the ability

to control the unit in order to accomplish the task

drops by 30% as well.5

Weiner and Ross describe the resonant characteristics

of the outer ear as boosting the sound pressure level of

the frequencies between 2500 Hz and 3500 Hz.6

Donahue and Ohlin describe the middle ear as

frequency selective because the transfer functions of

the middle ear allow the mid- to high-frequency

sounds (approximately 1500 Hz through 4000 Hz) to

pass through it with considerably less resistance than

the low-frequency sounds.4 The result is that the lowfrequency sounds reach the cochlea at a lower intensity

than when it entered the ear canal. Conversely, sounds

at frequencies between 1 kHz and 3 kHz are transferred to the cochlea with significantly less resistance

and greater intensity than when they entered the ear

canal. Rudmose and Ward independently demonstrated

that when high intensity pure tones reach the cochlea

in the 1 kHz to 3 kHz frequency range, the resulting

threshold shift occurs approximately a half to one

whole octave above the pure tone exposure.7,8 As the

waveform increases in amplitude on the basilar

membrane due to an increase in sound intensity, the

vibration becomes less localized and moves toward the

basal portion of the cochlea.4 Ylikoski and Ylikoski

state that this movement causes damage to loci of the

cochlea that are different from the stimulus

frequencies.9For broad-band noise with equal energy

in all bandwidths, the maximum threshold shift occurs

between 3000 Hz and 6000 Hz.8

Figure 1. Comparative spectrographs of the sentence, “get the white car.”
16 https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1

Studies of noise-induced hearing loss in the Global

War on Terror have been analyzed. Cave found that

more than 50% of 258 acoustic trauma patients seen at

the Walter Reed Army Medical Center from April

2005 through August 2005, had significant hearing

loss, and age could not account for the change in

hearing from before to after deployment. In addition,

one-half of these patients reported having tinnitus.10

Helfer data mined hearing loss associated diagnoses

codes of postdeployment and nondeployed Soldiers

between April 1, 2003 and March 31, 2004. He found

that 68% of 806 postdeployment evaluations had been

diagnosed for at least one of the following: acoustic

trauma (5.6%), permanent threshold shift (29.3%),

tinnitus (30.8%), eardrum perforation (1.6%), or

moderately severe hearing loss or worse (15.8%). The

nondeployed group had 4% of 141,050 diagnosed with

the same hearing loss related codes: acoustic trauma

(0.1%), permanent threshold shift (0.5%), tinnitus

(1.5%), eardrum perforation (0.1%), or moderately

severe hearing loss or worse (2.2%).11 In 2007, the

Veterans Administration Rehabilitative Research and

Development Department reported that 839,907

veterans were identified as having service-connected

hearing loss that required compensation from the

Veterans Benefit Administration. In 2006, total

compensation to Veterans was over $1.2 billion for

hearing loss and tinnitus disabilities12(p3) and accounted

for 17% of the total disability claims.12(p12) This is an

increase of 18% from the previous year and a 56%

increase since 2002.12(p12) These studies corroborate

that the sounds of combat can be devastating to a

Soldier’s hearing readiness.

Bohne and Harding found that the cochlea undergoes 2

histopathologic stages after an acoustic trauma:

degeneration of the outer hair cells and the continued

degeneration of supporting cells, afferent nerve fibers,

and additional hair cells. The second histopathologic

stage has a delayed onset with respect to identification

of threshold shifts with routine monitoring.13 Simply

put, hearing loss is progressive after an acoustic

assault and therefore the actual rate of hearing loss in

the Army is greatly underestimated. Multiple tours of

duty in Iraq and Afghanistan will accelerate this

delayed onset due to lengthy work days, no weekends,

and large doses of hazardous noise exposure on a

regular basis. The number of servicemen and

servicewomen on disability because of hearing damage

will increase no less than 15% a year under current

combat conditions and disability policies.14 The US

Army Center for Health Promotion and Preventive

Medicine has followed veterans’ disability claims

since 1969. In 2008, the disability payments from the

Veterans Administration for tinnitus and hearing loss

exceeded one billion dollars. Unfortunately, a Government Accountability Office investigation found that

the average pending and appeal process of applying for

a service connected disability in 2007 was 789 days.15

Even if a Soldier’s hearing thresholds are within a

normal tolerance, the damage may have begun. Future

hazardous noise exposure will append to previous

damage and lead to future hearing loss that is not

within acceptable limits for Army standards. Once a

Soldier’s Speech reception threshold in the best ear is

greater than 30 dB hearing level (measured with or

without hearing aid), their ability must be evaluated

for functionality and personal risk with respect to their

jobs. For instance, if a helicopter pilot has a hearing

loss and poor speech intelligibility; many lives are at

risk if the radio communication cannot be heard. Also,

the pilot risks further hearing loss to the hazardous

noise of the helicopter. If the findings of the review

board are negative, the Soldier is offered a medical

discharge or a change to a job that does not involve

hazardous noise exposure. Even if Soldiers choose to

change jobs rather than take a medical discharge, the

organizational knowledge and technical experience

goes with them.

VARYING EXPOSURES

The following cohort case studies were observed using

air conduction hearing threshold data collected during

evaluations conducted in 2006 at the US Army

Audiology Clinic in Baghdad, Iraq. The 2 cohort case

studies presented here are the effects of acoustic

trauma while wearing hearing protection and the

effects of acoustic trauma while not wearing hearing

protection.

Cohort Case Study No. 1

Paired data of predeployment and during deployment

hearing thresholds of 50 US Army Soldiers (100

individual ears) were randomly observed among

Soldiers that were exposed to acoustic trauma while

wearing hearing protection. All subjects were noisefree for at least 14 hours before evaluation. Only

threshold data from Soldiers with normal type A

Cohort Case Studies on Acoustic Trauma in Operation Iraqi Freedom
April – June 2009 17

THE ARMY MEDICAL DEPARTMENT JOURNAL

tympanograms were collected. Of this sample, 25 of

the Soldiers reported exposure to explosions in combat

while wearing some form of hearing protection and 25

that had not been exposed to explosions, but received

hearing screenings as a part of routine physical exams.

During each evaluation, predeployment

audiometric thresholds were compared to the

current results. One Soldier in the hearing

protected acoustic trauma group had one ear with

a perforated tympanic membrane, so that ear was

excluded from the data set, reducing the number

of ears to 49. Since data were paired, no

weighting for age or gender was used. The

differences in thresholds predeployment and

during deployment at the individual frequencies

of 500 Hz, 1 kHz, 2 kHz, 4 kHz, and 6 kHz were

then compared between groups with a one-way

analysis of variance (ANOVA) using Statistical

Package for Social Sciences (SPSS), Version

11.0 (SPSS Inc, Chicago, Illinois). Levene’s

statistic was used to test for homogeneity of

variance at each frequency between groups.

Since there were only 2 groups, no post hoc tests

were necessary.

The null hypothesis: there is no significant

difference between predeployment and ongoing

deployment audiometric threshold levels at the

individual frequencies of 500 Hz, 1 kHz, 2 kHz,

4 kHz, and 6 kHz between routine physical exam

group and hearing protected acoustic trauma

group. The null hypothesis was rejected for the

individual frequencies of 500 Hz, 1 kHz, and 2 kHz.

There was a significant difference in hearing threshold

levels at these frequencies. All frequencies passed

Levene’s test, except 4 kHz. Figure 2 displays the

mean threshold differences and error bars for each

group and frequency. The descriptive statistics are

displayed in the Table.

The analysis of variance at 500 Hz revealed a highly

significant difference between groups, F=9.463,

p<0.05 with a medium effect size (η

2

) of 0.09. The

analysis of variance at 1 kHz revealed a highly

significant difference between groups, F=6.076,

p<0.05 with a medium η

2

of 0.06. The analysis of

variance at 2 kHz revealed a significant difference

between groups, F=9.657, p<0.05 with a medium η

2

of

0.09. The analysis of variance at 4 kHz revealed no

significant difference between groups, F=2.707,

p>0.05 with a small η

2

of 0.03. Homogeneity of

variance was violated, α=0.045, p<0.05. The analysis

of variance at 6 kHz revealed no significant difference

between groups, F=1.607, p>0.05 with a small η

2

of

0.02.

The increase in standard deviation with the increase in

frequency is notable in the postdeployment thresholds,

but expected in individuals exposed to hazardous

noise. An analysis of men exposed to hazardous noise

in the International Standards Organization 1999

database by Bovo et al showed that male workers

exposed to a noise level of 100 dBA for 30 years

exhibited a hearing loss at 4 kHz with a variation of 60

dB.15 This is consistent with the findings of the hearing

protected acoustic trauma group. Further, several

studies attribute this variation to mechanical resonance

and sound transfer function of the ear canal, the action

of stapedial reflexes, and genetics.15-17 The

significance levels were least remarkable at 4 kHz and

6 kHz due to the low power and the violation of

homogeneity of variance at 4 kHz. Ferguson and

Tukane describe the one-way ANOVA as being robust

enough to overcome violations of homogeneity of

Figure 2. Graphical depiction of differences in predeployment

and during-deployment audiometric thresholds between paired

control and exposure groups.

Glossary

PE – routine physical exam group

AT – hearing protected acoustic trauma group

Notes

1. PE and AT are followed by the corresponding frequency in Hz

2. Decibels measurements are logarithmic.
18 https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1

variance.18 However, the results of 4 kHz and 6 kHz

interpretation should be based on the mean and error

bars in Figure 2.

The increase of hearing thresholds in the hearing

protected acoustic trauma group is least remarkable at

4 kHz and 6 kHz. The attenuation characteristics of

hearing protection may explain the greater protective

effect of the 4 kHz and 6 kHz over the lower

frequencies. Higher frequency sound energy is more

easily obstructed than lower frequency sound energy

in passive hearing protection. To a large extent, the

wavelength of the sound is responsible for this greater

attenuation in the high frequencies; the higher the

frequency, the shorter the wavelength and vice versa.

Generally speaking, acoustic energy is attenuated more

if the earplug is greater than one-half the wavelength

of the sound. Since the Soldiers in this cohort case

study were wearing a variety of approved hearing

protection (polyvinyl foam earplugs, combat arms

earplugs, and tactical communication and protective

systems), a properly sized and fitted hearing protector

of any given size or style will therefore attenuate

higher frequency sound with a shorter wavelength than

a lower frequency sound with a longer wavelength.

This is consistent with the protective effect at 4 kHz

and 6 kHz in this study.

The statistical significance at 500 Hz, 1 kHz, and 2

kHz may also be attributable to the earplug preventing

the acoustic reflex from occurring during the impulse

noise. Fletcher found that the acoustic reflex was more

effective at protecting hearing from gunfire in

frequencies below 1 kHz than the single

flanged earplug. However, he also found

the single flanged earplug to be most

effective in frequencies 2 kHz and

greater.17 This corresponds to the observed

hearing thresholds of this case study, but

also does not take into account bone

conduction of the sound. Berger found that

at 40 dB in the frequency of 2 kHz, sound

reaches the cochlea via bone conduction

even when hearing protection is worn.19 If

we take into account the half wavelength

theory mentioned in the previous

paragraph, it is expected that higher

frequencies are attenuated more through

the human body and therefore the lower

frequency sounds are louder at the cochlea

via bone conduction. This also may

account for some of the difference patterns observed.

Further, Price describes the middle ear as a linear

system up to 120 dB sound pressure level, and that the

transfer functions of the middle ear are flat in the

lower frequencies and decrease at a rate of 6 dB per

octave at frequencies above 1 kHz.20,21 Kobrak and

von Bekesy found that in human cadavers’ ears the

stapes changed its mode of vibration at high intensities

in such a way that less energy was transmitted to the

cochlea.22,23 These studies support the idea that the

middle ear can peak clip high intensity impulse noise.

Since the explosions could not be meticulously

measured, it is not plausible to argue that the hearing

protected acoustic trauma group benefited from this

middle ear peak clipping, but is worth mentioning.

Cohort Case Study No. 2

Independent samples of during deployment hearing

thresholds of 81 US Army Soldiers (161 individual

ears) were randomly observed in two groups: routine

physical exams and acoustic trauma without hearing

protection. All subjects were noise-free for at least 14

hours before evaluation. Only threshold data from

Soldiers with normal type A tympanograms were

collected. Of this sample, 34 of the Soldiers reported

acoustic trauma in combat and 47 had not been

exposed to acoustic trauma, but received hearing

screenings as a part of routine physical exams. One

Soldier in the acoustic trauma group had one ear with a

perforated tympanic membrane, so that ear was

excluded from the data set reducing the number of ears

Cohort Case Studies on Acoustic Trauma in Operation Iraqi Freedom

Data from comparative tests of predeployment and during-deployment

audiometric thresholds between paired control and exposure groups.

Glossary

PE – routine physical exam group

AT – hearing protected acoustic trauma group

Note: PE and AT are followed by the corresponding frequency in Hz
April – June 2009 19

THE ARMY MEDICAL DEPARTMENT JOURNAL

to 67. All subjects were under 25 years of age, so

no weighting for age or gender was used.24 The

thresholds at the individual frequencies of 500

Hz, 1 kHz, 2 kHz, 4 kHz, 6 kHz, 8 kHz, and 12

kHz were then compared between groups with a

one-way ANOVA using SPSS, Version 11.0.

Levene’s statistic was used to test for

homogeneity of variance. Figures 3 and 4

display the quartiles and outliers at each

frequency. Since there were only 2 groups, no

post hoc tests were necessary.

The null hypothesis: there is no significant

difference between audiometric threshold levels

at the individual frequencies of 500 Hz, 1 kHz, 2

kHz, 4 kHz, 6 kHz, 8 kHz, and 12 kHz between

the routine physical exam group and the acoustic

trauma group.

The null hypothesis was rejected for the

individual frequencies of 500 Hz, 1 kHz, 2 kHz,

4 kHz, 6 kHz, 8 kHz, and 12 kHz. There was a

significant difference in hearing threshold levels

at these frequencies.

The analysis of variance at 500 Hz revealed a

highly significant difference between groups,

F=5.485, p<0.05 with a medium η

2

of 0.03. The

analysis of variance at 1 kHz revealed a highly

significant difference between groups, F=6.371,

p<0.05 with a medium η

2

of 0.04. Homogeneity

of variance was not violated, α=0.67, p>0.05.

The analysis of variance at 2 kHz revealed a

significant difference between groups, F=11.661,

p<0.05 with a medium η

2

of 0.07. Homogeneity

of variance was violated, α=0.03, p<0.05. The

analysis of variance at 4 kHz revealed no

significant difference between groups, F=25.017,

p>0.05 with a small η

2

of 0.01. Homogeneity of

variance was violated, α=0.00, p<0.05. The

analysis of variance at 6 kHz revealed no

significant difference between groups, F=17.159,

p>0.05 with a small η

2

of 0.01. Homogeneity of

variance was violated, α=0.00, p<0.05. The

analysis of variance at 8 kHz revealed no

significant difference between groups, F=27.589,

p>0.05 with a large η

2

of 0.17. Homogeneity of

variance was violated, α=0.00, p<0.05. The

analysis of variance at 12 kHz revealed no

significant difference between groups, F=28.736,

AT12000Hz

PE12000Hz

AT8000Hz

PE8000Hz

AT6000Hz

PE6000Hz

Decibels

120

100

80

60

40

20

0

-20

Figure 4. Median and quartiles of the data comparing subjects of

the physical exam group versus those of the acoustic trauma

group.

Glossary

PE – routine physical exam group

AT – hearing protected acoustic trauma group

Note: PE and AT are followed by the corresponding frequency in Hz

AT4000Hz

PE4000Hz

AT2000Hz

PE2000Hz

AT1000Hz

PE1000Hz

AT500Hz

PE500Hz

Decibels

80

60

40

20

0

-20

Figure 3. Median and quartiles of the data comparing subjects of

the physical exam group versus those of the acoustic trauma

group.

Glossary

PE – routine physical exam group

AT – hearing protected acoustic trauma group

Note: PE and AT are followed by the corresponding frequency in Hz
20 https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1

p>0.05 with a large η

2

of 0.15. Homogeneity of variance was violated, α=0.00, p<0.05.

The significance levels were remarkable at all

frequencies. The increase in standard deviation with

the increase in frequency is notable, but expected in

hazardously noise exposed individuals. Several studies

attribute this variation to mechanical resonance and

sound transfer function of the ear canal, the action of

stapedial reflexes, and genetics.15-17

Balatsouras evaluated extended high frequency

hearing (greater than 8 kHz) in basic trainees of the

Greek Army.25 The purpose was to determine if there

was value added to the inclusion of extended high

frequency threshold testing with the standard

audiology battery. The subjects had been exposed to

acoustic trauma by small arms weapons fire. The

conclusion was that extended high frequency

temporary threshold shift subsided and there was no

significant benefit from the added time and effort for

conducting this procedure.

Hamernik identified impulse noise, specifically blast

waves with very short durations (0.5 millisecond) and

high peak intensities, as capable of producing a

mechanical impulse which can result in extremely high

shear stresses and premature failure of elastic

structures.26 He further described blast wave exposure

as producing 2 fundamentally different lesion patterns:

severe mechanical damage to the organ of Corti where

large pieces of sensory and supporting cells were torn

loose from the basilar membrane, and lesions that were

more limited in extent and consisted primarily of

missing or damaged sensory cells with the structural

elements of the organ of Corti remaining essentially

intact. This latter pattern of loss was frequently

associated with damage to the tympanic membrane.

The acoustic traumas in this study were from

improvised explosive devices or car bombs and the

results above 8 kHz were permanent and quite large

threshold shifts. This is likely due to the spectral and

intensity differences in small arms fire and improvised

explosive device exposure.

Improvised explosive devices (IEDs), which were used

sparsely at the outset of Operation Iraqi Freedom in

March 2003, now account for nearly 70% of all US

casualties from hostile action in Iraq.27

Understandably, the IED was the most common type

of impulse exposure in Iraq in 2006. During this phase

of Operation Iraqi Freedom, most of the IEDs were

constructed out of 105mm artillery shells. Price

measured the impulse and spectrum of this explosive

device. At 5.64 meters, the impulse has a spectral peak

at ~100 Hz with an A duration of 0.3 millisecond. The

second most common impulse exposure was from the

standard issue M16 rifle. At 4.24 meters, it has a

spectral peak of ~600 Hz with an A duration of 0.2

millisecond.21 Either of these, when situated where

there is a reflection of the impulse, will create a second

reflected impulse exposure that can be as much as 90%

of the initial impulse’s energy with similar spectral

energy. In an urban terrain such as Baghdad, warfare

often takes place in city streets where there is a great

deal of reflective surfaces. The spectral peak of the 2

most common combat exposures is below 1 kHz and is

another probable variable for the hearing protected

acoustic trauma groups hearing postexplosion

threshold configuration.

DISCUSSION

Army audiology plays a very important role in

preventive medicine and the standard 3 levels of

prevention are routinely used. Primary preventive

measures include proper selection and use of hearing

protection, annual education, and taking a baseline

audiogram. Secondary preventive measures involve

identification of the early stages of noise induced

hearing loss and taking steps to prevent its progression

through intervention, follow-up monitoring, and

clinical validation of results. If primary and secondary

prevention strategies do not work, tertiary services

such as hearing aid fitting, aural rehabilitation, and

administrative controls are used. The primary and

secondary preventive measures of hearing

conservation have had a tremendous impact in the

reduction of the number of Soldiers with hearing loss

over the past 4 decades, but current large scale combat

operations have reduced the success rate of

conventional hearing conservation in the Army.

Hearing conservation is a robust program in the Army.

Unfortunately, hazardous noise and its effects on

hearing cannot be eradicated with a one treatment

vaccination, it is an ongoing program that requires

continuous efforts and leadership support. Army

deployments are fluid and the environments to which

Soldiers are exposed are constantly changing. For the

prevention of hearing loss, this has traditionally posed

Cohort Case Studies on Acoustic Trauma in Operation Iraqi Freedom
April – June 2009 21

THE ARMY MEDICAL DEPARTMENT JOURNAL

a problem because hearing conservation programs

were not designed with combat in mind. With

asymmetric warfare (coalition forces observing

different rules of engagement than insurgents) and a

nonlinear battlefield (no frontlines), Soldiers are experiencing more exposure to the sounds of combat. This

has forced audiologists to rethink their approach to

prevention in these challenging environments.

Even though these cohort case studies were not able to

control for the many factors that affect hearing in

combat, they do provide a field perspective on hearing

protection being used in combat and how it correlates

with previous research. This article only addresses

hearing thresholds of Soldiers who reported wearing

hearing protection when they were exposed to an

explosion. It is important to point out that for the many

Soldiers were not wearing hearing protection, the

hearing loss was substantial and typically involved

conductive and sensorineural components. There is

also some anecdotal evidence that central hearing loss

was a comorbid component of traumatic brain injury.

The prevalence of this type of acoustic trauma in

Operations Iraq Freedom and Enduring Freedom are

not yet known, but are being studied.

The vestibular system may also be damaged by

hazardous noise due to its close proximity and

similarity in cell structure to the cochlea.28 Soldiers are

exposed to explosions, such as improvised explosive

devices, mortars, or car bombs. They are also exposed

to many steady-state noises such as aircraft, track

vehicles, or large electrical generators. These noise

sources may cause asymptomatic damage to their

vestibular system. Shupak et al did find that symmetric

noise-induced hearing loss is correlated with

symmetric peripheral vestibular system damage.29

These results were corroborated by M. Hill and D. S.

McIlwain (unpublished data, 2006). The reason it is

possible to be unaware of a vestibular deficit in

conjunction with acoustic trauma is because of the

complex relationship between the central nervous

system (CNS) of the brain and the 3 primary sensory

modalities critical to equilibrium (vestibular, visual,

and proprioceptive systems). If an insult to the

vestibular system occurs, the CNS relies heavily on

information from vision and proprioception to make

up for the lack of neural firing from the balance center

to compensate. The CNS adapts to the different levels

of neural input it receives. During this adaptation time,

the individual often experiences a slight feeling of

imbalance, dizziness, or even vertigo, especially in the

absence of vision. Symptomatic feelings of imbalance,

dizziness, and vertigo typically subside. The vestibular

system, combined with the visual and proprioceptive

systems, contributes to spatial orientation. It is

estimated that 80% of spatial orientation is based on

visual cues, but when visual cues are no longer

available or are diminished, the vestibular system’s

role is critically elevated. Situations while flying

aircraft or driving an armored personnel carrier, such

as white-outs (snow) or brown-outs (sand), may lead

to greatly reduced visual cues. If a pilot or driver’s

vestibular system is damaged, the chance of spatial

disorientation occurring in low-vision environments

may increase, resulting in a potentially catastrophic

accident. It is also possible that this spatial disorientation could be a cause of danger for the ground

troops in similar low visibility situations while

weighed down with a basic combat load.

CONCLUSION

The solution is on the battlefield. Even if the Soldiers

are not directly involved in combat, the common

denominator of the small but significant high

frequency threshold shift is a combat deployment.

Gates and Fallon recommend a more aggressive

operational hearing program should be implemented

with more Army audiologists deployed to meet the

recommended one Army audiologist per 10,000

Soldiers. Currently, there is only one audiologist for

over 160,000 deployed Soldiers in Iraq, and none in

Afghanistan.30

Increased sensitivity for secondary intervention is also

warranted. It is recommended that Soldiers with a

small but significant high frequency threshold shift

(average positive 10 dB threshold shift at 4 kHz and 6

kHz or a positive threshold shift of 15 dB in either 4

kHz or 6 kHz) postdeployment should receive a follow-up audiogram. Emphasis should be placed on

Soldiers avoiding noise of any kind for at least 14

hours with reeducation on what constitutes hazardous

noise. If a small but significant high frequency

threshold shift is confirmed on the follow-up audiogram, the Soldier should receive at least a verbal

acknowledgement that there has been a small change

in hearing, interviewed on possible causes, and a more

detailed education on the long-term personal and

professional consequences of hearing loss. The small
22 https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1

but significant high frequency threshold shift should

be viewed as an early indicator of noise induced

hearing loss because it places Soldiers at higher risk

for clinically significant noise-induced hearing loss.

The Army spends a considerable amount of time and

money training an all-volunteer force. In an instant, a

Soldier can become a risk for further injury as well as

put others at risk due to decreased job performance.

Currently, the best solution to the age-old problem of

hazardous noise in the Army is the military

audiologist. These professionals are indispensable in

developing solutions for unique situations such as

noise abatement and the selection and use of contemporary hearing protection in combat environments.

REFERENCES

1. Army Regulation 40-501: Standards of Medical

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

December 14, 2007:80.

2. McIlwain DS. CAOHC Deployed. CAOHC Update.

2004;16(3):4. Available at: http://www.caohc.org/

updatearticles/fall04.pdf. Accessed April 7, 2009.

3. Combat Recognition Requirements. Human

Engineering Report SDC 383-6-1. Office of Naval

Research. April 15, 1952:20-25.

4. Donahue A, Ohlin D. Noise and the impairment of

hearing. Occupational health: the Soldier and the

industrial base. Washington, DC: Borden Institute.

1993;207-252.

5. Garinther GR, Peters LJ. Impact of communications

on armor crew performance. Army Res Dev Acquis

Bull. January-February 1990:1-5.

6. Weiner F, Ross D. The pressure distribution in the

auditory canal in a progressive sound field. J Acoust

Soc Am. 1946;18:401-408.

7. Rudmose W. Hearing loss resulting from noise

exposure. In: Harris CM, ed. Handbook of Noise

Control. 1st ed. New York: McGraw-Hill; 1975.

8. Ward W. Noise-induced hearing damage.

Otolaryngol. 1973;2:377-390.

9. Ylikoski ME, Ylikoski JS. Hearing loss and handicap

of professional Soldiers exposed to gunfire noise.

Scand J Work Environ Health. 1994;20(2):93-100.

10. Cave K. Blast injury of the ear: clinical update from

the global war on terror. Mil Med. 2007;172:726-730.

11. Helfer T, Jordan N, Lee R. Post deployment hearing

loss in US Army Soldiers seen at audiology clinics

from April 1, 2003 through March 31, 2004. Am J

Audiol. 2005;14:161-168.

12. US Dept of Veterans Affairs. Annual Report:

National Center for Rehabilitative Auditory

Research, January 1 – December 31, 2007. Portland,

OR: 2008.

13. Bohn B, Harding G. Degeneration in the cochlea after

noise damage: primary versus secondary events. Am J

Otol. 2000;21(4):505-509.

14. Dole B. GAO Findings and Recommendations

Regarding DoD and VA Disability Systems.

Washington, DC: Government Accountability Office;

May 25, 2007.

15. Bovo R, Ciorba A, Martini A. Genetic factors in

noise induced hearing loss. Audiological Medicine.

2007;5:25-32.

16. Holmes A, Widen S, Erlandsson S, Carver C, White

L. Perceived hearing status and attitudes toward noise

in young adults. Am J Audiol. 2007;16(suppl):S182-

S189.

17. Fletcher J. Comparative attenuation characteristics of

the acoustic. J Acoust Soc Am. 1960;32:1524.

18. Ferguson GA, Takane Y. Statistical Analysis in

Psychology and Education. 6th ed. Montréal,

Quebec: McGraw-Hill Ryerson Limited; 2005.

19. Berger E, Kieper R, Gauger D. Hearing protection:

surpassing the limits to attenuation imposed by the

bone conduction pathways. J Acoust Soc Am.

2003;114:1955-1967.

20. Price R. Upper limit to stapes displacement:

implications for hearing loss. J Acoust Soc Am.

1974;56:3.

21. Price R. Relative hazard of weapons impulse. J

Acoust Soc Am. 1983;73:556-565.

22. Kobrak HG. The Middle Ear. Chicago, Illinois:

University of Chicago Press; 1959.

23. Von Bekesy G. Experiments in Hearing. Wever EG,

ed. New York: McGraw-Hill; 1960.

24. ISO 7029:2000. Acoustics - Statistical Distribution of

Hearing Thresholds as a Function of Age.

International Organization for Standardization:

Geneva, Switzerland; 2000.

25. Balatsouras D, Housioglou E, Danielidous V.

Extended high frequency audiometry in patients with

acoustic trauma. Clin Otolaryngol. 2004;30:249-254.

Cohort Case Studies on Acoustic Trauma in Operation Iraqi Freedom
April – June 2009 23

THE ARMY MEDICAL DEPARTMENT JOURNAL

26. Hamernik R, Turrentine G, Roberto M, Salvi R, Henderson D. Anatomical correlates of impulse noiseinduced mechanical damage in the cochlea. Hear Res.

1984;13:229-247.

27. Depenbrock P. Tympanic membrane perforation in

IED blasts. J Spec Oper Med. 2008;8,51-53.

28. Golz A, Westerman S, Westerman L, et al. The

effects of noise on the vestibular system. Am J

Otolaryngol. 2001;22:190-196.

29. Shupak A, Bar-El E, Podoshin L, Spitzer O, Gordon

C, Ben-David J. Vestibular findings associated with

chronic noise induced hearing impairment. Acta

Otolaryngol. 1994;114(6):579-585.

30. Gates K, Fallon E. Hearing Conservation Program:

Doctrine, Organization, Training, Materiel, Leadership and Education, Personnel and Facilities. Aberdeen Proving Grounds, MD: US Army Center for

Health Promotion and Preventive Medicine; 2007:7.

AUTHORS

MAJ McIlwain is an instructor and curriculum writer at the US Army Medical Department Center and School, Fort

Sam Houston, Texas.

MAJ (Ret) Sisk is the Coordinator of Outlying Clinics at the Veterans Administration Hospital, Temple, Texas.

Dr Hill is a principle investigator in the Department of Acoustics, US Army Aeromedical Research Laboratory, Fort

Rucker, Alabama.
24 https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1

Provider Resilience: The Challenge for

Behavioral Health Providers Assigned to

Brigade Combat Teams

LTC (Ret) Larry Applewhite, MS, USA

LTC (P) Derrick Arincorayan, MS, USA

INTRODUCTION

Deployment related mental health problems have

received increased attention since the Global War on

Terrorism began in 2001. In 2003, the Office of The

Surgeon General sanctioned Mental Health Advisory

Teams (MHAT) to research mental health issues of

deployed Warriors serving in Iraq and Afghanistan.

The most recent study, entitled MHAT V, found that

individuals who were on their third or fourth

deployment reported experiencing more mental health

symptoms, stress-related work problems and suicide

rates were elevated in both theaters of operations.1In

2004, Hoge et al, in a study of combat duty in Iraq and

Afghanistan, suggested conservatively that as many as

17% of combat veterans could develop mental health

disorders such as depression, alcohol misuse, and

posttraumatic stress disorder (PTSD) 3 to 4 months

after returning from deployment.2 The congressionally

mandated Department of Defense Task Force on

Mental Health examined mental health matters in the

armed forces and concluded in 2007 that

The system of care for psychological health that has

evolved over recent decades is insufficient to meet the

needs of today’s forces and their beneficiaries.3

Accounts of the personal struggles to adjusting to life

after serving in Operations Iraqi Freedom and/or

Enduring Freedom have provided insights into the

challenges confronted by many veterans. In a 2007

article, CSM Samuel Rhodes, who spent over 30

months deployed to the middle east, provided an

especially poignant description of his experiences with

PTSD and concluded his story by encouraging others

with similar symptoms to get help like he did.4

To address a seemingly growing problem, behavioral

health professionals routinely deploy as essential

components of combat stress control (CSC)

detachments and combat support hospitals. Lessons

learned from these deployments have been well

documented. Reger and Moore, psychologists who

deployed with the 98th and 85th CSC Detachments

respectively, emphasized the need to retain flexibility

in allocating assets in theater to maximize the efficient

and effective delivery of preventive and treatment

services in a combat zone.5In a study of the

effectiveness of critical event debriefings conducted in

Iraq, Pischke and Hallman, veterans of the 785th

Medical Company (CSC) in Iraq, reinforced the need

for psychological treatment and identified the benefits

of providing mental health services to Warriors on the

frontlines.6 While CSCs have performed a valuable

role in supporting deployed units, those psychologists

and social work officers who are assigned to brigade

combat teams represent the vanguard of behavioral

health resources in today’s expeditionary Army. These

personnel deploy directly with those who bear the

greatest burden fighting this asymmetrical war on

terrorism and confront many of the same threats faced

by combat arms Warriors. In order to adequately

prepare for the demands of duty in a combat zone,

behavioral health officers assigned to a brigade combat

team must recognize the challenges that await them

and develop an action plan to enhance personal

resiliency. Neglecting this critical predeployment task

can result in a behavioral health provider who becomes

less effective over the course of a long deployment,

and jeopardizes the quality of care needed to sustain

the psychological fitness of our Warriors.

THE STRESS OF BRIGADE BEHAVIORAL HEALTH

OPERATIONS

The demand of supporting 2 major combat operations

simultaneously has the potential to stretch our forces to

the breaking point. Multiple deployments, extended

tours, and stop-loss* policies are some of the factors

*Presidential authority under Title 10 US Code 12305 to suspend laws relating to...separation of any member of the

Armed Forces determined essential to the national security of the United States....7
April – June 2009 25

that have created an environment that can tax the

coping abilities of even well-trained, highly motivated

Warriors. Additionally, there are aspects of serving in

today’s military that compounds an already stressful

situation. Advances in technology have created greater

access to electronic communications, enabling

deployed Soldiers to stay in touch with families back

home. While maintaining family relationships may

provide much needed emotional support—particularly

during a time of crisis—it also means that troops may

be exposed to the “mundane stresses” associated with

the home front at a time when they can do little to “fix

it.”8 To help understand the psychological stress

inherent in contemporary military operations, Bartone

et al developed a model that clearly delineates the

primary sources of operational stress.9Initially applied

to Soldiers conducting peacekeeping operations in the

former Yugoslavia, Bartone later expanded the model

and applied it to other contingency operations,

including Operations Iraqi Freedom and Enduring

Freedom.10 The primary dimensions of stress identified

by Bartone and his colleagues are isolation, ambiguity,

powerlessness, boredom, danger, and workload.9,10

While all of these elements may produce stress to

some extent for all deployed Soldiers, isolation,

powerlessness, danger, and workload appear to be

those most pertinent to behavioral health operations in

a brigade combat team.

Isolation. A sense of “aloneness” can permeate the

time spent serving in a foreign land separated from

loved ones. The natural feeling of being alone can be

magnified for providers who join a unit through the

Professional Filler System (PROFIS).* These

individuals typically arrive at the unit just prior to

deployment and frequently have insufficient time to

fully integrate into the unit’s culture or to develop

meaningful relationships with fellow Soldiers. Having

a trusted confidant or battle buddy ‡has long been

recognized as an important source of support for

coping with the demands of a long combat

deployment. Establishing a relationship with a battle

buddy is made more difficult by the fact that

behavioral health officers are assigned one per brigade,

thus eliminating a coworker as a logical source of peer

support. Furthermore, behavioral health providers may

be hesitant to confide personally in others as they feel

the burden of responsibility of their position in which

they are expected to be a source of support for others.

Those individuals who are of similar rank

(commanders, chaplains, battalion surgeons, other

medical personnel) often refer Soldiers for behavioral

health assistance. Divulging personal concerns or

admitting to experiencing deployment-related stress

may damage the professional credibility that is

essential to being viewed as a dependable support

system for Soldiers. Additionally, the sense of being

alone can be intensified due to the constraints placed

on conversations with family and friends back home.

Discussing the details of working in a war zone with

spouses or others via telephone, webcam, or email may

be inappropriate and most likely violates operational

security.

Powerlessness. In many ways, brigade behavioral

health officers occupy a position similar to that of a

member of the special staff. Although they possess

valuable professional expertise, their capacity for

exercising direct power is limited. It is a well known

axiom that staff officers make recommendations,

commanders make decisions. Thus, it is necessary to

get command support for recommendations that affect

a Warrior’s duty status. For example, a Soldier seeking

behavioral health care for acute anxiety or a combat/

operational stress reaction may benefit from being

placed on alternate duty that does not require him or

her to go “outside the wire.” Recommending that the

Soldier temporarily “take a knee” while receiving

supportive behavioral health intervention could meet

resistance from the chain of command because the unit

probably needs all of their personnel to complete

mission requirements. One’s ability to succeed in

getting support for treatment and personnel

recommendations depends in part on the professional

*PROFIS predesignates qualified Active Duty health professionals serving in Table of Distribution and Allowance†units to

fill Active Duty and early deploying and forward deployed units of Forces Command, Western Command, and the

medical commands outside of the continental United States upon mobilization or upon the execution of a contingency

operation.11

†Prescribes the organizational structure, personnel and equipment authorizations, and requirements of a military unit to

perform a specific mission for which there is no appropriate table of organization and equipment (the document which

defines the structure and equipment for a military organization or unit).

‡Generally defined as the person to whom a Soldier can turn in time of need, stress, and emotional highs and lows who

will not turn the Soldier away, no matter what. This person knows exactly what the Soldier is experiencing because of

experience with similar situations or conditions, either current, previous, or both.
26 https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1

credibility that they have established, and not

necessarily from power inherent in the position. This is

particularly true for junior officers. A general sense of

powerlessness also can grow from limitations to

alleviate emotional distress caused by psychosocial

circumstances. Soldiers who experience “home front”

problems with the potential for serious consequences,

such as suspected marital infidelity, threats of divorce,

or child custody issues, often believe that going home

is the only solution to the situation: “The only way I

can save my marriage is to get home!” While these

claims may be legitimate and elicit empathy and

understanding from the provider, rarely do their

psychological symptoms warrant medical evacuation

from theater. Clinical strategies can be employed to

engage the individual in a therapeutic manner, but the

person may not be motivated to learn more adaptive

coping techniques and remains intent on going home

to address the problem. Professionals who are

dedicated to helping others may despair over working

in an environment that limits their options to effect

change and make a positive difference in the lives of

Soldiers. As the deployment grinds on, and disappointments mount, it is possible to adopt a hardened, “don’t

care” attitude to help manage expectations. This can

present an obstacle to developing therapeutic

relationships with Soldiers who need help.

Danger. According to the Department of Defense, as

reported in the Army Times [February 2, 2009], there

have been over 4,200 Warriors killed during Operation

Iraqi Freedom and 636 who have died supporting

Operation Enduring Freedom.12 This is not to overstate

the threat that behavioral health personnel face or to

imply that they confront the same level of hostile

forces as those who routinely patrol the streets of

Baghdad or the mountains of Afghanistan. However, it

is worth noting that all deployed Warriors work under

a degree of risk that they too could be hit by enemy

fire. Indirect fire, such as rocket and mortar attacks,

land indiscriminately on forward operating bases. The

threat of death or injury is compounded for those

providers who extend behavioral health support to the

combat outposts and joint security stations that

proliferated with the implementation of a

counterinsurgency strategy. Improvised explosive

devices are a risk for everybody who travels the streets

and roads of Iraq or Afghanistan. Additionally, there

exists the potential for contracting serious illnesses

associated with exposure to contaminants, pollutants,

and other toxic substances. Vehicle accidents such as

rollovers occur in theater as well. The threat of

becoming a casualty is by no means unique to

behavioral health personnel, however, it should be

acknowledged as a factor that can impact the conduct

of daily operations and can contribute to the erosion of

psychological defenses needed to cope in a war zone.

Workload. While the brigade behavioral health team

also includes an enlisted mental health specialist, the

officer is essentially responsible for supporting

approximately 4,000 combat troops. One of the great

successes deriving from the attention given to

deployment stress is that many brigade combat team

commanders now prioritize the establishment of access

to behavioral health care whenever it is needed and to

whomever needs it. This can significantly strain a 2-

person team. The workload oftentimes cannot be

shared because there are no other providers available

on the forward operating base. The demand for

behavioral health services can be driven by multiple

factors. Leadership variables, operational tempo,

degree of enemy contact, living conditions, and even

the effectiveness of support systems for families back

home influence the level of stress felt by deployed

Soldiers. Regardless of the demand for direct services,

the behavioral health provider must remain on-call 24

hours a day, every day, in order to be available for

crisis intervention—there is no time off for weekends

and holidays. Ensuring access to care becomes more

challenging when the unit’s battle space includes

numerous combat outposts and joint security stations.

Providing outreach to these sites further taxes

behavioral health teams simply by enlarging their

geographic area of operations. While CSC teams are

able to assist in some regions, the primary

responsibility for caring for the Warriors securing

these sites remains with the organic behavioral health

assets.

THE RISK OF COMPASSION FATIGUE

In addition to the amount of work, the nature of the

work itself places behavioral health providers at-risk

for developing psychological distress that can last far

beyond the deployment. Much of the clinical work

conducted by behavioral health officers involves

establishing therapeutic relationships with the Soldiers

they treat. Empathy is the bedrock of this process. The

core aspect of empathy is the ability to experience

another person’s state of being at any given moment.13

Provider Resilience: The Challenge for Behavioral Health Providers Assigned to Brigade Combat Teams
April – June 2009 27

THE ARMY MEDICAL DEPARTMENT JOURNAL

When clinicians listen to stories of fear, pain, and

suffering, such as those told by Warriors with combatrelated trauma, they too may feel similar fear, pain,

and suffering.14 Charles Figley, a pioneer in the field,

described compassion fatigue as a natural consequence

of working with individuals who experienced

distressing events and that being vicariously exposed

to the event and responding empathically contributes

to developing compassion fatigue symptoms.15

Irritability, withdrawal, a sense of hopelessness, anger,

and lowered frustration tolerance are common

psychosocial markers of compassion fatigue and can

resemble PTSD.16

Recent literature clearly demonstrates the relationship

between developing compassion fatigue symptoms and

working with trauma survivors. Boscarino et al, in a

random survey of 236 social workers living in New

York City, discovered that those who had worked with

survivors of the terrorist attack on the World Trade

Center were more likely to develop secondary

trauma.17 The authors further suggested that the degree

of exposure, personal history, availability of social

support, and environmental factors were variables that

influenced the development of symptoms. In

describing the Israeli experience, Fraidlin and Rabin

discussed the harrowing ordeal of social workers who

work with terrorist victims, and concluded that

“repeated incidents are capable of producing severe

reactions similar to those experienced by the casualties

themselves.”18 Similarly, in a case study, Tyson

connected the provision of trauma therapy by clinical

social workers in the Veteran’s Administration Vet

Centers (outpatient clinics) and compassion fatigue.19

She urged the mental health field to respond to the

needs of therapists by developing interventions and

educational programs to support those who work with

trauma survivors. In 2007, Bride’s study of 300 social

workers found that 5% met the diagnostic criteria for

PTSD, twice that of the general population.20 The data

also revealed an astounding 55% met at least one

diagnostic criterion for the disorder. Bride suggested

that the high rate of secondary trauma among clinical

social workers could eventually lead many to leave the

profession.

The risk for developing compassion fatigue is not

confined to those who provide behavioral health care.

Kenny and Hull, in a study of the experiences of

critical care nurses caring for war casualties, found

increased stress levels that resulted in symptoms

consistent with secondary trauma.21 The authors,

themselves active-duty Army nurses, attributed

workload factors, empathic responses to the suffering

of young wounded Warriors and their Families, as well

as distress over the inability to alleviate pain as major

factors in the compassion fatigue responses of nursing

personnel. The “hidden cost of caring” presents

challenges for health care managers as they must

establish organizations that provide supportive

environments for those who work with trauma victims

in order to retain personnel and to sustain a high

quality of care.22

In light of what is known about compassion fatigue or

secondary trauma, it is clear that behavioral health

providers deployed with a brigade combat team are at

an increased risk for developing psychosocial distress.

An effective behavioral health program includes

proactive traumatic event management measures. This

potentially places the behavioral health team in every

bad situation experienced by the brigade. Responding

to the aftermath of combat actions or the loss of a

fellow Soldier due to suicide or an accident exposes

the team to the emotions evoked by such incidents.

Another potentially emotional event is the memorial

service that follows the death of a Warrior. Deciding to

attend memorial services is ultimately a personal

decision that each behavioral health officer must make.

However, from a professional standpoint, there is

value to having a visible presence at the service as it

demonstrates a desire to be a source of support for the

unit while expressing respect for the fallen Warrior, as

well as those left behind who must continue the

mission. As casualty rates decline, as is hoped by all,

Bartone and his colleagues’ concepts of ambiguity and

boredom9 may rise to the forefront as sources of stress

for brigade behavioral health teams. Until that day

arrives, workload and the concomitant risk of

compassion fatigue will continue to pose the greatest

threat to the psychological well-being of the provider,

and could degrade the quality of care provided to our

Warriors.

RESILIENCY SUPPORT PLAN

Resilience is characterized as the capacity “to maintain

relatively stable, healthy levels of psychological and

physical functioning” when exposed to highly

disruptive circumstances.23 Resiliency in the face of

potentially overwhelming challenges can be bolstered

by actions taken by both the organization and the
28 https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1

individual. Structural solutions may hold the most

promise to reducing the potential impact of immediate

symptoms on workers exposed to trauma.24 Thus, the

organization can create an environment that promotes

resiliency through the use of combat stress doctrine,

personnel policies, and training initiatives that are

consistent with supporting a modular force. We

recommend:

 Increase behavioral health authorizations in the

brigade combat team. A 2-person team is

inadequate to support a brigade combat team

(BCT) with several thousand personnel. The task

becomes even more daunting when the unit is

dispersed across a broad front. Adding another

behavioral health officer or mental health

specialist, if not another complete team, would be

prudent given the Army’s reliance on BCTs to

support present and future contingency operations.

 Clarify the role of the behavioral health officer as a

brigade asset. While the behavioral health team is

assigned to the medical company, brigade support

battalion, the team should be clearly recognized as

a brigade asset in ways that other medical

specialties assigned to the level II medical support

unit are not. The behavioral health officer should

have the latitude to design and implement a

behavioral health program that supports the

maneuver units without the encumbrances of

overly-involved medical company and brigade

support battalion commanders. Perhaps the best fit

is to realign the behavioral health team within the

brigade’s headquarters company. This move

would better position the behavioral health officer

to interact directly with the brigade commander

and staff to incorporate behavioral health concepts

into operations in coordination with the brigade

surgeon.

 Emphasize that CSC detachments provide direct

support to BCTs. Independent CSC teams

operating in a BCT area of operations creates

confusion and inefficiencies in the delivery of

scarce behavioral health resources. Combat stress

detachments should position their assets to directly

support the BCTs operating in their battle space.

To ensure this occurs, combat stress teams should

be attached to, or, at a minimum, be operationally

controlled by the supported BCT. Brigade surgeons need to be able to directly influence the

CSC assets supporting the brigade in order to

create a coordinated behavioral health support plan

with clear lines of responsibility.

 Reduce the dependence on PROFIS providers.

Filling behavioral science officer authorizations

organic to BCTs should be the highest priority for

assigning behavioral health providers. If personnel

shortages dictate that some BCT positions require

PROFIS support, then field grade officers should

be slotted into these positions since their

experience should make them better equipped to

effectively adapt to the demands of a deployment.

 Combat/operational stress control (COSC) training.

In December 2008, The Army Surgeon General

mandated that all behavioral health care providers

will, prior to deployment, attend the COSC course

conducted by the Army Medical Department

Center and School. The course curriculum reflects

current lessons learned in Iraq and Afghanistan.

Commanders at all levels should support this

initiative by ensuring that their behavioral health

teams attend the course as an essential part of

predeployment training.

 Army Provider Resiliency Training Program (PRT).

The Army’s PRT program was implemented in

2008 to help reduce provider fatigue and burnout.

Commanders have a responsibility to their health

care personnel to fully support this important

program and individual providers must take

advantage of the potential benefits it has to offer.

In addition to systemic support, individuals can take

steps to fortify themselves against the rigors of combat. While a self-care plan is necessarily a personal

matter, the following components should be

considered:

 Establish a sense of mastery in the job.

Professional development through experience and

training is essential to gaining confidence in one’s

ability to perform under the most difficult

conditions. Young officers can benefit greatly

from a mentoring relationship with a trusted, more

experienced senior officer. Taking responsibility

for one’s career development will help prepare

young professionals to confidently conduct the full

range of behavioral health operations when

deployed.

 Maintain a social support network. Healthy

relationships are vital to a person’s psychological

well-being and emotional stability. Find a good

Provider Resilience: The Challenge for Behavioral Health Providers Assigned to Brigade Combat Teams
April – June 2009 29

THE ARMY MEDICAL DEPARTMENT JOURNAL

battle buddy and be one in return. All deployed

Soldiers should use the vast array of available

communication tools, including old fashioned

letter writing, to stay connected with family and

friends back home. However, this should be done

with the awareness that too much information

flowing in and out of theater can be

counterproductive.

 Nurture spiritual health. Frequent exposure to pain

and suffering can dim one’s inner spirit. Make

time, at least once a week, to engage in an activity,

such as attending religious services, meditating, or

performing Tai Chi exercises, for example, that

replenishes the spirit.

 Conduct aerobic activities. It is important to be

physically fit prior to deployment. Although the

opportunity to participate in physical exercise

during a deployment will be determined by

operational factors, it is essential that individuals

find a way to strengthen the body through aerobic

activities, preferably 3 times a week. Most forward

operating bases now have at least one gym

supplied with exercise equipment, and some larger

bases can accommodate running, assuming the

threat level allows it.

 Maintain physical nourishment and sleep discipline.

Eating 2 to 3 meals daily, staying hydrated, and

getting 7 to 8 hours of sleep a day are basic tenets

of most stress management programs. However,

during deployments, these simple tasks become

much more difficult to achieve just as they become

more critical to the maintenance of effective

functioning. Proper hydration is especially crucial

while conducting operations in an arid climate.

Getting sufficient restorative sleep may be

challenging due to the demands of irregular work

hours, convoy schedules, and being awakened to

respond to emergencies at night. Nevertheless, a

regular sleep schedule should be followed as much

as possible.

 Finding a meaningful purpose in life. A commitment to fulfill a meaningful purpose in life can

provide motivation, direction, and the peace that

comes from a sense of leading a satisfying life.

The path one chooses towards serving a greater

good, whether it is service to one’s country, to

relieve suffering, or freeing the oppressed, is

rooted in personal values and beliefs. Operationalizing the pursuit of one’s purpose extends far

beyond simply keeping a good attitude during

trying times. Personal sustainment can come from

keeping faith with those higher ideals that inspire

us to serve others when circumstances are at their

bleakest. As Victor Frankl quoted Nietzsche in his

classic work, Man’s Search for Meaning,

25

REFERENCES

1. Mental Health Advisory Team (MHAT) V: Operation

Iraqi Freedom 06-08, Iraq; Operation Enduring

Freedom 8, Afghanistan. Washington, DC: Office of

The Surgeon General, US Dept of the Army;

February 14, 2008:26. Available at: http://

www.armymedicine.army.mil/reports/mhat/mhat_v/

MHAT_V_OIFandOEF-Redacted.pdf.

2. Hoge CW, Castro CA, Messer SC, McGurk D,

Cotting DL, Koffman MD. Combat duty in Iraq and

Afghanistan, mental health problems, and barriers to

care. New Engl J Med. 2004;351(1):13-22.

3. Defense Health Board Task Force on Mental Health.

An Achievable Vision: Report of the Department of

Defense Task Force on Mental Health, June. Falls

Church, VA: US Dept of Defense; 2007. Available

at: http://www.health.mil/dhb/mhtf/MHTF-ReportFinal.pdf.

4. Rhodes S. Post traumatic stress disorder impacts all

levels of leadership. Infantry. July-August 2007:5-6.

5. Reger GM, Moore CJ. Combat operational stress

control in Iraq: Lessons learned during Operation

Iraqi Freedom. Mil Psychol. 2006;18(4):297-307.

6. Pischke PJ, Hallman CJ. Effectiveness of critical

event debriefings during Operation Iraqi Freedom II.

Army Med Dept J. July-September 2008:18-23.

7. Joint Publication 1-02: DoD Dictionary of Military

and Associated Terms. Washington, DC: Joint Staff,

US Dept of Defense; March 4, 2008. Available at:

http://www.dtic.mil/doctrine/jel/new_pubs/

jp1_02.pdf.

8. Mastroianni GR, Mabry TR, Benedek DM, Ursano

RJ. The stresses of modern war. In: Lukey B, Tepe V,

eds. Biobehavioral Resilience to Stress. Boca Raton,

FL: CRC Press; 2008:43-55.

He who has a why to live for

can bear any how.
30 https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1

9. Bartone PT, Adler AB, Vaitkus MA. Dimensions of

psychological stress in peace keeping operations. Mil

Med. 1998;163 (9):587-593.

10. Bartone PT. Resilience under military operational

stress: Can leaders influence hardiness? Mil Psychol.

2006;18(suppl):S131-S148.

11. Medical Corps Professional Development Guide.

Fort Sam Houston, TX: US Army Medical

Department Center and School; March 2002:27.

12. OIF and OEF casualty totals. The Army Times.

February 2, 2009:7.

13. Wilson J, Lindy J. Counter-transference in the

Treatment of PTSD. New York: Guilford

Publications; 1994.

14. Figley CR. Compassion Fatigue. New York: Brunner

-Mazel; 1995.

15. Figley CR. Compassion fatigue: psychotherapists’

chronic lack of self care. Psychother Pract. 2002;58

(11):1433-1441.

16. Gentry JE. Compassion Fatigue: Prevention and

Resiliency. Eau Claire, WI: PESI Health Care, LLC;

2005.

17. Boscarino JA, Figley CR, Adams RE. Compassion

fatigue following the September 11 terrorist attacks:

A study of secondary trauma among New York City

social workers. Int J Emerg Ment Health. 2004;6

(2):57-66.

18. Fraidlin N, Rabin B. Social workers confront terrorist

victims: The interventions and the difficulties. Soc

Work Health Care. 2006;43(2/3):115-130.

19. Tyson J. Compassion fatigue in the treatment of

combat-related trauma during wartime. Clin Soc

Work J. 2007;35:183-192.

20. Bride BE. Prevalence of secondary traumatic stress

among social workers. Soc Wrk. 2007;52(1):63-70.

21. Kenny DJ, Hull MS. Critical care nurses’ experiences

caring for the casualties of war evacuated from the

front line: Lessons learned and needs identified. Crit

Care Nurs Clin North Am. 2008;20(1):41-49.

22. White D. The hidden costs of caring: what managers

need to know. Health Care Manag. 2006;25(4):341-

347.

23. Bonanno GA. Loss, trauma and human resilience:

have we underestimated the human capacity to thrive

after extremely aversive events? Am Psychol.

2004;59(1):20-28.

24. Bober T, Regehr C. Strategies for reducing secondary

or vicarious trauma: do they work? Brief Treat Crisis

Interv. 2006;6(1):1-9.

25. Frankl VE. Man’s Search for Meaning: An

Introduction to Logotherapy. New York: Pocket

Books, Simon and Schuster; 1963:126.

AUTHORS

LTC (Ret) Applewhite is a faculty member of the Army

Fayetteville State University Masters of Social Work

Program, Army Medical Department Center and

School, Fort Sam Houston, Texas. He deployed with

the 1st Brigade Combat Team, 1st Cavalry Division to

Taji, Iraq from October 2006 to January 2008.

LTC (P) Arincorayan is Deputy Chief, Behavioral

Health Division, US Army Medical Command, Fort

Sam Houston, Texas. He deployed with the 4th Support

Brigade, 4th Infantry Division to Taji, Iraq from

October 2005 to October 2006.

Provider Resilience: The Challenge for Behavioral Health Providers Assigned to Brigade Combat Teams
April – June 2009 31

BACKGROUND: THE SQUARE PEG

Historically, in every conflict in which the US has

been involved, only 20% of all hospital admissions

have been from combat injuries. The other 80% have

been from disease and nonbattle injury (DNBI).1

Excluded from these figures are large numbers of

service members with decreased combat effectiveness

due to DNBI not serious enough for hospital

admission. During World War II, it became apparent

that more action was needed at the unit level to counter

the medical threat. To answer this need, the unit FST

concept was developed. Selected members from each

company-sized unit received special training in DNBI

prevention so they could advise the commander in

preventive medicine measures. This training enabled

the unit commander to provide arthropod control,

individual and unit disinfection of water, and safe food

supplies. These measures resulted in reduced DNBI

losses. Just as it was conceived over 60 years ago, the

unit FST continues today to be a critical front line

defense against medical threats.

AN ERA OF PERSISTENT CONFLICT: THE ROUND HOLE

The medical threat to field forces can be seen today in

operations where individual preventive medicine

measures are lacking and poor field hygiene and

sanitation exist. Indeed, the expeditionary nature of

our forces today and the Global War on Terrorism are

repeatedly placing US forces in locations where

significant, serious medical threats from infectious

diseases are commonly present. The number of DNBI

continues to reduce the effective strength of units and

minimize combat power. In some cases, Soldiers are

medically evacuated from theater due to preventable

diseases, such as leishmaniasis and malaria. In other

cases, training exercises almost grind to a halt due to

diarrheal illnesses.

However, usually these medical threats can be easily

countered by the implementation of basic field hygiene

and sanitation practices and individual preventive

medicine measures. Preventive medicine measures are

simple, common sense actions that any service

member can perform and every leader must know. The

application of preventive medicine measures can

significantly reduce time lost due to DNBI.

Both today’s fight and future engagements will require

our formations to operate as small teams, perhaps no

larger than squad- or platoon-sized elements

geographically dispersed throughout an area of

operation. The area of operation will most likely be in

urban or developed areas with limited resources

available, and characterized by long, unsecure supply

lines. These conditions add to the difficulties of

implementing and sustaining the unit FST using

existing doctrine and tactics, techniques, and

procedures. Therefore, how do we adapt the unit FST

concept to meet the needs of today’s fight, as well as

future engagements? We modify the peg.

The Unit Field Sanitation Team: A Square

Peg in a Round Hole

LTC Timothy Bosetti, MS, USA

CPT Davin Bridges, MS, USA

ABSTRACT

Basic field sanitation and hygiene is a lost art in today's modern Army. Today, more than ever, there is a need

for the unit field sanitation team (FST) to serve as advisors to unit commanders in the area of basic field

sanitation and hygiene. Soldiers should know how to construct field latrines, construct waste disposal

devices, conduct pest management and control activities, disinfect field water supplies, and practice personal

hygiene under field conditions. The current unit FST concept is centered on company-sized formations

operating in open terrain. This concept does not support current operations, transformed formations, rapidly

changing doctrine, and the expeditionary nature of the Army. This article does not present a new concept, but

rather a new look at an existing concept and practice based upon the lessons-learned and after-action reports

from the Global War on Terrorism to support the Army in transformation during an era of persistent conflict.
32 https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1

PUTTING A SQUARE PEG IN A ROUND HOLE

The objective is to develop a sustainable program that

emphasizes the need for field hygiene and sanitation in

the field. This is particularly important in an age where

a majority of our Soldiers come from urban areas and

not accustomed to austere conditions expected in the

expeditionary nature of our current and future

formations. This can be done by modifying the current

unit FST concept by changing current doctrine,

organization, training, materiel, leadership, education,

personnel, and facilities to retool the square peg to

meet current and future operational needs.

Doctrine

Current doctrine states that there will be one unit FST

for each company-sized element. Under previous force

constructs and Cold War doctrine, this was a good

concept; however, it does not fit today’s fluid

environment and focus on small-unit, full-spectrum

operations. The doctrinal allocation of one unit FST

per company should change to one unit FST per

platoon-sized element, at a minimum. This change

would enable the unit FST to operate at a lower level

and be able to support numerous small combat

outposts in an area of operation. Most of the current

concepts would still be applicable, only pushed down

one level to the platoon, rather than the company.

Doctrine must then also be updated to keep pace with

new and emerging technologies for waste disposal,

water reuse, personal hygiene, personal protective

equipment and measures, and disease prevention

tactics, techniques, and procedures.

Organization

The documentation of unit FST training as an

additional skill identifier (ASI) and inclusion of that

specialty in the table of organization and equipment*

(TOE) of all platoon-sized units should be considered.

This will require creation of the ASI and the

procedures to document it in the individual’s personnel

file. Individual Soldiers trained in a more intensive

unit FST training program would receive the ASI,

which would then be documented on an individual’s

personnel record to reduce the time and money

involved in repeatedly training individuals. In addition,

the documentation of the ASI on the TOE will allow

units to have individuals identified as unit FST

members, which can be reported on the Unit Status

Report (USR). This not only formalizes the unit FST

concept, but holds commander’s accountable for the

implementation of the program. Just as individuals are

identified as a “driver” (an additional duty) on the

TOE, members of the unit FST can be identified as

such. This would codify the existence of the unit FST

on the TOE and be used to ensure that Soldiers are

trained in this position by receipt of the ASI. This

process would also enable the tracking of these items

on the USR, resulting in visibility at all command

levels.

Training

The planning and contracting of field hygiene and

sanitation devices can be integrated into training

programs. This would allow unit commanders and

staff to plan for and implement the use of these

facilities in accordance with Army guidelines,

ensuring that they are knowledgeable on the number

and size of the facilities required to accommodate their

unit and mission. Several lessons learned from

operations in Afghanistan and Iraq showed that

individual units were able to construct field hygiene

and sanitation devices for themselves but encountered

problems when their population grew or their mission

changed. Now units are isolated away from their

respective battalions or brigades making the unit rely

on itself more than ever. Proper education and training

of leaders in the sizing, use, and limitations of field

sanitation and hygiene devices can alleviate these

problems. Commanders and staff will be educated on

when to sequence and construct additional facilities to

accommodate population surges and mission changes.

More importantly, training should focus on the

integration of planning for field hygiene and sanitation

devices prior to entering a theater to determine which

methods are most suited for the operation and what

materials are readily available. It does no good to plan

for the use of portable toilets when there are no means

to procure them in theater.

Materiel

The equipment required for personal protective

measures and to conduct basic unit FST missions

already exist in the inventory. What changes is how

this equipment is allocated to unit FST members, the

unit, and the individual Soldier. Many of the items

found in Appendix C of Army Field Manual 4-25.12 2

are common tables of allowance†(CTA-50-900, -909,

-970) items which could be issued directly to the

individual Soldier, rather than procured by the unit

The Unit Field Sanitation Team: A Square Peg in a Round Hole

*Defines the structure and equipment for a military organization or unit.
April – June 2009 33

THE ARMY MEDICAL DEPARTMENT JOURNAL

first, then issued to the Soldier. Avoiding the middle

man in this case reduces the burden on the unit in the

purchase of these expendable supplies. Other items

could be packaged into an equipment set to allow for

property book accountability and routinely checked as

part of the unit’s command supply discipline program.

Technology continues to advance and so do innovative

methods for waste disposal, water reuse, personal

hygiene, and personal protective equipment.

Leadership and Education

The primary phase to this concept is the integration of

unit FST training and emphasis of its importance into

all education systems, beginning with initial entry

training. The unit FST concept and tasks would be part

of initial entry training for all Soldier and officer

(officer candidate school, reserve officer training

course, US Military Academy) accessions. Soldiers

would receive additional training in advance individual

training courses, then again throughout the

noncommissioned officer education system. Likewise,

officers would receive training in all officer education

systems courses throughout their career. This

repetitive training is designed to emphasize the basic

fundamentals of field sanitation and hygiene, and

regain the “lost art” of those disciplines. Field hygiene

and sanitation information should be integrated into all

leadership and education programs across the Army,

not solely in the Army Medical Department

(AMEDD). These are knowledge and skills that are

required for force health protection and the reduction

of DNBI. Emphasis of this training throughout the

individual’s career is vital to the success of the

program and the conservation of our Army’s fighting

strength.

Personnel and Facilities

Assignment of an ASI to personnel trained in unit FST

principles does not require additional personnel. The

current force structure can be used. Likewise,

additional facilities are not required to implement this

program. Most training areas already have locations

that have standing dig permits to allow training on the

construction of hasty fighting positions and deliberate

fighting positions. We just need to encourage the use

of these existing facilities to train in the basic concepts

of unit FST.

CONCLUSION

As with the existing unit FST program, the most

significant barrier to the incorporation of an

“enhanced” FST concept is command emphasis.

Without command emphasis, the program will

continue to be less than successful in the prevention of

DNBI casualties. As with any new concept or change

from the status quo and the way the Army has done

things in the past, there will be resistance to change.

Overcoming the reluctance to change will be a major

challenge. Implementation of these changes and

transformation of the unit FST require a coordinated

effort by many organizations and cannot viewed as a

constraint or placed in the “too hard to do” box.

The unit FST program requires command emphasis in

order to be effective. The unit FST program is not

solely an AMEDD responsibility, but rather an Army

program critical to the conservation of fighting

strength through the reduction of preventable DNBI.

To be effective in meeting the expeditionary nature of

our Army in an era of persistent conflict, the

implementation and execution of the unit FST program

requires a new look at an old concept. The evaluation

of the current unit FST concept using the doctrine,

organization, training, materiel, leadership, education,

personnel, and facilities approach presented in this

paper will hopefully encourage discussion to transform

the unit FST to meet current and future operational

needs.

REFERENCES

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

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

2000:p1-1.

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

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

2002.

AUTHORS

LTC Bosetti is Chief of the Department of

Environmental Sciences at the US Army Center for

Health Promotion and Preventive Medicine – Europe.

CPT Bridges is an Environmental Science Officer and

the Program Manager of the US Army Center for

Health Promotion and Preventive Medicine – Europe

Deployment Environmental Surveillance Program.

†An equipment allowance document that prescribes basic

allowances of individual or organizational equipment, and

provides the control to develop, revise, or change equipment authorization inventory data.
34 https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1

Throughout the history of modern warfare, accounts of

prison atrocities have repeatedly surfaced which depict

active and passive aggression towards prisoners of war

(POWs). Yet, with each conflict, new accounts are

born and an undeniable reality of warfare inflicts fresh

scars for aggressors to bear. It is understandable, based

on human nature and the goals of war that a

government (or its representatives) will feel malice

toward enemy prisoners captured during a conflict. It

is unquestionably a challenge to overcome that human

nature, despite the statutes which outline lawful

treatment of POWs.2 While most aspects of warfare

have been revolutionized throughout history, the

means by which a military deals with its POWs

remains somewhat mired in the reluctance of leaders to

acknowledge that it will factor such into every

conflict. The management of POWs will, in fact,

become a source of controversy as long as it is handled

as an afterthought. As evidenced throughout history,

this article presents examples, dating back to the

Revolutionary War, of how law can only influence

human nature to a point, especially when resources are

Prisoner of War Camps: Lack of a Revolution

LTC Jennifer Caci, MS, USA

LTC Joanne M. Cline, MS, USA

DISCLAIMER

The definition and use of the term prisoner of war or enemy prisoner of war after 1949 are specifically outlined

in the Geneva Conventions of 1949, Convention (III) Relative to the Treatment of Prisoners of War1:

Art 4. A. Prisoners of war, in the sense of the present Convention, are persons belonging to one of the following

categories, who have fallen into the power of the enemy:

(1) Members of the armed forces of a Party to the conflict, as well as members of militias or volunteer corps forming

part of such armed forces.

(2) Members of other militias and members of other volunteer corps, including those of organized resistance

movements, belonging to a Party to the conflict and operating in or outside their own territory, even if this territory is

occupied, provided that such militias or volunteer corps, including such organized resistance movements, fulfill the

following conditions:

(a) that of being commanded by a person responsible for his subordinates;

(b) that of having a fixed distinctive sign recognizable at a distance;

(c) that of carrying arms openly;

(d) that of conducting their operations in accordance with the laws and customs of war.

(3) Members of regular armed forces who profess allegiance to a government or an authority not recognized by the

Detaining Power.

(4) Persons who accompany the armed forces without actually being members thereof, such as civilian members of

military aircraft crews, war correspondents, supply contractors, members of labour units or of services responsible

for the welfare of the armed forces, provided that they have received authorization, from the armed forces which

they accompany, who shall provide them for that purpose with an identity card similar to the annexed model.

(5) Members of crews, including masters, pilots and apprentices, of the merchant marine and the crews of civil

aircraft of the Parties to the conflict, who do not benefit by more favourable treatment under any other provisions of

international law.

(6) Inhabitants of a non-occupied territory, who on the approach of the enemy spontaneously take up arms to resist

the invading forces, without having had time to form themselves into regular armed units, provided they carry arms

openly and respect the laws and customs of war.

Terrorists do not meet the requirements above and are thus referred to as “unlawful enemy combatants/

detainees.” Those captured in Iraq after the official cessation of war are referred to as “civilian internees/

detainees.”
April – June 2009 35

limited, secrecy is paramount, ignorance is a reality,

and accountability is questionable.

During the American Revolutionary War, it was

obvious the British failed to plan for handling

thousands of POWs on foreign soil. With limited

facilities in New York City and funds not available to

build, the British decided to convert a dozen or so unseaworthy Royal Navy ships harbored in the area into

POW facilities.3 The most infamous of these was the

HMS Jersey, a former British hospital ship in

Wallabout Bay near Brooklyn, New York. The ship

was originally built as a destroyer in 1736, but was

converted by removing the masts and nailing up the

gun ports.4 The Jersey was decrepit and conditions

harsh, with overcrowding an immediate and ongoing

problem. Normally, the HMS Jersey was manned by a

crew of about 350 sailors, yet as a prison ship it

housed over a thousand POWs.3 Overcrowding only

worsened as the war progressed, due in large part to

issues with prisoner exchange (the British captured

thousands of prisoners and George Washington did not

favor exchanging veteran British Soldiers for sick,

untrained Americans who were often Privateers).5

The Department of Defense currently lists 4,435 US

battle deaths during the Revolutionary War. Another

20,000 died in captivity from disease or for other

reasons.5 Historians estimate the total number of

prison ship deaths between 8,000 and 11,644.6,7 An

estimated 4 of every 5 prisoners on the HMS Jersey

died and as many as 8 corpses a day were “buried in

Wallabout Bay.”7 The atrocious sanitary conditions

were ultimately responsible for a great majority of the

deaths: communal buckets for defecating resulted in

widespread dysentery and cholera; thousands of men

crammed below decks without light or fresh air aided

transmission of diseases such as tuberculosis,

smallpox, and yellow fever; and lack of fruit and

vegetables guaranteed scurvy among many prisoners.

What sparse food was provided to the prisoners was

normally maggot-infested, moldy, or simply rotten

beyond consumption. The political situation only

worsened the prisoners’ fate as British tensions led to

increased mistreatment. With no threat of retribution,

guards imposed inhumane and degrading treatment on

prisoners, often leading to injury and/or accidental

death.6 The Revolutionary War provided firsthand

experience for American Soldiers and leaders on the

ramifications of poor planning and mismanagement of

prisoners captured in combat. However, Americans

would repeat the mistakes of the British. In less than

100 years 2 Civil War POW camps would enter the

realm of infamy.

Andersonville, the infamous POW camp established

by the Confederacy in a small village of the same

name in Sumter County, Georgia, was one of the

largest Confederate military prisons established during

the Civil War.8 Although originally established to

move prisoners from the Richmond area to a more

secure location where food was abundant, the 26.5

acre stockade with its minimal staffing could not

adequately support the more than 45,000 Union

Soldiers confined inside its walls.9 Originally built to

house only 10,000, it was obvious why conditions at

Andersonville are described as worse than any other

prison camp, north or south.10 Severe overcrowding,

lack of shelter, diminishing resources, and the

inevitable contamination of the stream providing the

only water to the camp led to a 30% mortality rate.10

By the end of Andersonville’s 14-month life, nearly

13,000 men were dead from malnutrition and the

diseases associated with the deplorable conditions.11

As the former prison grounds appear now, one would

find it difficult to imagine the conditions and

challenges of running the camp in 1864, however, the

history of Andersonville tells the story of an army

unprepared for vast numbers of prisoners, a lack of

understanding or guidance of how to take care of them,

and an unfortunate officer, CPT Henry Wirz, who

“wore the blood of all prisoners on his hands.”11

CPT Wirz was not the first officer to take charge of the

Andersonville prison, nor was he solely responsible for

the lack of funds, resources, or personnel to run the

facility. However, when people in the north learned of

the horrors there, he became the most convenient

target. Although testimony from his trial indicates that

CPT Wirz did make an effort to improve conditions

after his arrival at Andersonville, the reality was that

prisoners were dying every day (one every 11 minutes

on one particularly bad day) of typhoid, gangrenous

infection, and communicable disease.12 To make

matters worse, the War Department stopped the

prisoner exchange program, further stressing local

families and contributing to the demand for vengeance.

Since there was no plan for how to handle the situation

at Andersonville or northern prison camps, creating a

spectacle out of the Wirz trial deflected attention away

from the north and the US government. Ironically,

CPT Wirz’s trial and subsequent hanging appeased the

population which had been so appalled by the

conditions at Andersonville—conditions which were
36 https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1

in part a result of the War Department’s termination of

the exchange program.11 There were, in fact, plenty of

reasons for the government’s attempts to deflect

attention away from the Union prison camps, which

harbored their share of squalor and death.

Conditions at the Union POW facilities at Camp

Douglas in Chicago and the lesser known prison at

Elmira, NY, (frequently referred to as “Helmira”)

rivaled those at Andersonville, although history less

willingly tells their story, and no Union commander

would ever die for the atrocities committed there.13

The Union Army did no better than the Confederates

in handling the challenge of managing POWs when, in

early 1862, Camp Douglas was hastily converted from

a training camp into a POW camp, eventually earning

the title, “eighty acres of hell.”14 Although the prisoner

population at the camp never rivaled the 45,000

housed at Andersonville, Camp Douglas was known as

the northern prison camp with the highest mortality

rate of all Union Civil War prisons, equaling and

sometimes exceeding the highest death rates at

Andersonville.13

The hasty placement of a POW camp in Chicago was a

tactical error on the part of the Union Army,

considering the city was filled with spies and southern

sympathizers who made efforts to arm the prisoners.

Initially, the location may not have seemed ill

conceived as the city residents regularly visited Camp

Douglas to gawk at the Confederate prisoners, and an

observation platform was even constructed to aid the

citizens’ viewing.13 Conditions inside the camp were

so deplorable that Henry Whitney Bellows, president

of the US Sanitary Commission, wrote to Colonel

Hoffman, his superior, after visiting the camp:

Sir, the amount of standing water, unpoliced grounds,

of foul sinks, of unventilated and crowded barracks, of

general disorder, or soil reeking miasmatic accretions,

of rotten bones and emptying of camp kettles, is enough

to drive a sanitarian to despair. I hope no thought will

be entertained of mending matters. The absolute

abandonment of the spot seems to be the only judicious

course. I do not believe that any amount of drainage

would purge that soil loaded with accumulated filth or

those barracks fetid with two stories of vermin and

animal exhalations. Nothing but fire can cleanse them.15

Inside the prison, multiple methods of torture, such as

reduced food rations, prisoner executions, isolation in

the “white oak” dungeon, hanging by thumbs, or being

forced to ride on Morgan’s wooden mule (with weight

hung on their feet to make it more painful) were

regularly utilized to keep the prisoner population

down, to maintain order, and to extract

information.13,15 In 1863, 75 prisoners made a timely

escape and managed to avoid the fate of over 11,000

prisoners who died the following year. Camp Douglas

was closed in 1865 when the remaining prisoners were

asked to take a loyalty oath to the US and then set

free.11 Despite fewer pages in the history books, the

Union prison camps are nonetheless evidence that

during the Civil War, neither side was prepared to

handle POWs and neither figured out how to

successfully remedy the situation once it presented

itself. Repeating the same mistakes as others, from the

atrocious depravities to establishing inadequate

facilities, Americans had failed miserably at their first

test as guardians of POWs.

In 1899, the term “prisoner of war” was originated at

the Hague Conference, which set forth the basic

principles governing the definition of a POW and the

treatment afforded them.16 The Hague Conferences of

1899 and 1907, and the subsequent Geneva

Conventions of 1929, established ground-rules for

managing POWs, but there was no guarantee that

every country would follow them. While it is not

unreasonable for a nation to expect fair treatment of its

Soldiers if they are taken prisoner by the enemy, the

expectation is flawed because it presupposes that the

enemy can understand the principle of surrender. As

was observed in World War II, this is not always the

case. While there are many examples of mistreatment

of POWs by our enemies (ie, the Germans at Berga

and the Japanese at Cabanatuan), few examples

compare to conditions at Camp O’Donnell, the

transient camp in the Philippines situated at the end of

the Bataan Death March route.

Camp O’Donnell has been referred to as

“Andersonville Revisited” for good reason.17 Despite

the passage of 80 years and multiple documents

outlining acceptable treatment of POWs, many of the

Filipino and American prisoners held at Camp

O’Donnell faced the same horrors of those interned at

Andersonville. One difference between the situations

was that during the Civil War, ignorance, lack of

resources, and malice were often the reasons for the

conditions, while at Camp O’Donnell, the primary

issue behind the maltreatment of prisoners was the

Prisoner of War Camps: Lack of a Revolution
April – June 2009 37

THE ARMY MEDICAL DEPARTMENT JOURNAL

inability of the Japanese to understand or accept that

honorable men were capable of surrender. To the

Japanese, the troops who survived the Bataan Death

March to reach Camp O’Donnell were not POWs, they

were nothing.18

Camp O’Donnell was originally a Filipino

Constabulary Post, partially constructed and with little

infrastructure. Like Andersonville, Camp O’Donnell

contained only one water spigot for approximately

50,000 prisoners and it was not unusual for a prisoner

to die in line after waiting all day and night for his

turn.18 In the first 2 months at Camp O’Donnell, more

than 1,500 American and 20,000 Filipino Soldiers

died, an average of 358 per day.19 The sanitary

conditions in the camp were so deplorable that the

meager servings of rice received by the prisoners were

inevitably consumed while covered with blue and

green bottle flies.18 Gravedigger detail was a common

requirement for prisoners strong enough to dig, and

dig they did, sometimes burying 400 bodies a day. The

graves were large shallow holes, which were dug up

by dogs each night creating festering pools of disease.

There was, surprisingly, a hospital at Camp

O’Donnell, although among the prisoners it was

basically considered a place where one went to die. It

is difficult to fathom that a group of civilized people

could allow and even condone the conditions at Camp

O’Donnell, but the Japanese government had not

signed nor approved of the Geneva Convention, and

therefore did not believe American and Filipino

prisoners were entitled to any safeguards.18 Ultimately,

even the Japanese recognized the potential backlash

resulting from Camp O’Donnell and moved the

prisoners to Cabanatuan in June 1942, where many

more would die before the Rangers executed a

successful raid on the camp. Unfortunately, POW

camps in WWII would not be the last time in the 20th

century that the Geneva Conventions were ignored and

an enemy significantly misunderstood.

During the Korean War, a lack of planning for and

management of Korean and Chinese POWs taken by

US and United Nations (UN) forces was an

unsurprising shortfall in the disjointed and limited

preparation for that conflict. While food, clothing, and

housing were listed as adequate by the International

Red Cross, the large number of captives, at one time

over 80,000, made close supervision difficult.20

Maintaining good order was nearly impossible, with

bloody clashes a common event inside the camps. UN

POWs held by North Koreans and the Chinese,

however, did not fare as well. It is alleged that North

Korean forces subjected UN POWs to forced labor,

beatings, starvation, and summary executions/

massacres such as those at Hills 312 and 303.21

American POWs were further subjected to physical

abuse and torture at the hands of the Chinese. US

Army POWs died in large numbers during the first

part of the war with a mortality rate of 40% while

confined, generally due to unchecked diseases,

untended wounds, malnutrition, and extreme cold.20

Alarmed at the extremely high death rate, the Chinese

eventually started to improve conditions at POW

camps and supplied food and medicine.20

Unlike Korea, in Vietnam there was plenty of time

prior to major hostilities when both sides could have

planned for the inevitable POW situation that would

arise. In the case of the North Vietnamese, it was not a

lack of planning, rather a pure disdain for the enemy

and disregard for the provisions of the Geneva

Convention which were updated in 1949. In a show of

somewhat poetic justice, the Hoa Lo, a prison built by

the French to hold Vietnamese prisoners captured

fighting for their independence from French

Indochina, was used by the North Vietnamese to

imprison Soldiers, Department of State personnel, and

supporters of the US effort. The Hoa Lo became one

of the most famous POW camps in history, heretofore

known as the “Hanoi Hilton.”22

As is the case with the majority of the POW camps

immortalized in historical records, the conditions at the

Hanoi Hilton were deplorable. Not only were more

than 300 prisoners subjected to miserable sanitary

conditions and regular bouts of tropical disease, there

is significant evidence that the prisoners at the Hanoi

Hilton were systematically abused, both physically and

psychologically. This is seemingly a fact, although the

Vietnamese government still denies it and the US

government failed to ever take any action on it. None

of the Vietnamese officials implicated in the abuse

have ever been formally charged by the US or its allies

nor has extradition ever been demanded.23 The

information regarding abuse was first revealed in the

late 1960s when release of prisoners began, but was

not made available to the general public for fear that

retaliation would be inflicted on those still in captivity.

It is widely known by the American public and much
38 https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1

of the world that American prisoners were tortured in

North Vietnamese prison camps, however, the fact that

little if any action was taken or even threatened against

the government responsible for that torture left the

status of POWs in future wars potentially uncertain.

After the shock of September 11, 2001, the US

government vowed that the victims of that day did not

die in vain. Over the next 18 months, 2 very different

fights were initiated in Afghanistan and Iraq as part of

the Global War on Terrorism (GWOT). While many

problems in the GWOT have been excruciatingly

dissected by armchair quarterbacks around the globe,

there is no argument with the fact that the incidents

which took place at the Bagram and Abu Ghraib

prison facilities (although realistically not comparable

to stories of prison camps past) put an indelible black

mark on US efforts in both countries, and that a lack of

planning for handling prisoners of war was in part

responsible.

In Afghanistan, it was obvious from the beginning of

the conflict that US military leaders failed to

appropriately plan for housing detainees (unlawful

enemy combatants) as the selected Bagram Theater

Internment Facility (BTIF) was not an ideal location.

Originally built by the Soviets in the 1980s as an

aircraft machine shop, the facility was retrofitted with

wire cages and wooden segregation cells (later

upgraded to concrete segregation rooms with latrine

and sink).24 Initially intended to serve as a temporary

facility, the BTIF has now housed detainees longer

than Guantanamo Bay.25 In the early days of the

conflict, conditions inside the BTIF mirrored those of

US Soldiers (except for the wire cages) to include burn

out latrines and makeshift wooden flooring.25 Over the

next several years, numerous upgrades and expansion

projects ensued. Nevertheless, even today, guard force

personnel remain extremely limited in the number and

quality of improvements they can make due to the

physical location of the facility and land space

allocation. With limited planning, little to no formal

training in handling detainees or managing detainee

camps, shortfalls in military reference material, and

the issuing of confusing, often conflicting, higher

headquarters’ guidance, it did not take long for

allegations of abuse, torture, and maltreatment to

surface, even though most were unsubstantiated. One

such event involved the deaths of 2 Afghan detainees

in December 2002, while in the custody of US forces

at the BTIF. Allegations of beatings, blunt force

trauma, and degrading treatment, as well as the alleged

cover-up of the circumstances surrounding their deaths

quickly reached several news outlets. The US Criminal

Investigation Command initiated an investigation and

in October 2004, determined there was probable cause

to charge 27 Soldiers with criminal offenses.26 During

this investigation it was also discovered that some of

these indicted Soldiers had deployed and helped

establish the interrogation and debriefing center in

Abu Ghraib, Iraq.26

In late 2002, LTG Richard Cody directed a bottom-up

review of the Military Police Corps (MPC) structure;

largely as a means of making it better suited to handle

the internment/resettlement (I/R) mission, and

potentially as a result of the incident at the BTIF.27

This indicates the likelihood that someone, somewhere

recognized the potential for a POW situation to

develop in the pending war in Iraq, and the need for a

means of dealing with it. Unfortunately, that foresight

did not change the fact that, although significantly

limited at the time, the existing I/R assets of the

Military Police Corps may have had a positive impact

on the detainee situation in Iraq and could have

lessened the likelihood of a detainee-related scandal

had they been deployed. Instead, the potential for a

significant POW situation was underestimated, the

power of human nature was once again denied or at

best misunderstood, and military policemen and

women whose fellow Soldiers were simultaneously

threatened on the streets around Baghdad daily were

expected to deny their instinctive desire for vengeance

and guard enemy prisoners without incident. Not only

was this a task they were not properly trained to

execute, but also a task that their nonhabitual higher

chain of command was not trained to supervise. While

we do not by any means condone the actions of the

Soldiers involved, it was likely inevitable that a

scandal of this nature would occur, considering the

circumstances and the power of human nature.

The Baghdad Central Confinement Facility (BCCF)

was established at the Abu Ghraib prison compound,

32 km west of Baghdad. Internationally known as

Saddam’s “torture house,” the facility was used by the

Ba’ath government to torture and execute presumed

dissidents.28 It was renamed BCCF after US forces

expelled the former Iraqi government. The decision to

use this facility as a POW (detainee) camp, already

Prisoner of War Camps: Lack of a Revolution
April – June 2009 39

THE ARMY MEDICAL DEPARTMENT JOURNAL

tainted internationally due to the thousands executed

by the Saddam regime, was presumably a tactical

error. Difficult to resupply due to its close proximity to

Fallujah and major combat operations early in the war,

Abu Ghraib also stood among heaps of trash and,

allegedly, the bones of previous occupants. Soldiers

were housed in former prison structures, complete with

torture hooks and the ghosts of the past. Ironically, in

close proximity to the hard site (now infamous as the

site where US forces abused detainees), several tent

camps were constructed to hold the ever-increasing

number of detainees, a necessary action reminiscent of

conflicts past. A number of factors contributed to the

overall situation and mindset of both guards and

prisoners: harsh environmental conditions, lack of

adequate infrastructure to provide basic sanitation and

hygiene conveniences, and a shortage of overhead

protection from combat operations within these tent

camps. These were problems that only exacerbated the

challenges at Abu Ghraib. In addition, the sheer

craftiness of detainees to continually circumvent and

negate any attempt by the guard force to improve

conditions for them set the stage for a battle of human

will and nature.

A window into this darker side of human nature was

illuminated over 30 years ago during the Stanford

Prison Experiment led by Professor Philip Zimbardo.29

The study selected college-aged men with positive

attitudes and apparent good mental health and then

studied the situational forces and psychological effects

of them becoming either a prisoner or prison guard.

Zimbardo writes: “My guards repeatedly stripped their

prisoners naked, hooded them, chained them, denied

them food or bedding privileges, put them into solitary

confinement, and made them clean toilet bowls with

their bare hands.”2 The study was halted after only 6

days due to the severe treatment of prisoners and the

resulting psychological trauma. Zimbardo concludes:

In a situation that implicitly gives permission for

suspending moral values, many of us can be morphed

into creatures alien to our own nature.2

Parallels exist between this study and the actions of the

Soldiers indicted in the Abu Ghraib scandal. The

situational forces present at Abu Ghraib in late 2003

certainly set the stage for the suspension of moral

values. Undoubtedly there were multiple human

factors existing at the facility, including inadequate

training, lack of proficiency in basic Soldiering skills,

under-manning, friction between different chains of

command, poor morale, staff inefficiencies, and

various psychological factors such as the differences in

cultures, Soldier quality of life, real pressures of

mortal danger over extended periods of time, and a

failure by the command to recognize and mitigate

these factors.27 Ultimately, these factors culminated in

the now infamous actions of those involved in the

scandal at Abu Ghraib.

While direct parallels between the detention camps of

today and the POW camps of the past do exist, it

would be inaccurate to conclude that no improvements

have been made in how the US handles POWs (and

other detainees). Typical trends and problems from the

past do not exist today in US held camps, such as

malnutrition, poor medical care, and high mortality

rates. Accountability for individual actions violating

the Geneva Conventions or humane treatment policies

is enforced as is evident by the legal action taken

against those involved with the cases discussed above.

Furthermore, prisoners today are provided medical

care far superior to that received by most other local

nationals. Yet with all the valuable insight gained from

our rich historical past, we remain a predominantly

reactive rather than proactive organization.

Department of Defense and governmental oversight of

facilities (Red Cross, combatant command assessment

teams, congressional hearings, etc) increased as a

reaction to Abu Ghraib, as did the number of

internment/resettlement units, policies, regulations,

and guidance. Yet none of these correct the lack of

planning for future wars, nor the need to better train

leaders in the site selection and organization of POW

camps, management strategies, and legal recourse,

functions ancillary to the basic housing of prisoners,

and cultural sensitivity/diversity (ie, Afghanistan is not

Iraq). These lessons must be learned to overcome our

reactive nature.

Enemy POWs are an inextricable facet of warfare.

Acknowledgement of this fact is critical if ever a

conflict is to be engaged with the hope of avoiding a

legacy of accounts comparable to those from the HMS

Jersey to Abu Ghraib. In 2005, Senator John McCain

proposed an amendment to ban the military and

government agencies from engaging in “cruel,

inhuman, or degrading treatment” of detainees because

apparently the Geneva Convention does not do that

already.30 While we support Senator McCain’s efforts

to ensure that what happened to him should never
40 https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1

happen to anyone else, especially at the hands of

Americans, we submit that if proper planning for the

handling of POWs in wartime is executed and the

mission tasked to those who are properly trained to

fulfill it, the horrific stories of POW camps past may

truly be history.

ACKNOWLEDGEMENT

Our thanks to Dr Jerold Brown at the Army Command and

General Staff College for his positive initial review of the

base document for this article. Without his confident

endorsement in 2006, it would have most certainly remained

unpublished.

REFERENCES

1. Diplomatic Conference of Geneva of 1949:

Convention (III) Relative to the Treatment of

Prisoners of War. [International Committee of the

Red Cross web site]. August 12, 1949. Available at:

http :/ / www. icrc.o rg/i hl .ns f/7 c4 d 0 8 d 9 b 2 8 7

a42141256739003e636b/6fef854a3517b75ac125641e

004a9e68. Accessed May 12, 2009.

2. Zimbardo PG. Power turns good Soldiers into “bad

apples”. The Boston Globe. May 9, 2004;Opinion

section. Available at: http://www.boston.com/news/

globe/editorial_opinion/oped/articles/2004/05/09/

power_turns_good_soldiers_into_bad_apples/.

3. The American Revolutionary War web site.

Revolutionary War Prisoners of War. Available at:

http://www.myrevolutionarywar.com/pow/. Accessed

January 11, 2009.

4. POWs of the American Revolution [DVD]. The

History Channel; 2006. Available at: http://shop.his

tory.com/detail.php?p=69115&v=history_sub

ject_war-and-warfare_revolutionary-war. Accessed

May 1, 2009.

5. Wikipedia.com web site. HMS Jersey (1736).

Available at: http://en.wikipedia.org/wiki/HMS_Jer

sey_(1736). Accessed January 11, 2009.

6. DeWan G. The wretched prison ships. Newsday.com.

Available at: www.newsday.com/community/guide/

lihistory/ny-history-hs425a,0,6698945.story?coll=nylihistory-navigation. Accessed January 11, 2009.

7. Boatner MM III.. Encyclopedia of the American

Revolution. New York: McKay Publishers; 1974.

8. Wikipedia.com web site. Andersonville National

Historic Site. Available at: http://en.wikipedia.org/

wiki/andersonville_prison. Accessed January 12,

2009.

9. Catton B. The American Heritage Picture History of

the Civil War. New York: American Heritage

Publishing Company Inc; 1960.

10. The War of the Rebellion web site. Andersonville

(Camp Sumter) Prisoner of War Camp. Available at:

h t t p : / / w w w . m y c i v i l w a r . c o m / p o w / g a -

andersonville.htm. Accessed January 12, 2009.

11. Eicher D. The Longest Night: A Military History of

the Civil War. New York: Simon & Schuster; 2001.

12. The Horrors at Andersonville Prison [DVD]. The

History Channel; 2006. Part of The Unknown Civil

War Collection [DVD]. The History Channel.

Available at: http://shop.history.com/detail.php?p=77

698&v=.

13. Burnham P. The Andersonvilles of the north. In:

Cowley R, ed. With My Face to the Enemy:

Perspectives on the Civil War. New York, NY: G P

Putnam’s Sons; 2001:367.

14. Eighty Acres of Hell [DVD]. The History Channel;

2006. Available at: http://shop.history.com/

detail.php?p=69494&v=history_subject_war-andwarfare_civil-war&pagemax=all.

15. Wikipedia.com web site. Camp Douglas (Chicago).

Available at: www.en.wikipedia.org/wiki/Camp

_Douglas_(Chicago). Accessed 11 January 2009.

16. Laws and Customs of War on Land. Hague

Conference of 1899: Hague II. New Haven,

Connecticut; Yale University Lillian Goldman Law

Library, The Avalon Project. Available at: http://

avalon.law.yale.edu/19th_century/hague02.asp#art1.

Accessed May 12, 2009.

17. Sides H. Ghost Soldiers. New York, NY: John Wiley

& Sons Inc; 2002.

18. Chalek W. Guest of the Emperor. San Jose, CA:

Writers Club Press; 2002.

19. The Bataan Survivor Association. 2006. http://

www.bataansurvivor.com.

20. Fact Sheet: Prisoners of War in the Korean War.

United States of America Korean War

Commemoration web site. Available at: http://

korea50.army.mil/history/factsheets/pow.shtml.

Accessed January 12, 2009.

21. Wikipedia.com web site. Korean War. Available at:

www.en.wikipedia.org/wiki/Korean_war#crimes

_against_pows. Accessed January 13, 2009.

22. Wikipedia.com web site. Hanoi Hilton. Available at:

http://en.wikipedia.org/wiki/Hanoi_Hilton. Accessed

May 12, 2009.

Prisoner of War Camps: Lack of a Revolution
April – June 2009 41

THE ARMY MEDICAL DEPARTMENT JOURNAL

23. Lander M. McCain, in Vietnam, Finds the Past Isn’t

Really Past. [Hanoiparis.com web site]. April 27,

2000. Available at: http://www.hanoiparis.com/con

struct.php?page=actutxt&idfam=26&idactu=305.

Accessed May 12, 2009.

24. Wikipedia.com web site. Bagram Torture and

Prisoner Abuse. Available at: http://en.wikipedia.org/

wiki/Bagram_torture_and_prisoner_abuse. Accessed

January 13, 2009.

25. Wikipedia.com web site. Bagram Theater Internment

Facility. Available at: http://en.wikipedia.org/wiki/

Bagram_theater_internment_facility. Accessed

January 13, 2009.

26. Jehl D. Army details scale of abuse in Afghan jail.

New York Times. March 12, 2005;World section.

Available at: http://query.nytimes.com/gst/

fullpage.html?res=9F01EFD9143CF931A25750

C0A9639C8B63&scp=80&sq=&st=nyt. Accessed

May 12, 2009.

27. Article 15-6: Investigation of the 800th Military

Police Brigade [In: The Taguba Report on the

Treatment of Abu Ghraib Prisoners in Iraq].

Available at: http://news.findlaw.com/hdocs/docs/

iraq/tagubarpt.html. Accessed January 15, 2009.

28. Wikipedia.com web site. Abu Ghraib Prison.

Available at: http://en.wikipedia.org/wiki/

abu_ghraib_prison. Accessed January 15, 2009.

29. Zimbardo PG. Stanford Prison Experiment [web site].

Available at: http://www.prisonexp.org.

Accessed January 15, 2009.

30. Cohen R. We don’t want a Hanoi Hilton. Washington

Post. October 27, 2005;Editorial section:A27.

AUTHORS

LTC Caci is the Environmental Science Officer, US

Special Operations Command, Fort Bragg, North

Carolina.

LTC Cline is Chief, Preventive Medicine Plans and

Operations, Office of the Command Surgeon, US Army

Central, Fort McPherson, Georgia.

US Army Central

United States

Special Operations Command
42 https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1

BACKGROUND

The diagnosis of malaria should be considered when a

febrile patient presents with a history of prolonged

overseas travel and or had worked in malaria-endemic

regions. A shrewd and perceptive medical provider

should suspect and recognize this disease since most

malaria in the United States are imported from other

countries.1

The Centers for Disease Control and Prevention

considers malaria as a potential medical emergency.2

Technological and clinical competencies are required

to avoid diagnostic delays and

judgment errors. The gold

standard is still a “malarialsmear” that demonstrates the

parasite but requires technical

skill to perform.

Since 2000, when the US

military forces increased its

overseas operations in malariaendemic areas, increasing

numbers of malaria cases have

been reported through its

surveillance database. For years,

the numbers of unspecified

malaria as a diagnosis had varied

widely from 6% (4 of 69 in

2002) to 33% (15 of 45 in 2005),

with an overall average of

19.6% (83 of 423 from 2000 to

2005).3 These numbers come only from the Reportable

Medical Event System of the US military and does not

include other reports that show unspecified malaria,

with an alarming proportion of 83% (1,140 of 1,381),

obtained from a 10-year malaria query-report of the

Defense Medical Surveillance System (DMSS).

This study analyzes the cases reported as unspecified

malaria and makes recommendations to improve

surveillance of malaria among US service members.

An examination of the outcomes across a longitudinal

90-day follow-up period of unspecified malaria from

all outpatient, inpatient, and reportable medical event

database reports of the DMSS from January 1, 1998, to

December 31, 2007, was performed. As shown in

Figure 1, there were 3 outcomes reported:

A. Malaria which was later-specified or later-confirmed (a specific malaria-species was identified

within the 90-day time frame).

B. Diagnoses that remained unspecified but probable

malaria, assigned if any one of the following was

present within the 90-day period:

 Another diagnosis of

unspecified malaria showed on

subsequent follow-up, or the

patient was hospitalized with a

primary or secondary diagnosis

of unspecified malaria.

 A diagnosis of fever or

pyrexia 30 days before the

diagnosis of unspecified malaria.

 The patient had a prior viral

infection 30 days before the

diagnosis of unspecified malaria.

 A malarial-smear procedure

was performed during any of the

clinic visits.

 The unspecified malaria was

reported in the reportable

medical surveillance system.

C. Diagnoses that remained unspecified but possible

malaria, assigned to those who had either only one

clinic visit where a diagnosis of unspecified was made,

or who did not have any of the previously enumerated

features of the probable malaria.

METHODS

Each military service is required to report all malaria

cases through their own public health reporting

The Reporting and Recording of Unspecified

Malaria in the Military, 1998–2007

LTC Joseph K. Llanos, MC, USA

Unspecified malaria

n=1,637

Excluded cases due to prior

history of specified malaria

n=256

Remained-unspecified

malaria (after 90 days)

n=1,140

Later-specified

malaria within 90 days

n=241

Unspecified and

probable malaria

n=226

Unspecified and

possible malaria

n=914

Figure 1. Distribution of unspecified

malaria cases retrieved from the Defense

Medical Surveillance System database for

the period January 1, 1998, through

December 31, 2007.
April – June 2009 43

systems. These reports are then forwarded to the

Armed Forces Surveillance Health Center, where they

are merged into the DMSS, and a

central repository of military health

surveillance data for the

Department of Defense. The DMSS

contains longitudinal records of all

service members personnel, medical, and serological information.3

A retrospective query was

performed on the population health

data for disease surveillance on

unspecified malaria having an ICD9 CM4

code of 084.6, labeling this

as the index case. The data was

loaded into the DMSS between

January 1, 1998, and December 31,

2007. All component services

(Active and Reserve Army, Marine

Corps, Air Force, Navy, Coast Guard) were taken, and

an incidence rule was applied requiring only one unspecified malaria diagnosis.

Each unspecified malaria report included demographic

information, date of diagnosis, and whether a malarial

smear was performed. Other queries added were diagnosis of fever, recurrent/relapsing/5-day fever, malaria

fever, periodic fever, 3-day fever, viral infection

within 30 days prior to the index case, and either a

Korea or Afghanistan deployment history within 2

years prior to the unspecified malaria diagnosis.

The ICD-9 CM code used 084.6 for unspecified

malaria. This code was also used for malaria fever and

recurrent fever. Fever, relapsing fever, 5-day fever,

periodic fever and 3-day fever were queried using

780.6, 087.9, 083.1, 277.31, and 066.0 respectively.

The current procedural terminology codes for blood or

malarial smears used were 85060, 86750, 86753,

87015, 87207, 87177, and 87209. The inpatient ICD-9

procedural codes used were 90.5, 91.5, v75.

The data was analyzed using SAS version 9.1 software

(SAS, Cary, NC) tabulations. The data was obtained

from the health surveillance of the US military

population and informed consent was not required for

this purpose.

RESULTS

During the 10-year period, 1,637 cases of unspecified

malaria were reported among US service members.

For the purposes of the study, 256 records of those

who had a prior (90 days before) history of a specific

malaria-species diagnosis were

excluded.

The remaining population, totaling

1,381, was labeled as unspecified

malaria index cases and selected for

analysis (Figures 1 and 2).

Demographic and Clinical

Features (Tables 1 and 2)

Later-specified or probable malaria

was found mostly among the young

(24-years old and younger) in the

enlisted ranks of E-4 and below, in

the Active component of their

service, most probably the Army.

In contrast, possible malaria was

found among the older (82%), commissioned or

warrant officers (85%), in the Air Force (91%), in the

Reserve/Guard component (75%). Clinical features

showed that the majority had no fever history 30 days

before (75%), did not have any viral infection (67%),

had no history of prior Afghanistan and or Korea tours

(81%), and had no blood smear taken (68%).

Frequency of Visits

Figure 3 presents the frequency of follow-up visits

among the 3 groups. The data for later-specified and

probable malaria showed that the majority of those

required 2 or 3 office visits, whereas those diagnosed

with possible malaria had mostly one visit (>90%).

TEN-YEAR UNSPECIFIED MALARIA REPORT

Figure 4 is a stacked-column chart which illustrates the

yearly reported and recorded unspecified malaria

diagnoses across the 10-year span. The outcomes

during the first 5 years (1998 to 2002) were compared

to the last 5 years (2003 to 2007). Possible malaria

diagnoses declined 40% during the last 5 years.

Likewise, the specified and probable malaria

diagnoses increased 70% in those last 5 years.

DISCUSSION

The article examines the meaning and significance of

unspecified malaria by defining 3 diagnostic outcomes

within a 90-day follow-up period: specified, probable,

and possible malaria. The criteria characterizing each

Unspecified-probable

n=226 (16%)

Later-specified

n=241 (17%)

Unspecified-possible

n=914 (57%)

Figure 2. Unspecified malaria classifications of diagnoses at the end of 90-

day follow-up period.
44 https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1

outcome was established before the database queries

were designed. The ICD-9 CM and CPT codes used

for retrieving fever, viral infection, and blood smear

data were exhaustive and were agreed upon at the

beginning of the study. The choice of 90 days to make

a further distinction between probable and possible

was arbitrary. The assumption was that patients who

really had malaria would mostly likely have repeated

medical care within this selected time frame. There

was no other way of validating the findings except by

a reexamination of medical records, which was

impractical, and probably impossible.

The finding that 83% (1,140 of 1,381) of the cases

remained unspecified 90 days after the initial diagnosis

was made, and only 17% (241) were later classified

with a specific malaria-species diagnosis is alarming

and needs urgent examination and scrutiny.

This article is a helpful reminder for responsible

parties involved with patient care, both directly and

indirectly, that prompt attention to the following areas

is required:

 Encourage immediate speciation and accurate

recording of malaria diagnosis.

 Medical providers should consider malaria in their

differential diagnosis among service members

returning from theater with demographic and

clinical attributes described earlier.

This report also emphasized the need for clinicians to

possess high indexes of suspicion when confronted

with nonspecific illness among military personnel. The

demographic characteristics suggestive of clues to the

diagnosis include young, active enlisted, 20 to 24 years

of age, with a prior exposure in either an Afghanistan

or Korea tour. This report also demonstrated that a

majority of these cases will clinically present to the

clinician with conditions other than fever or even other

than a common viral infection 30 days prior to the

The Reporting and Recording of Unspecified Malaria in the Military, 1998–2007

Note: Percentages (%) in table rows are calculated on the number of

cases (n) given for that demographic classification.

*Demographic information missing for 6 records in this category.

†Demographic information missing for 1 record in this category.

‡Demographic information missing for 7 records in this category.

LaterSpecified

Malaria

*n=241 (17%)

Probable

Malaria

†n=226 (16%)

Possible

Malaria

‡n=914 (66%)

Military Pay Grade

E1-E4 (n=509) 120 (23.5%) 103 (20.2%) 286 (56.1%)

E5-E6 (n=390) 83 (21.2%) 66 (16.9%) 241 (61.7%)

E7-E9 (n=130) 12 (9.2%) 25 (19.2%) 93 (71.5%)

Officers (n=338) 20 (5.9%) 31 (9.1%) 287 (84.9%)

Age Category

under 20 (n=52) 3 (5.7%) 11 (21.1%) 38 (73.0%)

20-24 (n=381) 102 (26.7%) 73 (19.1%) 206 (54.0%)

25-29 (n=280) 55 (19.6%) 58 (20.7%) 167 (59.6%)

30-34 (n=221) 39 (17.6%) 28 (12.6%) 154 (69.6%)

35-39 (n=208) 24 (11.5%) 26 (12.5%) 158 (75.9%)

40+ (n=225) 12 (5.3%) 29 (12.8%) 184 (81.7%)

Branch of Service

Army (n=750) 184 (24.5%) 172 (22.9%) 394 (52.5%)

Marines (n=83) 13 (15.6%) 11 (13.2%) 59 (71.0%)

Navy & Coast

Guard (n=152) 23 (15.1%) 22 (14.4%) 107 (70.3%)

Air Force (n=382) 15 (3.9%) 20 (5.2%) 347 (90.8%)

Component

Active (n=1,205) 220 (18.2%) 199 (16.5%) 786 (65.2%)

Reserve/National

Guard (n=162)

15 (9.2%) 26 (16.0%) 121 (74.6%)

Table 1. Demographic distribution of the investigated

unspecified malaria cases.

Table 2. Clinical factors of the investigated unspecified

malaria cases.

LaterSpecified

Malaria

*n=241 (17%)

Probable

Malaria

†n=226 (16%)

Possible

Malaria

‡n=914 (66%)

Prior Fever History

No (n=1,225) 173 (14.1%) 138 (11.2%) 914 (74.6%)

Yes (n=156) 68 (43.5%) 88 (56.4%) 0

Prior Viral Infection

No (n=1,309) 223 (17.0%) 205 (15.6%) 881 (67.3%)

Yes (n=72) 18 (25.0%) 21 (29.1%) 33 (45.8%)

Prior Tour in Afghanistan or Korea

No (n=955) 81 ( 8.4%) 101 (10.5%) 773 (80.9%)

Yes (n=426) 160 (37.5%) 125 (29.3%) 141 (33.0%)

Malarial-smear

No (n=1,330) 221 (16.6%) 195 (14.6%) 914 (68.7%)

Yes (n=51) 20 (39.2%) 31 (60.7%) 0

Note: Percentages (%) in table rows are calculated on the number of

cases (n) given for that clinical factor.

*Demographic information missing for 6 records in this category.

†Demographic information missing for 1 record in this category.

‡Demographic information missing for 7 records in this category.
April – June 2009 45

THE ARMY MEDICAL DEPARTMENT JOURNAL

index event. The more frequent number of visits was

considered suggestive of a probable malaria outcome

requiring close follow-up care by the clinician despite

remaining unspecified throughout the entire follow-up

period.

An important finding calling for immediate

improvement is the reporting and documentation of

malarial smears performed within military treatment

facilities (MTF). Even the later-specified malaria

group that confirmed the specific malarial species by

smears failed to document this procedure in 92% of

cases (221 of 241). MTFs should revisit

and review the process of data recording,

procedure documentation, and correctness

or accuracy of the ICD-9 CM, current

procedural terminology, and inpatient ICD

-9 procedural codes used.

The limitation of this study is the inability

to confirm some assumptions made

without looking at the medical records.

The 90-day time period was chosen to

follow-up unspecified malaria outcomes

with an assumption that patients who have

malaria will most likely seek medical care

within this window.

REFERENCES

1. Van Voorhis WC, Weller PF. Infectious

disease: XXXIV protozoan infections. ACP Med.

November 2004 update. Available at: http://

www.acpmedicine.com/acpmedicine/institution

al/instHtmlReader.action?readerFlag=chapt&

chapId=part07_ch34.

2. Malaria home page. Centers for Disease Control and Prevention website. Available at: http://

www.cdc.gov/malaria/diagnosis_treatment/diag

nosis.htm. Accessed 20 May 2008.

3. Ciminera P, Brundage J. Malaria in the US

military forces: A description of deployment

exposures from 2003 through 2005. Am J Trop Med

Hyg. 2007;76(2):275-279.

4. International Classification of Diseases, Ninth

Revision, Clinical Modification. Hyattsville, MD: National Center for Health Statistics; 2009. Available at:

http://www.icd9data.com/2009/Volume1/default.htm.

AUTHOR

LTC Llanos, assigned to the Walter Reed Army Institute

of Research, Washington, DC, is completing his residency

in Occupational Medicine at the Uniformed Services

University of the Health Sciences, Bethesda, Maryland.

Frequency of Visits (days)

Percentage

0

10

20

30

40

50

60

70

80

90

100

0

10

20

30

40

50

60

70

80

90

100

1 2 3 4 5 6 7 8 9

Later-specified malaria Probable malaria Possible malaria

Figure 3. Frequency of follow-up visits of patients relative to the

eventual classification of their malaria diagnoses.

Figure 4. Distribution by year of diagnosis of cases initially diagnosed as

unspecified malaria after a 90-day follow-up period.

20%

40%

60%

80%

100%

0% 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

14 16 15 13 7 27 24 31 46 33

8 19 18 14 15 40 32 17 49 29

181 56 110 115 89 83 95 81 56 48

Unspecified but probably malaria Later-specified malaria Unspecified but possibly malaria

UNIFORMED SERVICES UNIVERSITY

of the Health Sciences
46 https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1

INTRODUCTION

The federal government, including the Department of

Defense (DoD), is increasingly reliant on contractors

to carry out support functions in contingency

operations.1 The estimated number of private

contractors working in Iraq may now top 100,000 and

could exceed the actual number of troops in theater.2

In addition to US contractors and third country

nationals brought into Iraq to work for contracting

firms, Coalition forces are also contracting services

from local nationals at hundreds of smaller Coalition

outposts and joint security sites.

Contracting offers numerous advantages to the DoD. It

is an effective way to furnish the massive manpower

necessary to construct and sustain base camps, thus

freeing Soldiers from these onerous duties and

enabling them to focus their energies on winning the

counterinsurgency fight. Contracting provides

technicians and other highly-skilled professionals such

as Arabic interpreters, law enforcement trainers,

intelligence analysts, fire fighters, and unmanned

aircraft operators that are either critically short or

unavailable among the DoD civilian and service

member workforce. Contracting also aids in

stimulating host nation economies by pumping

American dollars to local businesses and employing

large numbers of local nationals. On the flip side, the

phenomenal growth in contracting has taxed DoD’s

oversight and accountability systems. This, in turn, has

made thwarting malfeasance, fraud, abuse, and second

rate performance more difficult.

THE FORCE HEALTH PROTECTION CHALLENGES OF

CONTRACTING

Most of the basic life support services delivered by

contractors have direct impacts on Soldier health.

These services include pest management, waterworks

(ie, potable water production, storage, transport, and

distribution), trash disposal, and dining facility

operations.3 Heightened disease and nonbattle injury

rates in the form of waterborne, foodborne, or

vectorborne disease outbreaks could result if these

vital services are delivered in a substandard manner.

The contractors themselves can pose a health threat to

Soldiers. Most third country national workers originate

from less developed countries, where medical care is

poor or nonexistent, and communicable diseases such

as tuberculosis and hepatitis are highly endemic. The

same conditions hold true for their local national

counterparts. Without proper precautions, third

country nationals and local nationals can transmit

diseases to Soldiers. Most contracts require workers to

pass a health exam or screening as a condition for

employment. There are generally no contract

provisions stipulating where these screenings occur.

As a result, the majority of screenings are conducted

abroad or in the host nation at nonaccredited,

insufficiently equipped, and meagerly staffed clinics.

Improvement of Force Health Protection

Through Preventive Medicine Oversight of

Contractor Support

MAJ Scott A. Mower, MS, USA

ABSTRACT

Unprecedented numbers of contractors are used throughout the Iraq theater of operations to alleviate military manpower

shortages. At virtually every major forward operating base, US-based contractors perform the preponderance of essential

life support services. At more remote sites, local national contractors are increasingly relied upon to maintain chemical

latrines, remove trash, deliver bulk water, and execute other janitorial functions. Vigorous oversight of contractor performance is essential to ensure services are delivered according to specified standards. Poor oversight can increase the

risk of criminal activities, permit substandard performance, elevate disease and nonbattle injury rates, degrade morale,

and diminish Soldier readiness. As the principal force health protection proponents in the Department of Defense, preventive medicine units must be tightly integrated into the oversight processes. This article defines the force health protection implications associated with service contracts and provide recommendations for strengthening preventive medicine’s oversight role.
April – June 2009 47

These clinic shortcomings, coupled with rampant corruption and several tuberculosis outbreaks among prescreened third country national contractor populations,

makes most screening results dubious at best.

Contracts utilizing third country nationals and US

workers usually obligate the contractor to furnish

medical care to their employees. Cases of

noncompliance are quite common with significant

numbers of laborers arriving in theater without the

support, equipment, and pharmaceuticals necessary to

medically sustain them. When this occurs, the burden

of care falls on the DoD medical facilities. Presently,

there is no standardized mechanism for the DoD to

charge the contractor for delivered medical services,

thus allowing the contractor to often escape paying

compensation and penalties for this contractual

violation.

Bases employing third country national and local

national laborers are more vulnerable to attacks on

critical infrastructure and intentional contamination of

food and water supplies should the contractors harbor

hostility towards Coalition forces. As residents and

frequent visitors to the bases, these laborers can poison

wells, bottled water stocks, and stored rations. They

could also destroy critical infrastructure such as

reverse osmosis water purification units and radar

systems by sabotage or relate invaluable targeting

intelligence to insurgent groups. Even without hostile

intent, the workers could steal unsecured rations or

bring unapproved and contaminated food supplies onto

the base to sell or serve to Soldiers

As the principal proponent for force health protection

(FHP), preventive medicine (PM) units must play a

decisive role in the contracting process. Their ability to

recognize health threats, assess camp sanitation conditions, discern food and water system vulnerabilities,

and devise disease prevention stratagems are crucial

towards resolving these daunting FHP challenges.

TYPES OF SUPPORT CONTRACTS

The two main types of basic life support service

contracts utilized within the Iraq theater of operations

are Logistics Civil Augmentation Program (LOGCAP)

and contingency contracts in the form of purchase

request and commitments (PR&Cs). Each contract

type has its own unique quality assurance and quality

control processes. For effective oversight to occur, PM

must understand these processes and the differences

between contract types.

LOGCAP is a worldwide contingency service contract

that reinforces military assets with civilian contract

support primarily focused on the provision of basic life

support services to Coalition forces. The sole

LOGCAP provider in Iraq for the Army is KBR, Inc

(Houston, Texas) which embeds its personnel within

the logistic divisions on the contingency operating

bases. LOGCAP services are not contractually

authorized for outlying locations with less than 150

Soldiers, with the exception of repairs essential to the

protection of life, health, and safety.4 Under LOGCAP,

contract administration, property administration, and

quality assurance are performed by the Defense

Contract Management Agency (DCMA).5

The more numerous and austere contingency operating

locations, such as joint security sites and Coalition

outposts, are unsupported by LOGCAP. At these sites,

PR&Cs are enacted that employ local national

contractors for services that cannot be provided by

organic combat support/combat service support assets

due to competing missions or lack of skill sets.4

PR&Cs are usually initiated at the battalion command

level and must include detailed statements of work

(SOWs) and 3 bids/estimates from different

contractors. Under unique time/safety/mission

circumstances, a sole-source contractor may be used.4

The SOWs and other supporting documents are

compiled into a packet staffed through brigade,

division, and corps headquarters before receiving ultimate approval or rejection from the Joint Contracting

Command-Iraq. The entire vetting process can take

several weeks, especially if the packet is incomplete

and the SOW is too vague or poorly written.

FORCE HEALTH PROTECTION SHORTFALLS IN THE

LOGCAP OVERSIGHT PROCESS

The DCMA quality assurance representatives are

tasked with monitoring the quality of LOGCAP

contractor work and assessing their performance. They

execute this mission by auditing contractor processes,

projects, and internal management controls and

receiving monthly assessments conducted by

contracting officer representatives (CORs) on specific

basic life support services.6In theory, personnel

designated as CORs are professionally trained and

subject matter experts who possess the technical

wherewithal to evaluate their basic life support area. In

reality, unqualified individuals are frequently assigned

COR responsibilities for expediency sake. This has

been especially problematic in the selection of
48 https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1

waterworks and pest management CORs, services

which PM personnel are uniquely qualified to assess.

Both quality assurance representatives and CORs use

checklists to perform their assessments. These

checklists typically mirror checklists found in existing DoD policy

documents. For example, the dining

facility operations checklist closely

resembles Army Form 5162-R,

Routine Food Establishment

Inspection Report, which is found in

Army Technical Bulletin MED

530.

7 Each requirement listed on the

checklist is furnished with the name

and paragraph number of its

corresponding reference document.

If there is no relevant DoD reference document , the

requirement is referenced against its corresponding

LOGCAP contract task order and section number.

Responses to inquiries made to DCMA by this author

suggest that PM reviews of checklists and task orders

relevant to force health protection occur sporadically,

but are not institutionalized document development

requirements.

FORCE HEALTH PROTECTION SHORTFALLS IN THE

PR&C OVERSIGHT PROCESS

Many of the battalion contracting officers tasked with

development, submission, and management of PR&Cs

receive no formal training on their duties before they

are named to the positions. Since the position is

considered an additional duty, the appointing

authorities often make opportune appointments and not

necessarily assign the person best-suited for the

position. In general, these contracting officers are

unfamiliar with PM and fail to recognize the FHP

implications of the contracts. When coupled with no

PM oversight, this unfamiliarity is a recipe for disaster

and has led to shoddy contract work and increased

health risks. Examples of this include the interior

coating of potable water storage tanks with paints

mixed/thinned with hazardous solvents, an attempt to

purchase and install a $108,000 commercial reverse

osmosis water purification system incapable of treating

the exceptionally salty water from a joint security site

groundwater source, and efforts to utilize local

national personnel who have not received food service

sanitation training or medical screening in food

preparation positions.

Level II PM (ie, brigade combat team PM sections and

division surgeon section PM officers) can prevent

PR&C shortfalls by carefully reviewing and inserting

FHP stipulations into statements of work. This will

provide the contracting officer with a defense against

poor performance since the contract

can be terminated if the local

national contractor fails to execute

the service in a manner protective of

health and safety. A tightly-written

statement of work also offers the

additional advantage of educating

local national contractors on

“acceptable” Coalition performance

standards, which, in numerous

instances, differ from their own.

Examples of FHP stipulations that

are often missing in common types of PR&Cs

statements of work are shown in the Figure.

STEPS TO ENHANCE CONTRACT OVERSIGHT BY

PREVENTIVE MEDICINE

The following changes in PM doctrine, training,

leadership, and education practices will strengthen

PM’s role in contract oversight processes:

• Clearly define contract oversight responsibilities in

PM policy documents. Current doctrine is woefully

insufficient on this subject. For example, there is no

discussion of contract oversight in Army Field Manual

4.02-17,

8

the Army’s premiere guidance document on

the organization, mission, function, capabilities, and

employment of deployed PM elements.

• Establish a rapport between Headquarters, DCMA,

and the service medical authorities to ensure FHP is

integrated into LOGCAP and PM input is incorporated

into contracting officer representative checklists. A

joint working group comprised of Army, Navy, and

Air Force PM experts could be created to collectively

address FHP-related contracting issues, should

excessive confusion arise from each of the individual

service’s respective PM proponents interactions with

DCMA. The Armed Forces Pest Management Board, a

jointly staffed organization, is pursuing this approach

to address vector control services. The joint working

group could also include health care administrators to

discuss the compensation mechanisms associated with

contract labor use of DoD medical assets.

Improvement of Force Health Protection Through Preventive Medicine Oversight of Contractor Support

Iraqi contractor and his son maintaining a

trash burning point at a joint security site

(February 11, 2008).
April – June 2009 49

THE ARMY MEDICAL DEPARTMENT JOURNAL

• Appoint PM officers and noncommissioned officers

(NCOs) as the waterworks and pest management

contracting officer representatives at LOGCAP sites.

Since these Soldiers receive extensive training on

water production and storage site inspections, water

system vulnerability assessments, and integrated pest

management practices, and deploy with the equipment

needed to monitor water quality and conduct pest

surveillance, they are ideally suited to assume

contracting officer representative responsibilities. At

forward operating bases, where both level II and level

III PM (ie, PM detachments) are present, level III PM

should; by default, be designated as the lead

evaluators. This is in deference to their greater professional experience and higher rank command structure.

• Task PM detachment entomologists (area of concentration 72B) to provide technical support to all pest

management contracting officer representatives

(CORs) within their respective geographical mission

support areas. With a minimum of a master’s degree in

entomology and graduation from the DoD certified

pesticide applicator course, they are the best-trained,

uniformed, pest management professionals in theater.

Their expertise should be put to good use training

CORs in the evaluation of performance oversight roles

and performance standards.

• Introduce contract oversight and PR&C statement of

work reviews as part of the 6A-F5: Principles of

Preventive Medicine Course, and the 6A-F6:

Preventive Medicine Program Management Course,

both of which are taught at the Army Medical

Department Center and School. Incorporate contract

oversight and statement of work review into Combat

Training Center scenarios and US Army Center for

Health Promotion and Preventive Medicine

(USACHPPM) technical assistance visits.

• Recommend that all officers and senior NCOs assigned to level II and level III PM units enroll and

complete the Defense Acquisition University’s online

COR course.* The course provides an excellent

overview of COR ethics, duties, and responsibilities.

Course completion is a prerequisite for COR position

assumption. Completion prior to deployment is preferable due to the connectivity challenges and online time

constraints commonly encountered in theater.

• Furnish CORs of other basic life support services

with copies of relevant inspections and alert them to

force health protection related deficiencies which are

detected during PM assessments and inspections. For

example, the food service and Morale, Welfare, and

Recreation CORs should be notified when contractoroperated dining facilities and fitness facilities fail their

routine sanitation inspections. This will aid those

CORs to more accurately assess performance and exert

their considerable influence in rectifying deficiencies.

• Archive completed waterworks and pest management

COR checklists in the USACHPPM occupational and

environmental health surveillance data archive.†

Competent and diligent performance of these services

is vital for the creation of salubrious environmental

health conditions at base camps. The health

consequences of substandard performance can be

severe and may not become evident until long after the

Contracted

Service

Necessary Force Health Protection

Stipulations

Chemical latrines

(portable toilets)

Mount and maintain hand sanitizer dispensers

Use 62% ethanol-based hand sanitizers

Refill with a “blue water” solution after

emptying

Trash removal Pressure wash/clean dumpsters on a monthly

basis

Require functioning dumpster lids and

replacement when broken

Request metal dumpsters rather than plastic

(metal dumpsters are preferable since trash

can be burned inside them when overfilled

or the contractor fails to empty them on

schedule)

Bulk water deliveries Delivered water must have a minimum 2 PPM

and maximum 5 PPM residual chlorine

Truck must be cleaned and inspected by field

sanitation team member before acceptance

of delivery

Water must meet acceptable aesthetic

qualities (color, odor, and clarity) as

determined by PM

Local national

janitorial support

Restrict laborers from direct food handling,

preparation, and serving

Prohibit sick individuals from working

Building renovation

and construction

projects

Ban use of paints with added diesel fuel,

benzene, and other thinners

Instruct contractor to use practices that

minimize aerosolization of paint chips,

insulation, and other debris to reduce

exposure risks to Coalition forces

Examples of force health protection stipulations that

should be included in purchase request and commitment

statements of work.

*Information available at https://acc.dau.mil

†Information available at oehs@amedd.army.mil
50 https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1

deployment. By archiving the checklists,

epidemiologists could better understand site health

conditions and diagnose the causes of post deployment

medical problems were they to arise.

• Assist contracting officers in preparing the initial

PR&C statements of work. This step would foster

teamwork between PM and battalion contracting

officers, strengthen the FHP provisions within the

statements of work, reduce approval delays, and better

educate the contracting community about the

importance of PM and how to write contracts

protective of health.

• Formalize the PR&C packet staff approval process to

mandate level II PM review of all statements of work

bearing FHP implications, with the initial and final PM

reviews performed by brigade combat team and

division surgeon section PM officers; respectively.

Such a process would ensure that FHP concerns are

addressed at the lowest levels, expediting packet

approval and contract letting. This was done with

much success by the Multinational Division–Baghdad

(MND-B) staff through an automated process that

permitted each section to examine scanned statements

of work in digitized packets on the secure internet

protocol router email and either approve, approve with

comments, or reject the contract.

CONCLUSION

Whether it is LOGCAP-provided cooks feeding

headcounts into the thousands at a large forward

operating base dining facility, or an Iraqi entrepreneur

pumping out chemical latrines at a joint security site or

Coalition outpost, contractors are now the main

providers of basic life support services at forward

operating bases. Contractor performance directly

impacts the health and welfare of our Soldiers, but the

current oversight mechanisms necessary to champion

force health protection are insufficient. The solutions

to this problem will require a concerted effort by

commanders, logisticians, and the PM community, and

implementation of numerous enhancements to contract

oversight processes.

ACKNOWLEDGEMENTS

I wish to extend special thanks to LTC Peyton Potts, MNDB G4 LOGCAP Officer, and MAJ Robert Huber, MND-B

Contracting Officer, for their review and input on the

contracting processes. Also, LTC David Ristedt, MND-B

Division Surgeon, Troy Ross, the MND-B Preventive

Medicine Officer, and MAJ James Waddick, MND-B

Deputy Division Surgeon, provided invaluable input to this

article.

REFERENCES

1. Office of the Comptroller General of the United

States. Defense Management: DoD Needs to

Reexamine Its Extensive Reliance on Contractors and

Continue to Improve Management and Oversight.

Washington, DC: US Government Accountability

Office; March 11, 2008. Available at: http://

www.gao.gov/new.items/d08572t.pdf.

2. Gregory L. Increasing reliance on private contractors

in Iraq raises questions. Chattanooga Times Free

Press. May 2, 2008;Local News. Available at: http://

timesfreepress.com/news/2008/may/02.

3. Llama W. Contingency contracting and LOGCAP

support in MND-B, Iraq. Army Logistician. 2007;37

(5):28-29. Available at: http://www.almc.army.mil/

alog/issues/SepOct07/browse.html.

4. Potts P. Presentation to the Victory Base Complex

Preventive Medicine Forum. January 2008; Camp

Liberty, Iraq.

5. Spencer GT. DCMA Supporting Multi-National

Forces in Iraq. [News release, Defense Contract

Management Agency Web site]. September 13, 2005.

Available at: http://www.dcma.mil/communicator/

news_release/2004/NR_091304.htm.

6. Office of the Assistant Secretary of the Army for

Acquisition, Logistics, and Technology.

Memorandum for Record. Subject: Contract

Administration and Surveillance for Service

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

February 9, 2007.

7. Technical Bulletin MED 530: Occupational and

Environmental Health Food Sanitation. Washington,

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

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

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

2000.

AUTHOR

MAJ Mower was the Multinational Division-Baghdad

Environmental Science Officer during Operation Iraqi

Freedom 07-09.

Improvement of Force Health Protection Through Preventive Medicine Oversight of Contractor Support
April – June 2009 51

OVERVIEW

Health sector development is a critical component of

nation-building and a cornerstone of any exit strategy

for US and coalition forces in Afghanistan. The

current fragmented organizational structure of military

health care assets is not conducive to comprehensive

development efforts.1 Centralized planning and

direction are essential to unity of effort and a

necessary ingredient to the coordination of health

sector development in Afghanistan. An organizational

structure is needed that enables leaders with vision to

vector military health sector strategy development.

The direction must be aligned with the Afghan

National Development Strategy, civilian organizations,

and coalition partners operating throughout the theatre.

As a lesson for future nation-building operations and

reinforcement of the concepts outlined in this paper,

Jones et al2observed that successful health sector

development efforts must include effective planning,

coordination, and leadership. The

price of failure to act can be

quantified not only in fiscal and

material terms, but in human

tragedy as well.

INTRODUCTION

Health sector development in

Afghanistan is foundational for

the future viability of the

government of Afghanistan and

the health and welfare of its

people.2In fact, as stated by the

US Joint Forces Command, “a

viable health sector is vital to a

nation’s well-being.”3(p7) Statistics

from UNICEF, presented in the

Table, show nearly zero

improvement in under-5 mortality

and infant mortality rates, among other significant

public health measures.4 Unfortunately, health sector

development in Afghanistan is suffering from a lack of

centralized planning and direction. While numerous

military professionals of all backgrounds and

affiliations are doing a great deal of things to try to

help the people, government, and country of

Afghanistan, there is a tremendous lack of unity of

effort within the military structure in the arena of

health sector development. The way ahead will require

significant change, including a reorganization of

healthcare services in theatre, dynamic leadership, and

the development of an achievable and coordinated

strategic plan that will generate unity of effort.

ORGANIZATIONAL STRUCTURE

Organizational structure serves as an enabling

backbone. In Afghanistan, the organization of

healthcare services is fractured, particularly as it

pertains to health sector development, resulting in a

dysfunctional execution of

strategy. The Afghan health

system has 3 major components:

the Ministry of Public Health

(MoPH) for the civilian sector, the

Ministry of Defense (MoD) for

the Afghan National Army, and

the Ministry of the Interior (MoI)

for the Afghan National Police,

among other security services. All

of these components contribute to

t h e n a t i o n a l h e a l t h o f

Afghanistan.

The healthcare assets of coalition

forces in Afghanistan also have a

number of major components

(Figure 1). One element of the US

Forces-Afghanistan is a staff

Health Sector Development in Afghanistan:

The Way Forward

Maj Paul Brezinski, MSC, USAF

Lt Col Montserrat Edie-Korleski, MSC, USAF

CPT Timur S. Durrani, MC, USAR

Col Douglas Howard, NC, USAF

COL Michael Manansala, AN, USA

Comparative child survival and birth statistics for Afghanistan showing essentially

no improvement in a 17-year span.

Source: United Nations Children’s Fund4

Children under age 5 mortality rate

(per 1,000 live births)

Calendar Year

1990 260

2007 257

Infant (under 1 year) mortality rate

(per 1,000 live births)

1990 168

2007 165

Crude birth rate

(number of births per 1,000 population)

1970 52

1990 52

2007 48
52 https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1

medical planner who has recently arrived on scene.

The International Security Assistance Forces (ISAF)

staff headquarters has primary responsibility for

strategic guidance regarding reconstruction and

development. The ISAF mission consists of 41

nations. There are 28 provincial reconstruction teams

(PRTs) located across Afghanistan, task organized

under maneuver tasks forces within regional

commands with a mission to help develop and aid in

governance and development. To complicate the

organizational structure, the PRTs are situated across 5

regional commands, each with a different lead nation.

To complicate the organizational structure, the PRTs

are located in 5 regional commands, each with a

different lead nation. The Combined Security

Transition Command-Afghanistan (CSTC-A), whose

efforts are directed at the Afghan National Army and

National Police, is responsible for embedded training

teams and police mentor teams. The Combined Joint

Special Operations Task Force-Afghanistan, with its

unique mission, provides direct patient care of an

episodic nature in high value geographic locations. In

the near future, a medical command will be added to

the fray. Finally, there are a number of task force

maneuver units which arrive and operate with their

own medical assets under the control of a line

commander. The end product of this conglomeration is

a command and control system which has little unity

of effort toward health sector development.

There are 11 units with medical assets located at

Bagram Air Base alone. Each of those medical

resources is organic to a combat arms unit and are

dedicated solely to that specific unit. Consequently,

those medical assets are at risk of being underutilized

in their medical specialties (depending on the

operations tempo) and unavailable to provide support

to other medical functions without prior coordination

and authorization. While each unit brings skills,

expertise, and workload capacity to Bagram Air Base,

there is little coordination of effort on the installation.

As is the case in many locations and in many

organizations across Afghanistan, there are superb

medics in the task forces that are doing great things in

isolation. However, because there is very little unity of

effort, these advances are often unsustainable. This is

the end result of an absence of an enabling strategy for

comprehensive health sector development.

Further complicating the organizational structure of

health services in Afghanistan are the existence of

numerous civilian organizations. The United Nations

Assistance Mission in Afghanistan is a coordinating

body to which a US military liaison officer is assigned.

The European Commission works with multiple

nongovernmental organizations (NGOs), including the

International Medical Corps, Aide Medicale

International, Health Net International, Medical

Refresher Course Afghanistan, among others. The US

Agency for International Development (USAID) also

works with numerous NGOs including Bactar

Development Network, Norwegian Afghan Corps,

Sanayee Development Organization, Afghan

Development Association, Adventist Development and

Relief Agency, among others.5 Many of these

organizations have designated geographic

responsibilities and all are heavily involved in health

sector development efforts.

Military units and civilian agencies, along with Afghan

organizations, contribute to health sector development.

At times, the missions of these organizations intersect,

however, their efforts are often uncoordinated. In fact,

a stove-piped structure of funding and leadership has

evolved which limits vision and inhibits cooperation.

There is a published commander’s intent which

enables decentralized execution, but there is little or no

Health Sector Development in Afghanistan: The Way Forward

TF Warrior TF Duke TF Currahee TF Eagle TF Sparta TF MED

RC-East/CJTF-101

ISAF USFOR-A

CJSOTF-A

CSTC-A

Figure 1. The command organization of coalition forces

with healthcare assets in Afghanistan.5

Glossary

ISAF: International Security Assistance Forces

USFOR-A: US Forces-Afghanistan

RC: Regional Command

CJTF: Combined Joint Task Force

CSTC-A: Combined Security Transition CommandAfghanistan

CJSOTF-A: Combined Joint Special Operations Task

Force-Afghanistan

TF: Task Force
April – June 2009 53

THE ARMY MEDICAL DEPARTMENT JOURNAL

centralized planning or control as advocated in joint

doctrine.6(pIV-16) The fractured structure dates back

several years and is likely an evolutionary result of

funds allocation in the area of responsibility. In

practice there is little, if any, interagency coordination.

The funding environment in Afghanistan is extremely

complex. A number of “colors of money” exist

including:

 Commander’s Emergency Response Program

funds which are earmarked for urgent

humanitarian relief and reconstruction.

 Afghanistan Security Forces Funds, often referred

to as Title 22, which are provided through CSTCA for training and sustaining Afghanistan National

Security Forces.

 Title X funds for active duty personnel and

operations, Field Order Officer funds used for US

Forces only and generally available for expenses

less than $10,000.

 Overseas Humanitarian Disaster and Civic

Assistance funds sponsored by the US State

Department.

In addition, organizations such as USAID, the

European Commission, and numerous NGOs, as well

as the MoPH, have their own funding sources, rules,

and regulations. Given all these “colors of money,”

there are funds available for comprehensive health

sector development and capacity building missions,

but the complexity required in this system encourages

thinking within the confines of the funding stream. In

addition, each type of funding comes with its own

administrative rules and reviews.7

What has evolved is a system of decentralized

planning and execution among the many

uncoordinated agencies and units in Afghanistan.

Essentially, many civilian agencies and military units

are moving forward in their respective lanes as they

understand and interpret their role within the Afghan

National Development Strategy (ANDS) construct,

and the strategic and operational environment. The

consequence of this uncoordinated approach is isolated

progress which is unsustainable over the long-term.

This unsustainable progress will potentially undermine

the credibility of the coalition and the government of

Afghanistan in terms of health sector development.

However, the coordination and combined efforts of

healthcare resources in Afghanistan could have a

positive tangible and sustained impact on the country’s

healthcare infrastructure.

STRATEGIC DIRECTION

Within the framework of the ANDS, a new and

comprehensive strategic direction is necessary for the

future of health sector development in Afghanistan.

While US and coalition forces provide superior and

well-coordinated care to wounded Warriors, the

humanitarian support and infrastructure development

missions are shrouded in fog and friction, not caused

by the war, but products of the organizational structure

and bureaucracy that has developed over time. The

way forward lies in improving the capacity and

capability of the Afghan health system through

training and skills development of healthcare

professionals and support staff, as well as through

bricks and mortar. While training and capacity

building are integrated into some existing strategy,

including that of Combined Joint Task Force-101

(CJTF-101), execution is more problematic.

As one example, the International Medical Mentorship

and Training Program (IMMTP) is designed to

improve the human capacity of Afghan physicians

across the country and is synergistic with a 2-week

program targeted at Afghan nurses and ancillary

medical staff. The program applies to all the major

healthcare entities in Afghanistan, including MoPH,

MoD, and MoI, and is a cooperative effort among the

US, Korean, and Egyptian hospitals on Bagram Air

Base. Unfortunately, the funding mechanisms in place

are not structured to support such a program, as it

crosses funding streams. Despite a nominal cost and

support by the commanding general, CJTF-101,

funding remains elusive. As a consequence, instead of

receiving training 6 days a week over 90 days in 3

coalition hospitals, the first 5 physicians in the

program traveled to and from Bagram Air Base from

outlying areas 2 days a week over the 90-day period.

The second class started in February 2009, with

subsequent cohorts of students entering training every

6 weeks. However, attendance of cohorts in the future

is at serious risk if funding issues are not resolved.

Currently, the commitment of the Afghan government

is illustrated by the agreement of the MoPH, MoD and

MoI to fund the salaries of their students for the

duration of the program. After 5 years of failed

attempts at starting such a program, the IMMTP has
54 https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1

begun and has taken a major step forward in building

relationships and capacity within the Afghan health

system. As stated by the US Joint Forces Command,

Sustainable projects that restore and build [host nation]

capacity, especially in public health systems, achieve

longer and wider spread results than limited scope

direct patient care projects. Capacity building also

garners positive good will and political capital without

creating misplaced dependency and does not undermine

[host nation] legitimacy to govern.3(p10)

The US is currently in jeopardy of losing one great

opportunity.

There are a number of viable solutions to the strategic

quandary that exists for health sector development in

Afghanistan. First, a number of medical challenges

must be understood, including the irregular

environment, the health and security relationship, and

the accomplishment of a health sector assessment that

enables the development of a strategy that leads to a

“culturally appropriate health sector capacity that

garners long-term positive effects for the

commander.”3(p3) The Afghan National Development

Strategy should serve as a guide for such efforts for

both military affiliated and civilian resources in

country. The fifth pillar of the ANDS, health and

nutrition, is based upon the basic package of health

services (BPHS) and the essential package of hospital

services (EPHS), which are foundational in meeting

the healthcare needs of the people of Afghanistan over

the long-term.

The statement from Joint Publication 1,

Attaining unity of effort through unity of command

may not be politically feasible given the sometimes

divergent missions of all the involved organizations, but

it should be a goal6(pxix)

is directly applicable to the coalition. The command

and control network for military health sector

development should be reorganized, including a plan

for integration that links the major players in the area

of responsibility and creates a central vision.

According to the Doctrine for the Armed Forces of the

United States,

Integration is achieved through joint operation planning

and the skilled assimilation of forces, capabilities, and

systems to enable their employment in a single,

cohesive operation rather than a set of separate

operations.6(pIV-17)

Leadership will be critical to this end, including those

of appropriate rank and ability to execute such a

monumental task. A funding system that can

accommodate the uniqueness and needs of the

environment will be essential to the development and

support of any strategic initiative. In addition, the

establishment and measurement of important

objectives, based upon public health goals as

advocated in the BPHS and EPHS, are essential. The

adoption of long-term public health measures, such as

infant mortality and malnutrition, will force a

paradigm shift in how business is normally conducted.

Finally, perspective of time has to adjust from one

focused on short-term goals tied to annual personnel

evaluations and deployment rotations (6 to 12 months)

to one focused on real substantive change in 5 to 10

years. The US and its coalition partners cannot afford

to continue to fight one year wars, particular as that

fight pertains to health sector development.

RECOMMENDATIONS

...the joint medical community must expand its

interagency and multinational relationships; joint force

commanders should seek innovative ways to employ

medical capabilities to help achieve security and

stability;...3(p3)

Beyond the joint force, it is imperative that the efforts

of the joint and combined force be aligned with the

multitude of NGOs and aid agencies operating in

Afghanistan to potentiate and sustain the effects. Three

specific recommendations include:

1. Dedicate resources specifically for health sector

development and clearly align the health sector

development mission under one joint medical

command and control element (JMC2E).*

A. Obtain a funding source dedicated entirely to

health sector development.

B. Funding is appropriated to the JMC2E for

execution.

The medical command that is currently in the process

of deploying to Afghanistan has the potential to be a

significant factor in the unity of command through the

provision of a centralized planning framework. More

importantly, the medical command structure should be

Health Sector Development in Afghanistan: The Way Forward

*The concept of a “medical command and control element”

was originated by LTC Mark McGrail, then the CJTF-101

Surgeon.
April – June 2009 55

THE ARMY MEDICAL DEPARTMENT JOURNAL

modified to become a JMC2E function. The primary

mission of US military medical units is to provide care

to US service members. The probability of making

real, timely, sustained progress would rise dramatically

if the health sector development function was

 established as a separate and important mission,

 recognized as an essential element of any exit

strategy, and

 specifically allocated to the JMC2E which was

then given the appropriate resources to execute

that mission.

A proposed organizational structure is presented in

Figure 2. As it currently stands, health sector

development is a secondary mission for most units

operating in theatre. The empowerment of the JMC2E

must include planning responsibility for all military

medical assets in theatre, including those of CSTC-A,

CJTF, and the Combined Joint Special Operations

Task Force, ensuring unity of effort. Any healthcare

lead in Afghanistan must be joint in structure and

operation. Establishing the JMC2E Surgeon as the US

Forces-Afghanistan Surgeon is a beginning. However,

providing the element with the necessary resources,

including funds earmarked for health sector

development, would give the element both the

authority and the responsibility to execute its mission.

If health sector development truly is important,

significant resources must be dedicated to it. In the

short term, this can be accomplished by adding more

personnel with public health training to incoming

medical units such as the medical command. In the

long-run, success will require changes to current

philosophy and changes to organizational structure to

complete health sector development missions.

Funding mechanisms must be established that do not

involve an inordinate approval process that impacts the

timeliness of execution of health sector initiatives. A

congressional mandate through the Department of

Defense may be required to establish the authority to

fund health sector development directly and eliminate

competition with other developmental initiatives.

2. Ensure the right people (leaders) are in the right

places with the right training and credentials. Strong

and visionary leaders will be critical to changing

course and aligning medical resources in-country.

Leaders for health sector development, at the JMC2E

and in supporting units, must, at a minimum, have

public health education, background, and/or

experience and rank appropriate for the authority,

responsibility, and importance the function holds. As

shown in Figure 2, the staff responsible for health

sector development planning need to have an

appropriate mixture of administrative experience

critical to planning and process, clinical experience

necessary for medical development, and mobility

enough to engage in relationship building and

sustaining those relationships across Afghanistan. It is

unknown at this time if the JMC2E will have this

capability; however the element must be supported

through joint action by the military and other US and

international agencies (Air Force, Navy, Army, Public

Health, US Agency for International Development,

European Commission, United Nations Assistance

Mission in Afghanistan, etc) to provide the manpower

needed to expand its mission of health sector

development.

Presently, medical leaders are expected to have

experience in health sector development. The military

would be better positioned if training were modeled in

homogeneous currency based platforms across all

services to develop the critical skills needed to

contribute to health sector development, similar to the

Air Force’s “Flight Path” methodology for personnel

development.8 This approach would be particularly

effective if the health sector development mission is

incorporated into each unit. Coordination of efforts

should not be expected but required, thus optimizing

unity of effort. If health sector development is not

made a priority for military units, the combination of

low priority, a lack of training, few available

resources, and leadership that is not dedicated to the

mission will lead to failure.

3. Develop a long-term strategy for military medical

assets that establishes clear objectives and aligns

resources toward accomplishing Afghan National

Development Strategy objectives. The strategy should

follow ANDS goals and be coordinated with all

medical agencies in Afghanistan, including USAID,

the European Commission, and associated NGOs.

Partnerships with other military and civilian

organizations are essential for successful health

interventions during stability operations.3 The JMC2E
56 https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1

Health Sector Development in Afghanistan: The Way Forward

Liaison Officer Cells

It is preferable that each LNO come from their respective organization, ie,

USAID LNO is an USAID employee; otherwise the US military may

provide an LNO.

Facilitate health sector development information and relationships.

Provide military commanders information and resources to implement the

MoPH health sector development strategy.

Coordinate all military health sector development with civilian and

government agency efforts.

Training Cell

Provide military units with Afghanistan

appropriate plans and programs to

achieve specific ANDS goals.

Ensure that all military medical assets

und erstand Afg han Natio nal

Development Strategy.

Ensure all military medical assets are

empowered to accomplish health sector

development.

Promote training of all types for women.

Public Health Cell

Create and promote training programs for

medical professional development,

medical administration, quality

assurance, medical equipment

maintenance and medical facility

maintenance.

Circulate within Afghanistan providing

expertise, guidance and support to any

military assets involved in medical

training programs.

Promote military commander awareness

of personnel training programs.

Plans, Programs, and Operations Cell

Coordinate all health sector plans with

MoPH, civilian, governmental and

individual military units.

Ensure health sector development is

synchronized with all other security and

development efforts.

Develop and publish nation-wide, longterm health sector development plans.

Finance

Manage all health sector development

funding.

Assist in all aspects of acquiring funding

for health sector development projects.

Establish long-term funding solutions.

Promote stability of the Afghan medical

community by developing economic

incentives.

Facilitate relationships with World Bank,

EU, and other international donors.

Ministry of

Interior

Liaison Officer

Ministry of

Public Health

Liaison Officer

Plans,

Programs, and

Operations

Finance

Public Health

Team

(not all

specialties

included)

European

Commission

Liaison Officer

UNAMA Liaison

Officer

USAID Liaison

Officer

Training

Disability Health

Benefits

Mental Health

Communicable

Disease/

Preventive

Medicine

Medical

Logistics/Health

Facilities

Planner

Public Nutrition

Child Health and

Immunizations

Maternal and

Newborn Health

JMC2E Surgeon/

USFOR-A Surgeon

Combat Health

Service Support

Function

Health Sector

Development

Cell

Figure 2. The proposed joint medical command and control element organization and structure for

Afghanistan.
April – June 2009 57

THE ARMY MEDICAL DEPARTMENT JOURNAL

would be responsible for nurturing relationships with

other agencies in Afghanistan and coordinating efforts

across organizations to amplify the effect of health

sector development efforts and initiatives. Given that

the US military will be in Afghanistan for an extended

period of time, the JMC2E is really a solution of 2 to 3

years in duration. A more robust organization,

designed around the concepts and principles described

in this paper, will have to be established to support an

enduring effort to develop the Afghan medical

infrastructure. Moreover, a sustainable economic

model with an entrepreneurship bent is a critical part

of the strategic direction needed to ensure the fiscal

viability of the health care system. Afghan medical

providers need economic security and incentives to

keep them from seeking opportunities in the United

States or abroad.

The time for action is now. Military participation in

health sector development is critical to nation building

efforts and any exit strategy. Lives, limbs, and

livelihoods of US Soldiers, Marines Sailors, and

Airmen, as well as those of our coalition partners and

the Afghan people hang in the balance.

ACKNOWLEDGMENT

The authors acknowledge the particular contributions

to the content and message of this article by the

following colleagues who were also serving and, in

some cases, continue to serve in Afghanistan:

CPT Kristy Linginfelter, SP, USAR, Surgeon/Physician

Assistant, 426th Civil Affairs Battalion

Lt Col Garry Feld, MSC, USAF, Deputy Commander

of Administration, Joint Task Force MED

Col Douglas Anderson, MSC, USAF, Lead Mentor,

CSTC-A Afghan National Police

CDR Evelyn Quattrone, NC, USN, Officer in Charge,

Cooperative Medical Assist Team

MAJ Maureen Nolen, AN, USA, Task Force MED J-5,

Plans and Programs

Lt Col Tamara Averett-Brauer, NC, USAF, Chief

Nurse, Task Force MED

We thank all of you for your insight, service, and

diligence in working to leave Afghanistan better than

you found it.

REFERENCES

1. Thompson DF. The role of medical diplomacy in

stabilizing Afghanistan. Def Horiz. May 2008;63.

2. Jones SG, Hilborne LH, Anthony CR, et al. Securing

Health: Lessons from Nation-Building Missions.

Santa Monica, CA: RAND Corporation; 2006. Available at: http://www.rand.org/pubs/monographs/2006/

RAND_MG321.pdf.

3. Emerging Challenges in Medical Stability Operations

White Paper. Norfolk, VA: US Joint Forces Command; October 4, 2007.

4. Afghanistan information page. United Nations Children’s Fund web site. Available at: http://www.unicef

.org/infobycountry/afghanistan_statistics.html.

5. Whitescarver HL, Hale TE. Presentation at Combined

Joint Task Force Surgeon’s Health Sector Development Conference; December 17, 2008; Bagram Air

Base, Afghanistan.

6. Joint Publication 1: Doctrine for the Armed Forces

of the United States. Washington, DC: Joint Staff, US

Dept of Defense; March 20, 2009 [ch 1]. Available

at: http://www.dtic.mil/doctrine/jel/new_pubs/

jp1.pdf.

7. CJTF-101 Chief of Staff Memorandum: Fiscal Year

2008 Resource Management Policy and Procedures.

July 1, 2008.

8. Roudebush JG. Medical readiness. Presentation to the

Military Personnel Subcommittee, Committee on

Armed Services, US House of Representatives,

Statement of Air Force Surgeon General, Lt Gen

James G. Roudebush; 8 May 2008; Washington, DC.

Available at: http://www.sg.af.mil/shared/media/docu

ment/AFD-070427-005.pdf.

AUTHORS

When this article was written, the coauthors were assigned

as follows:

Maj Brezinski was Plans and Programs Officer (J-5), Task

Force MED, Bagram Air Base, Afghanistan (Sept 2008-

Jan 2009).

Lt Col Edie-Korleski was Plans and Programs Officer (J5), Task Force MED, Bagram Air Base, Afghanistan (Jan

2009-July 2009).

CPT Durrani was the Senior Public Health Analyst, CJTF101, CJ-9, Bagram Air Base, Afghanistan.

Col Howard was the Deputy Commander, Craig Joint

Theatre Hospital, Bagram Air Base, Afghanistan.

COL Manansala was the Deputy Commander, CJTF-101,

Task Force MED, Bagram Air Base, Afghanistan.
58 https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1

Change is hard because people overestimate the

value of what they have—and underestimate the

value of what they may gain by giving that up.1

INTRODUCTION

Throughout military history, preservation of the health

of the force has been one of the greatest combat

multipliers. Sound preventive medicine (PM) mitigates

disease and nonbattle injuries and keeps the Soldier fit

to fight. In 2004, Army transformation began to

drastically change how PM support is provided to

combat units in the deployed environment.

The author experienced transformation of division PM

assets first hand when serving as the division

environmental science and engineering officer (ESEO)

in the Army’s last remaining main support battalion,

and then deploying to Multi-National Division North,

Iraq with the restructured 1st Armored Division

headquarters as the staff ESEO from September 2007

to December 2008. From a division staff officer

perspective, this article provides a description of how

force health protection for the ground Soldier was

more effectively delivered as a result of Army

transformation. Field commanders and medical

personnel at all levels should be aware of remaining

challenges and opportunities resulting from the

reorganization of PM assets across the operational

environment. The information presented here may also

serve as a useful after action review tool for any PM

Soldier that might potentially serve at the brigade

combat team or division level in a counterinsurgency

environment.

BACKGROUND

Prior to the Army Transformation in 2004, division

PM personnel who provided level II support were

colocated within the medical company of the main

support battalion. Modularization essentially

decentralized the division’s PM personnel. As

discussed by Ciesla,2this profoundly increased the

demand for ESEOs and placed a much greater

emphasis on force health protection. While the

previous model assigned one ESEO in support of an

entire division,3 modularization places an ESEO on the

division staff and one in each brigade combat team

(BCT).4

The 1st Armored Division served as the headquarters

for Task Force Iron during the Operation Iraqi

Freedom 07-09 rotation. Task Force Iron was

composed of more than 24,000 US service members

throughout northern Iraq, and included 4 brigade-sized

maneuver elements (BCTs*). The 3rd Armored

Cavalry Regiment had not yet transformed and was

assigned one preventive medicine specialist (staff

sergeant, military occupational specialty 68S30). The

other 3 brigades were modular in structure, and each

was assigned one ESEO and one PM specialist. With

the rapid expansion of base camps to accommodate

counterinsurgency operations in Mosul City, US

Soldiers lived and operated out of more than 90

different base camps across the division operational

environment. Base camps included contingency

operating bases, contingency operating sites, and

contingency operating locations which differed based

on the size and number of personnel supported. For

example, the largest, a contingency operating base,

may sustain between 20,000 and 25,000 personnel,

while a contingency operating location usually had no

more than a platoon of Soldiers on site.

CHALLENGES

Regarding his strategy of establishing joint security

stations in key locations, General Petraeus said “you

can't secure the people if you don't live with them.”5

Army Transformation and Level II Preventive

Medicine Within a Deployed Division Task

Force

MAJ Kenneth D. Spicer, MS, USA

*Throughout this article, brigade-sized maneuver elements are referred to as BCTs. They include infantry brigade combat team, heavy

brigade combat team, stryker brigade combat team, armored cavalry regiment, and stryker cavalry regiment. The Author
April – June 2009 59

Tactical dispersion of multiple, austere base camps in

urban areas required additional field sanitation and PM

support.

Level I PM - Field Sanitation Teams

Doctrine requires every company-sized unit to have

functional field sanitation teams (FSTs).6 Generally,

Task Force Iron BCTs with organic PM assets met the

FST requirement for each company. The ESEO and

PM specialist conducted predeployment training and

certification. Units’ FST personnel were tracked by

name and held responsible for conducting level I PM

in their respective operational environment.

Field sanitation teams were usually dysfunctional or

nonexistent at contingency operating locations where

small military, police, or border transition teams lived

and worked closely with Iraqi Security Forces in

extremely austere environments. Although basic field

sanitation is part of predeployment training, and team

medics receive a 2-hour block of instruction upon

arriving in theater, they typically do not receive the

comprehensive 40-hour FST certification course at

their respective home stations. As a result, organic

level I PM was not adequate at transition team sites,

especially at the beginning of a team’s deployment.

Healthcare specialists in the operational environment

should take ownership of this important responsibility.

In the current operational environment, medical

personnel bear the brunt of FST duties whether they

are FST trained or not. Current doctrine states that at

least one FST member must be a medic, if available.

This doctrine should be amended to mandate that all

medics fulfill FST duties. Further, initial training for

medics should be expanded to include detailed field

sanitation topics. With this training, the FST program

in a combat unit can be transitioned solely to medical

personnel.

Level II PM Teams – Stretched Thin

Even with acceptable level I FST support at the

majority of base camps, level II PM personnel

operated at maximum capacity for the duration of their

deployment. With a division operational environment

consisting of over 90 base camps, each of the 4

brigade PM teams covered an average of 23 sites. For

the modular BCTs with an ESEO and a PM specialist,

this was a daunting task. The job was virtually

impossible for the staff sergeant PM specialist who

was solely responsible for up to 25 sites in the 3rd

Armored Cavalry Regiment operational environment.

The goal was to conduct a monthly base camp

assessment of every site. Given the workload and

limited personnel, it was up to each level II PM team

to prioritize site assessments based on need, number of

personnel supported, and degree of contracted life

support. Small base camps in austere environments

usually had the greatest need. Larger contingency

operating sites and bases had many more personnel,

more contracted life-support functions, and overall

better field sanitation.

According to Army Field Manual 4-02.17,

7

Tactical dispersion places combat elements largely on

their own for PM self-protection; however, there are

opportunities for PM detachments to provide support in

these situations. The detachments must seek out such

opportunities and give priority to the combat

elements... Preventive medicine detachments provide

the most responsive support when they work directly

with units at the greatest risk.

Two PM detachments, each with a modified table of

organization and equipment* authorization of 13

Soldiers, provided level III support in the Task Force

Iron operational environment. They focused their

operations primarily on the highly populated logistical

hubs of Contingency Operating Base Speicher and

Joint Base Balad. After the rapid expansion of base

camps in Multi-National Division North, both of these

units stepped up and provided vital support to the Task

Force Iron BCT PM assets. Since the PM

detachments’ higher headquarters was the medical

brigade and not Task Force Iron, the division surgeon

coordinated with the MNC-I surgeon for PM support

from the medical brigade for 12 different base camps.

This synchronization of effort between BCT level II

PM and detachment level III PM paid tremendous

dividends.

Doctrinal change for the composition of BCT PM

assets is warranted in a time of persistent

counterinsurgency operations that involve multiple

dispersed base camps in harsh environments. Sames et

al8notes that a BCT PM team is composed of 2

relatively junior personnel. PM detachments will have

to continue to fill the gap by performing a level II PM

mission if no doctrinal change is made. The BCT

ESEO and PM specialist should be augmented with

another, more experienced PM specialist to ensure

more thorough base camp coverage. Alternatively, the

junior PM specialist could be replaced with a seasoned

*Defines the structure and equipment for a military organization or unit.
60 https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1

noncommissioned officer, significantly boosting the

experience level of the BCT PM team and helping to

facilitate practical, simple, and efficient solutions to

units’ field sanitation concerns.

PM Relationships with the Iraqi Security Forces

Helping others to help themselves is critical to winning

the long war.

9

Addressing field sanitation and general PM issues with

our Iraqi Security Force counterparts was a constant

challenge. The primary focus was issue resolution in

conjunction with Iraqi Security Force self-sustainability. Poor infrastructure, resource availability, and

cultural differences contributed to conditions that

occasionally threatened the health of Task Force Iron

personnel. Transition teams living on base camps

adjacent to Iraqi Security Force base camps were most

often affected. Examples include a burst main sewer

line and an entire sewer system that suddenly stopped

functioning due to lack of fuel for the generatorpowered lift stations. The BCT PM team identified the

immediate health threat from sewage overflow and

implemented basic personal protective measures

against vector-borne diseases.

The larger problems dealt with Iraqi Security Force

sustainability and prevention of similar incidents. Who

repairs the pipe? Who supplies gas for the generators?

With what money? How can the lift stations be

connected to the local grid so generator power is

unnecessary? The division ESEO collaborated with

other key staff sections such as division engineer (G7), logistics (G-4), and Iraqi Security Forces to facilitate long-term, self-sustainable solutions to problems

that had public health repercussions to Task Force Iron

personnel. This is a clear advantage resulting from

transformation and the division staff ESEO position.

OPPORTUNITIES

Modularity and the resulting reorganization of PM

personnel in BCTs and the division headquarters have

certainly provided new opportunities and allowed for

creative solutions to public health concerns in the

deployed environment.

Mobility

Traveling across the operational environment to

accomplish the PM mission was one of the greatest

hurdles to overcome. Travel by helicopter was limited

to hours of darkness, required extensive coordination,

was notoriously unreliable, and had limited space for

PM equipment. Ground convoy or combat logistics

patrols were used to conduct the majority of PM

missions. The location of the BCT PM team within the

brigade support battalion was ideal for coordination of

predictable and reliable travel to all base camps.

Force Protection Dogs

US Army 5th Corps General Order Number 1 (March

19, 2003) forbid the use or adoption of mascot

animals, but the prohibition was routinely ignored

throughout Iraq. Mascot dogs were present on

approximately 20% of the base camps throughout the

Task Force Iron operational environment. To address

the issue, all division ESEOs collaborated with the

MNC-I force health protection office and theater

veterinary officials to establish a force protection dog

program. The animal would no longer be classified a

mascot if it was:

 Employed as a legitimate force protection asset

(ie, patrolling, early warning, watch dog),

 Examined by a veterinarian and received a rabies

immunization, and

 Posted on official orders signed by the unit

commander. BCT PM teams facilitated the success

of this effort by assisting with transportation of

veterinary assets and maintaining accountability of

compliant versus noncompliant animals in their

respective operational environments. Over 40 dogs

in Multi-National Division North were part of the

program, which ultimately allowed the unit to

keep the animal for a legitimate purpose while

mitigating the associated health risk.

Division Force Protection Working Group

The division ESEO served as the surgeon cell

representative on the force protection working group.

Other team members included senior

noncommissioned officers and officers from the G-7,

safety, and provost marshal cells. Focusing on the

smaller base camps more vulnerable to enemy action

and field sanitation issues, team members personally

visited 95% of all contingency operating sites and

contingency operating locations in the Task Force Iron

operational environment. This was an excellent chance

to redefine traditional force protection that focuses on

barriers and concertina wire. Incorporating force

Army Transformation and Level II Preventive Medicine within a Deployed Division Task Force
April – June 2009 61

THE ARMY MEDICAL DEPARTMENT JOURNAL

health protection, specifically preventive medicine,

into this division-level working group accomplished 4

significant objectives:

 Inserted a medical aspect into protecting the force

and keeping Soldiers in the fight. This combat

multiplier demonstrated to the Warfighter that

medical authorities bring more than traditional

patient evacuation and treatment to the fight.

 Increased command emphasis of preventive

medicine issues and the willingness to follow

through with BCT PM team recommendations.

Unit leaders on the ground were more receptive to

a division-level assessment team with an ESEO

(rank of Major) conducting a PM assessment. The

division commander provided command emphasis

at the highest level when he directed that all

recently completed PM assessments and

outstanding issues be briefed at the weekly battle

update assessment. This truly put PM at the

forefront and facilitated the BCT PM team

mission.

 Allowed the division ESEO to travel throughout the

entire operational environment [a rare opportunity

for division staff officers] and really understand

issues the BCT PM teams were facing. The junior

BCT ESEOs, most of whom had less than a year

of service in the Army, accompanied the force

protection working group team when possible.

They were able to receive face-to-face instruction

and mentoring from a more seasoned ESEO.

 Facilitated the quality of life working group, a

chaplain-led initiative to improve the general living

conditions at small and austere base camps.

Effective PM is a key component of force

protection, as well as an important piece of the

Soldier’s quality of life.

CONCLUSION

The practice of PM operations in a counterinsurgency

environment remains very complex and is constantly

changing. Innovative and more efficient solutions to

PM concerns are always needed in the operational

environment. Army transformation has certainly

helped deliver better PM support to Soldiers on the

ground. The decentralization of PM personnel,

increased number of ESEOs, and addition of a field

grade staff ESEO in today’s modularized division has

paid tremendous dividends. In spite of these gains, the

suggested doctrinal and personnel changes must be

considered for optimal force health protection on

today’s nonlinear battlefield.

REFERENCES

1. Belasco JA, Stayer RC. Flight of the Buffalo: Soaring

to Excellence, Learning to Let Employees Lead. New

York, NY: Grand Central Publishing; 1994.

2. Ciesla JJ. The evolving role of environmental science

officers and environmental engineers in the Medical

Service Corps. Army Med Dept J. April-June

2006:20.

3. Field Manual 4-02.6: The Medical Company.

Washington, DC: US Dept of the Army; 1 August

2002:3-7.

4. Division / Brigade Combat Team Modified Table of

Organization and Equipment Authorizations. United

States Army Force Management Support Agency,

Force Management System web site [Restricted

access document]. Available at: https://webtaads.bel

voir.army.mil/protected/WebTAADS/Frame_Doc

Types.asp?GUID=1247913902.

5. Petraeus DH. Interview [transcript]. British

Broadcasting Corporation. September 11, 2008.

Available at: http://news.bbc.co.uk/2/hi/middle_east/

7610405.stm.

6. Army Regulation 40-5: Preventive Medicine.

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

2007:4.

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

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

2000:p4-3.

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

medicine: challenges for the future. Army Med Dept

J. April-June 2006:40-45.

9. Office of the Secretary of Defense. Quadrennial

Defense Review Report. Washington, DC: US Dept of

Defense; February 6, 2006.

AUTHOR

MAJ Spicer is the Division Environmental Science and

Engineering Officer for Headquarters, First Armored

Division, Wiesbaden, Germany.
62 https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1

BACKGROUND

In support of Operation Iraqi Freedom (OIF) 06-08, a

brigade combat team (BCT) assigned to MultiNational Division-Center was located in central Iraq,

southwest of Baghdad. The BCT’s operational

environment consisted mostly of rural farmlands and

villages. Fertile farmland and vegetation was relatively

prevalent throughout the area due to the proximity of

the Euphrates River, which supplies farms with water

through irrigation canals. The irrigation canals

historically have been vital to the livelihood of those

who live in the area. The Common Reed (Phragmites

australis) and the Giant Reed (Arundo donax) grow

along roadsides adjacent to these irrigation canals.1

Many of the primary and secondary canals parallel

roads used as alternate supply routes by coalition

forces to conduct patrol missions. Improvised

explosive devices (IEDs) were the primary casualtyproducing weapons of choice for insurgents against

coalition forces during OIF 06-08. The majority of

casualties occurred during mounted operations when

Soldiers were traveling in armored vehicles along

roads throughout the country. As shown in Figures 1

and 2, the reeds (14 to 20 feet tall in stands up to 30

feet wide) grow along the roadsides creating an alleylike effect that provides excellent concealment for

insurgents to emplace and detonate IEDs with minimal

risk of being observed, thus creating easy access and

evasion routes. The reeds conceal IEDs from early

detection by mounted patrols and also create limited

visibility and fields of fire around rural combat

outposts and patrol bases.

The increased IED risk associated with the vegetation

was a constant critical threat to the BCT during

counterinsurgency operations, especially during the

establishment and support of remote patrol bases. As a

result, removal of the reeds was a high priority for

commanders throughout the BCT. The necessity for

vegetation control along rural routes will likely remain

for future counterinsurgency operations and theaters of

conflict.

TARGET SPECIES

Control of the vegetation along the rural routes

throughout the BCT’s operational environment was

targeted primarily towards 2 specific reed species.

Understanding the reproductive physiology of these

target species is critical to implementing effective

control measures.

The target reed species common to the central marshes

in Iraq are Phragmites australis and Arundo donax.

1

They are large, perennial, rhizomatous grasses that are

found on every continent except Antarctica and may

have the widest distribution of any flowering plant.2

The reeds are common in and near freshwater and

brackish wetlands throughout the world’s temperate

zones. The reeds have a great affinity for growth along

railroad tracks, roadside ditches, and slight depressions

holding water, as they thrive through extensive water

uptake. These perennials are known to live for three to

six years.3

The reeds are typically the dominant species where

they exist through formation of robust monocultures.

They are capable of vigorous vegetative reproduction

through underground rhizomes and often form dense,

monospecific stands which can be over 30 feet in

diameter. The plants generally flower and set seed

between July and October.3 Despite the large

quantities of seeds produced, most are not viable.

Underground rhizomes are the primary means of

reproduction. Following maturity and seed set, the

majority of the nutrients are translocated back into the

rhizomes (up to 6 feet in depth) and the aboveground

portions of the plant die back for the dormant season.2

In Iraq, nutrient translocation was observed to occur

approximately in late November, with new, aboveground growth appearing in mid-March. As the

Control of Concealing Vegetation Along

Rural Routes in Iraq

CPT Dennis M. Rufolo, MS, USA

MAJ Rebecca A. Zinnante, MS, USA

CPT Ryan Bible, MS, USA
April – June 2009 63

nutrients translocate underground, the dead vegetation

remains standing until the next growing season,

providing year-round concealment.

VEGETATION CONTROL MEASURES IN OPERATION IRAQI

FREEDOM 06-08

Throughout the overlapping periods that the authors

were individually deployed to Iraq (September 2006 to

June 2008), maneuver commanders considered the

reeds to be a direct threat to Soldiers’ lives, and took

considerable measures to control them. Three methods

of vegetation removal were used in the operating

environment during this time frame: controlled

burning, mechanical removal using roadside flail

mowers, and manual removal by contracted local

nationals.

The primary method of reed removal along alternate

supply routes (ASRs) was through controlled burns

conducted by military personnel as shown in Figure 3.

Soldier safety was of paramount concern during the

burn operations, and a division level safety standard

operating procedure was created and implemented

specifically for the controlled burn mission. Due to the

high water content of the vegetation, the addition of an

external fuel source was required to initiate and sustain

the burn. The external fuel source usually consisted of

a combination of JP-8 (aviation fuel) and gasoline,

which was sprayed on the reeds prior to ignition. This

method was very effective for short term control, but

was ineffective for sustained removal. Burning alone

does not reduce the growth of reeds unless the roots

burn, which seldom occurs because the rhizomes are

usually covered by a layer of soil, mud, and/or water.4

Reed burns conducted at times other than late summer

(when the majority of the plant’s nutrients were above

ground) resulted in reemerging stands with greater

population densities.5 Ultimately, due to the inability

of the controlled burns to destroy the reeds’ rhizomes,

repetitive burning missions over the same ASRs were

necessary throughout the deployment.

Mechanical removal through cutting or mowing is

another method of suppressing reed growth, but it is

critical to perform the cut during the peak growing

season in order to have a significant impact on

reemergence of the reeds. The optimal time for

mechanical removal is when most of the nutrient

reserves are in the aerial portion of the plant, reducing

its vigor upon cutting. Improper timing may increase

stand density.6 As shown in Figure 4, the BCT

operated flail mowers (nicknamed Razorbacks) that

were mounted on armored trucks which allowed

roadside cutting up to 15 feet from the base of the

mower. This technique allowed Soldiers to remain

within the armored vehicles while cutting reeds, but

the equipment and technique received mixed reviews

Figure 1. A typical example of the dense vegetation growth, including the Common Reed (Phragmites

australis) and the Giant Reed (Arundo donax), along Iraq roadsides, which affords excellent concealment

for insurgents to emplace and detonate roadside bombs.
64 https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1

from brigade support battalion and forward support

company Soldiers with regard to its effectiveness.

Repetitive missions over the same rural roadsides were

again required throughout the deployment due to the

lack of rhizome destruction.

Utilizing contracted local national workers for the

manual removal of the roadside vegetation adjacent to

their villages did not result in effective control. Using

machetes and/or “weed whackers,” the workers

attempted to remove the reeds from the roadsides. This

method was much more time consuming than

initially anticipated, and posed an increased

threat to the workers’ physical well-being by

those who used the reeds for IED

concealment. The extended duration of initial

removal was compounded again by the need

for repetitive missions due to lack of rhizome

destruction.

PROPOSED CHEMICAL VEGETATION CONTROL

METHOD

Implementing a chemical vegetation control

method in conjunction with physical removal

methods mentioned above could help control

reed growth throughout the reeds’ active

growing season and improve route security.

Use of a US Environmental Protection

Agency (EPA) approved herbicide that

targets plants and is relatively nontoxic to humans and

fish minimizes the risk to the local nationals and the

environment of Iraq. The immediate benefit associated

with this method towards the direct protection of

human health from IEDs outweighs the relatively

minor risk of any environmental impact potentially

associated with elimination of this riparian zone

vegetation. Procurement of the appropriate spray

equipment could allow units to treat roadsides with

chemical herbicides quickly under the supervision of

Department of Defense (DoD) certified pesticide

applicators, while reducing their exposure to enemy

contact. However, presidential approval or an

exception to policy of Executive Order 11850 7is

required prior to the implementation of any method

using herbicides.

The proposed technique for reed removal along rural

routes is the implementation of an herbicide

application method through use of a DoD approved

pesticide and a right-of-way spraying system for the

sustained control of reeds. The 2 necessary chemical

components for the proposed chemical vegetation

control method are an herbicide and a surfactant. The

herbicide should be nonpersistent, nonselective, watersoluble, and designed to control the growth of

herbaceous and woody plants. A surfactant is a

combination wetting agent, activator, and penetrator;

its mode of action breaks down the waxy cuticle on

leaf surfaces, allowing herbicide penetration into the

conductive tissue. The herbicide then flows throughout

the plant (most importantly to the underground

Control of Concealing Vegetation Along Rural Routes in Iraq

Figure 2. Another example of dense reed growth

alongside a rural road in Iraq.

Figure 3. Controlled burn of roadside reed growth using an

external fuel source.
April – June 2009 65

THE ARMY MEDICAL DEPARTMENT JOURNAL

rhizomes and roots) for permanent destruction. Both

chemicals are designed to biodegrade quickly and

completely into CO2, N, H2O, and phosphates, resulting in little to no persistent effects on the environment.

For chemical dispersal along the ASRs, use of a rightof-way spraying system, such as those commonly used

in the United States by state-level departments of

agriculture and transportation, is recommended. These

systems are built on steel frames and can be mounted

easily on an armored military truck. Boomless

hydraulic sprayers (10- to 30-ft spray distance) are

controlled using an instrument panel inside the vehicle,

affording maximum protection to Soldiers from direct

fire and IEDs. Sprayers are powered by an internal

engine and have attached polyethylene storage tanks,

allowing up to a 500 gal capacity with jet agitation,

which permits adequate treatment of long routes

without the necessity to stop and remix. Additionally,

300-ft hoses with retractable reels are available to

allow dismounted spraying around walls, fences, etc.

Optimal application within the vehicle can occur at

speeds of 7 to 10 mph, which is comparable to speeds

typically used to travel along the edges of these roads

allowing vigilance for signs of IEDs.

The combination of a controlled burn without an

external fuel source following herbicide application, or

roadside mowing prior to herbicide dispersal, could be

effective in sustained reed removal along roadsides. A

combination of prescribed burning after chemical

treatment was reportedly successful along the east

coast of the United States.4,8 The proposed chemical

vegetation control method potentially could be

effective in persistent reed removal along roadsides

and would pose minimal negative impact to the host

nation. When considering the use of chemical methods

for vegetation control, the potential environmental

impact within local regions must be a factor of

consideration, compared with the currently used

methods.

Use of the above proposed chemical vegetation control

method by the US military is restricted by Executive

Order 11850: Renunciation of Certain Uses in War of

Chemical Herbicides and Riot Control Agents, enacted

on 8 April 1975, by President Gerald Ford. The

following is an excerpt from Executive Order 11850:

The United States renounces, as a matter of national

policy, first use of herbicides in war except use, under

regulations applicable to their domestic use, for control

of vegetation within US bases and installations or

around their immediate defensive perimeters.... The

Secretary of Defense shall take all necessary measures

to ensure that the use by the Armed Forces of the

United States of...chemical herbicides in war is

prohibited unless such use has Presidential approval, in

advance.7

Therefore, the ability to use commercially available,

EPA-approved herbicides to mitigate the threat to

US forces by improving the detection of IEDs along

the rural roadways of Iraq is impeded by Executive

Order 11850, issued 34 years ago.

In the aftermath of the attacks within the United

States on September 11, 2001, and the start of the

Global War on Terrorism, the nature of military

operations has changed significantly for US forces.

The primary threat towards Soldiers deployed to the

US Central Command area of operations is not

direct attacks on their defensive perimeters (where

Executive Order 11850 allows the use of herbicides

to reduce concealment), but rather through attacks

on mounted patrols and convoys, and by IEDs

emplaced along roadways. Due to the limitations

placed on effective vegetation control by EO 11850,

it is imperative that a review of EO 11850 be

conducted to obtain either an exemption for the

chemical control methods discussed above, or

presidential approval for their use during current

contingency operations. An exception to policy or

specific presidential approval may increase the ability

to effectively control vegetation along these roadways

in order to increase force protection for the Soldiers.

Figure 4. Flail mower mounted on an armored truck.
66 https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1

CONCLUSION

Due to the global presence of Phragmites australis,

Arundo donax and related species, there is potential for

the situation presented herein to remain a recurring

threat to deployed Soldiers as counterinsurgency

operations continue throughout the world. The

environmental science and engineering officers,

working in conjunction with entomologists in theater,

have the ability to assist commanders counter this

threat by implementing measures that would minimize

concealment of IEDs and those who emplace them,

thereby mitigating the risk to Soldiers. Force health

protection personnel possess the tools necessary to aid

commanders in reducing the vegetation associated risk

through use of an environmental management

alternative, but only if exception from Executive Order

11850 is obtained.

Controlling the vegetation will dramatically improve

visibility along roadways, enhancing Soldiers’ ability

to better identify the IEDs prior to detonation. Better

visibility and identification of IEDs along roadways

will likely save Soldiers’ lives.

Control of Concealing Vegetation Along Rural Routes in Iraq

REFERENCES

1. Bailey P. Fact Sheet on Vegetation of the Tigris and Euphrates Rivers and Associated Marshland. Washington, DC:

US Army Engineer Research and Development Center; February 2007.

2. Batterson TR, Hall DW. Common Reed-Phragmites australis (Cav.) Trin. ex Steudel. Aquatics. 1984;6:16-20.

3. Written Findings of the State Noxious Weed Control Board. Olympia, WA: Washington State Noxious Weed

Control Board; 2003. Available at: http://www.nwcb.wa.gov/weed_info/Phragmites_australis.html.

4. Beall DL. Brigantine Division - Marsh Vegetation Rehabilitation - Chemical Control of Phragmites. Unpublished

report by US Fish and Wildlife Service; Oceanville, New Jersey. 1984.

5. Cross DH, Fleming KL. Control of Phragmites or Common Reed. Fish and Wildlife Leaflet 13.4.12. Washington,

DC: US Dept of the Interior, Fish and Wildlife Service; 1989. Available at: http://www.nwrc.usgs.gov/wdb/pub/

wmh/13_4_12.pdf.

6. Osterbrock AJ. Phragmites australis, the problem and potential solutions. Cincinnati, OH: Ohio Field Office,

Stewardship; 1984.

7. Executive Order 11850. Renunciation of Certain Uses in War of Chemical Herbicides and Riot Control Agents.

Office of the Federal Register; April 1975. Available at: http://www.archives.gov/federal-register/codification/

executive-order/11850.html.

8. Lehman WC. Project Benchmark: Ecological Factors Governing Growth of Phragmites and Preliminary

Investigations of Phragmites Control with Glyphosate. Dover, DE: Delaware Division of Fish and Wildlife; 1984.

AUTHORS

CPT Rufolo is a project officer, Environmental Health Engineering Division, US Army Center for Health Promotion

and Preventive Medicine-West, Fort Lewis, Washington. Previously he was the Environmental Science Officer, 2nd

Brigade Combat Team, 10th Mountain Division deployed to southwest Baghdad from September 2006 to November

2007.

MAJ Zinnante is currently attending resident intermediate level education at Fort Leavenworth, KS. Previously she was

the Environmental Science Officer assigned to Headquarters Company, 1st Cavalry Division, Fort Hood, Texas. She

deployed to the Multi-National Division-Baghdad from October 2006 to February 2007.

CPT Bible is currently enrolled in the University of Washington’s Masters of Public Health program. Previously, he

was the Task Force Marne (3d Infantry Division) Environmental Science Officer for Multi-National Division-Center,

Baghdad, Iraq, from March 2007 to June 2008.
April – June 2009 67

INTRODUCTION

The Army Hearing Program (AHP) is evolving from

its predecessor, the Army Hearing Conservation

Program (AHCP). The AHP strives to prevent noise–

induced hearing loss during training and deployment

operations without compromising combat effectiveness. In contrast, the older AHCP is a garrison-based

model which worked well in peacetime, but fell short

of the mark with the onset of Operations Enduring

Freedom and Iraqi Freedom.1 The failures of the

garrison-based AHCP were well-documented by

Helfer et al2 who investigated the rates of noiseinduced hearing loss among several audiology clinics

in military treatment facilities across the Army. They

found that Soldiers who had deployed to a combat

zone showed exponentially higher rates of noiseinduced hearing loss, acoustic trauma, permanent

threshold shift, tinnitus, eardrum perforation, and H3

or H4 profile (defined in Table 1) compared to those

who had not deployed. In accordance with Army

Regulation 600-60,

3

Soldiers with H3 and H4 hearing

profiles are nondeployable pending adjudication by a

retention board.3(p8) Often, it is senior noncommissioned officers with prior combat experience who

are reassigned to a non-noise-hazardous military

occupational specialty (MOS) or separated from the

Army because of their H3 or H4 profile. Thus, a

largely preventable, noise-induced hearing loss

deprives the Army of invaluable leadership for junior

Soldiers with less (or no) combat experience. Our

national security depends on having well-trained

Soldiers on the battlefield, and that is why the Army

Hearing Program’s growth, and growing pains, have

involved much more than a name change.

The US Army Medical Command (MEDCOM)

Automated Staffing Assessment Model for Preventive

Medicine (ASAM PM) currently recommends one

Army audiologist and 2.5 audiology technicians for

every 18,000 Soldiers as a minimum staffing model.5

The ASAM PM model reflects the garrison-based

AHCP, and is not compatible with the operational

hearing services requirements of the new Army

Hearing Program. In January 2008, Fort Carson

received authorization for a second Army audiologist

in preventive medicine as part of the AHP pilot study

authorized by the MEDCOM Chief of Staff. This gave

us a ratio of 2 Army audiologists and 5 audiometric/

hearing health technicians for our approximately

18,500 Soldiers organic to Fort Carson (double what

the current ASAM PM model recommends). The

metrics presented in the following sections show that

the latter ratio resulted in a higher number of Soldiers

fit for deployment and a decrease in the amount of

hearing loss at Fort Carson within units engaged in

combat operations over the last calendar year. The data

demonstrates how the ASAM PM model must evolve

along with the new Army Hearing Program.

THE ARMY HEARING PROGRAM AT FORT CARSON

Fort Carson, located in Colorado Springs, Colorado, is

quickly growing into one of the Army’s largest Army

Forces Command bases. Fort Carson currently has a

population of approximately 18,500 Soldiers in

garrison. Fort Carson’s Soldier population is expected

to grow to 29,000 by the year 2011 with the addition

of 2 more brigade-sized elements. Fort Carson is also a

primary projection platform: in addition to our own

organic units, hundreds more Soldiers from the Army

National Guard and from the Army Reserves are

activated and demobilized from their deployments

throughout the United States, Europe, and the middle

Fort Carson: An Army Hearing Program

Success Story

CPT Leanne Cleveland, MS, USA

Table 1. Army Hearing Profiles 4(p80)

H1

Audiometer average level for each ear not more than 25 dB

at 500, 1000, 2000 Hz with no individual level greater than

30 dB. Not over 45 dB at 4000 Hz.

H2

Audiometer average level for each ear at 500, 1000, 2000

Hz, or not more than 30 dB, with no individual level greater

than 35 dB at these frequencies, and level not more than 55

dB at 4000 Hz; or audiometer level 30 dB at 500 Hz, 25 dB

at 1000 and 2000 Hz, and 35 dB at 4000 Hz in better ear.

(Poorer ear may be deaf.)

H3

Speech reception threshold in best ear not greater than 30

dB HL, measured with or without hearing aid; or acute or

chronic ear disease.

H4 Functional level below H3
68 https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1

east every year at the Fort Carson Soldier Readiness

Processing Center.

As part of the drastic Army-wide military to civilian

conversion of audiologist authorizations in the late

1990s and early 2000s, the Army audiologist authorization at Fort Carson disappeared in 2002, concurrent

with the onset of Operations Enduring Freedom

(October 2001) and Iraqi Freedom (March 2003).

Figure 1 shows that in 2003, the Fort Carson annual

(permanent) significant threshold shift [a metric

detailed on page 70] rate jumped from 12% to 16%.

This reflects the large number of Soldiers who

redeployed to Fort Carson from combat theaters with

hearing loss. In June 2006, the authorization for an

Army audiologist was reinstated under the Department

of Preventive Medicine, and the Army Hearing

Program was implemented.

Consider for a moment why the current ASAM PM

staffing model is impractical. The high number of

Soldiers requiring clinical hearing services (diagnostic

audiological evaluations) would prevent a sole

audiologist from ever leaving the clinic. This means

that there is no time available for the single audiologist

to train medics and other noise-exposed military

personnel on earplug fittings, no time to conduct

annual hearing health briefings, and no time for

inspections of noise hazardous areas. When preventive

efforts are incomplete or nonexistent, the rates of

hearing loss will perpetuate, which will further prevent

the audiologist from working outside of the clinical

demands.

Four elements comprise the Army Hearing Program:

 Hearing readiness

 Clinical hearing services

 Operational hearing services

 Hearing conservation

Although each element is distinct, the failure of one

area will have a direct influence on the other three. A

detailed explanation of the Army Hearing Program can

be found in Special Text 4-02.501: Army Hearing

Program.

6

HEARING READINESS

Hearing readiness implies that Soldiers have the

required hearing capabilities, personal protective

equipment, and medical equipment for deployment to

a combat zone. Required hearing capabilities are set by

Army Regulation 40-501.

4

Soldiers with H1 or H2

hearing profile (defined in Table 1)

are deployable, provided there is no

significant, underlying pathology of

the outer, middle, or inner ear.

Every Soldier on Fort Carson is

required to take an annual hearing

test, a predeployment hearing test, and

a postdeployment hearing test using

the Defense Occupational and

Environmental Health Readiness

System–Hearing Conservation

(DOEHRS-HC) audiometers. The

DOEHRS-HC hearing profile data

feeds into the Army Medical

Department Medical Protection

System (MEDPROS) medical

readiness database, which assigns a

hearing readiness (HR) category (defined in Table 1)

to each Soldier ranging from Class I to Class IV as

shown in Table 2.

The Fort Carson Hearing Program (FCHP) tracks the

HR status for all Soldiers on a monthly basis. Figure 2

illustrates 3 important facts:

 The hearing readiness “GO” rate has increased

steadily since the addition of a second Army

audiologist in January 2008.

 The number of Soldiers who are nondeployable

(“NO-GO”) due to hearing loss has steadily

decreased.

Fort Carson: An Army Hearing Program Success Story

Figure 1. Percentage of tested Fort Carson Soldiers with significant threshold

shift (STS) for the years 2000 through 2007.

Note: Numbers in parentheses – (number demonstrating STS/total number tested)
April – June 2009 69

THE ARMY MEDICAL DEPARTMENT JOURNAL

 The population of Fort Carson has

increased by almost 3000 Soldiers

from June 2007 (16,722) to

December 2008 (19,140).

Compare this to Figure 1. In 2000,

only 5,075 of Fort Carson’s Soldiers

received a DOEHRS-HC hearing test

and earplug fitting. That number has

nearly quadrupled in 8 years as a

result of the HR category on

MEDPROS.

Our goal is to continue to maintain a

minimum of 80% of Fort Carson

Soldiers at HR Class I or II. Looking

at Figure 2, note how it appears we

fell short of our goal of an 80% GO

rate from August to November 2007.

These numbers represent the Soldiers

from the 2nd Infantry Division who

were deployed in support of Operation

Iraqi Freedom for 15 months. MEDPROS

automatically identified many of those Soldiers as

Hearing Readiness Class IV because they were

overdue for their annual (12-month) hearing test. The

next version of DOEHRS-HC will include an

algorithm that takes into consideration the 15-month

deployment cycle.

The FCHP emphasizes the importance of appropriate

earplug fitting by qualified medical personnel

at the Hearing Readiness Section, located at

the Soldier Readiness Processing Center.

Every Soldier seen for a hearing test is

required to show their earplugs and

demonstrate knowledge on how to properly

insert them. If the Soldier does not bring

earplugs with them on the day of testing, they

are refitted by the hearing readiness

audiology technicians at that time. The

flowchart in Figure 3 illustrates the main

processes followed by the hearing readiness

staff at Fort Carson.

CLINICAL HEARING SERVICES

Clinical hearing services are required in both

garrison and deployed settings. Although

there is some overlap, the variance in services

delivered between these 2 environments is

operationally driven: In garrison, comprehensive

diagnostic audiological services are provided to

Soldiers in HR Class III and IV status. Diagnostic

audiology services include fitness for duty evaluations,

hearing profiles for readiness, speech recognition in

noise tests for Soldiers with H3 hearing profile,

significant threshold shift follow-up, acoustic trauma

injuries, and difficult to test patients (including

Soldiers who attempt to feign or exaggerate hearing

loss).

Figure 2. The monthly hearing readiness status of the Soldier population of

Fort Carson for 2008.

Note: Number in parentheses is total number of Soldiers on Fort Carson as shown in the

MEDPROS database.

Table 2. Army Hearing Readiness Categories4(p114)

CLASS I Soldier’s unaided hearing is within H1 standards for both ears. No

corrective action is required.

CLASS II

Soldier’s unaided hearing is within H2 or H3 standards. Soldier

has a current hearing profile assigned (H2 or H3), and a

completed Military Occupational Specialty Medical Retention

Board (H3) with no active middle ear disease or medical

pathology in the ear. If a Soldier wears hearing aids, he must

have hearing aids appropriate for hearing loss and a six month

supply of batteries. No corrective action is required.

CLASS III

Soldier’s unaided hearing is within H2 or H3 standards. Soldier

has a current hearing profile assigned (H2 or H3), and a

completed Military Occupational Specialty Medical Retention

Board (H3) with no active middle ear disease or medical

pathology in the ear. If a Soldier wears hearing aids, he must

have hearing aids appropriate for hearing loss and a 6-month

supply of batteries. No corrective action is required.

CLASS IV

Soldiers who do not have a DOEHRS-HC audiogram in their

medical record within one year. Soldier requires a hearing

examination. This includes Soldiers without a reference baseline

audiogram or whose last periodic audiogram is greater than oneyear old. Hearing readiness classification is unknown.
70 https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1

In deployed settings, hearing injury treatment services

may be provided within the confines of the combat

support hospital. The primary purpose of diagnostic

hearing care in theater is to determine a Soldier’s

fitness for duty status and to ensure that only Soldiers

in need of advanced audiological care are evacuated

out of theater.

The significant threshold shift (STS) criteria is a

familiar metric used to document trends over time, and

we believed it to be the most appropriate tool to

evaluate hearing loss trends and our clinical hearing

services at Fort Carson. STS is calculated by averaging

the patient’s hearing thresholds at 2000 Hz, 3000 Hz

and 4000 Hz. If the change from the reference

(baseline) audiogram is greater than or equal to +10

dB, a positive STS is recorded.

Referring to Figure 1, note that the Fort Carson STS

rate in 2002 was equivalent to the Army average STS

rate of 12%. In 2003, the STS rate increased to 16%.

We believe the increase is the result of 2 factors:

 The initial group of Soldiers who were deployed to

the first cycle of Operation Iraqi Freedom did so

without the combat arms earplugs which are

currently a rapid field initiative issue to all

deploying Soldiers. The combat arms earplugs

(CAE) allow low level sounds such as speech to

pass through unimpeded. The nonlinear filter in

the CAE dampens high level impulse noise such as

weapons fire. As with all earplugs, proper size and

fit are crucial. During the initial deployments for

the global war on terror, the CAE and

conventional earplugs for Soldiers were often not

available, not wanted, or not fitted properly, which

resulted in the dramatic STS increase in 2003.

 The elimination of the Army audiologist’s

authorization from Fort Carson in 2002 resulted in

the abandonment of key concepts, such as hearing

loss prevention education and the emphasis on

hearing protection devices and their proper use.

Generation of relative value units (RVUs) in a

clinical audiology setting was the only outcome

measure used by the command at that time.

Figure 1 also shows how the Fort Carson Soldier STS

rate decreased to 10% (on average) during calendar

year 2007. Figure 4 shows a breakdown of calendar

year 2008 and a current average STS rate of less than

11%. This represents the lowest rate of STS on Fort

Fort Carson: An Army Hearing Program Success Story

Figure 3. The hearing readiness screening process for all Fort Carson Soldiers as implemented by the Fort Carson

Hearing Program.

Notes:

For all cases of Soldiers reporting acute hearing loss, or suspected active pathology (TM perforation or bulging TM, or suspected malingering), contact the

military audiologist at the Hearing Readiness Clinic to book an appointment so that the condition can be confirmed.

ALL SOLDIERS MUST come through Hearing Readiness first. The HR technicians will refer to the Army Audiologists if required.

DO NOT book Soldier appointments with the civilian Audiologist in the ENT clinic.

DO NOT book a Soldier appointment with an ENT physician without going through Hearing Readiness first.

Check in at Hearing

Readiness Section/

Soldier Readiness

Processing Center

1042 O’Connell Drive

Otoscopic Exam Fit Earplugs

Does Soldier have

a current hearing

test/profile/MMRB

on record?

Yes

Yes

No

DOEHRS-HC audiogram

at Hearing Readiness

Section, Soldier

Readiness Processing

Center

Update MEDPROS and

DOEHRS DR, counsel on

hearing protection, clear

Soldier for deployment,

PCS, or retirement

H1? STS?

Appointment with clinical

(Army) audiologist at

Hearing Readiness

Section, Soldier

Readiness Processing

Center (not ENT clinic!!)

Yes No

No

Update MEDPROS &

DOEHRS DR, counsel on

hearing protection, clear

Soldier for deployment,

PCS, or retirement

Yes

Send for ear flush

and cleaning

No

Ear canals

clear?
April – June 2009 71

THE ARMY MEDICAL DEPARTMENT JOURNAL

Carson since the year 2000 when we were a peacetime

Army. The high STS rates in August 2008 (14%) and

in December 2008 (15%) are outliers, and reflect a

lack of compliance with the hearing program for 2

units undergoing predeployment hearing readiness

evaluations compared to similar units at Fort Carson.

Even with the outliers, however, the data in Figure 4

demonstrates that the implementation of the Army

Hearing Program at Fort Carson has reduced the

Soldiers’ overall STS rate to less than 11% during a

period of continuous active combat

deployments. Eliminating the 2

outliers from the post average puts

the rest of Fort Carson’s STS rate at

less than 10%.

A civilian audiologist works in the

Ear, Nose and Throat (ENT) Clinic as

part of the Fort Carson Hearing

Program. The civilian audiologist’s

main role is to provide diagnostic

audiology services to TRICARE*

eligible family members, dependents

and retirees. Under the Army Hearing

Program at Fort Carson, the civilian

audiologist only sees Soldiers who

are referred by one of the active duty

Army audiologists, or by one of the

ENT physicians. The civilian audiologist’s

responsibilities for Soldier care include clinical

rehabilitative services (such as dispensing hearing

aids), or advanced clinical testing (including

electrophysiological tests and vestibular tests). The

civilian audiologist also runs the newborn hearing

screening program in the hospital and provides

diagnostic and rehabilitative care for TRICARE

eligible family members.

It is crucial to distinguish the very different role that

the civilian clinical audiologist in the ENT or

department of surgery has from the active duty Army

audiologist (aligned under the department of

preventive medicine). Those audiologists’ roles are

entirely clinical and rehabilitative in nature, and their

patient population consists primarily of civilians.

Conversely, the active duty preventive medicine

audiologist’s role is only 50% clinical in nature. The

other 50% of the time is preventive and spent outside

of the clinic, involved in education and site

inspections. Their primary mission is the prevention of

noise-induced hearing loss and the improvement of

hearing readiness, in the hope that a hearing aid is not

required for as many Soldiers in the future. The

preventive medicine audiologist’s patient population

consists almost entirely of Soldiers. Figure 5 illustrates

the different clinical hearing services missions of the

preventive medicine (active duty) and the ENT

(civilian) diagnostic, clinical, and rehabilitative care.

OPERATIONAL HEARING SERVICES

We believe the reduced STS rate at Fort Carson is a

direct result of our focus on operational hearing

services in the Fort Carson Hearing Program. The

primary objective of operational hearing services is the

enhancement of Soldier survivability. Hearing is a

critical sense that directly affects mission success. The

ability to hear in a combat environment is critical

because normal hearing allows a Soldier to detect the

enemy and maintain effective communication ability

and situational awareness in noise. Operational hearing

services include education and instruction in tactical

communication and protection systems (TCAPS),

noise surveillance of hazardous and nuisance noise

environments, guidance on noise abatement and

control, and emphasis on prevention of hearing injuries

through education and readiness to maximize the

warfighter lethality and survivability on the battlefield,

without compromising communication and situational

awareness. Commanders enhance their units’

effectiveness by ensuring troops are equipped with

proper hearing protection and/or TCAPS.

Figure 4. Percentage of tested Fort Carson Soldiers with significant threshold

shift (STS) for each month of 2008.

Note: Numbers in parentheses – (number demonstrating STS/total number tested)

*TRICARE is the DoD health care program for members of

the uniformed services, their families, and their survivors. Information available at http://www.tricare.mil.
72 https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1

Commanders must ensure their units are provided the

opportunity to train with these devices and understand

their use and importance in maintaining effective

communication and situational awareness.

The metrics we developed monitor operational hearing

services in garrison, with the intent that Soldiers will

“fight as they train,” and transfer the training and skills

they learned in garrison onto the battlefield. We

followed guidance from the Department of the Army

Pamphlet 40-501, which states that commanders of

noise-exposed personnel must appoint a unit hearing

conservation officer.7 We incorporated this

requirement into a post-wide standing operating

procedure (SOP), which was endorsed by the Fort

Carson installation commander. The SOP states that

each unit on Fort Carson is required to formally

appoint a company level hearing program officer

(HPO). Each HPO must complete a half day of

training under the supervision of at least one of the

FCHP Army audiologists. The first portion of the class

explains the 4 elements of the hearing program, and

the HPO’s role as extensions of the FCHP core staff.

The second portion of the class involves several

practical exercises including: examination of the outer

ear canal with an otoscope; determination of the proper

size earplug for both themselves and their fellow

Soldiers; understanding noise reduction ratios; and

understanding that not all earplugs are equally

protective—some may in fact “over-protect.”

Attenuation of too much ambient noise could cause a

Soldier to reject all hearing protection based on a

negative experience with one type.

Each HPO must pass a written and a practical

examination. Graduates are issued a certificate of

completion and a pocket otoscope, which becomes

property of their company when the Soldier leaves the

unit. HPOs are expected to arrange for their unit to

participate in an annual hearing health briefing from

one of the FCHP preventive medicine audiologists.

HPOs are also expected to be ready for a site visit to

Fort Carson: An Army Hearing Program Success Story

Explain results to patient, profile as

necessary, document in AHLTA,

MEDPROS, and DOEHRS DR.

Temporary profiles are nondeployable

pending medical clearance

H1 & (P)H2: Fit for duty (Army Regulation

40-501 4). In some cases, refer for HAE

based on Soldier’s candidacy.

(P)H3: Nondeployable pending MMRB

adjudication (Army Regulation 600-60 3).

Fax paperwork to MMRB. Refer for

hearing aid evaluation based on

candidacy.

Is there any

suspected

underlying pathology

that must be ruled

out?

Check in at Hearing

Readiness Section,

Soldier Readiness

Processing Center

1042 O’Connell Drive

Soldier with a scheduled

appointment

Army audiologist

reviews past medical

and hearing history

Army audiologist

completes diagnostic

evaluation to

determine fitness for

duty

Sensorineural

STS?

Order

additional

tests and refer

as necessary

Update MEDPROS

& DOEHRS DR and

clear Soldier for

deployment, PCS,

or retirement

Conductive pathology?

Vestibular? Tumor?

Acute acoustic trauma?

No

Yes

Yes Yes

No

No

Civilian audiologist reviews past

medical and hearing history and

completes diagnostic evaluation,

orders additional tests, and refers

to other specialists as necessary.

Civilian audiologist also conducts

hearing aid evaluations for

Soldiers referred from the Army

audiologist ONLY.

Check in at Clinical

Audiology, ENT Clinic,

Evans Army Community

Hospital

Explain results to patient and

document findings in AHLTA.

Civilian audiologist does NOT

issue profiles to Soldiers

Tricare eligible family members and

retirees with scheduled appointments

Figure 5. The 2 distinct processes for clinical hearing services for Soldiers and others at Fort Carson. Soldier care is

the exclusive responsibility of the Army audiologist, who can make a necessary referral. Patients who are not

Soldiers are seen by the civilian audiologist through the ENT clinic at the Evans Army Community Hospital.
April – June 2009 73

THE ARMY MEDICAL DEPARTMENT JOURNAL

their area from the FCHP staff to ensure their

compliance with the hearing program. The flowchart

in Figure 6 illustrates the 3 branches of the operational

hearing services mission in garrison at Fort Carson.

Figure 7 shows that the FCHP has trained 321

company level hearing program officers in the last 2

calendar years. In so doing, we exceeded our goal of

training an HPO for 222 (80%) of the companies on

Fort Carson. Unfortunately we have fallen short of our

other goals for operational hearing services in the areas

of education and inspections. We had hoped to present

an annual hearing safety briefing to the same 222

companies, but only managed to provide 15 company

level hearing health briefings. We also failed in our

goal to inspect noise hazardous areas for the same 222

companies, only 14 noise hazardous areas were

inspected over the last 2 years. We believe this

shortfall was due to the deployment of one of our

active duty audiologists to Iraq for 120 days, and her

residency training at the Captain’s Career Course for

another 9 weeks in 2008. During her absence, the table

of distribution and allowances* showed that Fort

Carson had 2 uniformed audiologists on post running

the hearing program, while in reality; only one person

was available for more than half of the 2008 calendar

year. These numbers further support our belief that the

preventive medicine staffing model is inaccurate in its

estimation that one military audiologist and 2.5

audiology technicians are capable of providing

adequate preventive measures for every 18,000

Soldiers under the Army Hearing Program. Using the

old staffing model with the new AHP sets Army

audiologists up for failure.

HEARING CONSERVATION

The fourth element of the FCHP is

hearing conservation. The hearing

conservation element is designed to

protect noise-exposed government

civilian personnel employed at Fort

Carson from hearing loss due to

occupational noise exposure. This

element follows the garrison-based

Army Hearing Conservation

Program, but applies to noiseCompany is a

GO

Annual Hearing

Health Briefing

complete?

Request briefing from

Preventive Medicine Hearing

Program staff as required by

DA Pamphlet 40-501 4 and

Ft Carson SOP.

No

Inspection of noise

hazardous areas and

ranges complete?

Invite Hearing Program staff

for an inspection or await a

surprise inspection.

No

Yes Yes Yes

Garrison

“Train As You Fight!”

Assign Hearing Program

Officer who attends HPO class

as required by DA Pamphlet

40-501 4 and Ft Carson SOP.

Company level

HPO assigned?

No

Figure 6. Operational hearing services provided under the Fort Carson Hearing Program.

Figure 7. The cumulative number of trained, company level hearing

program officers in Fort Carson units, the number of hearing health

briefings presented, and the number of noise inspections performed shown

on a monthly basis for 2007 and 2008.

*Prescribes the organizational structure,

personnel and equipment authorizations, and requirements of a military

unit to perform a specific mission for

which there is no appropriate table of

organization and equipment.
74 https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1

exposed civilians only, and does not include our

Soldier population. There are 7 essential elements

included in the hearing conservation component of the

FCHP:

 Noise hazard identification

 Engineering controls

 Hearing protectors

 Monitoring audiometry

 Health education

 Enforcement

 Program evaluation

Figure 8 shows the annual STS rate for our noiseexposed civilian employees who are enrolled in the

Hearing Conservation Section of the Occupational

Health Clinic under the FCHP and the Department of

Preventive Medicine. Although we track the overall

STS rate monthly, we only graph the yearly percentage

of STS due to the significantly lower number of

civilians enrolled (411 total in 2008). In 2000, 30% of

the 128 noise-exposed civilians on Fort Carson

showed an annual significant threshold shift. The STS

rate for our civilian workforce in 2008 has dropped to

6%, the lowest it has been in more than 8 years, even

though the number of civilians tested has more than

tripled during the same time period. We contribute our

successes to increased interaction with the range

control office on Fort Carson. The FCHP is involved

in range control’s training classes for range safety

officers. We do not require the civilian population to

participate in the Hearing Program Officer Course, but

interestingly, several noise-exposed civilians have

learned of our class and asked to participate so that

they could assume the responsibility as the hearing

program officers for their work areas. Of course we

have been happy to oblige and accommodate them in

our classes.

CONCLUSION

The Fort Carson Hearing Program has documented

metrics which show the new Army Hearing Program

doctrine successfully decreased this post’s Soldier and

civilian STS hearing loss rate to levels predating the

Global War on Terror, while we have been an Army at

war. Additionally, the data shows that the addition of a

second Army audiologist in calendar year 2008

resulted in an increase of more than 3,000 Soldiers

who were fully ready to deploy, compared to calendar

year 2007. Our success is attributed to an increased

emphasis in operational hearing services, even though

we fell short of our goal of providing a full spectrum

and triad of operational hearing services to 80% of

Fort Carson’s companies in garrison. The FCHP

metrics show positive trends in all 4 elements: hearing

readiness, clinical hearing services, operational

hearing services, and hearing conservation. The

metrics also suggest that the Army Medical

Command’s preventive medicine staffing model’s

current recommendation of one audiologist and 2.5

technicians for every 18,000 Soldiers is insufficient

and predestines hearing loss prevention efforts for

failure. Finally, the FCHP shows that command

emphasis is crucial for a successful hearing program.

COL Kathy Gates, Audiology Consultant to The

Surgeon General, succinctly states the current reality:

The Army no longer needs to accept hearing loss

as an inevitable byproduct of military service.

Fort Carson: An Army Hearing Program Success Story

Figure 8. Percentage of noise exposed civilian employees

who are enrolled in the Hearing Conservation Section of the

Occupational Health Clinic with significant threshold shift

(STS) for the years 2000 through 2008.

Note: Numbers in parentheses – (number demonstrating STS/total

number tested)
April – June 2009 75

THE ARMY MEDICAL DEPARTMENT JOURNAL

ACKNOWLEDGEMENTS

I thank the following people for their assistance in

preparation and review of this paper:

COL Kathy Gates, Audiology Consultant to The

Surgeon General and Director of the Army Audiology

and Speech Center at Walter Reed Army Medical

Center.

COL James Terrio, Chief of Preventive Medicine at

Evans Army Community Hospital, Fort Carson.

LTC Vicki Tuten, Audiology Staff Officer, Proponency

for Office of Preventive Medicine, Office of The

Surgeon General.

LTC Nicholas Piantanida, Deputy Commander for

Clinical Services, Evans Army Community Hospital,

Fort Carson.

Dr Kenneth Stone, MD, Chief of the Occupational

Health Clinic, Department of Preventive Medicine,

Evans Army Community Hospital, Fort Carson.

CPT Jenny Davis, Hearing Program Audiologist, Occupational Health Clinic, Department of Preventive Medicine, Evans Army Community Hospital, Fort Carson.

Ms Janet Klieman, Medical Librarian at Evans Army

Community Hospital, Fort Carson.

REFERENCES

1. McIlwain D, Cave K, Gates K, Ciliax D. Evolution of

the Army hearing program. Army Med Dept J. AprilJune 2008:62-66.

2. Helfer T, Jordan N, Lee R. Postdeployment hearing

loss in US Army Soldiers seen at audiology clinics

from April 1, 2003, through March 31, 2004. Am J

Audiol. 2005;14(2):161-168.

3. Army Regulation 600-60: Physical Performance

Evaluation System. Washington, DC: US Dept of the

Army; February 28, 2008:8.

4. Army Regulation 40-501: Standards of Medical

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

September 10, 2008:80.

5. US Army Medical Command Automated Staffing

Assessment Model for Preventive Medicine.

Available at: https://www.us.army.mil/suite/

page/29142. (restricted access) Accessed December

31, 2008.

6. Special Text 4-02.501: Army Hearing Program. Fort

Sam Houston, Texas: US Army Medical Department

Center & School; February 1, 2008. Available at:

http://militaryaudiology.org/site/wp-content/images/

st_4_02_501.pdf. Accessed April 28, 2009.

7. Department of the Army Pamphlet 40-501: Hearing

Conservation Program. Washington, DC: US Dept of

the Army; December 10, 1998:2.

AUTHOR

CPT Cleveland, AuD, is Chief of the Fort Carson

Hearing Program at the Occupational Health Clinic,

Department of Preventive Medicine, Evans Army

Community Hospital, Fort Carson, Colorado.

US Army Medical Department Activity

Fort Carson, Colorado
76 https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1

BACKGROUND

Historically, 80% of all hospital admissions have been

from disease and nonbattle injuries.1Preventive

medicine measures are simple, common sense actions

that any service member can perform and to which

every leader can subscribe. In the preventive medicine

world, there have always been difficulties ensuring the

safety of geographically separated Soldiers. During

Operation Joint Endeavour in 1995, base camp

assessment teams were established to evaluate quality

of life at forward operating sites in Bosnia. Currently,

we have Soldiers located in many parts of the world,

eastern Europe, the middle east, southwest Asia, and in

the Balkans. The names change, but the basic concept

of a base camp assessment team remains the same—

and is always applicable.

It is easy when an entire brigade combat team is on a

single forward operating base, but what do you do

when there are many forward operating bases? For

example, while deployed to Afghanistan in 2006 for

Operation Enduring Freedom, my brigade was

dispersed over 12 geographically separated forward

operating bases. Since you cannot be everywhere at

one time, how do you prevent mission failure due to

environmental health issues? There must be a program

to organize a systematic, holistic approach to plan,

develop, implement, and maintain environmental

health surveillance at these forward base camps. That

program is the base camp assessment program.

Implementation of a base camp assessment program

begins prior to arrival in-theater.

BASE CAMP ASSESSMENT PROGRAM

The 2 main references that form the basis of an

environmental health surveillance program are

Department of Defense Instruction 6490.03,

2

and Joint

Chiefs of Staff Memorandum MCM 0028-07.

3 These

documents define environmental health surveillance as

the regular or repeated collection, analysis, archiving,

interpretation, and dissemination of data related to

deployment occupational and environmental health.

The base camp assessment program uses

environmental health surveillance data for health

monitoring, the determination of potential health

hazard impact on a population or individual personnel,

and for the timely intervention to prevent, treat, or

control the occurrence of disease or injury when

determined necessary.2,3 This is the starting point.

Department of the Army Pamphlet 40-11 (DA PAM

40-11)

4

defines the programs and services within the

medical functional area of preventive medicine. All

preventive medicine Soldiers should read this

pamphlet to identify US Army publications that

delineate functions and contain the detailed

Establishing a Base Camp Assessment

Program for a Forward Operating Base

CPT Davin Bridges, MS, USA

LTC Timothy Bosetti, MS, USA

ABSTRACT

Occupational and environmental health hazards can seriously impact the mission and erode public confidence in

the military’s ability to protect US personnel. With any forward operating base, it is critical to establish a

comprehensive base camp assessment program to optimize health readiness and protect deployed Department of

Defense personnel from occupational and environmental health hazards. It is an ongoing, never-ending duty to

educate and perform sanitary inspections as well as water, soil, and air surveillance. Establishing a base camp

assessment program for a forward operating base is critical to ensure continuous monitoring when the location

does not have a permanent environmental science officer or preventive medicine specialist onsite. The specific

goal of the base camp assessment program is to reduce disease and nonbattle injury. Lessons-learned have

shown the importance of accurate reporting and interpretation of environmental health assessments to reduce

disease and nonbattle injury.
April – June 2009 77

instructions, guidance, and procedures necessary for

implementing the policies and responsibilities outlined

in Army Regulation 40–5.

5

At this point many will say, “those are garrison

programs, I am in the field.” While it is true that these

are predominately garrison-based programs, they

should not be excluded. Where better to find out what

you can and should be doing than by mirroring an

established garrison-based program. Train as you fight.

DA PAM 40-11 4outlines all of the environmental

health programs included in a base camp assessment

program. It is more than just checking trash cans and

sniffing latrines.

OVERVIEW

The base camp assessment is the key in an active

preventive medicine program; however, there needs to

be a clear understanding of the

purpose of the base camp

assessment program. The program

is the assessment of the overall

health status of Soldiers. The

program should be flexible enough

to meet the continually evolving

needs of the Soldier and to

accommodate the operation and

changes in patterns of disease and

injury. The goal of the program is

to develop a comprehensive

preventive medicine program to

reduce disease and nonbattle injury

through proactive measures.

COMPONENTS OF THE PROGRAM

Using DA PAM 40-114as a guide, a base camp

assessment program can comprise many components.

The individual components will vary depending on the

forward operating base and the maturity of the theater.

Typically, a base camp assessment program will

consist of water surveillance, food service inspections,

living area inspections, waste disposal, pest

management, climatic injury prevention, and basic

camp sanitation inspections. But it need not be limited

to these (Figure 1). As the camp and theater mature,

some programs will become routine, while others will

emerge as greater risks. This may sound like a

daunting task and one that is beyond the scope of a

small preventive medicine cell within a brigade

combat team. However, it is what you already do. The

base camp assessment just brings it all together.

COMPREHENSIVE ASSESSMENTS:

A HOLISTIC APPROACH

Development of a base camp assessment program for a

forward base camp should follow a holistic approach.

Focusing on a few individual components will not be

sufficient in establishing a successful base camp

assessment program. It needs to address the full

spectrum of preventive medicine programs. A key to a

successful base camp assessment program involves

linking together what you already do, as illustrated in

Figure 2. The problem is that we typically do not look

at these programs on a continuum. Instead, we

approach them as individual stovepipes and miss or

overlook the warning signs. Typically, it is only after

an outbreak or an increased incidence of disease that

we start looking at the different environmental health

programs holistically.

Sickness can come faster than you

can anticipate. Being proactive

with your preventive medicine

duties is essential in stopping a

p o ss ib le mi s si o n fa il ur e .

Something as simple as Soldiers

not washing their hands could have

a catastrophic effect on a platoon.

Highlighting this simple failure as

the starting point for an example of

the spread of infection/disease/

illness: a Soldier acquires

gastrointestinal disease, he/she

 Water Supply

 Food Service Sanitation

 Troop Billeting/Sleeping Area

 Waste Disposal

 Pest Management

 Noise Hazard Identification & Control

 Field Sanitation Teams

 Barbershop Sanitation

 Heat Injury Prevention

Figure 1. Typical components of a base

camp assessment (list not exhaustive).

Base Camp Assessment

Document what you already do!

Heat/

Cold

Injury

Living

Area

BACT Water

DFAC

Inspection

Sanitary

Inspection Site Recon/

Assessment/

Walkthrough

CHPPM

OEHS

Reports

Checking

Unit FST

Ento EPI

DNBI

Hearing Conservation Industrial Hygiene

EPI†

DNBI‡

Checking

Unit FST§

DFAC*

Inspection

Water

Bacteriology

Industrial Hygiene

CHPPM#

OEHS**

Reports

Entomology

Heat/Cold

Injury

Living

Area

Sanitary

Inspection

Site Recon/

Assessment

Walkthrough

Document What You Already Do!

Hearing Conservation

Figure 2. A successful base camp assessment program

involves linking together what you already do.

*Dining facility

† Epidemiology

‡ Disease and nonbattle Injury

§ Field sanitation team

# Center for Health Promotion and Preventive Medicine

**Occupational & Environmental Health Surveillance
78 https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1

could easily spread that illness to all his/her fellow

Soldiers by playing cards. If the platoon is ineffective

because of sickness, the mission will suffer. This could

have a domino effect that could impact the battalion.

The break in the preventive medicine measures chain

can put other missions on hold. It is our job not only to

get the word out to the Soldier, but also to ensure the

Soldier is practicing his/her preventive medicine

measures.

A proper base camp assessment program attempts to

tie the different preventive medicine and environmental health programs into a single assessment. The

aim is to be proactive. To do this, we need to look at

the second and third order effects of the individual

findings. Then ask ourselves if any of them are related.

Do the less than satisfactory sanitation practices in the

dining facility, no chlorine residual, and a slight

increase in sick call numbers have anything in

common? Is it a sign of a bigger problem? These are

some of the questions we should ask ourselves when

we look at this holistically.

COMPOSITE RISK MANAGEMENT

The actual assessment portion of a base camp

assessment requires the use of the information

collected from your findings to identify hazards, assess

the potential risks, determine

appropriate risk control

measures, and communicate the

risks to the forces using

composite risk management

(CRM), graphically portrayed

in Figure 3. Hazard severity is a

measure of the impact of the

interaction of the health hazards

on Soldiers. Hazard probability

is determined by estimating the

percentage of the population

that could be exposed to that

hazard. Finally, the overall

health risk estimate is

determined by using the CRM

matrix in Table 3-3 of the US

Army Center for Health

Promotion and Preventive

Medicine (USACHPPM)

Technical Guide 230 6and

Army Field Manual 5-19.

7

Using CRM doctrine will

enable you to convey your message in a clear and

universally understandable language: green, amber,

red, and black. After determining the health risk, set in

place a risk communication plan to deliver key

messages of the health risk and the recommendations

to lower the risk.

COMMUNICATION

Communication consists of 3 key components:

document (eg, report), inform, and archive (Figure 4).

Documentation of everything is not only critical for

presenting accurate results to your chain of command,

it is essential for future missions. Having great

documentation can effectively help the next preventive

medicine team that follows you, and retains complete,

accurate records of your findings and

recommendations. Document the negative and the

positive findings, and, keep your findings

straightforward so that higher leadership will

understand. The report does not need to be complex or

a lengthy dissertation: keep it simple. Use an executive

summary for the senior commanders and staff. Ideally,

it should be a one-page snapshot of your work.

Graphics are good. The report should be detailed

enough to paint a picture of the health status of your

forward operating base. If you have the capability,

include all of your inspection

forms as enclosures. Document

negative findings; if you looked

at something and found nothing,

state it. It is important to note

when everything was okay. We

in preventive medicine do not do

a good job in this area. We are

very good about documenting

when we see deficiencies, but

fail to properly record and report

w h e n e v e r y t h i n g w a s

satisfactory.

Keep your command informed.

Routine reporting of your base

camp assessment to your

command keeps them apprised

of the preventive medicine

“health” of their command and

they will come to expect to see

your report. It is not whom you

include, it is whom you leave

Establishing a Base Camp Assessment Program for a Forward Operating Base

MISSIONS

Step 1:

Identify Hazards

Step 4:

Implement Controls

Step 2: Assess Hazards

Estimate probability

Estimate severity

Determine risk level

for each hazard and

overall mission risk

Step 3: Develop Controls

and Make Risk Decision

Develop controls

Make decision

Determine residual

risk level for each

hazard and overall

mission risk

Step 5: Supervise & Evaluate

Supervise Evaluate

Lessons

Learned

New

Hazards

Figure 3. The risk management process.
April – June 2009 79

THE ARMY MEDICAL DEPARTMENT JOURNAL

out. Inform critical personnel, key staff, and

commanders on a regular basis. Document and keep

records of whom you inform.

Archiving the base camp assessment reports is

important. All of your inspection forms and reports

should be archived by submitting directly to the

Defense Occupational and Environmental Health

Readiness System data portal.* Use historical data for

that specific site to develop an environmental health

surveillance program for a specific forward base camp.

Contact USACHPPM†to receive information on that

site/location, using the Global Threat Assessment

Program.

SOME TACTICS, TECHNIQUES, AND PROCEDURES

Putting prevention into practice is not always easy.

Inspect, monitor, and record all documents for dining

facilities, barbershops, gymnasiums, detention cells,

food establishments, and water storage containers to

ensure the safety of the Soldiers. There are a number

of ways to accomplish this mission, here are a few

tips:

1. Know doctrine and the regulations backwards

and forwards. If you know doctrine, you will

know when to follow it and when to modify it

according to your situation. Remember, doctrine

is a starting point. Likewise, regulations can

assist you in knowing what you need to do.

2. Establish field standard operating procedures

and smart-book checklists before you deploy.

Test your program in garrison, what better way

to run a battle drill and get your command

familiar with your reports and preventive

medicine. Use historical data for that specific

site to develop your base camp assessment

program for a specific forward base camp.

Contact USACHPPM†to obtain information on

that site/location, using the Global Threat

Assessment Program.

3. Do not settle for the status quo. Once you have

established the basic programs and they are

running smoothly, expand those programs.

Increase the level of expectation as facilities and

support services increase their ability to provide

safer, better quality services. If contracted

services are used, be sure you coordinate actions

through the contracting office.

4. Be an evangelistic preventive medicine Soldier.

You should be getting out and reaching out to

all. Everyone should know you. During

meetings, have a “tip of the week” for your

commander. Get out and go to every meeting.

Be around at all times. No matter what types of

questions they ask, they still know who you are.

These managers want to do what is right.

Helping them succeed means you have a better

chance to succeed in your preventive medicine

mission. In addition, develop personal working

relationships with the mayor’s cell, base camp

commander, and the contracting office on the

forward operating base.

CONCLUSION

The base camp assessment is not another rock in your

rucksack; it is a holistic approach to preventive

medicine that enables you to interconnect the

inspections you routinely do in order to gauge the

overall health and sanitation of your forward operating

base. It is what you already do: just a different

approach to packaging the findings. Use this collection

of data to lower the possibility of mission failure and

maximize the fighting strength. Have an established

base camp assessment program for forward base

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

†email address: chppm-gtap@amedd.army.mil

COMMUNICATION

Document

Report

Document negative findings

Executive summary (keep it simple)

Inform

Keep base camp & task force commanders informed

Set routine schedule/timeline for report

Get involved

Archive Data and Reports

Submit directly to DOEHRS data portal

https://doehrswww.apgea.army.mil/front.htm

Submit via email

Unsecured - oehs@apg.amedd.army.mil

Secured - oehs@usachppm.army.smil.mil

Submit via regular mail

USACHPPM Attn: MCHB-TS-RDD

Bldg E-1675

5158 Blackhawk Road

Aberdeen Proving Ground, MD 21010-5403

Figure 4. The elements of a risk communication

plan.
80 https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1

camps to monitor all aspects of preventive medicine.

The program is dynamic and must readily change and

adapt as Soldiers and missions change. The overall

result of a successful base camp assessment program

for forward base camps is lower numbers of casualties

due to disease and nonbattle injury.

REFERENCES

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

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

2000.

2. Department of Defense Instruction 6490.03:

Deployment Health. Washington, DC: US Dept of

Defense; August 11, 2006.

3. Office of the Chairman, Joint Chiefs of Staff.

Memorandum MCM 0028-07, Procedures for

Deployment Health Surveillance. Washington DC:

US Dept of Defense; November 2, 2007. Available

at: http://amsa.army.mil/Documents/JCS_PDFs/

MCM-0028-07.pdf.

4. Department of the Army Pamphlet 40-11: Medical

Services: Preventive Medicine. Washington, DC: US

Dept of the Army; October 20, 2008.

5. Army Regulation 40-5: Preventive Medicine.

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

2007.

6. Technical Guide 230: Chemical Exposure Guidelines

for Deployed Military Personnel. Version 1.3.

Aberdeen Proving Ground, MD: US Army Center for

Health Promotion and Preventive Medicine. May

2003. Available at: http://chppm-www.apgea.army

.mil/documents/tg/techguid/tg230.pdf.

7. Field Manual 5-19: Composite Risk Management.

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

2006.

AUTHORS

CPT Bridges is an Environmental Science Officer and

the Program Manager of the US Army Center for

Health Promotion and Preventive Medicine – Europe

Deployment Environmental Surveillance Program.

LTC Bosetti is Chief of the Department of

Environmental Sciences at the US Army Center for

Health Promotion and Preventive Medicine – Europe.

Establishing a Base Camp Assessment Program for a Forward Operating Base
April – June 2009 81

HISTORICAL BACKGROUND

Following the 1990-1991 Persian Gulf War, many

service members reported health problems and

believed these problems were associated with their

military service in the Persian Gulf. A paucity of

health and deployment data severely limited the ability

to investigate the nature and causes of these illnesses.

The National Defense Authorization Act for Fiscal

Year 1998,1enacted in November 1997, directed the

Department of Defense (DoD) to establish a system to

assess the medical condition of service members

before and after deployments. In 2002, the

Government Accounting Office (GAO) was asked to

determine if the military services met DoD’s force

health protection and surveillance requirements for

service members deploying in support of Operation

Enduring Freedom in central Asia and Operation Joint

Guardian in Kosovo, and if DoD had corrected

problems related to the accuracy and completeness of

databases reflecting which service members were

deployed to certain locations.

The findings of this GAO study were published in

September 2003.2 The GAO found that the Army and

the Air Force did not comply with the DoD’s force

health protection and surveillance policies for many

active duty service members, including the

requirement that they be assessed before and after

deploying overseas, that they receive certain

immunizations, and that health-related documentation

be maintained in a centralized location. The GAO’s

review of 1,071 service members’ medical records

from a universe of 8,742 at selected Army and Air

Force installations participating in overseas operations

disclosed that:

 From 38% to 98% were missing one or both of

their health assessments.

 From 14% to 46% were missing at least one of the

required immunizations.

The study2also found that the DoD did not maintain a

complete, centralized database of service members’

medical assessments and immunizations. Healthrelated documentation missing from the centralized

database ranged from 0% to 63% for predeployment

assessments, 11% to 75% for postdeployment assessments, and 8% to 93% for immunizations. Additionally, there was no effective quality assurance program

at the Office of the Assistant Secretary of Defense for

Health Affairs or at the Army or Air Force that helped

to ensure compliance with policies. The GAO believed

that the lack of such a program was a major cause of

the high rate of noncompliance. The GAO was

concerned that continued noncompliance with these

policies might result in the deployment of service

members with health problems, or delays in obtaining

care when they return.

Based on these findings, the GAO recommended that

the Secretary of Defense direct the Assistant Secretary

of Defense for Health Affairs to establish an effective

quality assurance program that would help ensure that

the military services comply with the force health

protection and surveillance requirements for all service

Army Force Health Protection: Past, Present,

and Future

E. Wayne Combs, PhD, RN

ABSTRACT

Following the 1990-1991 Persian Gulf War, many service members reported health problems and believed these

problems were associated with their military service in the Persian Gulf. A paucity of health and deployment data

severely limited the ability to investigate the nature and causes of these illnesses. Based on the findings from a 2002

study, the Government Accounting Office recommended that the Secretary of Defense direct the Assistant Secretary of

Defense for Health Affairs to establish an effective quality assurance program that would help ensure that the military

services comply with the force health protection and surveillance requirements for all service members. In November

2003, The Surgeon General of the Army tasked the US Army Center for Health Promotion and Preventive Medicine

(USACHPPM) with the development of a Deployment Health Quality Assurance Program for the Army. Since 2003, a

team from USACHPPM has visited approximately one Army installation per quarter. Over time, there has been

remarkable improvement noted in Army deployment health metrics and practices.
82 https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1

members. The DoD concurred with this

recommendation.

In November 2003, The Surgeon General of the Army

tasked the US Army Center for Health Promotion and

Preventive Medicine (USACHPPM) with the

development of a quality assurance program for

deployment health. The Army Deployment Health

Quality Assurance (DHQA) Program was designed to

provide a capacity for on-site record reviews as well as

a system for accountability (compliance with standards

and public law), quality assurance, and reporting.

Late in 2003, USACHPPM sent 2 teams to conduct the

first Army deployment health quality assurance site

visits at Fort Stewart, Fort Drum, Fort Lewis, Fort

Hood, and Fort McCoy. The visits consisted of

reviews of outpatient records, discussions with

medical staff and medical support staff, and visits to

deployment processing centers. During these first

visits, the teams found a general lack of knowledge

among medical staff and medical support staff

regarding deployment health policies and requirements

for deploying Soldiers. At that time, the deployment

health assessment forms were completed by hand, in

triplicate, and the copies were forwarded to the Army

Medical Surveillance Activity (AMSA). Once

received, the forms were scanned into a centralized

electronic database.

In January 2004, The Assistant Secretary of Defense

for Health Affairs issued HA Policy 04-001,

3 which

outlined specific guidance for the DoD Deployment

Health Quality Assurance Program. The major

requirements of this policy included

 Reports on centralized pre- and postdeployment

health assessments

 Reports on service-specific deployment health

quality assurance programs

 Visits to military installations to assess deployment health compliance and effectiveness

 Major findings and recommendations summarized

in an annual report and coordinated through the

Force Health Protection Council

PROGRESS SINCE 2003

Chapter 7 of The Department of the Army Personnel

Policy Guidance (PPG)4and Department of Defense

Instruction 6490.03 5serve as references for compliance standards, metrics, and reporting requirements for

Army DHQA activities. The PPG is updated

frequently and is reviewed routinely for the latest

guidance.

Current requirements of the Army DHQA program

include, but are not limited to

 Deployment health assessments

 A predeployment health assessment (DD

Form 2795) must be completed for all

Soldiers and Department of the Army (DA)

civilians before a major deployment, as

prescribed by DoD and DA policy, and

archived electronically at the Armed Forces

Health Surveillance Center (AFHSC)

(formerly AMSA). The required method for

completing and forwarding deployment health

forms is the Army Medical Department

Medical Protection System (MEDPROS).

 A postdeployment health assessment (DD

Form 2796) must be completed for all

Soldiers and DA civilians upon redeployment

as prescribed by DoD and DA policy, and

archived electronically at AFHSC.

 A postdeployment health reassessment (DD

Form 2900) must be completed for all

Soldiers and DA civilians upon redeployment

as prescribed by DoD and DA policy and

archived electronically at AFHSC.

 Deployment serum specimens. A predeployment

serum specimen must be drawn for all Soldiers and

DA civilians as prescribed by DoD and DA policy

and forwarded to AFHSC for storage in the DoD

Serum Repository (DoDSR). Similarly, a

postdeployment serum specimen must be drawn for

all Soldiers and DA civilians as prescribed by DoD

and DA policy and forwarded to AFHSC for

storage in the DoDSR.

 Immunizations. A record of each immunization

required for deployment will be documented using

MEDPROS. Immunization requirements vary by

deployment destination (for specific guidance, see

Army Regulation 40-562 6and the PPG4).

 Screening tests. A record of predeployment testing

for tuberculosis infection and human

immunodeficiency virus infection, performed as

prescribed by DoD and DA policy, will be recorded

Army Force Health Protection: Past, Present, and Future
April – June 2009 83

THE ARMY MEDICAL DEPARTMENT JOURNAL

using MEDPROS. A record of testing for

deployment-related tuberculosis infection, as

prescribed by DoD and DA policy, will also be

recorded using MEDPROS.

 Deployment health care. Health care provided

during deployment must be documented either

electronically, where available, or on appropriate

forms (eg, DD Form 2766 and SF600).

 Other metrics as required

Key elements of the Army DHQA program:

 Periodic status reports on centralized data and

serum specimens. AFHSC provides reports as

required on deployment health assessment data to

the Force Health Protection Quality Assurance

coordinator at the Office of the Deputy Assistant

Secretary of Defense for Force Health Protection

and Readiness (DASD/FHP&R).

 Site assistance visits to assess deployment health

programs.

 Onsite assistance visits complement the

corporate-level periodic reports. Site visits also

provide the opportunity to obtain an operational

perspective on the deployment health program,

identify the most efficient and effective

practices, and highlight quality assurance and

process improvement activities.

 The timing, site selection, and scope of the site

visits are determined by need and current

issues. Visits are designed to maximize

utilization of staff resources while minimizing

interruption of installation activities.

Since 2003, a team from USACHPPM has visited

approximately one Army installation per quarter,

including one visit per year with a team from DASD/

FHP&R. These visits focus primarily on force projection sites and have included, among others, Fort Bragg

and Fort Bliss, as well as return visits to Fort Drum,

Fort McCoy, and Fort Lewis. USACHPPM also

visited the US Army Corp of Engineers Headquarters

in Winchester, VA, at their request, to provide

guidance and recommendations for deploying DA

civilian engineers.

USACHPPM, with assistance from AFHSC, provides

all required reports to DASD/FHP&R on the Army’s

deployment health quality assurance program. Over

time, there has been remarkable improvement noted in

deployment health metrics and practices. Electronic

completion and capture of deployment related health

forms, archiving deployment health related forms and

data in the centralized database at AFHSC, and the use

of systems like MEDPROS to document and monitor

deployment health related requirements have all

improved dramatically.

MEDPROS was developed by the Army Medical

Department to track all immunizations, medical

readiness, and deployment data for all active duty and

reserve component Soldiers of the Army, as well as

DA civilians. It is a powerful tool allowing the chain

of command to determine the medical and dental readiness of individuals, units, and task forces. Commanders and leaders at various levels are responsible for the

use and implementation of MEDPROS to monitor

their units and/or individual readiness status.

Comprehensive medical readiness data in MEDPROS

includes all medical and dental readiness requirements.

Included are immunizations, permanent physical

profiles, eyeglasses, blood type, medical warning tags,

medications, pregnancy screening, DNA, HIV, and

dental status. Deployment health assessment forms can

now be completed electronically using the MEDPROS

link in the “My Medical” tab on the Army Knowledge

Online website. These forms are automatically

forwarded electronically to AFHSC to be archived in

the central database.

FUTURE DIRECTIONS

Department of Defense Instruction 6200.05 7implements policy, assigns responsibilities, and prescribes

procedures for establishing a comprehensive DoD

Force Health Protection Quality Assurance (FHPQA)

Program; and expands deployment health quality

assurance activities by applying FHPQA to key

elements throughout the entire period of an

individual’s military service. The DoD FHPQA

Program is designed to ensure that the health of

service members, as well as applicable DoD civilian

and contractor personnel, is effectively monitored,

protected, sustained, and improved across the full

range of military activities and operations.

FHPQA is focused on:

 The promotion and sustainment of a healthy and

fit force.
84 https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1

 The prevention of illness and injuries, and

protection of the force from health threats.

 The provision of medical and rehabilitative care to

the sick and injured.

CONCLUSION

The Army remains committed to providing quality

health care and maximum protection to its Soldiers,

regardless of geographic location and circumstances.

The new Force Health Protection Quality Assurance

Program is a force multiplier, designed to provide not

only a system for accountability (compliance with

standards), but also a system to assure quality and

continuous improvement in the care provided to our

Soldiers and DA civilians throughout their careers.

REFERENCES

1. Pub L. No. 105-85, 111 Stat 1629.

2. US General Accounting Office. Defense Health Care:

Quality Assurance Process Needed to Improve Force

Health Protection and Surveillance. Washington, DC:

US General Accounting Office; September 19, 2003,

Report GAO 03-1041. Available at: http://www.gao.

gov/new.items/d031041.pdf. Accessed April 27, 2009.

3. HA Policy 04-001: Policy for Department of Defense

Deployment Health Quality Assurance Program.

Washington, DC; Assistant Secretary of Defense for

Health Affairs: January 9, 2004. Available at: http://

fhp.osd.mil/pdfs/ha_memo_dep_health_quality

_assure_prog.pdf. Accessed April 27, 2009.

4. Department of the Army Personnel Policy Guidance

for Contingency Operations in Support of GWOT.

Washington, DC. US Dept of the Army; February 13,

2008. [updated April 13, 2009] Available at: http://

www.armyg1.army.mil/militarypersonnel/PPG/PPG.

Accessed November 1, 2008.

5. Department of Defense Instruction 6490.03:

Deployment Health. Washington, DC: US Dept of

Defense; August 11, 2006.

6. Army Regulation 40-562: Immunizations and

Chemoprophylaxis. Washington, DC: US Dept of the

Army; September 26, 2006.

7. Department of Defense Instruction 6200.05: Force

Health Protection Quality Assurance Program.

Washington, DC: US Dept of Defense; February 16,

2007.

AUTHOR

Dr Combs is a Community Health Nurse at the US

Army Center for Health Promotion and Preventive

Medicine, Aberdeen Proving Grounds, Maryland.

Army Force Health Protection: Past, Present, and Future
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