April – June 2010 

Perspectives 1

MG David A. Rubenstein; COL Mustapha Debboun; Richard Burton 

The US Army Public Health Command Initiative: 4 

Transforming Public Health Services for the Army 

Rosemarie M. Ugalde; John J. Resta, PE 

Entomological Terrorism: A Tactic in Asymmetrical Warfare 11 

CPT Derek Monthei; CPT Scott Mueller; Jeffrey Lockwood, PhD; COL Mustapha Debboun 

Issues Related to Burn Pits in Deployed Settings 22 

Coleen Baird Weese, MD 

Using Geographic Information Systems to Maximize 29 

Environmental Surveillance Efforts and Impact 

Brian C. Zeichner, Sheila Denice Adams 

Mystery of the X-Ray Overexposure: An Innovative Risk and 36 

Media Communication Mentoring Workshop 

COL Mark A. Melanson; Lori S. Geckle; Lyn C. Kukral; Michele Costanza, PhD 

The Impact Of Peer-Based Training on Reducing Radiation Doses from 43 

X-Ray Operations in an Interventional Pain Management Clinic 

MAJ Christopher D. Pitcher, COL Mark A. Melanson 

Resiliency Training for Medical Professionals 48 

LTC Sheila Adams; Cheryl Camarillo, LCSW; LTC Steve Lewis; CPT Nicole McNish 

Observed Noncompliance with Implementation of Vector-Borne 56 

Disease Preventive Measures Among Deployed Forces 

CPT Elizabeth W. Wanja 

Evolution of the Army Hearing Program in a Deployed Environment 65 

CPT Kara M. Cave; CPT Edward O. Price 

Battling Body Fat 68 

Todd Hoover, MA; COL Kyle D. Campbell 

Aguardiente at the Alamo: Alcohol Abuse and the 72 

Texas War for Independence, 1835-1836 

Wayne R. Austerman, PhD 

FORCE HEALTH PROTECTION:

EVOLVING CHALLENGES AND SOLUTIONS 
LTG Eric B. Schoomaker 

The Surgeon General 

Commander, US Army Medical Command 

MG David A. Rubenstein 

Commanding General 

US Army Medical Department Center and 

School 

April – June 2010 The Army Medical Department Center & School PB 8-10-4/5/6 

Online issues of the AMEDD Journal are available at http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1 

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DISTRIBUTION: Special 

Administrative Assistant to the 

Secretary of the Army 

JOYCE E. MORROW 
 April – June 2010 1

EDITORS’ PERSPECTIVE

The US Army has long recognized the inestimable 

value of a Soldier’s healthy mind and body to the combat readiness of the unit. The Army has continually 

sought improvements in effectiveness and efficiency in 

the methods and tools to ensure our Warriors remain 

healthy and fit, whether at home or in the theater of 

combat operations. The research, planning, application, and resources that are necessary to achieve this 

desired result are considerable. The recent establishment of the Army Public Health Command (APHC) is 

a significant step in the commitment to focus and 

optimize efforts among the various disciplines working 

towards that common goal. The leadoff article in this 

issue of the Journal is an account of the detailed 

planning and execution necessary to transition force 

health protection functions and responsibilities into the 

newly created APHC. The authors, Rosemarie Ugalde 

and John Resta, are key players in this ongoing process, and their article provides a detailed overview of 

the procedures involved, the schedule, and the ultimate 

organization of the APHC. 

Unconventional warfare presents an almost indefinable 

array of challenges to those charged with anticipating 

and countering the threats. Usually, thoughts of 

guerilla-style attacks or use of chemical or biological 

agents come immediately to mind. However, in a 

timely, important article, CPT Derek Monthei and his 

coauthors discuss a potential threat that usually does 

not enter most discussions—the use of insects as attack 

weapons, for destruction of food sources, or as disease 

vectors. Use of stinging or toxic insects in warfare has 

Perspectives Perspectives

It is with great personal pleasure that I present the first 

issue of the AMEDD Journal published during my tour 

as Commanding General, US Army Medical 

Department Center and School (AMEDDC&S). This 

publication exists for the specific purpose of enhancing and advancing the science of military medicine, 

the primary mission of which is maintaining the health 

and combat effectiveness of our military force. 

However, the vast majority of topics addressed in 

these pages also have direct corollaries in the practice 

of civilian healthcare. Indeed, the history of military 

medicine is replete with examples of the synergistic 

effect of efforts by both military and civilian resources 

producing results beneficial to both general 

populations and military mission accomplishment. 

The AMEDD Journal is an invaluable forum for the 

presentation of and dialogue about the most current 

healthcare issues and combat experiences related to 

military medicine and doctrine development for the 

medical battlefield. The Journal receives manuscripts 

from across the spectrum of medical professionals, including highly-experienced medical and dental practitioners, accomplished research scientists, preventive 

medicine and public health specialists, veterinarians, 

healthcare support and service specialists, and nonmedical professionals who contribute to healthcare 

delivery in various ways. The diversity of subject 

matter reflects the depth and breadth of functions in 

military medicine. 

Likewise, the AMEDD Journal has a broad reach in 

readership. It is distributed throughout the Army, 

Navy, Air Force, and DoD, as well as to many civilian 

medical schools and libraries. It is also distributed to a 

number of foreign military medical schools and commands. The quality of the content and presentation of 

the AMEDD Journal was recognized by the National 

Library of Medicine, which, in November 2009, selected it to be included and indexed in MEDLINE, the 

nation’s premier bibliographic database of life sciences 

and biomedical information from publications worldwide. The Journal is a superb presentation of who we 

are and what we do as healthcare professionals, both 

on the battlefield and in garrison. The topic of this edition also supports AMEDD Balanced Scorecard objective 3.0, “Improved Healthy and Protected Warriors.” 

For the fifth consecutive year, COL Mustapha Debboun, the senior medical and veterinary entomologist 

at the AMEDDC&S and Chairman of the AMEDD 

Journal Editorial Review Board, has organized and 

compiled an outstanding collection of articles 

addressing preventive medicine and public health in 

the context of force health protection. History has 

shown time and again that preventive medicine is the 

foundation for sustainable, effective combat capability. 

COMMANDER’S INTRODUCTION

MG David A. Rubenstein 
2 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

Perspective 

been chronicled throughout history, and the article 

explains how such a threat is not improbable today. 

However, the threats posed to food sources 

(agroterrorism) and as vectors of disease are of much 

greater concern. The article clearly and succinctly 

describes the threats represented, and the measures that 

have been, or should be, implemented to first detect 

and then control the outbreaks. 

As long as humans have congregated in living and 

working areas, accumulation of trash and solid waste 

has been an inevitable byproduct of our activities. The 

health threat of such accumulation has long been 

recognized, and has been a serious concern for US military operations for well over a century. In her excellent article, Dr Colleen Weese presents a historical 

perspective of the problem, and then describes the situation as it exists today in the Iraq theater. Not only are 

modern societies, including military forces, faced with 

the expected hygiene and sanitation problems of accumulating waste, but we are also dealing with new 

categories of toxic (or potentially toxic) substances 

which pose additional problems in safe handling and 

disposal. Dr Weese focuses on the particularly troubling disposal method of burn pits, which is often the 

only method a commander may have to address the 

immediate situation. The article is a well-researched, 

detailed discussion of the environmental and health 

hazards posed by open burning of accumulated waste, 

and the measures taken by the US military to mitigate 

those problems. It provides an in-depth look into how 

the hazards associated with waste disposal should be 

addressed. This article is a must-read for those charged 

with planning and implementing waste disposal 

procedures for deployed forces. 

Brian Zeichner and Sheila Adams have contributed an 

article describing a technological tool to assist preventive medicine and public health specialists in the collection and analysis of environmental data related to 

entomological threats in a given area. They demonstrate how readily-available geographic information 

system instruments can be used to define source areas 

of mosquito infestations, and then enable precise planning to attack those areas. They also illustrate identification of tick infestations, as well as agriculturally important beetle infestations. This is an interesting, easily 

understood article which presents sound, statistical 

evidence of the effectiveness of the techniques 

employed. The article should provide a stimulus for 

others to adopt the techniques for local, immediate 

applications addressing similar entomological threats. 

We have all become accustomed to the use of radiation 

in diagnosis and treatment of various health 

conditions. Although we are aware of the hazards 

represented by the radiation, we trust that the 

professionals employing it are experts in their craft, 

and the threat is essentially nonexistent. Indeed, this is 

the case. It is so because of the continuous training, 

practice, and attention to every detail of the clinical 

use of radiation that is demanded of these 

professionals. The next 2 articles discuss various 

aspects of that attention to training and monitoring of 

their potentially hazardous tools. First, COL Mark 

Melanson and his coauthors discuss a workshop for 

Army Nuclear Medical Science Officers to expand 

their skills in working as a group in communicating 

information about a potentially hazardous situation 

which could be present following a radiation incident, 

with special emphasis given to dealing with potential 

victims, and then the media. The workshop presented 

training in the personal skills and techniques necessary 

for such situations, and then participants worked 

through a real-world case study to understand how it 

can either get quickly out of control, or handled 

correctly and sensitively for all concerned. In the 

second article, MAJ Christopher Pitcher and COL 

Melanson describe the concerns presented by the 

expanding use of fluoroscopy in interventional pain 

management (IPM), an increasingly important specialty which uses nerve blocks and other techniques 

for pain management. The Health Physics Office at 

Walter Reed Army Medical Center performed a measurement study and implemented a peer-based training 

program to reduce as much as possible the radiation 

doses experienced by staff, patients, and the public as 

a result of the operation of the IPM clinic. This is a 

well-developed, thoroughly researched article which 

demonstrates the correct way to evaluate and address 

potentially hazardous situations which may exist in our 

medical facilities. 

The emotional and psychological toll on medical 

providers who treat casualties of war has been 

recognized for years, but was not directly addressed as 

a potentially serious condition until relatively recently. 

Over the last few years, the AMEDD Journal has 

published several articles discussing the evolving 

understanding of this condition, and the ongoing 

research and developing approaches to deal with it. 

LTC Sheila Adams and her coauthors present the latest 

article on this subject, describing the formal training 

course, Professional Provider Resiliency Program, 
 April – June 2010 3

THE ARMY MEDICAL DEPARTMENT JOURNAL

introduced by the AMEDD Center and School in May 

2009. The article is a detailed discussion of the basis 

on which the training was developed, the training 

itself, and includes the results of a survey of the 

participants in a recent class who evaluated the 

training received. This is a valuable depiction of 

another of the increasingly more sophisticated 

approaches that the AMEDD is taking to answer the 

proverbial question, “who heals the healer?” 

The military has dedicated considerable resources to 

research, training, and the development of equipment 

to mitigate environmental health threats, both endemic 

to the location and resulting from military operations. 

Unfortunately, the best of preventive measures and 

equipment are valueless if not diligently, continuously 

applied throughout all levels and locations of military 

units and facilities. CPT Elizabeth Wanja has 

contributed an important, revealing article that details 

her deployment experiences investigating and 

addressing a number of problems resulting from 

noncompliance with preventive medicine regulations 

and training, as well as the inconsistent distribution 

and availability of equipment. Such problems should 

be expected in the chaos and unpredictability of 

extensive, ongoing combat operations, but cannot be 

tolerated in a mature theater of fixed installations and 

reduced combat activity. Sadly, this is not a new 

situation. Commanders and other leaders must 

constantly balance priorities and resources—but the 

health and safety of their Soldiers must always be the 

first of those priorities. This article is must-reading for 

all who are charged with that responsibility, whether 

as leaders or providing preventive medicine support to 

units and facilities. 

The Army Hearing Program was instituted in 2007 and 

has been implemented throughout Army installations 

in the United States. However, application of the Program elements in the deployed theaters has been 

problematic, in that available audiologists were 

necessarily focused on diagnostic care of injured 

Soldiers. The article by CPTs Kara Cave and Edward 

Price describe how the Program elements were 

implemented in Iraq as soon as the circumstances 

permitted. As the clinical role diminished, CPT Cave 

began training technicians, including classes in noise 

hazard evaluation in collaboration with CPT Price of 

the preventive medicine medical detachment. The 

arrangement expanded to proactive evaluations of 

noise hazards, and resulted in a fully developed model 

and process of identifying and mitigating noise 

hazards throughout the Iraq theater. This article is 

another excellent example of how the initiative and 

competence of our military medical professionals 

benefit the Warfighters who serve every day, 

everywhere in the world. 

In their article, Todd Hoover and COL Kyle Campbell 

address a health problem that is completely preventable among healthy individuals, namely, excess body 

fat. They describe the collaboration between what is 

now the APHC (Provisional) – Europe and the Army 

Medical Department Activity, Heidelberg, to develop a 

weight reduction program designed around each 

individual’s metabolic rate and other physiological 

factors. Using students over a year of training cycles at 

the Warrior Leader Course as the target population, the 

program achieved a 99% success in the body fat 

standards, and 6-month follow-on checks indicate that 

over 86% remain within the established standards. 

This approach could be applicable in similar 

environments throughout the Army. 

Dr Wayne Austerman closes this issue with an 

excellent historical perspective on another completely 

preventable condition that not only damages the 

individual’s health, but also, without question, 

severely degrades combat effectiveness. The abuse of 

alcohol has always been a part of human history, 

which includes a significant presence in military history. The article examines the role it played during the 

Texas War for Independence, highlighting the 

legendary battle of the Alamo where alcohol was a 

constant debilitating element, among both the men and 

some of their leadership. As Dr Austerman relates in 

fascinating detail, as the Mexican Army approached 

San Antonio, the majority of the Alamo garrison had 

been engaged in 2 days of revelry and drinking in 

town, rendering them virtually unable to mount a 

serious defense to any attack. Fortunately for Texas, 

bad weather and timid leadership delayed any action 

from the Mexicans. The article then postulates on how 

history may have changed had the Mexicans rolled up 

the defenders in the streets of town. Today’s military 

leaders must still be alert to the appeal of alcohol, 

whether chronic or opportunistic, and ensure immediate, positive action always addresses its abuse. No 

individual’s self-inflicted impairment can ever be 

allowed to jeopardize either the mission or his or her 

fellow Warriors. 
4 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

INTRODUCTION

The United States is at a healthcare crossroads. We 

spend more on healthcare than any other nation on the 

planet (in excess of $2 trillion (1012) per year, or about 

16% of gross domestic product) and yet our 

population’s health is, at best, only average by most 

measures (life expectancy, chronic disease rates, 

access to healthcare, infant mortality, etc).1

 This 

problem is projected to worsen as the US population 

ages. The Army follows the overall US trends. Army 

medical beneficiaries (Active Duty, military retirees, 

their Families, and Army civilian employees) are as 

healthy or unhealthy as their civilian counterparts. 

Army beneficiaries suffer the same chronic disease 

rates, use tobacco and alcohol at equal or higher rates, 

and are as overweight and/or obese as their civilian 

counterparts, with 2 important exceptions: our Soldiers 

are fitter than their civilian counterparts due to 

mandatory physical fitness training and weight limits 

but suffer more injuries due to the physical nature of 

their duties, and our beneficiaries have universal 

access to quality medical care.2,3

Recognizing that more must be done, the Army 

Medical Command (MEDCOM) has begun to place an 

increased emphasis on improving beneficiary health by 

using a public health-centric approach to its overall 

strategy.4

 This approach uses such initiatives as: 

Creating incentives for Army medical treatment 

facilities (MTFs) to improve their beneficiaries’ 

health via enhanced preventive health screenings 

measured by the Healthcare Effectiveness Data 

and Information Set (HEDIS*) metrics5

 and 

outcome based care measured with ORYX†

metrics6

 The MEDCOM has established an 

enterprise goal that Army MTFs will exceed 90% 

for 8 different preventive health screening HEDIS 

measures and 4 additional ORYX measures. 

Reducing the rates of workplace injuries in Army 

MTFs by providing MTF commanders with data 

about the rates and types of injuries suffered by 

their employees, and testing various safe patienthandling practices to identify which techniques 

best reduce workplace injuries. 

Decreasing the rate of overweight and obese 

Family members and retirees by adopting the 

Healthy Population 2010 7 goals for overweight 

and obesity and implementing a standardized 

weight management program developed by the 

Department of Veterans Affairs.8

A key component of this increased emphasis on public 

health is the creation of an Army Public Health 

Command as part of the overall MEDCOM reorganization. This article describes the Army Public 

Health Command (APHC), its objectives, and current 

status. 

BACKGROUND

In July 2008, the MEDCOM Chief of Staff formed an 

APHC Workgroup to conduct a staff analysis and 

provide recommendations to the Commander, 

MEDCOM on the feasibility of a command focused on 

public health. The Workgroup members consisted of 

representatives from the Army Center for Health 

The US Army Public Health Command 

 Initiative: Transforming Public Health 

 Services for the Army 

Rosemarie M. Ugalde, BSPH 

John J. Resta, PE 

*HEDIS is a tool used by more than 90% of America’s health plans to measure performance on important dimensions of care and 

service. HEDIS was developed and implemented by The National Committee for Quality Assurance, a private sector, US-based, 

not-for-profit organization offering accreditation to health plans throughout the United States and Puerto Rico. 

†ORYX is the performance measurement and improvement initiative of the Joint Commission (One Renaissance Blvd, Oakbrook 

Terrace, Illinois 60181), a private sector, US-based, not-for-profit organization founded in 1951. The Joint Commission operates 

accreditation programs for a fee to subscriber hospitals and other healthcare organizations. 
 April – June 2010 5

Promotion and Preventive Medicine (CHPPM), the 

Army Veterinary Command, the Proponency Office 

for Preventive Medicine, the Department of Defense 

(DoD) Veterinary Service Activity, and the 6 

MEDCOM regional medical commands. John Resta 

[coauthor], was chosen to lead this effort and served as 

the chair of the Workgroup. 

The APHC Workgroup followed a military decisionmaking process: conducting a mission analysis, 

developing courses of action (COAs), analyzing and 

comparing the COAs, and ultimately recommending a 

COA for approval.9

 The workgroup completed an 

Enterprise Risk Assessment of the final COAs to 

ensure that the final decisions were fully informed.10

Enterprise Risk Assessments are designed to identify 

and assess risks across 7 dimensions: scope, people, 

strategy, technology, contracting, process, and external 

factors.11 Typically, the risk assessments are done to 

support major acquisition efforts but have been used to 

support organizational studies in the private sector. As 

a direct result of the efforts and analyses conducted by 

the Workgroup, in July 2009, the Commander, 

MEDCOM directed the establishment of the APHC, 

comprised of missions and resources from the CHPPM 

and the Army Veterinary Command. The Commander, 

CHPPM was tasked to lead the reorganization effort. 

STRUCTURED APPROACH TO TRANSFORMATION

A structured approach was developed to engage the 

challenge of establishing the APHC. On August 28, 

2009, the Commander, CHPPM signed a charter to 

form an APHC Transition Team consisting of an executive board, steering committee, and a core team to 

serve as an advisory team and conduct the necessary 

staff analyses to fully establish the APHC. John Resta 

and COL Gary Vroegindewey, Assistant Chief, Army 

Veterinary Corps, serve as cochairs in leading this 

effort. The Transition Team adopted the “A3 Thinking” methodology to employ a systematic, structured 

means of analyzing the various complexities involved 

in the APHC transition and identifying solutions. 

A3 Thinking is a Toyota-developed, “lean” method of 

problem solving or performance improvement.12 There 

are 9 steps in the method: 

1. Reason for action 

2. Initial state 

3. Target state 

4. Gap analysis 

5. Solution approach 

6. Rapid experiments 

7. Completion plan 

8. Confirmed state 

9. Insights 

All 9 steps can be represented in a 9 box format on an 

11 in by 17 in (international standard A3) sheet of 

paper. 

A3 working groups have been established to review, 

revise, and republish all policies, regulations, and 

procedures needed to govern the operations of the 

APHC; develop the appropriate procedures and 

agreements to conduct enterprise oversight of 

installation level public health services; and, in 

conjunction with the regional medical commands, 

consolidate installation public health assets under the 

command and control of the medical treatment facility 

commander. These working groups are being led by 

senior personnel from throughout CHPPM and the 

Army Veterinary Command. 

MISSION

The mission of the APHC is to promote health and 

prevent disease, injury, and disability to Soldiers and 

military retirees, their Families, and Army civilian 

employees; and assure effective execution of full 

spectrum veterinary services for Army and DoD 

Veterinary missions (Figure 1). This mission is 

significantly broadened because it commits the Army 

Medical Department to providing public health 

services to military Family members, military retirees 

and their Families, as well as to Soldiers and Army 

civilian employees. Previously, Army public health 

programs were focused on Soldiers and Army civilian 

employees. The APHC will sustain the Veterinary 

Command’s unique mission as the sole provider of 

veterinary services to the Department of Defense and 

all military services. Those missions include medical 

care for government-owned animals; zoonotic disease 

surveillance and control; food safety and quality 

assurance; food defense; and medical care for 

beneficiary-owned pets. 

COMMAND COMPOSITION

The APHC is being formed by integrating missions 

and personnel from CHPPM and the Veterinary 

Command. Its headquarters will be organized as a 

distinct headquarters element with command and 
6 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

control, policy development, and oversight 

responsibilities. The headquarters will be located at 

Fort Sam Houston, Texas. 

Five public health command regions (Figure 2) will 

report to the headquarters. These regional commands 

will initially be at the current locations of CHPPM or 

Veterinary Command regional subordinate commands. 

They will be responsible for monitoring the public 

health programs of MTFs and providing technical 

consultation and support to public health programs at 

MTFs, installations, and operational units. A primary 

goal of the APHC transformation is to collocate these 

regions with the corresponding regional medical command headquarters to encourage collaboration. Fourteen public health command districts (Figure 2) will 

report to the various regional public health commands. 

What was formerly known as CHPPM-Main at 

Aberdeen Proving Ground, Maryland, will become the 

US Army Institute of Public Health, reporting directly 

to the APHC headquarters. The institute will deliver 

unique, low-density public health services to MTFs, 

installations, and operational units; provide 

consultative assistance to public health regions and 

districts; develop Armywide public health programs; 

and oversee public health program process 

improvement and quality assurance. 

The US Army Public Health Command Initiative: Transforming Public Health Services for the Army 

Figure 1. The respective missions and functions of CHPPM and the Veterinary Command which will be the responsibility of the 

APHC as of October 1, 2011. 

Glossary 

CONOPS: Concept of operations 

AR 40-3: Army Regulation 40-3 13

AR 40-5: Army Regulation 40-5 14

AR 40-656: Army Regulation 40-656 15

AR 40-657: Army Regulation 40-657 16

AR 40-905: Army Regulation 40-905 17

NAF: Nonappropriated funds 
 April – June 2010 7

THE ARMY MEDICAL DEPARTMENT JOURNAL

The DoD Military Working Dog Center at Lackland 

Air Force Base, Texas, will remain as is, and report 

directly to the APHC headquarters. 

Installation-level public health teams will be created 

by combining installation veterinary services missions 

and personnel from the Veterinary Command with 

preventive medicine missions and personnel from the 

installation MTFs. These installation public health 

teams will be under the command and control of the 

MTF commander/director of health services. However, 

installation veterinary services delivered overseas will 

remain within the APHC under the command and 

control of the overseas (Europe, Pacific) APHC 

regions. This organizational structure is depicted in 

Figure 3. 

The relationship between the APHC and the 6 regional 

medical commands (North Atlantic, Southeast, Great 

Plains, Western, Pacific, Europe) will change 

significantly. To ensure that public health programs 

across the Army are optimized and properly 

synchronized, the APHC will have enterprise oversight 

of all Army public health activities in accordance with 

Army Core Enterprise governance guidance. The 

Army’s Core Enterprise initiative is an emerging 

Department of the Army business transformation effort 

that provides multiple stakeholders with the ability to 

synchronize efforts in a specific area while 

maintaining separate command and control 

structures.18 This new approach to management will 

require preparation and revision of MEDCOM 

regulations and policies, as well as creation of 

management controls to ensure that public health 

activities throughout the Army are synchronized and 

achieving the program goals. 

TIMELINE

The APHC will be established in 2 phases over a 2-

year period (Figure 4). In the first phase (October 1, 

2009 through September 30, 2010), the MEDCOM 

established an APHC (Provisional) to integrate the 

capabilities of CHPPM and the Veterinary Command, 

and continue the delivery of public health and 

veterinary medical services during the transition. This 

phase includes the development of a concept plan 

describing the APHC mission, roles, and 

responsibilities; policies that define an integrated 

Army public health program; and the assignment of 

enterprise oversight, monitoring, and execution 

responsibilities to the various MEDCOM 

organizations. 

In the second phase, scheduled to begin October 1, 

2010, the APHC (Provisional) will achieve an initial 

operational capability. This phase actually begins with 

the Department of the Army approval of the APHC 

concept plan, and ends when all tasks outlined in the 

concept plan have been completed, to include 

activation of the APHC and inactivation of CHPPM 

and the Army Veterinary Command. 

CONCLUSION

The decision to create the APHC marks a distinct 

change in both the strategic and practical approaches 

in the Army Medical Department’s delivery of 

services to those in its care. In the words of The Army 

Surgeon General, 

The establishment of the USAPHC (Provisional) is the 

most visible step in Army medicine’s efforts to 

transform the nation’s sick-care paradigm to a 

healthcare paradigm where disease and injury 

prevention become the foundation for American and 

military healthcare.19

While it will continue to deliver excellence in clinical 

and rehabilitative care, the Army Medical 

Department’s shift to a public health-centric approach 

better serves its beneficiaries by sustaining and 

improving individual health and unit readiness through 

APHC Region - Europe (Landstuhl, Germany) 

APHC District - North Europe (Kaiserslautern, Germany) 

APHC District - South Europe (Vicenza, Italy) 

APHC Region - Pacific (Tripler, HI) 

APHC District - Central Pacific (Fort Shafter, HI) 

APHC District - West Pacific (Apra Harbor, Guam) 

APHC District - Korea (Yongsan) 

APHC District - Japan (Camp Zama) 

APHC Region - North (Fort Belvoir, VA) 

APHC District - Fort Knox (KY) 

APHC District - Fort Belvoir (VA) 

APHC District - Fort Eustis/Fort Bragg (Fort Bragg, NC) 

APHC Region - South (Fort Sam Houston, TX) 

APHC District - Fort Hood (TX) 

APHC District - Fort Gordon (GA) 

APHC Region - West (Joint Base Lewis-McChord, WA) 

APHC District - Joint Base Lewis-McChord (WA) 

APHC District - San Diego (CA) 

APHC District - Fort Carson (CO) 

Figure 2. The planned designations and locations of the 5 

APHC regions and the 14 districts as of October 1, 2011. 
8 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

The US Army Public Health Command Initiative: Transforming Public Health Services for the Army 

prevention, promoting health behaviors and personal 

responsibility for health, and making necessary care 

more available through sound stewardship of our 

human and fiscal resources. 

ACKNOWLEDGEMENT

We thank Lyn Kukral for her assistance in editing and 

review of this article. 

REFERENCES

1. US Dept of Health & Human Services, Centers for 

Medicare and Medicaid Services. National healthcare 

expenditures 2008 highlights. Available at: http://

www.cms.gov/NationalHealthExpendData/downloads/

highlights.pdf. Accessed May 4, 2010. 

2. TRICARE Management Activity. Health care survey 

of DoD beneficiaries: 2008 adult annual beneficiary 

report. Available at: http://www.tricare.mil/survey/

hcsurvey/annual-report.cfm. Accessed May 4, 2010. 

Figure 3. The planned structure of roles and responsibilities of the APHC. 

Glossary 

APG - Aberdeen Proving Ground 

C2 - Command and control 

DoD - Department of Defense 

EH - Environmental health 

FPM- Field protective medicine 

IPH - Army Institute of Public Health 

MWD - Military working dog 

OCONUS - Outside of the continental 

United States 

PH - Public health 

PHC - Public Health Command 

PHCD - Public Health Command District 

PHCR - Public Health Command Region 

RMC - Regional medical command 

VCO - Army Veterinary Corps officer 
 April – June 2010 9

THE ARMY MEDICAL DEPARTMENT JOURNAL

3. Military Health System. 2008 DoD Survey of Health 

Related Behaviors Among Active Duty Military 

Personnel. Washington, DC: US Dept of Defense; 

December 2009. Available at: http://www.tricare.mil 

/2008HealthBehaviors.pdf. Accessed May 3, 2010. 

4. AMEDD Balanced Scorecard resources page. US 

Army Medical Department Center & School Web 

site. Available at: https://ke2.army.mil/bsc/ [restricted 

access]. Accessed May 5, 2010. 

5. National Committee for Quality Assurance. What is 

HEDIS?. NCQA Web site. Available at: http://

www.ncqa.org/tabid/187/Default.aspx. Accessed 

May 3, 2010. 

6. ORYX facts page. The Joint Commission Web site. 

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

AccreditationPrograms/Hospitals/ORYX/

oryx_facts.htm. Accessed May 4, 2010. 

Figure 4. The planned transition timeline to full operational capability of the newly established APHC. 

Glossary 

COA - Course of action 

CofS - Chief of Staff 

CONOPS - Concept of operations 

CONPLAN - Concept plan 

DVC - District Veterinary Command 

FOC - Full operational capability 

FRAGO - Fragmentary order 

IOC - Initial operational capability 

IPR - In-progress-review 

MEDCOM - Army Medical Command 

MTF - Medical treatment facility 

OPCON - Operational control 

PHC - Public Health Command 

REORG - Reorganization 

RMC - Regional medical command 

TDA - Table of Distribution and Allowances*

TSG - The Surgeon General of the Army 

TT - Transition Team 

UIC - Unit identification code 

VETCOM - US Army Veterinary Command 

WARNO - Warning order 

*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 (defines the structure and equipment for a 

military organization or unit). 
10 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

The US Army Public Health Command Initiative: Transforming Public Health Services for the Army 

7. Office of Disease Prevention and Health Promotion. 

Healthy people. US Dept of Health and Human 

Services. Available at: http://www.healthypeople. 

gov/. Accessed May 6, 2010. 

8. VA National Center for Health Promotion and 

Disease Prevention. MOVE! weight management 

program. US Dept of Veterans Affairs. Available at: 

http://www.move.va.gov/. Accessed May 6, 2010. 

9. Field Manual 5-0: The Operations Process. 

Washington DC: US Dept of the Army; March 26, 

2010:B1-B39. 

10. Business Transformation Agency. Enterprise risk 

assessment methodology. US Dept of Defense. 

Available at: http://www.bta.mil/products/eram.html. 

Accessed May 4, 2010. 

11. Defense Business Transformation Agency. Enterprise 

risk assessment methodology. US Dept of Defense. 

Available at: http://www.bta.mil/products/eram.html. 

Accessed May 6, 2010. 

12. Sobek DK, Smalley A. Understanding A3 Thinking: 

A Critical Component of Toyota's PDCA 

Management System. New York, NY: Taylor & 

Francis Group, LLC; 2008. 

13. Army Regulation 40-3: Medical, Dental, and 

Veterinary Care. Washington, DC: US Dept of the 

Army; February 22, 2008. [Revision 3, March 12, 

2010] 

14. Army Regulation 40-5: Preventive Medicine. 

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

2007. 

15. Army Regulation 40-656: Veterinary Surveillance 

Inspection of Subsistence. Washington, DC: US Dept 

of the Army; August 28, 2006. 

16. Army Regulation 40-657: Veterinary/Medical Food 

Safety, Quality Assurance, and Laboratory Service. 

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

2005. 

17. Army Regulation 40-905: Veterinary Health Services. 

Washington, DC: US Dept of the Army; August 29, 

2006. 

18. 2010 United States Army Report to Congress, Office 

of Business Transformation. Washington, DC: Office 

of the Under Secretary of the Army, US Dept of the 

Army; March 1, 2010. Available at: http://

w w w . a r m y o b t . a r m y . m i l / d o w n l o a d s / 2 0 1 0 

_congressional_report.pdf. Accessed May 4, 2010. 

19. The Surgeon General’s Blog. National public health 

week: comprehensive soldier fitness. Army Medicine 

Web site; April 8, 2010. Available at: https://

blog.amedd.army.mil/tsg/?Page=PostViewMulti 

&displayMonthlyArchives=April%26nbsp%3B2010 

&month=4&year=2010. Accessed May 4, 2010. 

AUTHORS

Ms Ugalde is the Executive Officer of the Army Public 

Health Command Transition Team, US Army Public 

Health Command (Provisional), Aberdeen Proving 

Ground, Maryland. 

Mr Resta is the Scientific Advisor to the Commander, 

US Army Public Health Command (Provisional), and is 

co-leader of the Army Public Health Command 

(Provisional) Transition Team, Aberdeen Proving 

Ground, Maryland. 

Articles published in  the Army Medical Department Journal are indexed in 

MEDLINE,  the  National  Library  of  Medicine’s  bibliographic  database  of 

life  sciences  and  biomedical  information.  Inclusion  in  the  MEDLINE 

database  ensures  that  citations  to  AMEDD Journal  content  will  be 

identified  to researchers during searches  for relevant information using 

any of several bibliographic search tools, including PubMed. 
 April – June 2010 11

Historically, most US wartime casualties have been 

from disease and nonbattle injuries. If proper 

precautions are not taken, diseases like malaria, 

leishmaniasis, giardiasis, and botulism can have a 

detrimental impact on military personnel, their units, 

and their missions. Preventive medicine and public 

health personnel at all levels must remain vigilant 

during deployments to protect Soldiers from 

contracting food, water, and vector-borne diseases. 

The current operational environment, with insurgents 

using unconventional, indirect attacks against US 

forces, has caused the military to prepare for a wide 

array of enemy tactics. Improvised explosive devices 

(IEDs), vehicle-borne IEDs, snipers, and suicide 

bombers have all been used against military personnel, 

local security forces, and various local nationals in the 

Iraq and Afghanistan theaters. Another unconventional 

tactic that could be used by our nation’s enemies is the 

use of biological terrorism, also known as 

bioterrorism. 

Bioterrorism is defined as the deliberate release of 

viruses, bacteria, or other pathogens to cause illness or 

death in people, animals, or plants.1

 It should be noted 

that this definition excludes macrobiotic organisms, 

such as insects, which have been used to attack 

humans and agriculture. We would expand the Centers 

for Disease Control and Prevention definition to 

recognize the history and future of bioterrorism as 

including all living organisms. Insects have the 

potential to act as effective instruments for 

bioterrorism. This article will specifically address the 

threat posed to both the US civilian population and 

military personnel from entomological terrorism. 

Entomological terrorism can be organized into 3 major 

categories: the use of insects as weapons of direct 

attacks, as agents of agroterrorism, and as disease 

vectors.2

 We would note that these categories are not 

mutually exclusive. For example, a plant disease 

vector could be an agent of agroterrorism. 

Composite risk management (CRM) is the Army’s 

primary decision-making process to identify hazards, 

reduce risk, and prevent both accidental and tactical 

loss.3

 The US Army Center for Health Promotion and 

Preventive Medicine Technical Guide 288,

4

 used by 

preventive medicine personnel, applies the CRM 

concept to vector-borne disease threats encountered by 

military personnel. Risk management in the Army, 

regardless of what is being assessed, ultimately seeks 

to preserve the fighting force for future operations. 

Technical Guide 288 provides the framework to assess 

entomological hazards faced by military personnel, but 

was not intended to serve as a guide for analyzing 

entomological terrorist threats to our nation. The 

tactics used by our adversaries in overseas contingency 

operations have in many instances focused on targets 

other than military personnel. Unconventional 

strategies used by our enemies have included terrorist 

attacks to our nation on September 11, 2001, our 

international embassies, and our allies to include the 

Iraq and Afghan governments. Bioterrorism, including 

entomological terrorism, can instill fear in a society, 

devastate economies, and cause disease throughout a 

populace. Entomological threats should be further 

evaluated with considerations given to their potential 

use in attacks by our nation’s enemies. Applying the 

Army’s CRM and using Technical Guide 288 as a 

Entomological Terrorism: A Tactic in 

 Asymmetrical Warfare 

CPT Derek Monthei, MS, USA 

CPT Scott Mueller, MS, USA 

Jeffrey Lockwood, PhD 

COL Mustapha Debboun, MS, USA 

ABSTRACT

The current operational environment presents military forces with enemies that use unconventional warfare to 

achieve their goals. Although the US government has dedicated significant resources to address threats of 

bioterrorism, the adaptive nature of our adversaries necessitates additional emphasis on bioterrorism awareness among military health professionals. This article provides an overview of 3 categories of entomological 

terrorism and examples from each category with a risk assessment. 
12 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

guide, examples of each form of entomological 

terrorism (direct attacks, agroterrorism, and disease 

vectors) are assessed in this article to illustrate their 

potential threat to the health of our nation’s military, 

economy, and society. 

DIRECT ATTACKS

Stinging insects were used for millennia in conflicts as 

a means of defending fortifications or routing enemies 

from entrenched positions.2

 It may appear that modern 

weapons have eliminated the need to conscript insects 

for such purposes, but such tactics were used by the 

Vietcong against US troops in Vietnam,2

 and their use 

by terrorists in a direct attack is not altogether 

improbable. More likely, military personnel will have 

natural exposures to biting, stinging, or toxic insects as 

part of military deployments in less sheltered 

conditions and unfamiliar environments. 

According to Technical Guide 288: 

In addition to vector-borne and zoonotic disease, 

entomological hazards during deployment also include 

those hazards associated with biting and stinging 

arthropods, animals, poisonous plants, and pesticide 

exposure. Biting and stinging arthropods can degrade 

mission readiness and combat effectiveness even 

though they are relatively free of vector-borne disease. 

These arthropods can cause casualties from secondary 

infections and even death from allergic reactions to 

their venom. Annoyance from high populations of 

pests, itching bites, and loss of sleep can also reduce 

morale.4(p2)

One documented threat to military personnel that 

could be used in a direct attack or encountered in the 

environment is the Paederus beetle.5

 Paederus is a 

genus of rove beetles (family Staphylinidae) and are 

found in the Middle East and the Asian subcontinent. 

Most species are slender, about 7 mm to 13 mm long, 

and are distinctly colored with black heads, orange 

bodies, black abdominal tips, and metallic blue or 

green elytra5

 (Figure 1). A string of suppurating sores 

appears when someone brushes away a beetle and 

inadvertently smears the insect and the toxin, pederin, 

across the skin. Less than a hundred-thousandth of a 

gram of this chemical can cause festering lesions.2

Intense pain and temporary blindness have been 

reported when pederin is introduced into the eyes. 

These sores, although not fatal, may result in lost duty 

time.6

 Ingestion of the beetle leads to severe and even 

deadly internal damage. Pederin is lethal if injected 

into the bloodstream.2

Military personnel currently conduct operations in environments throughout Iraq that support Paederus beetle populations. The entomological hazard assessment4

for Paederus beetles in these areas of Iraq was 

evaluated based on the severity and probability of 

exposure. Paederus beetles pose a “marginal” hazard 

to military personnel and the probability of receiving 

an injury by these beetles would be “occasional,” 

therefore, the risk estimate for this entomological 

threat is “moderate” in areas with Paederus beetle 

populations. Military personnel can reduce the risk of 

the typical method of exposure to these beetles by 

applying an indoor residual spray (permethrin) in tents 

(D. A. Strickman, PhD, oral communication, January 

2010), not working or resting under bright lights 

during May through July, properly wearing uniforms, 

and using window screens to help prevent Paederus

beetles and other insects from traveling toward light 

sources indoors.6

The stings and bites of insects and arthropods are one 

threat the US Army should be able to manage 

effectively. Since its adoption, the Geneva Protocol of 

1925 7 has prevented most nations from using chemical 

or biological weapons. The use of insects to vector 

pathogens is also prohibited under the Protocol. 

However, terrorists do not bind themselves to such 

protocols and could possibly employ biological 

weapons against the United States. The difficulty in 

Entomological Terrorism: A Tactic in Asymmetrical Warfare 

Figure 1: Dorsal and Ventral view of a Paederus beetle. Image 

courtesy of US Army Public Health Command (Provisional).6 
 April – June 2010 13

THE ARMY MEDICAL DEPARTMENT JOURNAL

the control of biological pathogens indicates that 

terrorists would probably use them at a location remote 

from their own territory (ie, against civilians residing 

in the United States). On the other hand, it is evident 

that terrorists are willing to both kill their countrymen 

and to die in attacks against US forces, which suggests 

that there are no places entirely safe from biological 

weapons. The 2 main entomological terrorism threats 

to the United States at home are agroterrorism and 

vector-borne disease threats. 

AGROTERRORISM

Agroterrorism is defined as: 

the deliberate introduction of an animal or plant disease 

as well as damage to crops and livestock with the goal 

of generating fear, causing economic losses, and/or 

undermining social stability.8

Insects can be agents of agroterrorism as they can 

vector plant or animal pathogens or directly damage 

economically important crops and livestock. Table 1 

identifies plant pests of significant concern in terms of 

bioterrorist potential. Many insects that are 

problematic to agriculture are invasive species. 

Invasive species can be defined as species that have a 

demonstrable ecological or economic impact and that 

have become established in a region outside of their 

native range.10 Insects that become invasive to the 

United States can arrive in various ways, including: 

 Accidental introductions of a species by global 

travel or trade 

 Species originally released for agricultural or 

economic gains that later became problematic 

pests 

 Species released in an act of bioterrorism against 

our nation 

Agriculture and livestock remain a vital part of the 

economic stability of the United States. Although 

farming employs less than 2% of the country’s 

workforce, 16% of the workforce is involved in the 

food and fiber sector, ranging from farmers and input 

suppliers to processors, shippers, grocers, and 

restauranteurs.11 The US produces and exports a large 

share of the world’s grain. In 2003, the US share of 

world production was 42% for corn, 35% for 

soybeans, and 12% for wheat. Of global exports, the 

US accounted for 65% for corn, 40% for soybeans, 

and 32% for wheat.12

Economic losses from an agroterrorist incident could 

have the following effects: 

 Value losses in terms of lost production, cost of 

destroying diseased animals or products, and cost 

of containment (drugs, diagnostics, pesticides, and 

veterinary services).8

 The imposition of trade restrictions on US exports 

by foreign nations to prevent the disease or pest 

from spreading. 

 Damage to the US economy as tourism and 

agriculturally dependent businesses suffer. 

 State and federal governments burdened by the 

significant costs associated with disease or pest 

eradication, containment efforts, and compensation to farmers for their losses. 

The Mediterranean fruit fly (Ceratitis capitata

Wiedemann), commonly known as the Medfly (Figure 

2), is a possible entomological agent that could be used 

against the United States for the purposes of 

agroterrorism. The species is found in Hawaii, but is 

not established on the US mainland . The larvae of this 

fly eat a wide variety of plants, including avocados, 

coffee, olives, tomatoes, bananas, citrus, mangos, and 

peaches.2

 If Medflies were established in California, a 

total quarantine of California fruits, both nationally 

and internationally, would result in the loss of 132,000 

jobs and $13.4 billion.13 

Medflies played the central role in a relatively recent 

entomological threat faced by our nation’s citrus 

growers. In 1989, an ecoterrorist group known as the 

“Breeders” threatened to release Medflies in California 

if the state did not stop its pesticide spraying program. 

The State of California was spraying pesticides, 

ironically, to remove Medflies that had appeared in the 

Los Angeles area.2 

Applying the criteria of Technical Guide 288, the 

severity of damage caused by Medflies to the United 

States would be “critical” and the probability of this 

pest occurring and becoming established is “likely,” 

therefore the risk assessment for this pest is “high.” 

There are mechanical, cultural, biological, and 

chemical control measures that can be used to control 

and eliminate Medflies, however, preventing the 

Medfly from establishing itself on the mainland would 

be less expensive than control measures. 
14 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

Entomological Terrorism: A Tactic in Asymmetrical Warfare 

Pest 

Common Name(s): 

Scientific Name 

Expected Range Ecological 

 Suitability b

Survey 

Difficulty c

Taxonomic 

Difficulty d

Primary 

Damage 

Potential 

Economic 

Risk 

Potential 

Environmental 

Impact 

Potential 

for 

Establishment 

Japanese wax scale:

Ceroplastesjaponicas

67% US (eastern and

western states) High High Medium OrnamentalsFruits High High High

Metallic beetle, Oak

splendor beetle: Agrilus

biguttatus

67% US (eastern and

western states) High High Medium

Oak

Beech

Chestnut

High High High

Rice cutworm, Cotton

leafworm: Spodoptera

litura

67% US (eastern and

western states) High Medium High VegetablesField crops High (Low) High

Silvery moth: Autographa

gamma

50% US (eastern and

parts of western

states)

High Medium High

Vegetables

Field Crops

Greenhouses

High (Low) High

Egyptian cotton leafworm:

Spodoptera littoralis

67% US (eastern and

western states) High Medium High

Cotton

Vegetables

Ornamentals

Forages

High (High) Medium‐

High

Passionvine mealybug:

Planococcus minor

67% US (westernand

mid‐western states) Medium High Medium Many crops High High High

Light brownapple moth:

Epiphyas postvittana 90% US High Medium High OrnamentalsFruits High (Low) Medium

Khapra beetle:

Trogoderma granarium

67% US (eastern and

western states) High Low High Stored grain High Medium High

Arrowheadscale: Unaspis

yanonensis

33% US (eastern,

portions ofmidwest

and California)

Medium High Medium

Citrus

Vegetables

Trees

High Medium High

Siberian silk moth:

Dendrolimussuperans

80% US (except parts

of westernstates) High Low Medium‐Low Conifers High High High

Ambrosia beetle: Platypus

quercivorus

33% US (eastern

states and Oregon) Medium Medium Medium OakChestnut High High Medium

Summer fruit tortrixmoth:

Adoxophyes orana

25% US (eastern

states and Oregon) Medium Low Medium Fruit High High High

Pink gypsy moth:

Lymantria Mathura

50% US (eastern and

parts of western

states)

Medium Low Low Fruit crops

Forests High High Medium

a Data adapted from the USDA Animal and Plant Health Inspection Service Mini Pest Risk Assessments.9 There is no comprehensive summary of 

agricultural threats, although these pests are representative of the agents that could be used for bioterrorism. The ratings of risk presume that each 

of the listed categories is of equal weight. The qualitative assessments were converted into scores and summed, such that “high” = 3, “medium” = 

2; “low” = 1 (in all columns “high” is associated with a quality favorable for bioterrorism). Because potential environmental impact was not explicitly 

listed for all species, this category was not included in the summed risk score (the authors’ estimates for this assessment, based on the USDA 

descriptions, are shown in parentheses). When totaled scores yielded a tie, potential environmental impact and expected range were used. 

b Ecological suitability concerns whether the pest’s life history accords with climates, soils, and host plants in the United States and the extent to 

which these ecological conditions are available. 

c Survey difficulty addresses whether the United States has methods to readily detect the pest (eg, pheromone traps and sampling methodologies) 

and the extent to which the pest and its damage remain cryptic. 

d Taxonomic difficulty reflects the ease with which the pest can be differentiated from native insects, the variability of the pest across its life stages, 

and the availability of supporting materials (eg, taxonomic keys). 

e Species evaluated in the “mini pest risk assessments” representing lower threats and not included in this table are (in alphabetic order by common 

name): Chestnut weevil, Curculio elephas; European grape vine moth or Grape berry moth, Lobesia botrana; False codling moth, Thaumatotibia 

leucotreta; Fruit piercing moth, Eudocima fullonia; Giant woodwasp, Urocerus gigas; Old World bollworm, Helicoverpa armigera; Soft wax scale, 

Ceroplastes destructor

Table 1. Exotic plant pests of greatest risk.a
 April – June 2010 15

THE ARMY MEDICAL DEPARTMENT JOURNAL

There are ways to mitigate the threat of agroterrorism 

to our nation. Monitoring, containment, and continued 

research will help prevent a terrorist event. The 

following are several suggestions to stop 

agroterrorism: 

Increase funding for research and eradication 

programs of invasive species present in the United 

States. 

Establish or continue monitoring programs for 

invasive species such as the Medfly, the Emerald 

Ash Borer (Agrilus planipennis Fairmaire) 

(monitoring in adjacent states that have not 

previously had this pest),

and the Khapra beetle 

(Trogoderma granarium

Everts), a grain and stored 

products pest. 

E n s u r e a g e n c i e s 

responsible for monitoring 

trade and security threats to 

the United States are 

train ed t o iden tify 

entomological hazards and 

deter their entry to the 

United States. Possible 

participating agencies 

include the Food and Drug 

Administration, Food 

Safety and Inspection 

Service, and US Customs 

and Border Protection. The 

a g e n c y p r i m a r i l y 

responsible for this 

function is the US Department of Agriculture 

(USDA) Animal and Plant Health Inspection 

Service (APHIS). 

DISEASE VECTORS

An intentional release of a vector-borne disease by 

adversaries of the United States is a realistic threat to 

our nation. Table 2 provides a list of arthropodtransmitted diseases that could be delivered in a 

terrorist act that pose significant risks to plant, animal, 

and human health. The adverse effects caused by the 

introduction of certain arthropod-vectored pathogens 

to the United States, whether accidental or intentional, 

could ultimately result in illness and death from 

disease or devastation of the economy. This could be 

compounded if the introduced pathogen became 

established within our nation’s borders and persisted, 

despite control and eradication efforts. Engineering 

new strains of viruses would require resources that 

typical insurgent groups do not possess at present, but 

many naturally occurring pathogens do exist that 

would need minimal effort to develop into biological 

weapons. Furthermore, the delivery of these diseases 

by terrorists to US soil could be simple and leave little 

to no evidence of the attack. 

Rift Valley fever is an excellent example of a disease 

that would require little effort to deliver to the United 

States, and could have 

devastating effects on the 

nation’s public health and 

livestock industry. Rift Valley 

fever (RVF) is caused by a 

v i r u s i n t h e f a m i l y 

Bunyaviridae and occurs in 

various regions of sub-Saharan 

Africa and Madagascar.19

Recent outbreaks in the 

Arabian peninsula, the first 

reported cases outside the 

African continent, have raised 

concerns that the disease could 

extend into Asia and Europe20

(Figure 3). Numerous mosquito 

species transmit the virus that 

causes RVF, including those 

inhabiting North America and 

the United States.21 The virus 

can be passed to an infected 

mosquito’s offspring via 

transovarial transmission, thus enabling its persistence 

and maintenance in the environment through long 

stretches of dry conditions. Eggs infected with the 

virus can lay dormant until rains arrive when they will 

then hatch, develop in the larval and pupal stages, and 

emerge as disease-carrying adults. The public health 

and economic impacts of a RVF outbreak in the US 

could far exceed anything experienced by recent West 

Nile virus events.2,22 Although these diseases spread in 

much the same manner, both the infection rate and 

proportion of those exhibiting severe symptoms are 

vastly higher in RVF. 

The intentional introduction of RVF through infected 

mosquitoes, humans, and/or livestock represents a 

Figure 2. Adult Mediterranean fruit fly. Image 

courtesy of US Department of Agriculture 

(http://www.ars.usda.gov/is/graphics/

photos/jun00/k8898-2.jpg).
16 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

serious threat to both our military and civilian 

populations, whether delivered by a terrorist or 

through accidental introduction. The RVF virus is 

transmitted to humans by the bite of an infected 

mosquito or through contact with animals/meat that 

are infected. The mild form of RVF observed in most 

human infection manifests itself in the form of flu-like 

symptoms. The more severe form of the disease 

appears in one of 3 syndromes: ocular disease, 

meningoencephalitis, or haemorrhagic fever. Using 

RVF’s approximate case fatality rate of 1%,19 the 

analysis of a hypothetical attack allows us to better 

understand the implications of such an 

outbreak. If a small community with a 

population of just 10,000 people experienced a 

10% RVF attack rate, the results would 

overwhelm the local health care infrastructure. 

Approximately 1,000 cases of the disease 

would require medical attention, with 

approximately 10 people ultimately dying from 

debilitating symptoms. In this age of constant 

news streams from cable networks (ie, CNN, 

MSNBC, Fox News), word of even a small 

outbreak of RVF would make headlines. 

The absence of human cases occurring in a 

RVF bioterrorist attack would not equate to 

failure for our adversaries. An intentional 

release of RVF would also be a form of 

agroterrorism, for the livestock losses this 

disease can cause could cripple a large part of 

our national economy. Cattle, sheep, dogs, and 

rodents are among the many animals susceptible to RVF. Outbreaks of RVF have been 

characterized by high attack rates in livestock, 

with 30% mortality and abortion rates 

approaching 100%.23 Corrie Brown, an animal 

infectious disease specialist who supervised the 

pathology section of USDA’s Plum Island 

Animal Disease Center in New York, contends 

that if an outbreak occurred in the United 

States, domestic beef exports would shut 

down.2,24 This impact on the beef industry 

would result in a $3 billion (109

) loss to the 

economy.2,24 

The composite risk assessment for the threat of 

RVF being delivered in an act of terrorism was 

estimated to be a “high" due to its “critical” severity and its probability occurrence “likely.”4

Control measures that can mitigate the risk of RVF 

include: 

 Continue mosquito surveillance programs to both 

monitor various pathogen infection rates (ie, West 

Nile and Eastern Equine Encephalitis) in vector 

populations as well as maintain preparedness in 

the event of an RVF or other mosquito-borne 

disease outbreak. 

 Monitor conditions suitable for RVF outbreaks 

(eg, regional flooding, hurricanes) to focus 

mosquito control and surveillance efforts. 

Entomological Terrorism: A Tactic in Asymmetrical Warfare 

Disease Vector(s) Pathogen Host(s) 

Chikungunya Mosquitoes Virus Humansb

Yellow fever Mosquitoes Virus Humansc

Japanese encephalitis Mosquitoes Virus Humans, pigs, birds

Rift Valley fever Mosquitoes Virus Humans, livestock,

birds

Lumpy skin Mosquitoes and

other flies Virus Cattled

African horse sickness Biting midges Virus Horses

Russian spring‐summer

encephalitis Ticks Virus Humanse

Crimean‐Congo

hemorrhagic fever Ticks Virus Humansf

Cattle tick fever Ticks Virus Cattle

Africanswine fever Ticks Virus Pigs

New World screwworm Adult screwworms

flies NA Mammalian

livestockg

Tomato yellow leaf curl Whiteflies Virus Tomatoesh

Citrus chlorotic dwarf Whiteflies Virus Citrus

Citrus variegated

chlorosis Leafhoppers Virus Citrus

Lime witches’ broom Leafhoppers Phytoplasma Lime

Pierce’s disease Leafhoppers Bacterium Grapes

Potato wilt or brown rot Leafhoppers,

beetles, aphids Bacterium Potatoesi

Citrus greening Psyllids Bacterium Citrus

a Data sources: US DA,9 Frazier and Richards on,14 G eissler,15 P elzel,16 Wilson et al,17 and World Health 

Organization.18

b Various nonhuman animals can serve as reservoirs. 

c

 Other pri mates can serve as res ervoirs. 

d Insect vectors are highly suspected but have not been specifically identified. 

e Small mammals can serv e as reservoi rs. 

f

 Small mammals and domestic livestock can serve as reservoirs. 

g

 Infestations of sc rewworms are not a disease in the classic sense but share many important 

commonalities with pathogenic infections. 

h Localized infections have been found in California, but the disease is not yet established. 

i

 Insect vectors are highly suspected based on ex periments with closely related diseases but have not been 

specifically identified. 

Table 2. Arthropod-transmitted exotic diseases of potentially 

significant risk to plant, animal, and human health.a

 
 April – June 2010 17

THE ARMY MEDICAL DEPARTMENT JOURNAL

 Develop and rehearse RVF outbreak response 

plans to be implemented by the Department of 

Homeland Security (DHS) and Federal Emergency 

Management Agency. 

 Ensure RVF vaccine could be readily available for 

the public in the event of an outbreak. An 

inactivated vaccine has been developed for human 

use. However, this vaccine is not licensed and is 

not commercially available. It has been used 

experimentally to protect veterinary and laboratory 

personnel at high risk of exposure to RVF. Other 

candidate vaccines are under investigation.20

 Institute a mobile, federal vector control force that 

could respond to such emergencies. 

Various state, federal, and international entities have 

recognized the threat of RVF and have implemented 

some of the above control measures. Contingency 

planning, predictive disease modeling, and outbreak 

response exercises represent some of the recent 

developments to combat RVF threats in both endemic 

and potentially exposed geographic regions. The Food 

and Agriculture Organization (FAO) of the United 

Nations is just one of the international agencies 

providing guidelines for development of RVF 

contingency plans.25 The FAO provides vital 

information for animal and human health authorities of 

individual countries by specifying RVF details 

regarding risk analysis, prevention strategies, early 

warning signs, forecasting, and control strategies. 

Weather patterns and anomalies have been used 

recently to model and predict RVF outbreaks. In 

Africa, outbreaks of RVF are integrally tied to 

widespread elevated rainfall, and the subsequent 

flooding and increase in vegetation.26 Risk mapping 

using climate and normalized difference vegetation 

index data led to the first prediction of an RVF 

outbreak from December 2006 to May 2007.27 The 

predicted RVF occurrence provided a warning period 

of 2 to 6 weeks that facilitated response and mitigation 

Countries with endemic disease and 

substantial outbreaks of RVF: 

Gambia, Senegal, Mauritania, Namibia, South Africa, 

Mozambique, Zimbabwe, Zambia, Kenya, Sudan, Egypt, 

Madagascar, Saudi Arabia, Yemen 

Countries known to have some cases, 

periodic isolation of virus, or serologic 

evidence of RVF: 

Botswana, Angola, Democratic Republic of the Congo, 

Congo, Gabon, Cameroon, Nigeria, Central African 

Republic, Chad, Niger, Burkina Faso, Mali, Guinea, 

Tanzania, Malawi, Uganda, Ethiopia, Somalia 

Figure 3: Rift Valley Fever Distribution Map. Graphic courtesy of the US Centers for Disease Control and Prevention 

(http://www.cdc.gov/ncidod/dvrd/spb/mnpages/dispages/rvf/rvfmap.htm). 
18 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

activities. The outbreak that subsequently occurred 

validated the utilization of risk mapping models to 

predict future RVF events. 

While contingency plans and outbreak predictions 

provide the logistical framework and science needed, 

rehearsing the execution of epidemic disease 

scenarios, with all responding agencies involved, 

ultimately provides the best gauge of response 

preparedness. In November 2008, Paul Gibbs, PhD, 

from the College of Veterinary Medicine at the 

University of Florida supervised a multiagency test of 

Florida’s response to a hypothetical introduction of 

RVF (http://www.flsart.org/rvf/index.htm). 

Incorporating various state and federal participants, 

including the DHS, the Federal Bureau of 

Investigation, and the USDA, the exercise trained 

major stakeholders to collaborate in response to an 

introduction of RVF virus into Florida. In light of the 

original event’s success, 2 additional RVF exercises 

were planned and conducted in Puerto Rico and the 

Virgin Islands by Dr Gibbs and Dana McDaniel, 

DVM, in 2010 (Dr McDaniel, oral communication, 

March 2010). 

The control measures discussed could reduce the 

impact from an RVF outbreak, whether the virus is 

delivered by terrorists or arrives by accident. Without 

further scientific advances in RVF forecasting, vaccine 

development, vector control, and diagnostic 

capabilities, it may be unrealistic to expect to attain the 

necessary resources required to build and maintain 

comprehensive control measures to eliminate the threat 

to our nation of RVF and similar vector-borne 

diseases. We conclude that the residual risk associated 

with the threat of RVF, and other vector-borne 

diseases, remains “high.” 

DISCUSSION

Entomological terrorism, regardless of its form, is a 

current and future threat faced by the United States. 

The estimated risks of the threats outlined in this 

article are speculative, however, it would be difficult 

to argue that the hazards associated with entomological terrorism are negligible. The US government 

has long recognized the consequences of biological 

warfare. The federal agencies conducting research and 

development on vector-borne diseases and crop pests 

include, but are not limited to the following: 

 DHS: National Center for Foreign Animal and 

Zoonotic Disease Defense, and US Customs and 

Border Protection 

 US Army Medical Research Institute of Infectious 

Disease (USAMRIID) 

 Walter Reed Army Institute of Research 

 USDA–Agricultural Research Service (ARS) and 

Animal and Plant Health Inspection Service 

Additionally, some local abatement districts, a few 

state governments (ie, Florida, California), and numerous universities have also made significant contributions to research on vector-borne infectious diseases. 

Merely studying the biology of a disease does not 

prepare us for response to an actual outbreak. Many 

aspects of an appropriate response to an entomological 

emergency still must be addressed, including: 

Is the pest management community prepared for 

an outbreak with the necessary equipment and 

knowledge to implement control techniques? 

Can pest management resources be quickly 

consolidated, mobilized, and deployed to outbreak 

locations? 

Are emergency organizations prepared with 

individual response plans for specific entomological threats, especially those posing high risk? 

Accidental introductions of invasive arthropod species 

have a higher likelihood of occurring than intentional 

deliveries through terroristic plots. Military personnel 

moving to and from forward deployed environments 

can do their part in preventing the introduction of 

invasive species by thoroughly inspecting cargo transported by military transportation vehicles and by 

conducting retrograde washdowns of vehicles and 

equipment after a deployment.28 The importance of 

preventing invasive species is illustrated by the costs 

currently incurred by these species in the United 

States. Damage caused by invasive species currently in 

the United States is estimated at $120 billion to $138 

billion each year.29 Crop losses and control costs due 

to invasive insects and pathogens were estimated at 

$25 billion in 2005.29 There are approximately 500 

invasive insect and mite species in crops and an 

estimated 20,000 species of microbes, including 

introduced plant pathogens, that have invaded the 

United States thus far.29 Additional invasive species 

Entomological Terrorism: A Tactic in Asymmetrical Warfare 
 April – June 2010 19

THE ARMY MEDICAL DEPARTMENT JOURNAL

would only compound the problem and costs caused 

by these pests. 

Even with proper systems and technological advances 

in place to prevent attacks or mitigate the effects of 

disasters, the United States still faces a deficiency in 

the number of trained, qualified healthcare professionals. A large portion of the healthcare workforce 

(including public health professionals, clinicians, and 

related healthcare fields) in the United States is 

approaching retirement age.30 Health professionals are 

not being trained at a rate needed to fill the loss of 

retirees.30 Federal (including the US Army) and state 

agencies responsible for emergency preparedness and 

response will soon face personnel challenges requiring 

additional efforts to educate, train, and retain such 

public health professionals. A terrorist attack, 

especially with a biological weapon, would be more 

devastating if the medical infrastructure is poorly 

prepared, staffed, and funded. 

CONCLUSION

Vector-borne diseases are a current threat because of 

the self-perpetuating capabilities and delayed 

morbidity and mortality following exposure or 

infection.31 Most disease causing organisms used as 

biological weapons, particularly the zoonoses, can be 

delivered to a target population without risk of 

immediate detection.31 This article illustrates that 

insects and other arthropods can be used by an enemy 

to attack US military personnel and civilians. Some 

recommendations on how to mitigate the specific 

threats given (ie, Paederus beetles, Medfly, Rift 

Valley fever) were presented, however, all military 

personnel can mitigate vector-borne disease threats by 

taking relatively simple actions. 

Deploying Soldiers and DoD personnel should 

practice operational risk management (ORM) for 

infectious diseases. Excellent resources for 

understanding and following ORM are Technical 

Guide 288,

4

 as well as the website for the National 

Center for Medical Intelligence (http://

www.phsource.us/PH/MI/index.htm). 

Personal Protective Measures should be implemented when training within the United States and 

when deploying outside the country. Treating uniforms with permethrin, or purchasing uniforms 

that are pretreated with permethrin, as well as 

using N,N-diethyl-3-methylbenzamide (deet) on 

exposed skin can reduce the likelihood of contracting mosquito- or tick-borne diseases during field 

training. The use of personal protective measures 

will not only help protect the individual from a 

new emerging vector-borne disease like RVF, but 

also prevent Soldiers from contracting Rocky 

Mountain spotted fever, Lyme disease, West Nile 

virus, Ehrlichiosis, and other vector-borne diseases 

present in the United States. 

Military personnel conducting food and water 

vulnerability assessments32 or retrograde 

operations are critical players in security by 

helping protect food and water from exposure to 

biological agents and by preventing them, 

including vectors and invasive species, from 

entering the country. 

Invasive pests and the diseases they may carry 

represent a threat that is magnified when terrorism is 

involved. The research conducted by academic institutions, a host of federal agencies (eg, USDA-ARS) and 

the US military (eg, USAMRIID), coupled with 

entities capable of organizing emergency response 

activities (eg, DHS, Federal Emergency Management 

Agency, state and local authorities), provide the critical framework needed to address the entomological 

threats we face. It would be ideal to provide a definitive countermeasure to entomological terrorism, 

however, this may be unfeasible due to the financial 

and logistical challenges involved. The most critical 

countermeasure to entomological terrorism is the same 

for any form of terrorism—vigilance by the US military, government agencies, citizens, and our allies.31

ACKNOWLEDGEMENTS

We thank Dan Strickman, PhD, Alex Gerry, PhD, LTC 

Mark Carder, LTC Timothy Bosetti, LTC Robert Richards, 

MAJ Robert Lowen, CPT Wes McCardle, and Jim Harrison 

for constructive comments and review of this article. 

REFERENCES

1. CDC (Centers for Disease Control and Prevention). 

Bioterrorism Overview Page. Available at: http://

www.bt.cdc.gov/bioterrorism/overview.asp. Updated 

February 12, 2007. Accessed December 26, 2009. 

2. Lockwood JA. Six-legged Soldiers: Using Insects as 

Weapons of War. New York, NY: Oxford University 

Press, Inc.; 2009. 
20 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

3. Field Manual 5-19: Composite Risk Management. 

Washington, DC: Dept of the Army. August 2006. 

4. Technical Guide 288: Entomological Operational 

Risk Management. Aberdeen Proving Ground, MD: 

US Army Public Health Command (Provisional). 

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

TG288.pdf. Accessed April 15, 2010. 

5. Davidson SA, Norton SA, Carder MC, Debboun M. 

Outbreak of dermatitis linearis caused by Paederus 

ilsae and Paederus iliensis (Coleoptera: 

Staphylinidae) at a military base in Iraq. Army Med 

Dept J. July-September 2009:6-15. 

6. Just the Facts...Paederus Beetles 18-071-1108. 

Aberdeen Proving Ground, MD: US Army Public 

Health Command (Provisional). November 2008. 

Available at: http://usachppm.apgea.army.mil/

Documents/FACT/PaederusBeetleFactSheet.pdf. 

Accessed December 28, 2009. 

7. Protocol for the Prohibition of the Use of 

Asphyxiating, Poisonous or Other Gasses, and of 

Bacteriological Methods of Warfare. Geneva, 

Switzerland: Conference for the Supervision of the 

International Trade in Arms and Ammunition; June 

17, 1925. Available at: http://www.icrc.org/IHL.NSF/

FULL/280?OpenDocument. Accessed December 26, 

2009. 

8. Monke J. Agroterrorism: Threats and Preparedness. 

Washington, DC: Congressional Research Service; 

March 12, 2007:1. CRS Report for Congress Order 

Code RL 32521. Available at: http://www.fas.org/

sgp/crs/terror/RL32521.pdf. Accessed December 27, 

2009. 

9. Mini Pest Risk Assessments page. USDA Animal and 

Plant Health Inspection Service Website. Available 

at: http://www.aphis.usda.gov/plant_health/

plant_pest_info/pest_detection/mini-pra.shtml. 

Accessed March 12, 2010. 

10. Lockwood JL, Hoopes MF, Marchetti MP. Invasion 

Ecology. Malden, MA: Blackwell Publishing Ltd; 

2007. 

11. USDA Economic Research Service. Table 1: Key 

Statistical Indicators of the Food & Fiber Sector, 

April 2005. Available at: http://www.ers.usda.gov/

publications/agoutlook/aotables/2005/04apr/. 

Accessed April 19, 2010. 

12. US Bureau of the Census. Statistical Abstract of the 

United States: 2004-2005. 124th ed. Washington, 

DC: US Bureau of the Census Agriculture; 2005. 

Available at: http://www.census.gov/prod/2004 

pubs/04statab/agricult.pdf. Accessed April 19, 2010. 

13. Root-Bernstein RS. Infectious terrorism. Atlantic 

Monthly. 1991; May: 44-50. 

14. Frazier TW, Richardson DC, eds. Food and 

agricultural security: guarding against natural threats 

and terrorist attacks affecting health, national food 

supplies, and agricultural economics. Ann New York 

Acad Sci. 1999;894:1-232. Theme issue. 

15. Geissler E, ed. Biological and Toxin Weapons Today. 

New York, NY: Oxford University Press; 1986. 

16. Pelzel AM. Cattle fever tick surveillance in Texas. 

NAHSS Outlook [serial online]. August 2005. 

Available at: http://www.aphis.usda.gov/vs/ceah/

ncahs/nsu/outlook/issue7/cattle_fever_tick_ 

surveillance.pdf. Accessed April 12, 2010. 

17. Wilson TM, Logan‐Henfrey L, Weller R, Kellman B. 

2000. Agroterrorism, biological crimes, and 

biological warfare targeting animal agriculture. In: 

Brown C, Bolin C, eds. Emerging Diseases of 

Animals. Washington, DC: ASM Press; 2000:23‐57. 

18. World Health Organization. Global early warning 

system for major animal diseases, including 

zoonoses. Available at: http://www.who.int/zoonoses/

outbreaks/glews/en/index2.html. Accessed March 24, 

2010. 

19. Center for Disease Control and Prevention. Rift 

Valley Fever Fact Sheet. Available at: http://

www.cdc.gov/ncidod/dvrd/spb/mnpages/dispages/rvf/

rvf_qa.htm. Updated January 2, 2007. Accessed 

January 17, 2010. 

20. World Health Organization. Rift Valley fever. 

Available at: http://www.who.int/mediacentre/

factsheets/fs207/en/. Updated September 2007. 

Accessed January 18, 2010. 

21. Gargan TP, Clark CG, Dohm DJ, Turell MJ, Bailey 

CL. Vector potential of selected North American 

mosquito species for Rift Valley fever virus. Am J 

Trop Med Hyg. 1988;38:440-446. 

22. Selim J. Virus code red. Discover Mag. March 

2005:14. 

Entomological Terrorism: A Tactic in Asymmetrical Warfare 
 April – June 2010 21

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23. Patrick KW, ed. Military Preventive Medicine: 

Mobilization and Deployment. Vol 2. Washington, 

DC: Office of The Surgeon General, Dept of the 

Army; 2005:825. 

24. McGinnis D. Looking for loopholes. Beef Mag. July 

2004. Available at: beefmagazine.com/mag/beef_ 

looking_loopholes/. Accessed April 19, 2010. 

25. FAO Animal Health Manual No. 15: Preparation of 

Rift Valley fever (RVF) contingency plans. Rome, 

Italy: Food and Agriculture Organization of the 

United Nations; 2002. Available at: ftp://ftp.fao.org/

docrep/fao/005/y4140e/y4140e00.pdf. Accessed 

February 18, 2010. 

26. Davies FG, Linthicum KJ, James AD. Rainfall and 

epizootic Rift Valley fever. Bull World Health 

Organ. 1985;63:941-943. 

27. Anyamba A, Chretien J, Small J, et al. The first 

prediction of a Rift Valley fever outbreak. PNAS: 

Proc Natl Acad Sci USA. 106.3 2009:955-959. 

28. Technical Guide 31: Retrograde Washdowns: 

Cleaning and Inspection Procedures. Washington, 

DC: Armed Forces Pest Management Board. March 

2008. 

29. Pimentel D, Zuniga R, Morrison D. Update on the 

environmental and economic costs associated with 

alien species in the United States. Eco Econ. 

2005;52:273-288. 

30. American Association for the Advancement of 

Science. Center for Science, Technology and Security 

Policy Page. Available at: http://cstsp.aaas.org/

content.html?contentid=2215. Accessed February 17, 

2010. 

31. Kendall RJ, Presley SM, Austin GP, Smith PN, eds. 

Advances in Biological and Chemical Terrorism 

Countermeasures. Boca Raton, FL: CRC Press; 2008. 

32. Technical Guide 188: US Army Food and Water 

Vulnerability Assessment Guide. Aberdeen Proving 

Ground, MD: US Army Public Health Command 

(Provisional). July 2008. 

AUTHORS

CPT Monthei is a Medical Entomologist, Entomological Sciences Division, US Army Public Health 

Command (Provisional) Public Health Region–West, 

Joint Base Lewis-McChord, Washington. 

CPT Mueller is a Medical Entomologist, Entomological 

Sciences Division, US Army Public Health Command 

(Provisional) Public Health Region–North, Fort Meade, 

Maryland. 

Dr Lockwood is Professor of Natural Sciences and Humanities at the University of Wyoming, Laramie, WY. 

He is the author of Six-Legged Soldiers: Using Insects 

as Weapons of War (2009, Oxford University Press). 

COL Debboun is Program Manager, Medical Education 

Training Campus Transition, and Chairman of the 

AMEDD Journal Editorial Review Board, US Army 

Medical Department Center & School, Fort Sam 

Houston, Texas. 
22 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

Issues Related to Burn Pits in 

 Deployed Settings 

Coleen Baird Weese, MD, MPH 

NOT ANOTHER AGENT ORANGE

In August of 2009, President Barack Obama promised 

that burn pits would not become another “Agent 

Orange.”1

 Agent Orange was a defoliant used by the 

US military in Vietnam, and Veterans expressed 

concerns that their exposure led to a range of health 

conditions. This eventually resulted in the Agent 

Orange Act of 1991.2

 This legislation addressed the 

presumption of service connection for diseases 

associated with exposure to certain herbicide agents. 

According to this act, any Veteran who served in the 

Republic of Vietnam and developed Type II diabetes; 

Hodgkin’s disease; Non-Hodgkin’s lymphoma; 

peripheral neuropathy; porphyria cutanea tarda; 

prostate cancer; certain soft tissue sarcomas; cancer of 

the lung, bronchus, or larynx; or chloracne and who 

did not have such a condition prior to service has 

presumed service connection. These are based on the 

Institute of Medicine’s* assessment of diseases related 

to Agent Orange exposure, specifically dioxin or 2, 4-

dichlorophenoxyacetic acid. The Institute of Medicine 

regularly evaluates other associations and the strength 

of the association. This information is provided to the 

Secretary of the Department of Veterans Affairs.3

 In 

2009, this list was extended to include B-cell 

leukemias, Parkinson’s disease, and ischemic heart 

disease.4

 The legislation ensures that Veterans do not 

have to prove an exposure, and thus if they have any of 

these conditions, it is “presumed” to be related to their 

service if they served in Vietnam. This speeds up the 

process of obtaining benefits.5

 Interestingly, type II 

diabetes, ischemic heart disease, and prostate cancer 

are relatively common diseases in aging populations. 

Many Veterans had expressed dissatisfaction that this 

legislation was not passed until 1991—many years 

after the Vietnam War. The Institute of Medicine held 

its first meeting to address exposures to burn pit smoke 

on February 23, 2010. 

Burn pits (Figure 1) have been the subject of Soldier 

concerns, media attention, and Congressional inquiries 

and legislation. A recent, simple Google search of the 

term “burn pits” brought up over 25 pages of pertinent 

media articles, websites, and discussions of lawsuits. 

AN OLD PROBLEM, WITH SOME NEW TRASH... 

Trash and solid waste have required attention as long 

as there have been armies and conflicts. Human 

activity generates waste. In the United States, each 

person generates approximately 4 to 6 pounds of waste 

per day.6(p455) Solid waste may consist of a variety of 

materials to include 

...any garbage, refuse, sludge, and other discarded 

material including solid, liquid, semisolid or gaseous 

material resulting from industrial, commercial, 

agricultural operations and community activities.7

Proper solid waste management is important from a 

public health perspective. Improper disposal may 

potentially result in groundwater contamination with 

radioactive substances, chemicals, or by pathogenic 

organisms. Uncontrolled wastes also attract insects, 

rodents, or other vermin that may become vectors for 

disease organisms. In addition, it is a nuisance, 

aesthetically unpleasing, generates foul odors, and 

attracts animals. Military preventive medicine 

Figure 1. A section of an operating burn pit in Afghanistan, 

2009. (Photo provided by the author) 

*The Institute of Medicine, established in 1970 under the National Academy of Sciences, provides unbiased, evidence-based, 

authoritative information and advice on issues relating to biomedical science, medicine, and health to policy makers, 

professionals, leaders, and the public at large. Information available at: http://www.iom.edu/About-IOM.aspx. 
 April – June 2010 23

physicians have long noted the importance of 

appropriate waste handling. 

During the Spanish American War, when the city of 

Santiago, Cuba surrendered to General William 

Shafter on July 17, 1898, one of the first orders of 

business was the recognized necessity to clean up the 

city, resulting in the removal of 200 loads of trash per 

day for the first 2 months.8

 Similarly, MAJ Lewis 

Balch, Brigade Surgeon, made the following 

observation about the city of Trinidad: 

To insure the health of the troops in this province, 

necessary sanitary work should be done quickly... The 

camps are near towns. Disease is to be feared from 

these towns... It is therefore just as necessary that 

sanitary measures for prevention, the cleaning of 

streets, garbage collection, disinfection, reports of 

contagious disease, its location and character, the 

isolation of infected persons or things, and such like 

measures be taken, as it is to have camps pitched in 

healthy localities and properly policed.9

In deployed settings, there are a variety of conditions 

that may affect the process of waste disposal. There 

may be minimal to no waste stream segregation, 

disposal infrastructure, or technology to support 

incineration and landfills for disposal options. There 

may be local individual and neighborhood disposal 

sites that utilize dumping above ground and burning. 

Vermin control may be minimal. In many locations, if 

military waste is concentrated at a burn pit or disposal 

site, locals may attempt to scavenge the site for items 

for their own use or resale. During a recent observational visit to some locations in Iraq and Afghanistan, waste handling was observed to differ somewhat 

based on the location and maturity of the camp. Base 

camps located in more urban locations with means to 

use local nationals may have formal waste removal, 

with hauling to a recycling center where segregation of 

recyclables is performed. This can provide local jobs. 

At other isolated locations, recycling is less feasible 

because segregated materials must be transported 

somewhere. Typically, hazardous materials must be 

packaged and shipped out of theatre. This is not 

always possible, and as Miller and Roberts point out, 

However, if there is not a supporting infrastructure or 

contracting possibilities, or if units are not located near 

such support, or if other tactical considerations prohibit 

such arrangements, then field disposal methods must be 

employed. Generally, the options are burial, incineration, or a combination of these two methods.6(p450) 

The nature and composition of trash has changed over 

the years, as bottled water becomes the norm, Styrofoam is used for food containers, and individuals have 

personal electronics like computers, music players, and 

cellular phones, many with batteries. This adds 

complexity to waste handling and sorting (Figure 2). 

The plastics most commonly encountered include 

polystyrene, polyethylene, and polyethylene 

terephthalate, which is used in single use drink bottles 

(Figure 3). These plastics contain carbon, hydrogen, 

and oxygen, and with sufficient oxygen can be 

completely converted to carbon dioxide and water 

when burned at high temperature. These are not toxic. 

However, burn pits are inherently difficult to control 

with respect to temperature and oxygenation, and thus 

intermediate compounds may be formed. Additionally, 

polyvinyl chloride or other plastics containing chlorine 

may form dioxins when burned. An article reviewing 

Figure 2. Solid waste material sorting area at Joint Base 

Balad, Iraq. (Photo provided by the author.) 

Figure 3. A pile of plastic water bottles at the Joint Base 

Balad solid waste material sorting area at Joint Base Balad, 

Iraq. (Photo provided by the author.) 
24 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

the emissions of organic air toxics from open burning 

noted that due to less than ideal combustion 

conditions, open burning generates soot and particulate 

matter, carbon monoxide, methane and other light 

hydrocarbons, volatile organic compounds, and 

semivolatile organic compounds including polycyclic 

aromatic hydrocarbons. Depending on the source, 

dioxins and furans and polychlorinated biphenyls 

(PCBs) may be produced, as well as metals such as 

lead and mercury. As open burning is not regulated, I 

found only 4 citations which provided sampling data 

from open burning at landfills. Of the four, one had 

data on criteria pollutants, two had data on semivolatile organics, and two had information on dioxins, 

furans, and PCBs. None had information on metals or 

acid aerosols.10

JOINT BASE BALAD

Joint Base Balad is one of the largest air bases in Iraq, 

and was home to 25,000 military, civilian, and 

coalition personnel. Since 2003, burn pits have been 

used to facilitate solid waste disposal activities at 

Balad.11(p3) The burn pit, estimated at 10 acres in size, 

was the largest in Iraq. It was estimated that about 2 

tons of material per day was burned in the early stages 

of troop deployment, but by 2008 it was noted that it 

might be as high as several hundred tons per day. 

“Rough sort” was accomplished where flammables, 

ammunition, and bulk metals were removed. The pit 

did not always effectively burn the volume of wastes 

generated, and smoke had been known to blow over 

living areas under various weather conditions.11(p3)

Although incinerators had been obtained for the base, 

they were not operational due to some contractual 

issues. During the period of 2005-2006, some samples 

were collected by preventive medicine personnel, with 

occasional detections of volatile organic compounds 

and dioxin, but not at levels associated with any health 

effects. From January 2007 through April 2007, a 

sampling effort was conducted by onsite military 

public health personnel, with support from the Air 

Force Institute for Operational Health (AFIOH) and 

the Army Center for Health Promotion and Preventive 

Medicine (now the Army Public Health Command 

(Provisional)). As described in the report, 

The air sampling targeted expected emissions from the 

burn pit to include particulate matter, volatile organics, 

metals, polycyclic aromatic hydrocarbons, and 

polychlorodibenzodioxins/furans (dioxins and furans). 

Sampling locations were selected to represent typical 

and maximum exposure levels for the general 

population. The samples were collected over multiple 

24 hour periods to account for some of operational and 

meteorological variability in exposure levels. A total of 

163 samples were collected resulting in 4811 individual 

analyte results.11(pES-2)

Sample results were compared to military exposure 

guidelines (MEGs). These are values below which no 

health effects are anticipated for the associated 

exposure duration. These values and their applications 

have been reviewed by the Committee on Toxicology 

of the National Academy of Sciences.12 The one-year 

MEGs assume an exposure to that concentration for 

one year. If a chemical is detected above this MEG, it 

will not necessarily be a health concern as the MEG 

assumes a one-year exposure, which would not be the 

case if the source is identified and rectified, or if 

conditions are variable. The one-year MEGs were 

exceeded in 52 samples, of which 50 were for 

particulate matter (PM) less than 10 μm in diameter 

(PM 10). Particulate matter levels were typical of what 

would be expected in the region, and were similar to 

background levels not in proximity to the burn pit. PM 

has previously been identified as a common exposure 

due to blowing dust, vehicle emissions, and other 

sources. While it did not appear that the burn pits 

significantly increased particulate matter levels, PM 

from combustion may vary in composition from more 

typical regional particulate matter associated with 

crustal material such as dust. All PM samples were 

analyzed for metal concentrations, and no metal was 

detected above a one-year MEG in these samples. 

Apart from particulate matter, MEGs for volatile 

organic compounds (VOCs) were exceeded twice. 

Concentrations of acrolein and hexachlorobutadiene 

exceeded the MEG in one of 44 samples. Each sample 

was analyzed for 77 different VOCs. No other VOCs 

were detected in the other 43 samples. No dioxins or 

furans were detected above a one-year MEG in any of 

the 32 samples analyzed for dioxins and furans. No 

polycyclic aromatic hydrocarbons (PAHs) were 

detected above a one-year MEG in any of the 30 

samples analyzed for PAHs.11(p5)

The results were used for a composite risk 

management estimate (also sometimes called an 

operational risk management estimate) that focuses on 

mission impact. This methodology uses comparisons 

to the MEGs, and then evaluates the severity of the 

health risk (how high was the level?) and the 

Issues Related to Burn Pits in Deployed Settings 
 April – June 2010 25

THE ARMY MEDICAL DEPARTMENT JOURNAL

probability of occurrence (was anyone exposed for the 

duration? How frequently was it detected?). The 

subsequent risk estimate for exposure to all substances 

analyzed in this sampling effort was considered low, 

not considering PM 10. The single acrolein measurement which was above the one-year MEG was below 

the 14-day MEG. This suggests that an occasional 

finding at that level would not be a concern. Acrolein 

can be irritating to eyes, nose, and lungs at levels much 

higher than measured, or if exposure is continuous for 

long periods. The single hexachlorobutadiene sample 

result was above the one-year MEG, but below the 8-

hour MEG. This suggests that the measured level was 

not sufficient to cause an acute effect, but, on the other 

hand, it would be important to see that this was an 

infrequent detection. Hexachlorobutadiene is a solvent 

that can cause dizziness or headache at an elevated 

level. Given that these compounds were detected over 

the most conservative one-year screening level only 

once, the probability that individuals would be 

exposed to elevated levels for an entire year was 

considered unlikely.13

The data from the Balad burn pit sampling effort was 

used in a quantitative screening human health risk 

assessment, using the Human Health Risk Assessment 

Guidance for Superfund methodology outlined by the 

US Environmental Protection Agency (EPA).14 This 

evaluation uses comparison values which are designed 

for longer term exposure scenarios of the general 

population, including children and the elderly. It 

allows for theoretical or probabilistic cancer risk 

estimates based on time at site used for the exposure 

scenarios as well as additive assessment of 

carcinogenic (cancer) risk. It uses what is termed 

exposure point concentrations (EPCs), calculated as 

the 95th upper confidence limit of the mean of each 

chemical, which is very conservative. Risks were 

calculated assuming a 24-hour/ 7 day per week exposure, for 12 months, 4 months, and one month. 

Additionally, a combined EPC was derived, as well as 

EPCs representing various locations where sampling 

occurred. Using this methodology, both noncancer and 

cancer risk were “acceptable” or “safe” as per the EPA 

classification. Two incinerators became operational at 

Balad by July 2007, and plastic segregation (Figure 3) 

and other measures such as disposal of cooking oil and 

grease were instituted. Additional sampling was 

conducted in October and November of 2007 with 

results that again showed some infrequent detections 

of volatile organic compounds. By April 2008, a third 

incinerator was operational. By June of 2009, more 

incinerators were operational, others were being 

installed (Figure 4), and open burning had been 

reduced to approximately 10 tons per day. The burn pit 

was closed on October 1, 2009. 

While many of the assumptions or applications of data 

in the risk assessment were conservative which might 

point to an overestimation of risk, the screening health 

risk assessment could not definitively address all 

concerns regarding human health risk for several 

reasons. The methodology does not incorporate PM 10 

or PM 2.5 concentrations. PM is a mixture, and does 

not have a toxicological value for use in the 

methodology. The list of analytes was not exhaustive. 

The sampling was conducted over a 4-month period, 

and represents conditions during that time. The waste 

streams can vary, and analyte concentrations would be 

presumed to vary. In short, if meteorological 

conditions are variable and waste streams change, it is 

difficult to generalize. Screening health risk 

assessments indicate the general probability that a risk 

is present under very specific exposure conditions. 

This can be useful to make decisions regarding the 

need to take remedial actions, but is not well-suited to 

inform regarding an individual’s risk for a health 

outcome. All risk assessments have stated assumptions 

and limitations which tend to be overlooked in 

summary statements communicated to individuals not 

familiar with the methodology. The US Central 

Command (CENTCOM) worked rapidly to declassify 

the report to make it available to interested parties, and 

risk communication was conducted, but it is unknown 

as to whether the report actually relieved people’s 

concerns. It is of interest to note that if the report was 

evaluated in a vacuum, most risk managers would see 

Figure 4. Incinerators in operation at Joint Base Balad, Iraq, 

November 2009. (Photo provided by the author.) 
26 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

it as evidence that the situation did not require 

remedial actions, although they might request 

additional data to cover information gaps, such as 

sampling for different analytes, or in a different 

season. 

The use of PM 10 measurements to address chronic 

risk is still under consideration. Relative to the United 

States, high levels of PM 10 and PM 2.5 are common 

in the CENTCOM areas.15 Acute effects include eye 

and respiratory irritation and potential aggravation of 

asthma. To address long-term risk, variable daily PM 

exposure levels must be considered. Under the 

Ambient Air Quality Standards for PM 10, the EPA 

identifies short term health effects associated with 

acute, daily exposure levels.16 Health effects 

associated with long-term exposure to elevated levels 

of particulate matter have been suggested, such as 

increased rates of chronic obstructive pulmonary 

disease (asthma, bronchitis), but the aggregate levels 

of exposure related to increased risks are not clearly 

defined. In 2009, the US Army Public Health 

Command (Provisional) (USAPH (P)) asked the 

Committee on Toxicology of the National Academy of 

Sciences to review an extensive enhanced particulate 

matter sampling effort which sampled for particulate 

matter every sixth day for one year at 15 sites in the 

CENTCOM area of responsibility.17 A key question is 

how to use this data to understand risk of health 

effects. A report is expected this year.18 

The Defense Health Board (DHB) reviewed the 

conclusions of the initial screening health risk 

assessment. The DHB is an independent board 

comprised of experts from private industry and 

universities. The DHB agreed with the conclusion that 

no long-term health effects should be expected due to 

dioxin or the analytes measured and used in the risk 

assessment. However, that statement is not equivalent 

to definitive, long-term health risk. Conclusions 

regarding long-term risk are limited by the short-term 

nature of the sampling event. The DHB also made 

some recommendations and offered to remain engaged 

on the issue.19 Currently, a strategy for additional 

sampling is under evaluation. 

The goal of preventive medicine efforts is the 

elimination or reduction of any identified hazards. 

Various CENTCOM policies have instructed commanders to use all other means feasible to reduce 

reliance on burn pits. The USAPHC(P)/Air Force 

Institute of Health sampling effort at Balad was 

conducted when concerns arose regarding the potential 

health implications of the burn pits. Other preventive 

medicine assets in theatre have sampled intermittently 

at burn pits at other locations, or have taken samples in 

troop locations when there was concern about smoke. 

These are typically not sufficient in number for use in 

a risk assessment. The results of the sampling efforts 

have not identified a definite hazard based on 

measured analytes compared to available standards. In 

a sense, then, the sampling could be viewed as 

supporting a conclusion that there is no clear hazard. 

However, as previously noted, sampling identifies 

conditions at the time of sampling and it is understood 

that conditions can be variable. Burn pit sampling is 

intermittent and waste streams and meteorological 

conditions are variable. While sampling can be used to 

identify a potential concern, it does not refute all 

concerns because it cannot address all locations and 

conditions at all times. As such, limitations to 

sampling will generally be identified, as these are 

complex, variable situations with multiple potential 

hazards. Additionally, the methodologies available to 

evaluate complex mixtures in terms of potential health 

effect are limited. Therefore, sampling does not always 

reassure, nor lead to definitive answers to complex 

questions. 

Clear expectations of the purpose and limitations of 

sampling data must be understood. Those who 

communicate findings must be clear not to overgeneralize the findings. From a preventive medicine 

perspective, the prevention, reduction, or mitigation of 

untoward exposures is the goal. If operational 

constraints prevent this goal from being achieved, it 

should be recognized that sampling data which fails to 

demonstrate a risk may not alleviate concerns because 

it has limitations in number and type of sample, time 

and space, and the population at risk. Sampling that 

does demonstrate a potential risk may be difficult to 

interpret to precisely define the predictive risk, and the 

population at risk on large base camps. Thus, sampling 

is best used as an adjunct to prudent practices. 

The difficulties inherent in using intermittent 

environmental data to determine health risk have been 

well described. A Committee on Environmental 

Epidemiology of the National Research Council report 

Issues Related to Burn Pits in Deployed Settings 
 April – June 2010 27

THE ARMY MEDICAL DEPARTMENT JOURNAL

entitled Public Health and Hazardous Wastes

evaluated epidemiological studies conducted around 

hazard waste sites and identified several limitations.20

These included limited exposure data, nonspecific 

health outcomes, insufficient power, latency and 

confounding, and small relative risk. Most of these 

limitations would apply to the use of intermittent 

sampling data to evaluate health outcomes in 

populations where actual levels of exposure of 

individuals are not known. More specifically, the 

Committee on Health Effects of Waste Incineration of 

the National Academy of Sciences published a report 

entitled Waste incineration and Public Health.

21

Although the report specifically evaluated the 

relationship between incineration and health effects in 

communities surrounding incinerators, many of the 

same issues apply to the use of burn pits. The report 

identified particulate matter, lead, mercury, dioxins, 

and furans as the contaminants of most concern. It 

noted that epidemiological studies had failed to 

identify health effects but noted that the problems of 

misclassification, limited sampling data, health effects 

with multiple potential etiologies, etc, limited 

conclusions. The report also noted that the variability 

of emissions, periods of less than optimal performance 

of incinerators, changing weather conditions, distance 

of population from the incinerators, and 

susceptibilities and activity patterns of the surrounding 

populations are important uncertainties in the study of 

health effects related to incineration. 

Many of the limitations cited in the 2 reports are 

relevant to the assessment of the association between 

burning trash and future health outcomes. Sampling 

will likely always have limitations, and the 

epidemiological studies conducted with or without 

exposure levels to contaminants will have limitations. 

Ideally, epidemiological studies use populations of 

sufficient size and reasonable comparison groups, and 

address the issue of latent conditions. This may allow 

for an assessment of the relative rate of potential 

health outcomes, which will contribute to the 

understanding of whether or not outcomes appear to be 

occurring at increased rates, and provide an estimate of 

the size of the increase. 

While surveillance for health outcomes of interest is a 

role of preventive medicine, it is a secondary goal to 

that of striving to prevent the occurrence of such 

outcomes. Attention to waste management issues by 

preventive medicine personnel in 1898 was prompted 

by nuisance and infectious disease concerns, as 

opposed to those relating to chemical exposure. To this 

day, waste and waste handling remain major, 

significantly more complex concerns. 

REFERENCES

1. Shane L III. Obama says burn pits won’t become 

another Agent Orange. Stars and Stripes [serial 

online]. August 4, 2009. Available at: http://

www.stripes.com/article.asp?section=104&article 

=64035. Accessed March 30, 2010. 

2. Agent Orange Act of 1991, Pub L No. 102-4, (1991). 

3. Institute of Medicine Board on Population Health and 

Public Health Practice. Veterans and Agent Orange: 

Health Effects of Herbicides Used in Vietnam. 

Washington, DC: National Academies Press; 1994. 

4. Institute of Medicine Board on Population Health and 

Public Health Practice. Veterans and Agent Orange: 

Update 2008. Washington, DC: National Academies 

Press; 2008. 

5. Samet JM, Bodurow, eds. Improving the Presumptive 

Disability Decision-Making Process for Veterans. 

Washington, DC: National Academy Press; 2008. 

6. Miller RL, Roberts WC. Environmental health. In: 

Kelley PW, ed. Military Preventive Medicine: 

Mobilization and Deployment. Vol 1. Washington, 

DC: Borden Institute, Office of The Surgeon General, 

US Dept of the Army; 2003. 

7. Salvato J. Environmental Engineering and 

Sanitation. Somerset, NJ: John Wiley and Sons; 

1997: 665. Cited by: Miller RL, Roberts WC. Environmental health. In: Kelley PW, ed. Military 

Preventive Medicine: Mobilization and Deployment. 

Vol 1. Washington, DC: Borden Institute, Office of 

The Surgeon General, US Dept of the Army; 2003: 

445. 

8. Erickson RL. The historic role of military preventive 

medicine and public health in US armies of 

occupation and military government. In: Kelley PW, 

ed. Military Preventive Medicine: Mobilization and 

Deployment. Vol 1. Washington, DC: Borden Institute, Office of The Surgeon General, US Dept of the 

Army; 2003: 62. 

9. The Report of the Surgeon General of the Army to the 

Secretary of War for Fiscal Year Ending June 30, 

1899. Washington, DC: Government Printing Office; 

1899: 167. Cited by: Erickson RL. The historic role 

of military preventive medicine and public health in 

US armies of occupation and military government. 

In: Kelley PW, ed. Military Preventive Medicine: 

Mobilization and Deployment. Washington, DC: 

Borden Institute, Office of The Surgeon General, US 

Dept of the Army; 2003: 62. 
28 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

Issues Related to Burn Pits in Deployed Settings 

10. Lemieus PM, Lutes CC, Sanotianni DA. Emissions of 

organic air toxics from open burning: a 

comprehensive review. Progr Energ Combust Sci. 

2004;30:1-32. 

11. Screening Health Risk Assessment, Burn Pit 

Exposures, Balad Air Base, Iraq. Aberdeen Proving 

Ground, MD: US Army Center for Health Promotion 

and Preventive Medicine. May 2008. USACHPPM 

Report No. 47-MA-08PV-08 / AFIOH Report No. 

IOH-RS-BR-TR-2008-0001. Available at: http://

www.dtic.mil/cgi-bin/GetTRDoc?AD=ADA 

493142&Location=U2&doc=GetTRDoc.pdf. 

Accessed March 30, 2010. 

12. National Research Council Committee on 

Toxicology. Review of the Army’s Technical Guides 

on Assessing and Managing Chemical Hazards to 

Deployed Personnel. Washington, DC: National 

Academy Press; 2001. 

13. Addendum: Screening Health Risk Assessment, Burn 

Pit Exposures, Balad Air Base, Iraq. Aberdeen 

Proving Ground, MD: US Army Center for Health 

Promotion and Preventive Medicine. May 2008: 4-5. 

USACHPPM Report No. 47-MA-08PV-08 / AFIOH 

Report No. IOH-RS-BR-TR-2008-0001. Available at: 

http://www.dtic.mil/cgi-bin/GetTRDoc?AD= 

ADA493142&Location=U2&doc=GetTRDoc.pdf. 

Accessed March 31, 2010. 

14. Office of Emergency and Remedial Response. Risk 

Assessment Guidance for Superfund. Volume 1. 

Human Health Evaluation Manual, Part A. 

Washington, DC: US Environmental Protection 

Agency; December 1989. EPA/540/1-89/002. 

Available at: http://www.epa.gov/oswer/riskassess 

ment/ragsa/pdf/rags-vol1-pta_complete.pdf. Accessed 

March 30, 2010. 

15. Weese CB, Abraham JH. Potential health 

implications associated with particulate matter 

exposure in southwest Asia. Inhal Toxicol. 2009;21

(4):291-296. 

16. Environmental Protection Agency, National Ambient 

Air Quality Standards for Particulate Matter, Final 

Rule. 70 Federal Register 61144 (2006) (codified at 

40 CFR Part 50). Available at: http://www.epa.gov/

ttn/naaqs/standards/pm/data/fr20061017.pdf. 

Accessed March 30, 2010. 

17. Englebrecht JP, McDonald EV, Gillies R, Jayanty 

KM, Casuccio G, Gertler AW. Characterizing 

mineral dusts and other aerosols from the middle east. 

Inhal Toxicol. 2009;21(4):297-336. 

18. Committee on Toxicology of the National Academy 

of Sciences. Task 2003AA: Review of DoD’s 

Enhanced Particulate Matter Surveillance Program 

Report, 2009 Interim Report. Washington DC: 

National Academy of Sciences; 2009. 

19. Defense Health Board Memorandum for Assistant 

Secretary of Defense, Health Affairs: Defense Health 

Board Findings Pertaining to the Health Risk 

Assessment Burn Pit Exposures, Balad Air Base Iraq. 

Washington, DC: US Dept of Defense; 2008. DHB 

2008-05. 

20. Committee on Environmental Epidemiology, 

National Research Council Board on Environmental 

Studies and Toxicology. Public Health and 

Hazardous Wastes. Washington, DC: National 

Academy Press; 1991. 

21. Committee on the Health Effects of Waste 

Incineration, Board on Environmental Studies and 

Toxicology, National Research Council. Waste 

Incineration and Public Health. Washington, DC: 

National Academy Press; 2000. 

AUTHOR

Dr Weese is the Environmental Medicine Program 

Manager, US Army Public Health Command 

(Provisional), Aberdeen Proving Ground, Maryland. 
 April – June 2010 29

INTRODUCTION

What is a field geographic information system? A 

geographic information system (GIS) makes it easier 

to organize, store, access, retrieve, manipulate, 

synthesize, and apply information to our benefit. The 

geographic component describes where events, 

activities, and other things happen or exist on the face 

of the earth and relates them in space to other data. 

Google Maps and Google Earth (Google, Inc, 

Mountain View, California) are examples of a simple 

GIS. A desktop GIS application 

frequently used in the Department 

of Defense (DoD) for planning and 

mapping is ESRI’s ArcView 

(Environmental Systems Research 

Institute Inc, Redlands, California). 

For the purpose of this article, a 

field GIS is defined as a software/

hardware system that allows the 

user to instantly view the samples 

location on a map; to electronically 

record the latitude and longitude of 

a location; to enter extensive, 

customized data about that location; 

and to easily transfer the data into a 

desktop GIS application. Standalone 

global positioning systems (GPS) 

generally do not fit these criteria 

because they lack the ability to enter 

extensive, customized data about a 

specific location and are unable to save the 

information in a file format (shapefile), which can 

easily transfer the data into a desktop GIS application. 

EXAMPLES

Mosquito Breeding Pool Mapping 

Figures 1 and 2 show a field GIS system that we have 

used extensively to take literally tens of thousands of 

data points. In the example shown in Figure 1, we 

chose to map a mosquito breeding pool by selecting 

the boundary theme, then selecting 

“GO” and walking the perimeter of 

the pool. 

Once we arrive back at our starting 

point the data table opens (Figure 2). 

This table tells us the perimeter and 

area of the pool so we can calculate 

the amount of insecticide needed to 

treat for mosquitoes, and allows us 

to enter treatment and survey notes 

into the data table. Figure 2 

illustrates an open pick-list which 

allows us to record the type of 

breeding site. 

Mosquito Survey 

Figures 3, 4, and 5 show the planning and execution of a multiteam 

Using Geographic Information Systems to 

 Maximize Environmental Surveillance 

 Efforts and Impact 

Brian C. Zeichner 

Sheila Denice Adams 

ABSTRACT

There has been tremendous advancement in geographic information systems (GIS) software and hardware 

over the last 2 decades. This article illustrates how these advancements can be used to greatly increase the 

ease and efficiency of collecting environmental samples and demonstrates how environmental data collected 

within a GIS is more valuable because of the visualization, analysis, and historical capabilities of the 

technology. This article reviews 6 actual field surveys conducted using desktop GIS and field GIS by 

entomologists with the US Army Public Health Command (Provisional). While these examples involve 

entomological data, the techniques and procedures are applicable to any type of environmental data. 

Figure 1. Field GIS Hewlett-Packard 

personal digital assistant with US 

GlobalSat GPS, and Farm Works field 

GIS software shown mapping a 

mosquito breeding pool identified by 

black arrow. 
30 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

mosquito survey. Figure 3 shows the area to be 

surveyed broken into 5 equal areas labeled Oscar, 

Yankee, Golf, Bravo, and Victor. 

Each team was assigned an area and 

given a field GIS loaded with the 

data for only their respective area of 

responsibility. The data layers on 

the field GIS included roads, 

streams, and human action areas. 

Each team walked throughout their 

area and mapped mosquito breeding 

sites and applied larvacide as 

necessary. Because the mapped 

larval sites appeared on the field 

GIS map, it was easy to insure complete and thorough 

coverage of the wooded area. Figure 4 shows the 

results of 3 days of surveillance. The red dots are the 

larval breeding sites that were found and the columns 

show the results of mosquito light traps. The ability to 

map this data while onsite proved valuable because it 

became immediately obvious that the number of larval 

sites found in the vicinity of the light trap in the 

southwest corner were insufficient to explain the 

number of adult mosquitoes caught in that light trap. 

The area was resurveyed the next 

day, and an intermittent stream and 

temporary pool were discovered to 

the southwest (Figure 5). These are 

mapped in green and light blue. 

Please note that the odd shape of the 

temporary pond is due to poor signal 

reception by an earlier generation 

GPS. While the shape of the 

temporary pool is not accurate, its 

location is accurate to within 30 feet. 

These breeding sites were treated 

with larvacide and mapped for future reference. 

Had we not had the capability to rapidly load the 

surveillance data into a GIS, we would not have 

realized that a major breeding site had been missed 

while we were still onsite and able to investigate. This 

clearly demonstrates the value of taking GIS into the 

field and doing even a simple analysis prior to leaving 

the field. This example also shows the historical value 

of GIS. In addition to a shapefile with the larval 

breeding sites, the installation was provided a 

topographical map showing all the larval breeding 

sites. In the future, the sites can be rechecked using the 

topographical map or the shapefile can be loaded into 

a field GIS and found using the navigation tool. This 

preserves the efforts of the surveillance team because 

the information is easily accessible. Had the team 

simply recorded the latitude and longitude in a table, it 

is unlikely that anyone in the future would take the 

time and effort necessary to manually enter the 

coordinates into a GIS so that the information could be 

used. 

Tick Population Studies 

Figure 6 illustrates the clear superiority of GIS as a 

survey planning tool. In this scenario we wanted to 

investigate the relationship between the tick population 

and soil type, soil slope, and vegetation type 

(deciduous or coniferous). The tick population would 

be determined by dragging a one-meter by one-meter 

flannel cloth 100 meters through the habitat. Each soil 

type, soil slope, and vegetation type would have to be 

sampled an equal number of times over the survey 

week. An analysis of the GIS soil layer revealed that 

while there were 27 soil types within the study site, 12 

Using Geographic Information Systems to Maximize Environmental Surveillance Efforts and Impact 

Figure 3. The area to be surveyed broken into 5 

named equal areas with roads, streams, human action 

or activity areas. 

Figure 2. Field GIS data table opened 

for the mapped mosquito breeding 

pool and ready for data entry. 
 April – June 2010 31

THE ARMY MEDICAL DEPARTMENT JOURNAL

Figure 4. Survey site showing larval sites as red dots and 

results of mosquito light trap data as stacked columns. 

Figure 5. Location of pond, green, and intermittent stream, 

light blue, discovered upon resurvey of the area. 

Figure 6. Using GIS to insure that proposed tick drag, red line, is within desired 

vegetation, soil type and slope. 
32 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

types accounted for 88% of the study site. Each of 

those 12 soil/slope types would have to be sampled 8 

times for a total of 120 drags. 

Figure 6 shows a section of the study site with the soil 

layer (numbered polygons), soil slope (indicated by a 

letter), and a winter aerial photo (allows one to discern 

between deciduous or coniferous). Using the Create 

New Feature Task, drag locations were selected within 

a particular soil type/slope and vegetation type. The 

arrow indicates a line being drawn to represent a drag 

in soil type 105, slope C, coniferous. In the bottom left 

corner of the window the program shows the length of 

the line drawn, in this case 100.7 meters, and the 

direction of the line, 69.7 degrees true north. 

These tools allowed all 120 sample sites to be selected 

prior to going to the field and ensured that each 

parameter was sampled equally. The drag routes were 

divided equally among the 4 teams, and each team 

received a field GIS system with only their assigned 

drag routes. The drag routes were numbered in the 

order they were to be done. Designating the drag 

completion order controls for weather related sampling 

bias. In the field, each team used the field GIS to select 

the beginning of their next drag, then used the 

navigation feature to go to the starting point. A 

compass was used to determine the direction of the 

drag. This approach ensured the successful 

accomplishment of the sample plan with no confusion 

or time lost searching for survey sites on the ground. 

Figures 7 and 8 illustrate the high value of 

georeference data. In this survey of lone star ticks, 103 

sites were selected throughout the study area. At each 

location, 3 collection sites were placed about 5 meters 

from each other, consisting of a piece of dry ice on 

slippery white cloths. The site was left, and after 2 

hours survey personnel returned to the site and 

collected the ticks off of the white sheet using a piece 

of masking tape (Figure 7). 

Since many of these sites were deep in dense woods, 

the GPS component of field GIS was critical to ensure 

that the teams could return to the sites within the 

allotted time interval. However, the greatest 

contribution was the geostatistical data analysis made 

possible because the sites had been georeferenced. 

Without georeferencing the sites, the most we could 

have done with the data is report the basic statistics: 

ticks collected ranged from 0 to 522 per site, the 

median was 3, the mean was 30.5, and the standard 

deviation was 70.8. About all this type of analysis tells 

you is there are places with lots of ticks and places 

with few ticks, something anyone familiar with the 

area would know without the survey. 

Figure 8 shows the data following geostatistical 

analysis. The region within the yellow to red colored 

areas is the part of the study site where there is a 50%

or greater probability that those regions contribute to 

85% of the tick population. A detailed discussion of 

the geostatistics involved is provided by Brenner et al.1

Using Geographic Information Systems to Maximize Environmental Surveillance Efforts and Impact 

Figure 7. Tick survey site showing post to mark the site, dry 

ice on white cloth, and inset, the collecting of ticks off the 

cloth with masking tape. 

Figure 8. Results of geostatistical analysis showing those 

areas, yellow to red, which contribute to 85% of the tick 

population. 
 April – June 2010 33

THE ARMY MEDICAL DEPARTMENT JOURNAL

The Figure 8 legend shows the probability associated 

with each color area, the percent of the total area 

(which is indicated by an orange line), and the total 

square feet. For example, the clear uncolored area has 

a probability of 0 to 0.49, and accounts for 82.5% or 

11,716,893 square feet of the study site. Therefore, 

85% of the ticks were on just 17.5% of the study site. 

Unlike the basic statistics, this is actionable 

information since, once mapped, those areas 

accounting for 85% of the tick population can either be 

treated or avoided. Insect populations, like most 

environmental data, are not randomly distributed but 

occur in clumped distributions. Therefore, it is 

common to find that the majority of a population is on 

a minority of the area of interest. The ability of 

geostatistical analysis to identify and map these areas 

is a powerful tool. 

June Beetle Control 

Figures 9, 10, 11, and 12 provide another example of 

how environmental data collected within a GIS is more 

valuable because of geostatistical analysis capability. 

In the scenario associated with the figures, the task 

was the prevention of green June beetle damage to a 

golf course fairway. Green June beetles negatively 

impact play by creating dirt mounds as they tunnel into 

the turf each morning. Typically the spray technician 

would treat the entire fairway. In order to be more 

efficient, we mapped the green June beetle population. 

This was accomplished by counting the number of dirt 

mounds within each of 163 sampling rings dropped on 

the ground. Figure 9 shows the sampling ring and dirt 

mounds, and the location of the sample sites on the 

fairway which were recorded with field GIS hardware/

software. 

Figure 10. Raw data population contours show those areas, 

gray to purple, where the population action threshold (6 or 

more mounds per sampling ring) was exceeded. The red 

polygons are the proposed pesticide treatment areas. 

Figure 9. Sampling ring with yellow arrows pointing to green 

June beetle mounds on a golf course fairway and location of 

sample sites. 
34 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

The golf course superintendent set a threshold of 6 or 

more mounds per sampling ring as the trigger for 

control action. Because the field data was collected in 

a GIS within a half hour of the last sample, we were 

able to produce Figures 10 and 11. Figure 10 shows 

the raw data population contours produced by 

performing a geostatistical inverse distance weighting 

analysis of the data.1

 The areas colored gray to purple 

display where there were 6 or more mounds per 

sampling ring. The red polygons are the proposed 

pesticide treatment areas. 

Figure 11 is the map that was provided to the spray 

technician. The treatment boxes were drawn so they 

could be referenced with readily apparent landmarks: 

yard markers, sprinkler heads, rough/fairway 

boundary, sand traps, and green. 

The post treatment survey (Figure 12) shows that 95% 

control was obtained by treating less than 30% of the 

total fairway. In this case, use of GIS reduced the 

Using Geographic Information Systems to Maximize Environmental Surveillance Efforts and Impact 

Figure 11. Treatment map presented to spray technician. 

Figure 12. Post insecticide treatment map showing raw 

data population contours, gray to orange, where there 

were 6 or more mounds per sampling ring. The black 

polygons are the areas actually treated with insecticide. 
 April – June 2010 35

THE ARMY MEDICAL DEPARTMENT JOURNAL

amount of pesticide placed in the environment, 

reduced cost because less area was treated, and 

achieved the desirable level of control. 

Pesticide Residue Mapping 

Figure 13 is an example of mapping environmental 

data other than insects. In this scenario, a pesticide 

storage facility was to be converted to an office. Forty 

seven wipe samples were taken and analyzed for 

pesticide residue. The outline of the building was 

converted to a shapefile and loaded into the field GIS. 

Since GPS signals do not penetrate buildings well, the 

manual location tool was used and the location of the 

wipe samples were visually georeferenced, using the 

building outline as a reference. Inverse distance 

weighting was used to create contours of the total 

pesticide concentration, and all areas exceeding the 

threshold of 5 or more micrograms are shown in 

Figure 13. At a glance, this map shows where 

remediation is needed. This data presentation is far 

superior to a 6-page table detailing the results of the 

individual wipe samples. 

Additional examples illustrating the value of using 

GIS for environmental data can be found at http://

chppm-www.apgea.army.mil/Entomology-GIS/. 

SUMMARY

The 6 examples presented here clearly illustrate that 

use of GIS improves the efficiency and efficacy of 

field work and ensures that field teams do not waste 

time by inadvertently sampling outside their 

area of responsibility. Data entered into a 

GIS is more valuable because the spatial 

component is captured. The spatial component allows 

the data to be related to other spatial data and be 

geostatistically analyzed. Geostatistical analysis is a 

powerful tool that allows one to identify and map the 

areas of concern so either remediation efforts can be 

focused where they are most needed, or those areas of 

greatest concern can be avoided. Providing a map of 

the data is far superior to providing data tables and 

hoping that the reader will be able to interpret the 

information accurately. Maps also provide a historical 

reference superior to data tables. Field surveys and 

analysis of environmental samples are very expensive. 

It is, therefore, only logical to enter the data into a GIS 

so that the greatest return on that investment will be 

realized. 

REFERENCE

1. Brenner RJ, Focks DA, Arbogast RT, Weaver DK, 

Shuman D. Practical use of spatial analysis in 

precision targeting for integrated pest management. 

Am Entomol 1998;44:79-101. 

AUTHORS

Mr Zeichner is a Master Consultant Entomologist, 

Entomological Sciences Program, US Army Public 

Health Command (Provisional), Aberdeen Proving 

Ground, Maryland.

Ms Adams is a Biological Sciences Laboratory 

Technician, Entomological Sciences Program, US 

Army Public Health Command (Provisional), Aberdeen 

Proving Ground, Maryland. 

Figure 13. Raw data contours showing those areas where total pesticide 

concentrations exceeded the threshold of 5 μg per wipe sample. 
36 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

INTRODUCTION

This paper describes a unique, integrated professional 

development workshop that was recently designed and 

conducted for Army Nuclear Medical Science Officers 

(NMSOs) to further hone their special expertise in 

health physics (radiation safety), while developing 

their skills in both risk and media communications. 

The 2-day workshop, held in conjunction with the 

Annual Force Health Protection Conference, was a 

collaborative effort, bringing together health physics, 

mentoring/coaching, risk communication, and public 

affairs experts. The key to a highly successful training 

event was the amplification of individual and group 

NMSO self-awareness, the study of a real-world Army 

health physics radiation case study, and the practical 

use of effective risk and media communication 

principles. The workshop was also an effective group 

mentoring experience for all of the officers. Other 

force health protection practitioners may benefit from 

the lessons learned from the development and 

implementation of this truly innovative professional 

development vehicle, and can use it as a template for 

their own professional groups or organizations. 

WORKSHOP CADRE

In order to accomplish this very ambitious training 

event, a highly diverse group of experts was brought 

together to both design and conduct the workshop. The 

leader of the cadre was the career field leader for the 

Army’s roughly 60 NMSOs (lead author M. A. Melanson). An independent consultant was contracted to 

assist with the self-awareness, mentoring, and 

coaching portion of the training. To provide risk 

communication expertise, a senior risk communicator 

from the Army Public Health Command (Provisional) 

(APHC(P)) partnered in the effort. The APHC(P) 

public affairs officer was also invited to craft the 

media communication piece of the exercise. Finally, 2 

health physicists, one civilian and one NMSO, also 

participated in the development and implementation of 

the workshop case study. 

WORKSHOP PARTICIPANTS

Twenty-four Army NMSOs registered for and attended 

the 2-day workshop. They included both junior and 

senior officers from the Active Army, the Army Reserves, and the Army National Guard, and represented 

a diverse cross section of the specialty. The demographics were 6 lieutenants, 12 captains, 3 majors, 

and 3 lieutenant colonels. The officers came from various stateside and overseas duty stations and accounted 

for roughly half of the Army’s inventory of NMSOs. 

GOAL OF THE WORKSHOP

The workshop goal was to provide the NMSO 

participants with an integrated learning opportunity 

based upon a real world case study, enhancing 

individual and group health physics expertise while 

providing practical risk communication and media 

communication training. The cadre also wanted to 

foster a supportive learning environment that would 

allow individual and group self-awareness and foster 

individual and group mentoring. 

WORKSHOP OVERVIEW

The workshop was a preliminary conference to the 

Army’s Annual Force Health Protection Conference 

(FHPC), a premier military public health conference. It 

was scheduled to unfold over 2 consecutive days, just 

before the opening of the main FHPC. In addition to 

being an icebreaker and warm-up for the participants, 

the first day allowed the NMSOs to increase their own 

self-awareness while also learning about the overall 

Mystery of the X-Ray Overexposure: An 

 Innovative Risk and Media Communication 

 Mentoring Workshop 

COL Mark A. Melanson, MS, USA 

Lori S. Geckle 

Lyn C. Kukral 

Michele Costanza, PhD 
 April – June 2010 37

group and its individual members. The enhancements 

of individual and group awareness resulted in an 

increased understanding and mutual respect among the 

individuals. This served to facilitate the group learning 

efforts planned for the second day. 

On the second day, the participants applied their newly 

found self and group awareness to solve a complex 

health physics problem based upon a real world 

radiation overexposure case study. Once organized 

into small groups each led by a senior officer, the 

NMSOs were presented with the case study and then 

began to collect critical information to determine what 

actually happened. Once the case study was solved, the 

next phase was preparation to explain the risks of the 

alleged radiation overexposure incident to 

nonscientists. The culmination of the workshop was 2 

role playing exercises where 2 selected participants 

either explained the radiation risks to an actor playing 

the alleged overexposed Soldier, or conducted a staged 

media interview with a simulated news reporter. 

WORKSHOP DESIGN

Design of the workshop’s 2 interrelated parts occurred 

concurrently. As the workshop leader worked closely 

with the mentoring and coaching consultant to design 

the self and group awareness day, he simultaneously 

worked with the health physics experts to convert the 

real world overexposure incident into a daylong 

exercise while partnering with the risk and media 

communication subject matter experts to plan the 2 

role playing exercises. Fortunately, the workshop 

leader had an existing good working relationship with 

the entire workshop cadre which greatly facilitated this 

ambitious integrated effort. 

Design of Day 1 – Self and Group Awareness 

The mentoring and coaching consultant was briefed on 

the overall goal of the workshop’s first day: self and 

group awareness. The cadre leader also expressed his 

desire to use the Myers-Briggs Type Indicators 

(MBTI) (CPP Inc, Mountain View, CA), a popular and 

useful self-awareness tool. The consultant then 

suggested that the use of the MBTI could be bolstered 

by the addition of training about Emotional 

Intelligence Competencies (EICs). 

Myers‐Briggs Type Indicators

First developed in 1962, the MBTI was the product of 

collaboration between 2 psychologists, Katharine 

Briggs and her daughter, Isabel Briggs Myers.1,2 The 

MBTI is directly based upon the cognitive theories of 

the famous psychologist Carl Gustav Jung.3

 Through 

the use of a questionnaire, the MBTI identifies and 

measures psychological preferences by which people 

perceive the world and make decisions. The 

questionnaire first determines how an individual gets 

his or her energy, either from looking inside or from 

interacting with others. Next, it assesses how a person 

prefers to receive information, by focus on details or 

by viewing the big picture. The survey then addresses 

how a person’s decisions are made using this 

information, by using logic or relying on feelings. 

Lastly, the test reveals how the individual orients him 

or herself with respect to the rest of the world, by 

being regimented or by being flexible. 

Emotional Intelligence Competencies

The theory of emotional intelligence stems from the 

seminal work by Dr Daniel Goleman4,5 and is traceable 

to Charles Darwin’s work on the role of emotions in 

survival and adaptation.6

 Mastery of emotional 

intelligence is the result of mastering key 

competencies designated as EICs. These EICs are 

broken into 2 large groups, Personal Competence and 

Social Competence. Subcompetencies under the 

category of Personal Competence include Selfawareness (emotional awareness, accurate selfassessment, self-confidence), Self-regulation (selfcontrol, trustworthiness, conscientiousness, 

adaptability, innovativeness), and Self-motivation 

(achievement drive, commitment, initiative, 

optimism). The other group of competencies, Social 

Competence, includes Social Awareness (empathy, 

service orientation, developing others, leveraging 

diversity, and political awareness), and Social Skills 

(influence, communication, leadership, change 

catalyst, conflict management, building bonds, 

collaboration and cooperation, and teamwork). Given 

the goals of the workshop, the mentoring and coaching 

consultant recommended focusing on the following 6 

EICs: Communication, Empathy, Developing Others, 

Self-Confidence, Teamwork, and Collaboration. 

Throughout the day, interactive exercises or “games” 

were used to help understanding and awareness of selfawareness tools and to sustain individual and group 

participation. This made the day fun and memorable. 

Many of these games involved intentional pairing of 

junior officers with senior officers to facilitate flash 

mentoring. Along with this broad guidance, the 

consultant was also provided an overview of the 

second day, so that she was aware of the skills and 
38 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

insights necessary for the participants to work through 

and solve the radiation overexposure case study and 

complete the role playing exercises. The schedule of 

the first day is outlined in Figure 1. 

Design of Day 2 – The Radiation Overexposure 

Mystery 

The second day was technical. The focus was on the 

investigation of a real world health physics case study 

and the preparation and delivery of both a risk 

communication message and the completion of a mock 

media interview. Given the central place of the case 

study in the second day of the workshop, the focus 

shifted to a summary of the actual alleged radiation 

overexposure incident. 

The Case Study – A True Health Physics Mystery

The mystery to be solved by the participants was 

closely based on an actual potential radiation exposure 

incident that occurred in the summer/fall of 2008. A 

Soldier, an x-ray specialist with the 25th Infantry 

Division at Schofield Barracks, was scheduled to 

deploy to Iraq. As part of his preparation for 

deployment, the individual deployed with his unit to 

the National Training Center (NTC), Fort Irwin, 

California, for collective unit training. Upon arrival at 

Fort Irwin, the x-ray tech went 

to the post hospital to obtain a 

radiation dosimeter to wear 

while he simulated shooting 

radiographs while training in 

the field. He was given a 

radiation dosimeter, also 

referred to as a radiation badge, 

by the Fort Irwin Medical 

D e p a r t m e n t A c t i v i t y 

(MEDDAC) Radiation Safety 

Officer (RSO) to wear during 

the 10 days that he trained at 

the NTC. Upon completion of 

the training, the deploying 

Soldier turned the dosimeter in 

at the Radiology Clinic of the 

Fort Irwin MEDDAC. The 

Soldier then subsequently 

deployed to Kuwait on his way 

to Iraq. Since the dosimeter 

was on a quarterly exchange 

cycle, it remained in the 

MEDDAC Department of 

Radiology, stored with the other dosimeters for a 

couple of months. Then, the badge was shipped to the 

US Army Dosimetry Center at Redstone Arsenal, 

Alabama, for processing. 

When the dosimeter was read, it indicated that there 

was a dose over 40 times the allowable annual legal 

limit. Further, the reading was the largest radiation 

dose ever recorded in the over 50-year history of Army 

radiation dosimetry. Most important, this high level of 

radiation dose could pose a serious health risk if it had 

been actually received. The Army Dosimetry Center 

immediately notified the RSO at Fort Irwin 

MEDDAC, the Army RSO, and the Radiological 

Hygiene Consultant to the Army Surgeon General 

(author Melanson). 

Given the magnitude of the dose and the complexity of 

the incident, the initial investigation was passed to the 

Command Radiation Safety Officer (CRSO) for 

Western Regional Medical Command (WMRC), 

another Nuclear Medical Science Officer. With 

guidance from the Radiological Hygiene Consultant, 

the WRMC CRSO obtained information about the 

radiation characteristics and output of the field medical 

x-ray system used by the deploying Soldier while he 

was training at the NTC. Information about the 

effective energy of the radiation 

on the exposed dosimeter was 

obtained from the Army 

Dosimetry Center. The deployed Soldier was contacted and 

interviewed by the Theater 

Radiation Safety Officer, 

another NMSO deployed to 

Iraq. During the interview, the 

potentially overexposed Soldier 

provided information about the 

number of times he fired the xray machine during the 10 days 

of NTC field training, where he 

was standing with respect to the 

x-ray machine, and whether or 

not he was wearing a lead 

apron. 

Through further investigation, it 

was scientifically determined 

that the Soldier could not have 

received the dose on the 

dosimeter. First, the effective 

Mystery of the X-Ray Overexposure: 

An Innovative Risk and Media Communication Mentoring Workshop 

0800 – 0830

Welcome. Logistics of Room and

Workshop. Purpose and Objectives.

Introductions.

0830 – 1000

Administration of the MBTI

Questionnaire. Overviewof

Personality Type Theory and MBTI.

1000 – 1015 Break

1015 – 1115 MBTI Debrief. Validation of

Personality Types.

1115 – 1200 Emotional Intelligence Competencies

1200 – 1300 Working Lunch:Stress and Type

1300 – 1400 Communication and Empathy

1400 – 1415 Break

1415 – 1500 Developing Others

1500 – 1600 Self‐ConfidenceTools and Strategies;

Teamwork and Collaboration

1600 – 1615 Wrap Up

1615 – 1645 After Action Review

Figure 1. Schedule for day 1, group and self 

awareness.
 April – June 2010 39

THE ARMY MEDICAL DEPARTMENT JOURNAL

energy of the radiation dose on the radiation badge, a 

thermoluminescent dosimeter, was greater than the 

maximum energy of the field medical x-ray system. 

This proved that the x-ray machine could not have 

produced the massive radiation dose on the badge. 

Additionally, it would have taken over 700 shots of the 

x-ray system to have delivered the large magnitude 

dose measured on the dosimeter. Since the Soldier was 

not using any other radiation sources and had no other 

source of potential radiation exposure on the NTC, it 

was concluded that the badge was irradiated after it 

had been turned in to the Radiology Department at the 

Fort Irwin MEDDAC, but before the badge was sent to 

be processed about 2 months later. The theater RSO in 

Iraq met with the deployed x-ray tech to inform him 

that he did not receive this large dose of radiation, 

what his estimated radiation dose actually was, and to 

answer any questions that he might have. He was 

relieved to learn that he had not been overexposed to 

radiation and was safe. 

With the determination that the badge was irradiated 

after it had been returned by the deploying x-ray 

technician, the question still remained as to how the 

dosimeter received such a high radiation dose. The 

Radiological Hygiene Consultant conducted a formal investigation into the incident. This 

investigation included going to 

Fort Irwin MEDDAC and 

interviewing the hospital staff. 

As it turned out, the effective 

energy of the radiation measured on the dosimeter was 

consistent with the fluoroscopy 

x-ray system located within the 

Fort Irwin MEDDAC X-Ray 

Department. Interestingly 

enough, over 15 minutes of deliberate fluoroscopy operation 

with the badge in the beam 

would have been required to 

produce the massive radiation 

dose. Unfortunately, the investigation could not ascertain who 

intentionally irradiated the dosimeter after the deploying Soldier turned it in and before it 

was sent to the Army Dosimetry Center for measurement. 

Designing an Exercise to Solve the Overexposure Mystery

It was expected that after the events of the first day, 

the NMSOs would come together as a group and 

would be prepared for the next phase of the workshop. 

The schedule for the second day is shown in Figure 2. 

Before unveiling the case study, the ground rules of 

the day were explained. Next, the NMSOs were 

divided into 4 separate, 6-person groups, each lead by 

a senior field grade officer (lieutenant colonel or senior 

major). Once the groups were identified and allowed 

to reseat themselves with their leader and new 

teammates, an introduction of the real-world case 

study was given, providing the participants some, but 

not all of the information required to solve the 

mystery. The teams then had to process the initial 

information received, identify additional data that they 

needed, request this new information, incorporate all 

newly obtained data into their evolving understanding 

of the incident, and finally determine whether the 

overexposure was real or not (which it was not). After 

this, the 4 groups developed a plan to estimate and 

explain the radiation dose and risk to an actor playing 

the allegedly overexposed individual and another actor 

playing a news reporter investigating the incident. 

When each of the 4 groups had 

developed a plan to brief the 

incident, an individual from 

within one of the 4 groups was 

selected to play in the first role 

playing event, the risk 

communication exercise. After 

the risk communication role 

planning exercise was completed, the risk communication 

expert provided a half-hour 

presentation on risk communication, and also evaluated the 

first participant’s performance 

in the role playing exercise. 

With the risk communication 

exercise completed, the 

participant for the media 

communication exercise was 

selected and allowed a brief 

time with his or her group to 

finalize preparation for the 

mock media interview. As in 

the case of the previous role 

playing exercise, the participant 

0800 – 0815 Group Assignments and Group

Assembly

0815 – 0830 Introduction of Radiation

Overexposure Case Study

0830 – 1100 Groups Work on CaseStudy and

Gather Information

1100 – 1230 Open Discussion and Presentation of

the “Solution”

1230 – 1400 Lunch and Group Preparations for

Role Playing Exercises

1400 – 1430 First Exercise Participant Selected and

Group Assistance in Final Preparation

1430 – 1445 Risk Communication Role Playing

Exercise

1445 – 1515 Risk Communication Training and

Feedback

1515 – 1545

Second Exercise Participant Selected

and Group Assistance in Final

Preparation

1545 – 1600 Medic Communication Role Playing

Exercise

1600 – 1630 Media Communication Training and

Feedback

1630 – 1700 After Action Review

Figure 2. Schedule for day 2, radiation overexposure case study.
40 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

performed the interview with the reporter. Once that 

was completed, the media communication expert 

delivered a lecture on effective media communication 

and critiqued the performance of the second 

participant. The last day concluded with an after-action 

review of both the second day and the entire 

workshop. 

WORKSHOP EXECUTION

Day 1 – Self and Group Awareness 

The first day of the workshop proceeded pretty much 

as planned. The participants were enthusiastic about 

the agenda for the entire workshop, especially the 

second day. As the career field leader for the Army 

NMSOs explained the relevance and importance of the 

first day’s activities to successful completion of the 

case study on the second day, he also affirmed the 

importance of self and group awareness in effective 

Army officer leadership. The mixture of lectures and 

games served to sustain individual and group interest, 

and helped the participants relax and remain focused 

on the workshop. Throughout the day, COL Melanson 

reminded the group that they, as scientists, were very 

different from most members of the general public and 

individuals who work in the news media, and that they 

should keep this in mind as they prepared briefings for 

the second day. At the end of the first day, an afteraction review was held (without the consultant 

present) and the feedback was constructive. While the 

attendees enjoyed the day, they would have preferred 

to have more time to delve into the Emotional 

Intelligence Competencies since many were already 

familiar with the Myer-Briggs Type Indicators. 

Day 2 – Solving and Explaining the Radiation 

Mystery 

As expected, the group of attendees was comfortable 

with each other and warmed-up for the second day’s 

activities. Everyone was told that they had a chance to 

be selected to engage in one of the 2 role playing 

exercises; this risk of being “put on the hot seat” 

helped to sustain individual participation and focus. 

The conference room was then rearranged to facilitate 

the exercise as shown in the conceptual presentation of 

Figure 3. Group tables were rearranged so the 4 groups 

could face each other. The controllers who had 

designed the case study exercise were placed in the 

front right corner and were prepared to respond to 

written questions from the groups. Each table was 

given a courier to deliver written questions to the 

controllers. The workshop leader served as the 

exercise conductor and timekeeper to help keep 

everything on schedule. A separate table was placed in 

the center of the room to serve as a “fishbowl,” where 

the 2 role-playing exercises would play out while the 

other participants silently watched. Once the case 

study summary was presented, the exercise 

commenced. There was a slight delay as the groups got 

organized, but they quickly began asking additional 

questions of the controllers. 

Periodically throughout the morning, the conductor 

would stop the exercise and conduct a “reset,” which 

involved the conductor asking each of the groups 

what they had learned from asking questions of 

the controllers. At first the groups were unhappy 

about this since it interrupted their individual 

group’s momentum and there was an innate desire 

to outperform the other groups and not share what 

they had learned. The workshop leader explained 

that the goal of the exercise was not to “beat” the 

other teams. The goal of the exercise was to 

ensure that whoever was selected for each of the 2 

role-playing exercises was completely prepared to 

succeed. After the explanation, the groups no 

longer focused on outplaying the other groups. 

Just before the lunch break, the 4 groups had fully 

investigated the case study and had all of their 

facts. Over a working lunch, the groups prepared 

their information for briefing the potentially 

overexposed Soldier and the news reporter. 

Conductor Controllers

Group A

Group C

Group B

Group D

“The Fish Bowl”

Role Players

Figure 3. The conceptual layout of the conference room for the Day 

2 role-playing exercise. 

Mystery of the X-Ray Overexposure: 

An Innovative Risk and Media Communication Mentoring Workshop 
 April – June 2010 41

THE ARMY MEDICAL DEPARTMENT JOURNAL

After lunch, the workshop shifted to the 2 role-playing 

exercises. This began by selecting the first participant. 

The conductor had thought about randomly selecting 

the player, however, the decision was made to select a 

senior company grade officer with prior risk 

communication training in order to maximize success 

and provide a positive example for the others 

observing the exercise. Two actors were involved in 

the first role-playing exercise: one of the controllers 

played the Soldier (he also was the theater RSO in Iraq 

who actually briefed the possibly overexposed 

individual), and the risk communication expert played 

the Soldier’s wife. Overall, the first participant did 

very well. She showed genuine empathy and calmly 

explained the situation and the process that she used to 

come to the conclusion that the Soldier was not 

overexposed. Unfortunately, her overreliance on 

calculations to estimate the Soldier’s dose did not 

resonate well with either the Soldier or his wife, and 

ultimately limited the effectiveness of the risk 

communication message. Once the risk communication exercise was completed, the risk communicator 

gave a short briefing on effective risk communication 

and highlighted the positive and negative aspects of 

the role-playing exchange. The key points of the risk 

communication training were defining risk communication as an interactive process, the importance of 

empathy, and the fact that risk is a combination of the 

magnitude of actual hazard plus the degree of personal 

outrage of the person subjected to the risk.7

 Elements 

of successful risk communication include the credibility and the skill of the risk communicator and the 

effectiveness of the risk message. Credibility is first 

built upon empathy, then it rests upon honesty and 

openness. Finally, trust and credibility rests upon dedication and commitment on the part of the risk communicator, and ultimately his or her competence.8

 The 

audience was also warned to avoid humor and jargon. 

Next, the exercise immediately shifted to the mock 

media interview. The second “contestant” was selected 

by the workshop leader. This individual was a 

seasoned, midcareer major who had recently returned 

from a deployment to Iraq. The public affairs officer 

played the role of the reporter and started the interview 

on a positive note. Then, however, she shifted to a 

more adversarial posture, implying that the Army 

system for monitoring Soldiers was flawed and her 

impression that the interviewee was hiding something. 

Although the second participant got flustered, he still 

managed to maintain his composure and completed the 

interview. As in the case of the risk communication 

exercise, the role-playing was followed by a lecture on 

effective media communication that also critiqued the 

performance of the second participant. The media 

communication training explained the similarities and 

differences between risk communication and media 

communication. Both need planning and preparation 

and use effective communication techniques. Risk 

communication focuses on addressing concerns, 

whereas public affairs explains the message of the 

organization. In public affairs, it is important to stay 

on the record, to stay in one’s lane, and to avoid 

speculating on hypothetical questions. Also, it was 

stressed that one must never lie. Tips included 

preparing messages in advance and rehearsing them, 

stating these messages up front, and keeping them 

simple. The importance of “speaking with one voice,” 

that is a consistent message was also emphasized. The 

audience was told that it was proper to say “I don’t 

know,” but that one should commit to finding out the 

answer and providing it later. The public affairs officer 

also stressed the importance of setting the record 

straight and correcting reporter errors. 

In order to wrap-up the exercise, the conductor 

presented the resolution of the actual case study to the 

participants. Coincidentally, all of the key players 

involved in the real incident were actually present and 

part of the cadre for the second day’s exercise. An 

impromptu chronological walk-through of the incident 

was done. Finally, after-action reviews were held with 

the group for the second day, and then for the entire 

workshop. Feedback from the group was 

overwhelmingly positive. The only complaint was the 

decision to have the participants work over the lunch 

period on both days. 

SUMMARY

This paper presents an innovative training workshop 

that combined self and group awareness with the 

completion of a real world radiation overexposure case 

study to enhance the technical skills of the attending 

Army Nuclear Medical Science Officers. It also 

included 2 role-playing exercises to learn and practice 

effective risk communication and media 

communication techniques. The workshop was 

structured to allow a supportive learning environment 

that was conducive to individual and group mentoring. 
42 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

Mystery of the X-Ray Overexposure: 

An Innovative Risk and Media Communication Mentoring Workshop 

As previously stated, the feedback from the 

participants was overwhelmingly positive. Other 

public health practitioners may find this innovative 

professional development approach useful, and may 

wish to use the design of this work-shop to further 

their own professional development. 

REFERENCES

1. Saunders FW. Katherine and Isabel: Mother’s Light, 

Daughter’s Journey. Palo Alto, CA: Consulting 

Psychologists Press; 1996. 

2. Myers IB. Gifts Differing: Understanding Personality 

Type. 2nd ed. Palo Alto, CA: Consulting 

Psychologists Press, Inc; 1995. 

3. Jung CG. Psychological types. In: Hull RFC, transed. The Collected Works of C. G. Jung. Vol 6. 

Princeton, NJ: Princeton University Press; 1976. 

4. Goleman D. Emotional Intelligence: 10th 

Anniversary Edition; Why It Can Matter More Than 

IQ. New York, NY: Bantam Dell; October 2006. 

5. Goleman D. Working With Emotional Intelligence. 

New York, NY: Bantam Dell; October 2006. 

6. Darwin C. The Expression of Emotions in Man and 

Animals. London: John Murray; 1872. 

7. Sandman PM. When people are “over-reacting” to 

risk. The Synergist. 2004;15(2):22-24. Available at: 

http://www.psandman.com/col/over-re.htm. Accessed 

April 5, 2010. 

8. Peters RG, Covello VT, McCallum DB. The 

determinants of trust and credibility in environmental 

risk communication: an empirical study. Risk Anal. 

1997;17(1):43-54. 

AUTHORS

COL Melanson is Director, Armed Forces 

Radiobiology Research Institute, Bethesda, Maryland, 

and the Radiological Hygiene Consultant to The Army 

Surgeon General. 

Ms Geckle is Senior Health Risk Communication and 

Environmental Protection Specialist, Health Risk 

Communication Program, US Army Public Health 

Command (Provisional), Aberdeen Proving Ground, 

Maryland. 

Ms Kukral is the public affairs officer at the US Army 

Public Health Command (Provisional), Aberdeen 

Proving Ground, Maryland. 

Dr Costanza is owner of MultiGen Coaching, 

specializing in organizational development and training.
 April – June 2010 43

INTRODUCTION

Although physicians have sought to relieve their 

patients’ pain for centuries, pain management as a 

specific medical discipline began with the founding of 

the International Association for the Study of Pain in 

May 1973.1

 During the last decade, pain management 

has evolved into an essential part of patient care. 

Physician specialists, such as physiatrists, are medical 

doctors who specialize in physical medicine and 

rehabilitation with a special interest in musculoskeletal 

conditions. Some physiatrists have advanced training 

in interventional pain management (IPM).2

 In this 

specialized subfield of pain management, procedures 

such as diagnostic and therapeutic nerve blocks, 

sympathetic blocks, discography, peripheral nerve 

blocks, and radiofrequency denervation are performed. 

Additionally, fluoroscopy is an integral part of IPM 

and is primarily used to ensure target specificity and 

accurate delivery of the injectate.3-6

In 2002, Walter Reed Army Medical Center, a large 

US Army teaching hospital, began the operation of an 

IPM clinic. There are 3 separate populations that could 

possibly receive exposure to ionizing radiation as a 

result of this clinic’s activity: staff, patients, and the 

general public. There have been multiple studies to 

characterize the exposure of the IPM specialist to 

ionizing radiation.3-8 However, it is much more 

difficult to characterize the radiation dose to a patient 

during a fluoroscopic procedure. Since the primary 

method of exposure to the physician performing a 

fluoroscopic procedure is scattered radiation from the 

patient, the relative dose to the patient can be inferred 

The Impact Of Peer-Based Training on 

 Reducing Radiation Doses from X-Ray 

 Operations in an Interventional Pain 

 Management Clinic 

MAJ Christopher D. Pitcher, MS, USA 

COL Mark A. Melanson, MS, USA 

ABSTRACT 

This paper describes the measurement and characterization of the radiation exposure to the staff, patients, and 

the general public as a result of the operation of an interventional pain management (IPM) clinic, as well as 

the effectiveness of a peer-based fluoroscopy training program to keep doses as low as reasonably achievable 

(ALARA). During the last decade, pain management has evolved into an essential part of patient care. IPM, a 

subfield of pain management, uses fluoroscopic imaging in its procedures. As a result, there are 3 separate 

populations who could possibly receive exposure to ionizing radiation as a result of an IPM radiographic 

procedure: staff, patients, and the general public. Staff doses, as well as doses to the general public, are easily 

measured with radiation dosimetry. Conversely, it is very difficult to characterize the radiation dose to a 

patient during a fluoroscopic procedure and, realistically, it is not possible to measure patient dose directly. 

However, it is plausible to infer relative patient exposure from direct measurement of the physician’s dose. 

The most common and practical way to measure the dose to members of the general public is to monitor the 

ambient radiation levels within a medical treatment facility and extrapolate these measurements to the general 

public. Ultimately, the goal is to maintain all doses (patient, physician, and the general public) using the 

ALARA principle. Using a Panasonic thermoluminescent dosimetry system, it was determined that a peerbased fluoroscopy training program effectively reduced the cumulative dose to clinic staff by approximately 

50%. It was also determined that the standard building materials used in our facility provide enough shielding 

to keep doses to members of the general public below acceptable limits. 
44 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

from the measurement of the physician’s dose. This 

idea of inferring a relative dose to the patient from a 

direct measurement of the physician’s dose assumes a 

proportional relationship between the two; therefore, a 

decrease in the physician’s dose is equivalent to a 

proportional decrease in the patient’s dose. In order for 

a relative dose based on a physical dose measurement 

to be meaningful, it must be compared to a similar 

measurement (eg, dose measurements before and after 

a training event). The 2 relative doses must also have 

equivalent proportionality to the base measurements. 

In the case of fluoroscopy, a proportionality based on 

scattered radiation would change if the geometry 

between the patient and physician, or if the presence of 

shielding material changes significantly. If these 

requirements are satisfied, it is valid to assume that 

comparing 2 similar exposure scenarios would yield 

comparable relative dose assessments. 

It is impractical to directly measure the dose to each 

member of the general public that might be exposed to 

ionizing radiation as a result of this clinic’s activity. 

The most practical way to estimate these doses is to 

measure the ambient radiation levels around the IPM 

clinic and extrapolate these measurements to conservative estimates of the doses to the general public. 

The mission of the Health Physics Office at our 

facility is to maintain the doses resulting from any 

medical use of ionizing radiation as low as reasonably 

achievable (ALARA). During an annual review of our 

dosimetry program at the end of calendar year 2003, 

the dosimetry custodian noticed an average increase in 

the total effective dose equivalent (TEDE) to those 

personnel who are occupationally exposed to ionizing 

radiation and are issued personnel dosimetry. The 

increase was not large (from 0.60 mSv to 0.80 mSv), 

but a quick review of the dosimetry data revealed a 

large discrepancy in the average dose received by the 

physicians, residents, and fellows in the IPM clinic as 

compared to personnel working elsewhere in the 

facility. In order to reduce these doses, a special 

training program focused on the proper use of 

fluoroscopic x-ray equipment by the IPM clinic staff 

was implemented to supplement the regular annual 

radiation safety training. This paper describes the 

measurement and characterization of the radiation 

exposure to the 3 populations listed above as a result 

of the operation of an IPM service, as well as the 

effectiveness of this new training program in reducing 

radiation doses in the clinic. 

MATERIALS AND METHODS

X-Ray Source 

The fluoroscopic x-ray systems used in our facility’s 

IPM clinic (photo on page 47) are the General Electric 

Model OEC 9800 (GE Healthcare Systems, Waukesha, 

Wisconsin). This c-arm style unit has many features 

that are designed to limit both the user’s and the 

patient’s radiation exposure while maintaining 

acceptable image quality. Despite these features, the carm units have the ability, if not used properly, to produce an x-ray field capable of delivering significant 

levels of exposure to both patient and user alike. This 

fact became evident during an annual x-ray safety 

compliance survey of these units when the maximum 

exposure level at 30 cm from the focal spot was measured to be 128 roentgens per minute with an MDH ion 

chamber (Radcal Corporation, Monrovia, California). 

Dose to Patients and Staff Members 

In the US Army, all personnel who are occupationally 

exposed to ionizing radiation and may exceed 10% of 

the occupational dose limit of 5 rems (50 mSv) per 

year are issued dosimetry.9

 The US Army uses a 

thermoluminescent dosimetry (TLD) system to 

measure and characterize this exposure. The TLD 

system is provided by the US Army Dosimetry Center, 

Redstone Arsenal, Alabama. This center is accredited 

by the National Voluntary Laboratory Accreditation 

Program for the determination of TEDE using a 

dosimetry system manufactured by Panasonic 

(Secaucus, New Jersey). This dosimetry system 

consists of a Panasonic model UD-802AS dosimeter in 

a model UD-874AT holder and a model 710 reader. 

In order to determine the TEDE, a combination of 2 

dosimeters is used. One is worn on the trunk of the 

body under any lead shielding and the second is worn 

at neck level outside of any lead shielding. The TEDE 

is calculated from the deep (depth of 1.0 cm in tissue) 

dose determined from each dosimeter using the 

following formula10: 

TEDE = 1.5 × Body + 0.04 ×Neck

where Body and Neck refer to the deep dose 

determined from the dosimeter worn on the trunk of 

the body and at the neck level respectively. 

The Impact Of Peer-Based Training on Reducing Radiation Doses from X-Ray Operations 

in an Interventional Pain Management Clinic 
 April – June 2010 45

THE ARMY MEDICAL DEPARTMENT JOURNAL

Fluoroscopy Training Program 

The need for physician training programs on the 

effective use of fluoroscopic x-ray equipment has been 

presented in the literature.11,12 However, the methods 

used to provide this training can vary significantly. 

Within the US Army Medical Department, the 

individual Radiation Safety Officers at different 

medical facilities have employed varied training 

methodologies ranging from instruction by the health 

physics staff to internet-based training. The selected 

methodology used at our facility was peer training. In 

August 2004, a training class in the proper use of 

fluoroscopy was given to the IPM clinic staff by an 

experienced, board certified interventional radiologist. 

All personnel in the IPM clinic using fluoroscopy were 

required to attend the training. The class included the 

following topics: pulsed and low dose fluoroscopy; 

fluoroscopic magnification modes; use of last image 

hold; time, distance, and shielding concepts; 

recognition of the x-ray field size; and proper wear of 

dosimetry. 

In order to determine the effectiveness of this training 

program, the cumulative TEDE to the staff of the IPM 

clinic was compared before and after the training. The 

dosimetry for the personnel in this department is 

exchanged monthly. The cumulative TEDE for the 

clinic was tallied using all individual monthly dose 

readings for 2 equal time periods (July 2003 through 

September 2004 and October 2004 through December 

2005) immediately before and after the described 

training. It is important to note that no new personnel 

joined the clinic staff during the period of this study. 

Doses to Members of the General Public 

Since x-ray operations are regulated by the individual 

states, there are no specific federal regulations that 

deal with the shielding of x-ray facilities. Despite this, 

there are multiple federal regulations limiting the dose 

from ionizing radiation to members of the general 

public.13,14 The dose limit of 1 mSv per year is incorporated into the US national consensus standards used 

to determine the shielding requirements of x-ray 

facilities.15 Additionally, the US Army has specific requirements for the shielding of x-ray facilities which 

are published in Technical Bulletin MED 521.

16 Paragraph 4-12 of this bulletin states that “...a qualified 

expert will ... ensure that the design [of the x-ray 

facility] is adequate to meet regulatory dose limits and 

keep doses to personnel ALARA.”16(p4-10)

Due to the mobile nature of a c-arm fluoroscopic x-ray 

system, the facility design (eg, shielding) that normally 

accompanies the installation of a permanent x-ray 

system is not required. However, according to the 

National Council on Radiation Protection and 

Measurements: “If a mobile x-ray system is used in a 

fixed location, a qualified expert shall evaluate the 

need for structural shielding.”15(p14) This is precisely 

the situation that occurred as a result of starting an 

IPM clinic at our facility. Originally, the clinic was to 

only be at its present location temporarily. However, 

when it was decided that the location would be permanent, the shielding of the rooms containing the xray units had to be evaluated. In order to do this, 14 

Panasonic model UD-802AS dosimeters in model UD874AT holders were placed both inside and outside of 

each protective barrier in the patient treatment rooms, 

patient waiting area, and the hallway adjacent to the 

patient treatment rooms. The dosimeters were left in 

place for a period of 2 months in early 2004. 

RESULTS AND DISCUSSION

Dose Reductions From Training 

The cumulative dose to a member of the IPM clinic 

staff before the implementation of the new training 

program was 18.14 mSv. After the training, the 

cumulative dose dropped to 9.55 mSv. This marked 

decrease demonstrated that the new training program 

was effective in reducing the dose to the staff of the 

IPM clinic. Since the doses to the staff are proportional 

to the doses patients receive, the training program was 

effective in reducing the patient exposure as well. 

Discussions with the staff revealed that the primary 

procedural change that occurred as a result of the 

training were the use of the last image hold and the 

low dose mode. Therefore the relative doses had 

equivalent proportionality to the direct measurements 

both before and after the training event. 

It was recognized that changes in fluoroscopic 

procedures due to the new training program are not the 

only potential cause for a reduction in staff doses. 

Workload changes could also affect the measured 

cumulative doses. However, since beginning 

operations in 2002, the workload at our facility’s IPM 

clinic has seen a slight increase and has subsequently 

stabilized at around 5000 fluoroscopic procedures 

annually. This includes the time period considered 

during this study. 
46 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

The Impact Of Peer-Based Training on Reducing Radiation Doses from X-Ray Operations 

in an Interventional Pain Management Clinic 

Shielding Evaluation 

Only 4 of the 14 dosimeters that were used in 

determining the shielding properties of the barriers in 

the IPM clinic showed a measured deep dose greater 

than background (as measured with control TLDs). 

The 4 dosimeters were all located within the 2 

treatment rooms and recorded monthly deep doses of 

0.10 mSv, 0.25 mSv, 0.28 mSv, and 0.30 mSv 

respectively. All dosimeters in patient waiting areas 

and the hallway showed no discernable exposure 

above background. The Panasonic dosimeters used in 

this study have a minimum detectable dose of 0.01 

mSv.17 Therefore, a dose of up to 0.12 mSv per year 

would not be detectable in the areas measured. It was 

determined from these results that no additional 

shielding was required for the IPM clinic to be in 

compliance with Army regulations. 

CONCLUSION

The operation of an IPM clinic exposes clinic staff, 

patients, and members of the general public to ionizing 

radiation. With a few simple precautions, the radiation 

exposure to all 3 populations can be maintained below 

regulatory limits and in accordance with the ALARA 

principle. It was not necessary to make any shielding 

enhancements to our IPM clinic to protect the 

members of the general public. The primary method of 

reducing dose to the staff and patients was through the 

implementation of a peer-based training program 

focused on effective use of the c-arm fluoroscopes. 

Using an experienced interventional radiologist in the 

training process worked very well as evidenced by the 

significant reduction (by a factor of two) in the total 

doses to the clinic staff after the peer-based training 

program. 

REFERENCES

1. Meldrum ML. A capsule history of pain management. 

JAMA. 2003;290:2470-2475. 

2. Thomas SA. Role of the pain management specialist. 

Spineuniverse.com web site. Available at http://

www.spineuniverse.com/displayarticle.php/

article3337.html. Accessed July 25, 2006. 

3. Botwin KP, Freeman ED, Gruber RD, Torres-Ramos 

FM, Bouchlas CG, Sanelli JT, Hanna AF. Radiation 

exposure to a physician performing fluoroscopically 

guided caudal epidural steroid injections. Pain 

Physician. 2001;4:343-348. 

4. Manchikanti L, Cash KA, Moss TL, Pampati V. 

Radiation exposure to the physician in interventional 

pain management. Pain Physician. 2002;5:385-393. 

5. Manchikanti L, Cash KA, Moss TL, Pampati V. 

Effectiveness of protective measures in reducing risk 

of radiation exposure in interventional pain 

management: a prospective evaluation. Pain 

Physician. 2003;6:301-305. 

6. Zhou N, Singh N, Abdi S, Wu J, Crawfor J, Barach 

P. Fluoroscopy radiation safety in interventional pain 

procedures. 24th Annual Scientific Meeting, 

American Pain Society; March 30, 2005; Boston, 

MA. Poster 775. 

7. Botwin KP, Fuoco GS, Torres FM, Grubber RD, 

Bouchlas CC, Castellanos R, Rao S. Radiation 

exposure to the spinal interventionalist performing 

lumbar discography. Pain Physician. 2003;6:295-

300. 

8. Zhou N, Singh N, Abdi S, Wu J, Crawfor J, Furgang 

FA. Fluoroscopy radiation safety for spine 

interventional pain procedures in university teaching 

hospitals. Pain Physician. 2005;8:49-53. 

9. Department of the Army Pamphlet 385-24: The Army 

Radiation Safety Program. Washington, DC: US 

Dept of the Army; August 24, 2007. 

10. Department of the Army Pamphlet 40-18: Personnel 

Dosimetry Guidance and Dose Recording Procedures 

for Personnel Occupationally Exposed to Ionizing 

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

June 30, 1995. 

11. Castronovo FP. A fluoroscopic credentialing/safety 

program at a large research hospital. Health Phys. 

2004;86 (suppl2):S76-S79. 

12. Archer BR, Wagner LK. Protecting patients by 

training physicians in fluoroscopic radiation 

management. J Appl Clin Med Phys. 2000;1:32-37. 

13. Federal Radiation Protection Guidance for Exposure 

of the General Public. 69 Federal Register FRL-5126

-7 (1994). 

14. Radiation Dose Limits for Members of the General 

Public. 56 Federal Register 23398 (1991) (codified at 

10 CFR Part 20 Subpart D). 

15. Report No. 147 - Structural Shielding Design for 

Medical X-Ray Imaging Facilities. Bethesda, MD: 

National Council on Radiation Protection & 

Measurements; 2004. 

16. Technical Bulletin MED 521: Occupational and 

Environmental Health Management and Control of 

Diagnostic, Therapeutic, and Medical Research XRay Systems and Facilities. Washington, DC: US 

Dept of the Army; February 26, 2002. 
 April – June 2010 47

THE ARMY MEDICAL DEPARTMENT JOURNAL

17. Product Manual: New TLD “TL Badge System”. Secaucus, NJ: Panasonic Industrial Company; 2006. 

AUTHORS

MAJ Pitcher is Deputy Chief of the Chemical, Biological, Radiological, Nuclear, and High-Yield Explosives Branch, 

Department of Preventive Health Services, Academy of Health Sciences, US Army Medical Department Center and 

School, Fort Sam Houston, Texas. During the period covered by this paper, he was the Operations Branch Chief, 

Health Physics Office, Walter Reed Army Medical Center, Washington, DC. 

COL Melanson is Director, Armed Forces Radiobiology Research Institute, Bethesda, Maryland, and the Radiological 

Hygiene Consultant to The Army Surgeon General. 

One of the treatment rooms of the Interventional Pain Management Clinic at Walter Reed Army Medical Center. 
48 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

INTRODUCTION

The Army Medical Department Center & School 

launched the Professional Provider Resiliency 

Training (PPRT) course in May 2009. The purpose of 

the course is to provide a venue where medical 

professionals can learn self-resiliency techniques 

targeted specifically for medical staff, ie, doctors, 

nurses, ancillary staff.* The course integrates the most 

advanced research, concepts, techniques, and theories 

as they relate to self-care management. Throughout 

this course, medical professionals have the opportunity 

to participate in various experiential learning 

exercises, such as mind-body techniques that are 

aimed at improving self-care. Using personal 

introspection, medical professionals focus on internal 

and external stressors/processes that contribute to 

workplace burnout and compassion fatigue. The 

purpose of this article is to promote an understanding 

of the extent to which medical professionals value 

resiliency training, identify which mind-body techniques are most helpful, and identify if they are more 

aware of the value of developing a resiliency self-care 

plan. 

KEY CONCEPTS REVIEWED

All providers are at risk for fatigue and burnout which 

result from work stressors. In the military environment, the risk is likely to be much higher given the 

current tempo of operations. For example, the USA 

Today reported that the cost of military health care 

programs has increased significantly (increase 

projected as 167%, 2001-2011).1

 Further, the increase 

is a result of more physical problems and mental 

health issues due to multiple deployments. Most 

medical professionals experience fatigue on some level 

at some point and time in their career. When medical 

professionals value their work and workplace, but are 

exposed to physical and/or psychological stressors, a 

fatigue response is not uncommon. Fatigue may result 

from exposure (typically observing the aftermath of an 

event or when details of a traumatic/stressful situation 

are shared) to an extremely stressful event that a 

patient experienced and shares directly or indirectly.2

Fatigue adversely affects a person’s framework; 

emotional, cognitive, physical, social, and spiritual 

aspects are compromised.3

 The concept of provider 

fatigue in the Army Medical Department builds on the 

basic concept of fatigue in the current literature. 

Provider fatigue encompasses the realities of the 

Resiliency Training for Medical Professionals 

LTC Sheila Adams, MS, USA 

Cheryl Camarillo, LCSW 

LTC Steve Lewis, MS, USA 

CPT Nicole McNish, MS, USA 

ABSTRACT

For the past 10 years, the military medical system’s costs have increased by an estimated 167%. Behavioral 

health issues and physical ailments are major contributors to the increased costs. As a result, fatigue and 

burnout of medical professionals are growing concerns. The Army Medical Department (AMEDD) 

recognizes that physical and psychological stressors adversely impact personal well-being and organizational 

goals. Thus, an emphasis on enhancing the individual’s resiliency framework is essential to the stamina and 

long-term endurance necessary to sustain the continued provision of high quality medical care. To that end, 

the Army Medical Command (MEDCOM) has instituted the Provider Resiliency Program. The Professional 

Provider Resiliency Training (PPRT) conducted by the AMEDD Center and School should be a key element 

of the MEDCOM Provider Resiliency Program. The PPRT provides medical professionals the opportunity to 

significantly develop and enhance their resiliency skills. This article includes outcome data from 172 medical 

professionals who attended the PPRT. Specific focus is on their perspective about resiliency training. The 

findings in this article revealed that the doctors (100%), nurses (98%), behavioral health providers (90%) and 

other professionals (100%) who attended the PPRT course valued the training and indicated that they will use 

the learned mind-body resiliency techniques. 

*Civil Service level GS-11 and above, enlisted military rank E7 

and above 
 April – June 2010 49

military environment, which includes the unique 

aspects of a military theater of operations. The impact 

of fatigue under either circumstance includes feelings 

of being trapped, on edge, exhausted, overwhelmed, 

and infected by others’ trauma. Fatigue and burnout 

are often discussed as 2 separate phenomena even 

though they share similarities,4

 and are connected. 

Burnout occurs over time and is a feeling of helplessness that results in low workplace performance.2

Burnout characteristics are not that different from 

fatigue, however, symptoms may be more exacerbated 

and one’s perspective of the workplace is negative, 

value of the work is not apparent, resulting in feelings 

of unhappiness, disconnectedness, and insensitivity.2

In this article, fatigue and burnout are viewed on a 

continuum. If one experiences fatigue and it remains 

unmanaged, the likely result will be burnout. 

Resiliency can be a protective factor to combat fatigue 

and burnout. A resilient framework will likely promote 

satisfaction in the workplace and in other spheres of a 

person’s life. Resiliency is a state of being that 

promotes wellness and decreases the impact of 

physical and psychological stress.5

 A strong resiliency 

framework entails intact and healthy adaptive 

emotional, cognitive, physical, social, and spiritual 

characteristics. Stressful or traumatic events that are 

experienced will shape one’s resiliency framework, 

either directly or indirectly. Thus, the positive factors 

that manifests from these experiences are desirable 

traits that lead to a strong resiliency framework.6

 A 

simplified definition is presented to focus the reader on 

the concept of resiliency building factors/skills that are 

indicative of how we perceive events and take care of 

ourselves. The self-care plan is derived when a 

medical professional makes a conscious effort to 

nurture their physical, mental, emotional, social, and 

spiritual aspects.7

There are internal resiliency factors/skills that we 

personally evolve, and external factors that we manage 

but may not control completely. External factors refer 

to organizational factors in the clinical environment or 

theater of operations. All medical professionals have 

the ability to promote individual positive self-growth 

on some level. Thus, a person’s internal resiliency 

factors can be evolved into a positive or negative 

framework over time. The resiliency training at the 

Army Medical Department Center and School is aimed 

to do just that—provide medical professionals with a 

multitude of resiliency building skills to enhance their 

resiliency framework over time across all aspects 

outlined in the self-care plan. It is a medical 

professional’s responsibility to embrace the concept of 

personal responsibility for improving his or her own 

mental and physical stamina. When this occurs, he or 

she is more likely to be receptive to enhancing or 

developing new resiliency skill building techniques. 

RESILIENCY THEORETICAL FRAMEWORK

Internal resiliency factors that we want to see in our 

medical professionals can be vast. Certainly, many 

medical professionals possess resiliency building 

skills. We are all familiar with some basic concepts 

and maybe even personally embrace them consciously, 

thus contributing to a stronger resiliency framework. 

Siebert’s Resiliency Model5

 is presented as a unified 

theory. He identifies 5 key principles that are 

indicative of a resilient person: 

Managing health 

Problem-solving 

Increasing self-strengths: self-esteem, selfconfidence, and self-concept 

Developing positive response choices 

Learning good lessons from difficult situations 

The following case study is presented to assist the 

understanding of this theoretical framework: 

CPT Lee is a behavioral health officer working in an 

Army medical treatment facility. She has been in the 

Army for 10 years. In 2007, she was deployed to Iraq. 

While deployed, she became very distraught with the 

long deployment. Her thoughts became more negative, 

she personalized situations that affected the entire unit 

and ignored managing her weight and health. To make 

matters worse, her tour of duty was extended for an 

additional 3 months. She described herself as 

depressed and ineffective at her job. 

CPT Lee now identifies herself as someone who has 

changed her perspective on how she manages 

stressors/challenges. She embraces Siebert’s key 

principles5

 as a way of life. This is a new way of 

thinking, doing, and managing for her, but the work 

and commitment that she has put forth has been 

rewarding. CPT Lee notes that her outlook on life now 

is significantly more positive and that she is much 

happier as a person. She further states that her 
50 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

subordinates, coworkers, and leadership have 

repeatedly commented on her ability to reframe 

situations in a positive manner (“the glass half full”). 

When asked to describe her past and present 

perspective in dealing with a stressful work situation, 

she shared the following experience: recently she was 

informed that she will deploy as a backfill in support 

of another behavioral health officer. She noted that 

while the situation is not desirable, due to the 

acquisition of the skills, she is prepared for the task 

and has a positive perspective about the situation. 

She learned several new resiliency skills at the PPRT 

and developed a self-care plan that is realistic for her. 

Now, she is proactive in updating her self-care plan 

which keeps her focused on the 5 target areas. Table 1 

Resiliency Training for Medical Professionals 

Table 1. CPT Lee’s successful application of Siebert’s 5 key resiliency principles which countered her fatigue/

burnout responses to her perceived negative deployment experience. 

Siebert’s 

Resiliency 

Principles6

Symptoms of 

Fatigue/Burnout 

Successful Development of 

Resilient Framework/Perspective 

Health Management 

(Overall Wellness) 

CPT  Lee  was  not  taking  personal 

responsibility  for  her  overall  well‐

being.  Her  negative  perspective  con‐

sumed  her and led  to  cognitive, emo‐

tional  and  behavioral  responses  that 

were  debilitating.  Her  lack  of  moti‐

vation  was  evident  in  her  work  and 

personal self care. 

She  has  been  very  proactive  in  managing  her  overall  well‐

being.  Her  positive  perspective  led  to  adaptive  cognitive, 

emotional and behavioral choices. She realizes that she does 

not  have  control  over many events  that affect  her life in  the 

military,  but  she  does  have  control  over  how  she  perceives 

them, and her reactions. 

Proactive 

Problem‐Solving 

During  the  deployment,  she  often  felt 

powerless  and  focused  on  those 

things  that were  upsetting  to  her. She 

was often miserable and had negative 

thoughts.  CPT  Lee  expressed  how 

helpless  she  was  and  noted  that  she 

slept  a  lot.  Her  emotions  drove  her 

and  how  she  perceived  her  environ‐

ment. 

Recently  she  was  informed  that  she  must  backfill  another 

behavioral  health  officer in  8 weeks.  CPT  Lee has been busy 

preparing  her  family  by  ensuring  that all  personal  matters 

are in order and spending quality time with the family doing 

fun and eventful activities. She came up with a “to do” list at

work  to  ensure  that  she  closed  out  all  administrative  and 

patient  care activities  appropriately.  Weekly  updates  were 

sent  to  her  supervisor.  She  is  able  to  look  at  things 

rationally. 

Increase 

Self‐Strengths: 

Self‐Esteem, 

Self‐Confidence, 

and Self‐Concept 

As  a  way  of  life,  she  isolated  herself 

from  others  and  avoided  people  that 

were  positive.  When  she  had  the 

opportunity  to  help  in  humanitarian 

missions,  she  declined  unless 

required by her supervisor. 

CPT  Lee  maintains  her  weight  and  health,  rewards  herself 

for  accomplishments,  and  often  volunteers  to  assist  her 

supervisor  with  command  briefings.  She  is  more  open  to 

learning  how  to improve  her work  performance, as well as 

her life. She embraces events as  opportunities  to grow and 

change. 

Developing Positive 

Response Choices 

When her  tour  of  duty was extended, 

she  often  complained  to  peers  and 

became  passive  on  the  job.  She  did 

not  see  the  value  of her  contributions 

to the overall war effort. 

When  her  supervisor  told  her  that  she  would  be  tasked  to 

backfill  another  officer  for  3  months,  she  initially  became 

anxious.  Immediately  she  calmed  herself  by  reframing  the 

situation—she  only  had  to  go  for  3  months.  She  began  to 

think  about  the  hidden  opportunities  that  the  3  months 

might present. 

Learning Good 

Lessons from 

Difficult Situations 

During  the  deployment,  she  would 

often  tell  her  family  that  there  was 

nothing positive about her experience 

and  that  she  was  miserable.  She  was 

often  tearful  and  tangential,  and 

perceived most  of  her experiences as 

negative. 

CPT  Lee  realized  that  during  her  first  deployment, 

everything about  the  situation was  negative  from  her  point 

of  view.  She  is  now  able  to  identify  personal  gains  from  a 

difficult  situation by  changing  her  view  of  the  past. Now  she 

realizes  that  she  is  happier  and  accomplishes  a  lot  more 

when  she focuses  on being  proactive and positive about  the 

situation.  Even  her ability  to  manage  complex  situations  is 

markedly  improved.  Additionally,  people  like  to  be  around 

her and  she exudes a  positive energy in  the work  place and 

at home. 
 April – June 2010 51

THE ARMY MEDICAL DEPARTMENT JOURNAL

synopsizes CPT Lee’s experience with fatigue and 

burnout, and how she successfully dealt with them. 

Difficult experiences, traumatic situations (direct or 

indirect), stressful life events (expected or unexpected) 

in the workplace or in our personal lives are inherent 

of the human experience. In a military theater of 

operations environment, physical and psychological 

stressors should be expected, and reactions to 

experiences are often very intense. The cognitivebehavioral literature presents the ABC model, which is 

an evidenced based model used in multiple settings.7-10

Additionally, this model asserts that when we 

experience any situation (A), it is interpreted and we 

formulate a belief (B) about that experience, which 

may be rational or irrational. This leads to an 

emotional, behavioral, and thought response (C), based 

solely on the belief we derive. This is an excellent tool 

for understanding how any situation can be cognitively 

framed by a person. A medical professional with a 

resilient framework will likely be a rational person that 

has a positive thought process. Table 2 presents the 

ABC model in the context of the CPT Lee case study. 

The PPRT offers skills to medical professionals that 

aid in managing stress, which leads to a restructuring 

of thoughts from a perspective of helplessness or 

negativity to an empowering attitude with a positive 

outlook. The PPRT provides training on mind-body 

techniques, which include deep breathing, journaling, 

tai chi, meditation, guided imagery, and biofeedback, 

just to name a few. These are techniques that most 

medical professionals have heard of, theoretically 

understand their benefits, and often recommend to 

patients. Yet, medical professionals typically do not 

focus on themselves and what they personally need to 

enhance or sustain a strong resiliency framework. 

In an effort to enhance one’s resiliency framework, 

one must have a myriad of skills that are nurtured and 

practiced over time. Three questions are answered in 

this article: 

 Do medical professionals who attended the 

AMEDDC&S PPRT course value the training? 

 What are the top 3 mind-body techniques that 

medical professionals viewed as most helpful? 

 Is there a relationship among the following 

variables: I found value in the materials; I will use 

the techniques; I am thinking more about selfassessment; and I am thinking more about 

developing a self-care plan? 

METHODOLOGY

This study used a convenience sample of 172 

professionals (82%) from a total of 210 medical 

professionals who attended the PPRT course. 

Participation was voluntary. Professionals were nurses, 

behavioral health providers, doctors, and 

administrative and enlisted personnel. Professionals 

were predominantly in the Army and consisted of 

civilian and military personnel. A response was 

defined as a completion of any part of the survey. Data 

was collected from 7 different cohorts beginning in 

May 2009 and ending in March 2010. The end of the 

course surveys were used to answer the questions for 

this study. There are 3 major sections in the survey: 

 First part – basic demographical information. 

 Second part – a 5-item (Likert Scale) self-report 

scale used to answer the questions for this 

research. 

 Third part – open-ended questions that allowed respondents to give feedback about the course in 

their own words. 

Participants 

The majority of the participants (89%) in the study 

were professionals from various Army medical 

treatment facilities. There were also representatives 

from the other services, Reserve and National Guard 

components, and the Department of Veterans Affairs 

(11%). Most participants were nurses and behavioral 

health practitioners. 

Findings 

As shown in Figure 1, most attendees were either 

Army nurses (35%) or behavioral health professionals 

(23%), 12 participants (7%) were Army doctors, and 

21 attendees (12%) were enlisted. The majority of 

participants work in a hospital environment (41%), and 

33% of the participants indicated that they worked in a 

Warrior Transition Unit (Figure 2). The Great Plains 

Regional Medical Command (20%) and the South East 

Regional Medical Command (20%) had the highest 

number of attendees, while the Europe Regional 

Medical Command recorded the lowest number (8%) 

(Figure 3). 
52 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

Resiliency Training for Medical Professionals 

MIND-BODY TECHNIQUES

The vast majority of the participants in this 

study found the PPRT valuable. Ninety-eight 

percent of the nurses, 90% of the behavioral 

health providers, and 100% of the doctors, 

enlisted personnel, and ancillary professionals reported that they found value in the 

materials provided. Most participants in the 

study found the deep-breathing exercise 

(95%), tai chi (86%), and guided imagery 

(85%) to be the 3 most helpful mind-body 

resiliency techniques. Overall, 96% of the 

participants reported that they plan to use the 

learned mind-body techniques in the future. 

The study also provides valuable information 

indicating that the PPRT enhances the selfawareness of participants and their 

propensity to develop effective coping skills. 

Results from the survey showed that 90% of 

the participants were more mindful of their 

personal resiliency after completing the 

training. Additionally, 92% reported that 

they were thinking more about conducting 

self-assessments, and 93% reported thoughts of 

developing a self-care plan. 

A correlation was computed using the Spearman’s 

rank correlation coefficient (rho) nonparametric test to 

determine the magnitude and direction of the 

relationship between each pairing of the following 

Likert Scale variables11,12: 

1. Value materials 

2. Plan to use techniques 

3. Thinking more about self-assessment 

4. Thinking more about developing a self-care plan 

Table 3 demonstrates the significant positive 

relationship between each pairing of the variables. The 

magnitude of the relationship between each of the 

variables was strong. Participants who valued the 

material are also more likely to indicate that they plan 

to use techniques learned in the future (correlation 

coefficient ρ = 0.589); and participants who are 

thinking more about self-assessment are also strongly 

related to participants who are thinking more about 

developing a self-care plan (ρ = 0.649). The relationship is not by chance as determined by the test of 

Negative Belief Perspective Positive Belief Perspective 

Activity/Event 

Deployment Experience 

Activity/Event 

Upcoming Deployment 

Belief–My contributions do not 

matter 

Thought‐Why  even  try,  my 

efforts will not have an impact 

Belief–Deployment is part of the 

job 

Thought‐Not  so  bad,  I  only  have 

to  go  3  months;  shift  focus  to 

more  important  tasks  to 

prepare;  close  out  loose  ends  at 

work  and  spend  quality  time 

with family 

Consequence–Emotional (tearful 

and often depressed); 

behavioral (isolate, avoid, 

passive approach); cognitive 

(negative outlook and thought 

process) 

Consequence–Emotional (happier 

with family, more positive); be‐

havioral (active at work and with 

family, task oriented and 

focused, proactive in work‐

place); cognitive (organized 

thoughts; oriented, optimistic 

outlook) 

Table 2. Application of the ABC model8-11 to CPT Lee’s experience 

with fatigue and burnout. 

Figure 1. Distribution of medical professionals who participated 

in the study. 

Doctors Nurses Behavioral

Health Ancillary Enlisted Other Missing

Figure 2. Distribution of work locations of participants in the 

study 
 April – June 2010 53

THE ARMY MEDICAL DEPARTMENT JOURNAL

significance. The results do not imply causation 

between the variables. It is more likely that medical 

professionals value the training and plan to use the 

skills because they require resources and support. 

Further, they need to focus on taking care of 

themselves to enhance their resiliency framework, 

given the increased workload demands in the military 

medical environment. 

DISCUSSION

In their 2005 report, the Mental Health Advisory Team 

(MHAT) recommended that the US Army Surgeon 

General “research and establish a program designed to 

prevent and reduce compassion fatigue and burnout.”13

The MHAT report revealed 45% of deployed primary 

care providers and 33% of behavioral healthcare 

providers self-reported burnout. Most importantly, the 

study showed that 15% of all providers reported that 

burnout affected their overall performance. As a result 

of this finding, The Acting US Army Surgeon General 

established the Provider Resiliency Program to institute 

provider fatigue surveillance and oversight, and 

training for the providers. In a recent analysis on 

burnout of medical personnel, using the Professional 

Figure 3. Distribution of participants in the study as 

sourced from regional medical commands. 

Glossary: 

GPMC - Great Plains Regional Medical Command 

SERMC - Southeast Regional Medical Command 

PRMC - Pacific Regional Medical Command 

WRMC - Western Regional Medical Command 

NRMC - Northern Regional Medical Command 

ERMC - Europe Regional Medical Command 

 Variable 1 Variable 2 Variable 3 Variable 4 

Value in materials 

provided 

(Variable 1) 

Correlation Coefficient 0.589* 0.244* 0.246*

Sig. (2-tailed) 0.000 0.002 0.002

N 167 160 162 

Plan to use techniques 

in future 

(Variable 2) 

Correlation Coefficient 0.589* 0.240* 0.248*

Sig. (2-tailed) 0.000 0.002 0.001

N 167 160 162 

Thinking more about 

Self‐assessment 

(Variable 3) 

Correlation Coefficient 0.244* 0.240* 0.649*

Sig. (2-tailed) 0.002 0.002 0.000

N 160 160 161 

Thinking more about 

Developing a Self‐care Plan 

(Variable 4) 

Correlation Coefficient 0.246* 0.248* 0.649* 

Sig. (2-tailed) 0.002 0.001 0.000 

N 162 162 161 

Table 3. The statistical correlation (Spearman’s rank correlation coefficient nonparametric test) between each 

pair combination of the Likert Scale variables as reported in responses of the participants. 

*Correlation is significantat the 0.01 level (2 tailed)
54 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

Quality of Life Scale, 18% of medical personnel in 

MEDCOM (52,000 participants) reported burnout.14 In 

contrast, doctors and enlisted personnel reported a 

higher percentage rate of burnout, 27% and 23% 

respectively, when compared to the MEDCOM-wide 

percentage. The adverse personal effects of fatigue and 

burnout are self-medicating behaviors, depression, and 

acute stress responses.2

Building resiliency will counter fatigue and burnout. 

Organizational prevention programs are believed to 

enhance personnel well-being and counter fatigue 

responses.2

 In a study on resiliency using an 

experimental design conducted in a large government 

organization, findings indicated that participants in a 

resiliency program reported more improvement than 

the control group.15 Interestingly, this result prevailed 

even though the experimental group reported more 

adverse pretest scores. The training cited in that report 

consisted of 35 hours over a 5-week period. The total 

hours trained is consistent with the PPRT course. 

Additionally, the training in the study is similar to the 

PPRT, which focuses on mind-body techniques that 

are aimed at enhancing self-care. Throughout the 

PPRT, the curriculum focuses on maladaptive 

cognitive shifts that occur as a result of exposure to 

difficult situations or secondary trauma. Building 

cognitive skills is one of the cornerstones of resiliency 

training because it aims to combat distortions that lead 

to distressing outcomes.6

 The case study depicted 

earlier is a good example of how cognitive processes 

can lead to negative or positive responses which have 

an impact on the person and organization. 

The concept of resiliency in the Army is new and the 

Army Medical Department's endorsement of this 

prevention effort is a model for other services and the 

civilian medical community. However, that 

endorsement of provider resiliency is not without 

controversy, indeed, some medical professionals are 

leery. There are a number of possible reasons for that 

reticence, including: 

 A lack of trust in the system or its intent. 

 Embarrassment with pursuing training that 

promotes self-growth. 

 They may not fully understand the relevance. 

 They view it as a waste of time. 

 Fear of validating that their job might be 

negatively impacting them. 

 They simply anticipate becoming overwhelmed 

with yet another mandated training requirement. 

It has been shown that participants who attended the 

training view it as valuable (93%, n =167) and plan to 

use the techniques learned (92%, n = 162). 

Additionally, the relatedness among the variables 

revealed all significant results. Leaders, supervisors, 

and medical professionals will require more education 

on the overall benefits of resiliency training. 

Nurses and behavioral health providers represent a 

higher percentage of participants attending the 

training. Given the recent findings of the analysis of 

fatigue and burnout in MEDCOM,13,14 more doctors 

and enlisted personnel should be encouraged to attend 

the PPRT. Moreover, the long-term benefit of the 

training will enhance personal endurance. Refusal to 

address fatigue and burnout issues result in turnover, 

lower morale, lower productivity, greater use of sick 

leave, and physical illness that lead to patient errors.2

In short, long-term organizational gains outweigh the 

short-term sacrifice. Medical professionals are typically not trained or encouraged to sustain and manage 

a self-care plan that enhances resiliency. Therefore, 

leadership endorsement, time, information, education, 

and consistency will prompt a cultural shift in support. 

CONCLUSION

The documented increased demands in the military 

environment continue to impact medical professionals. 

Fatigue and burnout responses have an undesirable 

impact on personal well-being and the organization. 

Organization prevention programs can be effective. 

The PPRT is very similar to a program15 that has 

demonstrated positive effects of resiliency training. 

The MEDCOM Provider Resiliency Program is a great 

opportunity for the Army Medical Department to show 

medical personnel that the leadership is interested and 

concerned about their well-being, and understand that 

training opportunities benefit personal interest and 

organizational mission sustainment. 

The results of this study cannot be generalized and 

must be received with caution. As a baseline, it does 

establish a clear precedent about how medical 

personnel perceive training. Of special note, the 

majority of the sample included nurses and behavioral 

health personnel. In the future, a more stringent study 

will include input from doctors, enlisted personnel, 

and other ancillary providers to validate findings. 

Resiliency Training for Medical Professionals 
 April – June 2010 55

THE ARMY MEDICAL DEPARTMENT JOURNAL

More information is needed about participants who 

attended the training. For example: 

(a) Are the medical professionals in this study 

more likely to focus on self-care as a norm? 

(b) Why do they elect to attend training? 

More research on understanding the impact of 

resiliency as it pertains to personal and organizational 

benefits in the military medical environment is needed. 

Future studies that encompass an experimental design 

and look at the differences between medical 

professionals who receive training and those who do 

not will be cutting edge research. Future studies must 

also be able to demonstrate value to the organization 

using measures of sick-day absence, retention, and 

customer satisfaction, to name a few. Thus, a resiliency program that demonstrates efficacy is imperative 

to justify funding for continued surveillance, training, 

and future research initiatives. 

ACKNOWLEDGEMENTS

We thank Dexter Freeman, PhD; Lisa Landry, PhD; 

MAJ Terry Martinez; and Cindi Geeslin for their assistance in preparation and critical review of this article. 

REFERENCES

1. Zoroya G. Military health care costs booming. USA 

Today [serial online]. April 22, 2010. Available at: 

http://www.usatoday.com/news/military/2010-04-22-

vet_N.htm. Accessed April 23, 2010. 

2. Stamm BH. The Concise ProQOL Manual. Pocatello, 

ID: The ProQOL.org; 2009. Available at: http://

www.proqol.org/uploads/ProQOL_Concise_9-

2009.pdf. Accessed April 30, 2010. 

3. McCann IL, Pearlman LA. Vicarious traumatization: 

a framework for understanding the psychological 

effects of working victims. J Trauma Stress. 

1990;3:131-149. 

4. Leone SS, Huibers MJH, Knottnerus JA, Kant IJ. 

Similarities overlap and differences between burnout 

and prolonged fatigue in the working population. 

QJM. 2007;100(10):617-627. 

5. Siebert AL. The Resiliency Advantage. San 

Francisco, CA: Berrett-Kuehler Publisher, Inc; 2005. 

6. Calderon-Abbo J, Kronenberg M, Many M, Ososfsky 

HJ. Fostering healthcare providers’ posttraumatic 

growth in disaster areas: proposed additional core 

competencies in trauma-impact management. Am J 

Med Sci. 2008;336(2):208-214. 

7. Sharpe M, Wilks D. ABC of psychological medicine: 

fatigue. Br Med J. 2002;325:480-483. 

8. Lam D, Gale J. Cognitive behaviour therapy: 

teaching a client the ABC model—the first step 

toward the process of change. J Adv Nurs. 2000;31

(2):444-451. 

9. Stevens JC. Cognitive behavioral therapy: ABC 

model. [basic-counseling-skills Website]. Available 

at: http://www.basic-counseling-skills.com/cognitivebehavioral-therapy.html. Accessed May 3, 2010. 

10. Beck JS. Cognitive Therapy: Basics and Beyond. 

New York, NY: The Guilford Press; 1995. 

11. Pagano RR. Understanding Statistics In the 

Behavioral Sciences. 5th ed. Pacific Grove, CA: 

Brooks/Cole Publishing; 1998. 

12. Rubin A. Statistics for Evidence-Based Practice and 

Evaluation. Belmont, CA: Brooks/Cole Publishing; 

2010. 

13. Operation Iraqi Freedom II, Mental Health Advisory 

Team (MHAT) II Report. Washington, DC: Office of 

The Surgeon General, US Dept of the Army; January 

30, 2005. Available at: http://www.armymedicine. 

army.mil/reports/mhat/mhat_ii/OIF-II_REPORT.pdf. 

Accessed April 22, 2010. 

14. Adams S, Bicknell G. Building resilience: rebounding from and preventing compassion fatigue. 

Presented at: 12th Annual Force Health Protection 

Conference; August 17, 2009; Albuquerque, NM. 

15. Waite PJ, Richardson GE. Determining the efficacy 

of resiliency training in the work site. J Allied Health. 

2004;33(3):178-183. 

AUTHORS

LTC Adams is Deputy Chief, Dept of Behavioral 

Science, Army Medical Dept Center and School, Fort 

Sam Houston, Texas. 

Ms Camarillo is Provider Resiliency Training Team 

Leader, Provider Resiliency Training Program, Army 

Medical Dept Center and School, Fort Sam Houston, 

Texas. 

LTC Lewis is Chief, Dept of Behavioral Science, Army 

Medical Dept Center and School, Fort Sam Houston, 

Texas. 

CPT McNish is a graduate student in the ArmyFayetteville State University Master of Social Work 

Program, Army Medical Dept Center and School, Fort 

Sam Houston, Texas. 
56 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

BACKGROUND

Due to the nature of military operations, US Soldiers 

are exposed to various diseases not commonly 

experienced by the general population. Service 

members deploy to various parts of the world, usually 

in developing countries, where infectious diseases 

continue to be a leading cause of mortality and 

morbidity. Among the major concerns are vectorborne diseases such as malaria, leishmaniasis, 

trypanosomiasis, dengue fever, and other arboviral 

infections. Other diseases that are potential sources of 

concern for deployed military are parasitic helminthes. 

In disease endemic areas, the local population may not 

manifest these diseases but remain as reservoirs. 

Service members who occupy such areas could easily 

get the infections due to lack of prior exposure to these 

diseases.1 Also, multiple deployments to different 

disease-endemic regions may confound diagnosis, 

prevention, and treatment due to repeated exposure to 

different parasite species. This may result in the 

reintroduction of parasites in areas where they had 

formerly been eradicated, and thereby burden the 

health care system. 

The US military has mechanisms in place to ensure 

that disease and nonbattle injuries (DNBI) are 

prevented by continuously searching for better ways of 

protecting the Warfighter. Some of the active 

preventive programs include medical threat assessment 

and risk communication, use of vaccines and 

chemoprophylaxis, and research and product 

development. In the area of vector–borne disease 

prevention, personal protective equipment consisting 

of use of topical insect repellent, N, N-diethyl-3-methyl 

benzamide (deet) and proper wear of permethrin 

treated uniforms remain the first and most effective 

line of defense. The continuous search for safer and 

more effective arthropod repellents for skin and 

clothing applications, development of more effective 

insecticide treated bed nets, dissemination of 

information and training materials, and timely vector 

assessment and control is testimony to the importance 

that US military medical community places on force 

health protection (FHP). 

The military also ensures that preventive medicine 

(PM) detachments are part of the deployed force. The 

PM detachments perform continuous checks on food 

facility sanitation, air quality monitoring, water safety, 

and general sanitation. They conduct surveillance of 

vectors of medical importance to assess disease threat, 

determine pest population, and recommend management and control. This is important since it not only 

facilitates vector control but also puts in place integrated pest management practices in order to reduce 

pesticide use. Historically, DNBI have been reported 

as causing more casualties than combat, and “seriously 

degrading the mission” more than combat-related 

injuries. From the time of Napoleon who lost over 

80% of his half million Soldiers to DNBI during the 

French invasion of Russia in 1812 2 to the most recent 

Observed Noncompliance with 

 Implementation of Vector-Borne 

 Disease Preventive Measures 

 Among Deployed Forces 

CPT Elizabeth W. Wanja, MS, USA 

ABSTRACT

Failure by individual service members and units to implement preventive measures to mitigate environmental health 

threats have always resulted in reduced efficiency of the Warfighter, with the attendant reduction in combat capability. 

This article describes observations at 2 sites in northern Iraq from July 2007 to September 2009 of deficiencies in the 

use of preventive and protective measures to reduce incidences of vector-borne diseases. Observations included 

individual service member’s indifference or negative attitude toward use of personal protective equipment and unit 

leaders’ failure to provide required resources and enforce use of personal protective measures. Implications of these 

actions and recommendation for enhancing compliance are discussed. 
 April – June 2010 57

US military operations in Liberia, Somalia, Iraq, and 

Afghanistan, noncombat related injuries continue to 

reduce military efficiency.3

 Many of the disease 

infections were attributed largely to noncompliance 

with recommended disease preventive measures.4

Units deploying for combat operations are expected to 

be fully prepared to execute their mission successfully. 

Consequently, commanders take time to ensure that 

personnel are trained on all equipment and maneuvers 

to be used during combat prior to deployment in 

accordance with the Army training and evaluation 

program manuals. In the area of combating vectorborne diseases, supplying personal protective materials 

and training on recommended PM measures have to 

some extent been part of the predeployment 

preparation process. The outcome of this preparation 

has been a reduction in the rates of DNBI as reported 

for Operation Iraqi freedom (OIF) and Operation 

Enduring Freedom (OEF) when compared to 

Operations Desert Shield and Desert Storm.5

 However, 

despite the numerous FHP resources available to 

individual service members, US forces continue to be 

plagued by numerous vector-borne diseases that could 

easily be prevented if proper personal protective 

equipment is used as recommended. 

OBSERVED CONCERNS

This report covers the period of the author’s 

deployment with the 926th Medical Detachment (PM) 

to the Iraq theater from July 2007 to September 2008. 

During this period, failure by individual Soldiers as 

well as gross failure by leadership to enforce 

implementation of simple PM recommendations were 

rampant. Following are some of the aspects of 

noncompliance to implement vector-borne disease 

preventive measures that were observed at the 

Contingency Operating Base (COB) Speicher and 

Forward Operating Base Q-West. 

Many of the Soldiers wore physical training shorts and 

tee-shirts in the evenings and remained outdoors for 

extended periods of time for various recreation 

activities. Also, due to high temperatures, physical 

training was conducted in the early hours of the 

morning or evening. Both periods coincide with the 

peak biting periods for sand flies and mosquitoes. 

We created a questionnaire, shown at Figure 1, to 

gather initial information about the existing environmental conditions, knowledge of preventive measures, 

and availability and use of preventive materiel when 

responding to a unit’s complaints of arthropod bites or 

request for pest control. From the responses to the 

questionnaires, we concluded that there was a marked 

distinction in the level of knowledge about personal 

preventive measures and availability of protective 

equipment (PPE) between the Active Army and 

Reserve (USAR) units. 

Availability of PPE was noticeably less among USAR 

units. More than 75% of the USAR units deployed 

without treated uniforms and did not have any Individual Dynamic Absorption Application (IDAA) kits 

for uniform treatment. Also, over 50% of these units 

had not been issued deet but had other types of arthropod repellents that were bought from the post exchange or were sent to them by family members. Some 

of the most commonly used repellents included OFF! 

Deep Woods Insect Repellent Spray (S.C. Johnson & 

Son, Inc, Racine, WI) containing 23.8% deet; OFF! 

FamilyCare Insect Repellents pump-spray containing 

5% to 15% deet; and Cutter (Spectrum Brands, Inc, 

Atlanta, GA) family Insect repellent containing 7% 

deet. Among Active Army units, approximately 50% 

of the units did not have permethrin-treated uniforms, 

although they had been issued the IDAA kits. Furthermore, more than 75% of the Soldiers did not know 

how to use the kits. About 75% of units had deet but 

more than 50% of the Soldiers did not use it as recommended for various reasons, such as safety concerns. 

Almost 90% of all units deployed without bed nets. 

One of the greatest challenges involved waste disposal. 

At COB Speicher, food waste was dumped at the burn 

pit and left overnight. Much unburned food was left 

outside the pit attracting many wild and feral animals. 

Rotting food waste also provided good breeding 

habitat for flies. Waste was not separated and heaps of 

tires, metal, plastic, and wood littered the landfill, 

providing breeding sites for mosquitoes and habitat for 

snakes, scorpions, rodents, and small mammals. In 

turn, rodent and other small mammals’ burrows 

provided breeding ground for sand flies. Thousands of 

birds flocked the area for food and shelter and posed 

serious problems for aircraft, especially during 

landing, since this area was close to the flight line. 

Wild and feral animals were a major problem on COB 

Speicher. Food waste left in open bins close to the Soldiers’ central housing units (CHUs) attracted animals. 

To compound this issue, Soldiers continuously fed 

dogs, cats, birds, and foxes, thereby encouraging them 
58 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

Observed Noncompliance with Implementation of Vector-Borne Disease Preventive Measures 

Among Deployed Forces 

Unit Name: Phone#: DATE: 

Unit Commander: SGM/1st Sergeant/Detachment SGT 

COB/FOB: 

Building Number: LSA: GRID:

Complaint:

GENERAL CONDITIONS

 YES NO

Total 

a. Branches cut back at least 2 feet from roof, ledges or other access ways? 

b. No debris allowed accumulating for greater than 72 hours? 

c. No vegetation around buildings/tents 

d. *No standing water, or suspected animal burrows in/around site? 

e. No hollow Sidewalks or walkways? 

More than 2 "N0" marks, equal high risk (* Denotes critical issues equal to 2 "No") 

STRUCTURAL CONDITIONS 

a. If dropped ceiling, are all tiles securely in place, present, good repair? 

b. Windows closed at all times, or approved screening present? 

c. *Walls free of holes greater than 1/4 inch in diameter? 

d. Floors extend to meet the walls with no gaps? 

e. *Floors free of cracks/holes greater than 1/4 inch. 

f. Doors hung properly, with no gaps greater than1/4 inch? 

g. If "No" are door sweeps or seals installed and in good repair? 

More than 2 "N0" marks, equal high risk (* Denotes critical issues equal to 2 "No")

SANITARY CONDITIONS

Total YES NO

a. Garbage cans cleaned adequately at least daily or when filled up? 

b. Garbage bags present/used? 

c. Dirty or soiled linen kept in approved containers. 

d. *Area free of live pets or mascots of any kind? 

e. Rodent traps checked daily? 

f. Fly traps removed once 70% full? 

g. *Food stored/consumed only in approved areas? 

h. *Food (including drink mixes) stored in hard plastic/metal containers? 

i. *No evidence of rodents (droppings, gnawing, rubmarks)? 

More than 2 "N0" marks, equal high risk (* Denotes critical issues equal to 2 "No") 

EDUCATION/PREVENTIVE MEASURES

a. *Acting Field Sanitation Team certified and appointed (on orders)? 

b. Proper wear of the uniform IAW FM 21-10 enforced? 

c. Uniforms treated with permethrin? 

d. # of treated uniforms /soldier 

e. Use of deet enforced? 

f. # of deet tubes issued? 

g. Other types of insect repellents? 

h. Repellents obtained from? 

i. Education of Arthropods of military importance posted/provided? 

j. Time PT conducted? 

k. PT uniform? 

l. Evening/nonduty hour uniform? 

More than 2 "N0" marks, equal high risk (* Denotes critical issues equal to 2 "No") 

ASSESSMENT TOTAL

Total 

Input the total number of "Yes"/"No" observations from above.

FINDINGS 

Circle all that apply

 YES NO

Area IS / IS NOT at risk of infestation due to RODENTS/SNAKES/SCORPIONS/MOSQUITOES/SAND 

FlIES/OTHER.

If other, specify:

Inspector Name: Rank/Grade Phone

Signature: 

Representative Name: Rank/Grade Phone

Follow up inspection date: 

Figure 1. The 926th Medical 

Detachment (PM) questionnaire used for vector assessment and control requests. 
 April – June 2010 59

THE ARMY MEDICAL DEPARTMENT JOURNAL

to remain in close proximity to human habitation. 

Foxes, cats, and sometimes dogs were observed 

sleeping under CHUs during the day and wandering in 

search of food in the evenings with no fear of humans 

(Figures 2 and 3). Some Soldiers adopted dogs and 

cats as pets, and on occasion kittens were found hidden 

in Soldiers’ CHUs. Some Soldiers also released 

animals from traps set by the civilian vector control 

contractor, thereby frustrating efforts to remove 

animals from living areas. This also exposed these 

individuals to possible bites and scratches because 

trapped animals exhibited highly aggressive behavior. 

Rodents were attracted to the living and work areas as 

a result of poor food storage and disposal. Trash bins 

filled with food waste were oftentimes left open. 

Soldiers complained of mice gnawing on their fingers 

and toes while they slept, a consequence of rodenthuman cohabitation. Also, the rodents attracted snakes 

to these areas. Since most of the buildings had 

numerous openings due to bombings and other acts of 

war, exclusion was almost impossible. Large numbers 

of plastic tamper-proof rodent bait stations a containing 

0.005% Brodifacoum anticoagulant rodenticideb

placed around most buildings reduced mice numbers 

but could not eliminate the problem because there was 

an unremitting supply of new rodents from 

surrounding farms. The result was an incredibly high 

number of rodents, demonstrated by the large amount 

of rodent droppings as shown in Figure 4. 

Birds were another vector control problem. Large 

numbers of pigeons, sparrows, and other species of 

birds were common both inside and outside of buildings. Bird droppings and feathers accumulated inside 

and outside of many occupied and unoccupied structures. Mechanical removal of birds by shooting with a 

pellet rifle (.22 caliber)c

 or trapping with bird trapsd

was mostly used to reduce the population. Unfortunately, when removed from one building, the birds 

migrated to another building, and their control was 

almost impossible. To compound this control problem, 

Soldiers put up bird feeding stations and continuously 

provided food and water to birds. This attracted more 

birds, as well as other animals, to these feeding 

stations that were often close to living and work areas. 

Filth fly and other types of fly infestation were 

common occurrences. Dining facility entrances 

without adequate mesh screening and/or air curtains 

had serious fly problems. Soldiers left doors open 

allowing fly movement into and out of food serving 

areas. Also food waste bins outside the dining areas 

were not emptied and cleaned daily (or when filled), 

leaving food waste to rot, which in turn created fly 

breeding habitats. Fly traps (Fly Terminator Pro, 

Farnam Companies Inc, Phoenix, Arizona) e with a fly 

attractant f placed outside the dining facility could not 

eliminate flies altogether. 

Sanitation was not properly practiced, especially 

around most of the living and work areas. Grass and 

shrubbery were not removed from around tents and 

hard structures. The vegetation served as habitat for 

rodents, scorpions, snakes, and sand flies. Buildings, 

tents, and storage containers were poorly maintained 

and had large openings that facilitated rodent and other 

animal entry. Discarded piles of wood waste, old sand 

bags, and other barrier materials provided habitat for 

scorpions, snakes, and rodents around buildings. 

Infestation from the common bed bug, Cimex 

lectularius Linnaeus (Hemiptera: Cimicidae), was 

observed among US forces, contractors, and third 

country nationals (TCNs). Bed bugs, which are part of 

reemerging pests, especially in developing 

 countries, were to a lesser extent a problem among US 

service members. Infestations were more common 

among civilian employees, especially the TCNs. 

Soldiers complained of sand fly bites which we 

confirmed to be caused by bed bugs. Unfortunately, 

many Soldiers lacked education/information on bed 

bug infestation or what to do if infested. 

IMPLICATIONS

Soldiers continued to complain of arthropod bites and 

sometimes sought medical treatment due to dermatitis, 

secondary infection, or allergic reactions to bites. 

During this period, sand flies tested for leishmania 

parasite infection were all negative. However, some 

Soldiers became infected with cutaneous leishmaniasis 

indicating the presence of the parasite in this region. 

Although there were only 2 reported cases of 

cutaneous leishmaniasis and no cases of malaria in the 

2 locations during this period, malaria and leishmania 

remain significant medical problems for US 

personnel deployed worldwide. Over 500 

cases of cutaneous leishmaniasis were 

a. National Stock Number (NSN) 3740-01-423-0737 d. NSN 3740-01-542-9963 

b. NSN 6840-01-508-6085 e. NSN 3740-01-561-9678 

c. NSN 1005-01-544-1044 f. NSN 3740-01-561-9732 
60 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

Observed Noncompliance with Implementation of Vector-Borne Disease Preventive Measures 

Among Deployed Forces 

reported among US Soldiers in the first year of OIF.6

Four cases of visceral leishmaniasis were reported 

among US personnel deployed to Iraq 7 and 38 cases of 

malaria reported in US personnel deployed to eastern 

Afghanistan from 2002 to 2004.6

 Even in the absence 

of diseases, annoyance pests could negatively affect 

morale and performance. 

Pesticides were often used to control disease vectors 

that were above the recommended threshold of 25 

female anopholine mosquitoes or 15 female 

phlebotomine sand flies per trap per night. Pesticide 

application frequency was, on average, one to 2 

applications per week during peak periods. Due to the 

nature of sand fly habitat, control of immature forms 

was very difficult, and adult control through fogging 

was the most applicable method. Two of the most 

commonly used insecticides were Scourge a (Bayer 

CropScience LP, Montvale, NJ) containing 4% 

resmethrin and 12% piperonyl butoxide, and Anvil 

10+10 ULV b (Clarke Inc, Roselle, Illinois) with 10% 

3-Phenoxybenzyl-(1RS, 3RS; 1RS, 3SR)-2,2-dimethyl

-3-(2-methylprop-1-enyl) cyclopropanecarboxylate. 

We observed that repeated pesticide applications were 

always required to bring down sand fly numbers. This 

may be partly due to the harsh climatic conditions 

where pesticides were rapidly degraded, ineffective 

application methods in targeting precise 

microhabitats,8

 or already developed pesticide 

resistance as a result of chemical use in agricultural 

and other pest control needs by the host nationals. 

Selection pressure may result in development of 

insecticide resistance due to persistent pesticide 

applications. This phenomenon has been reported for 

most vectors of human diseases and classes of 

pesticides.9,10 Continuous monitoring of insecticide 

resistance emergence in disease vectors is therefore 

necessary in military operations where chemical 

control is constantly used. 

Scorpion stings were mostly from less poisonous scorpion species, although we found some of the medically 

important scorpion genera, Androctonus and Leiurus 

(Buthidae) and Hemiscorpius (Liochelidae) in this 

region. Stings were mostly on the legs. All individuals 

who were stung were wearing shorts and tee-shirts. 

Many of these cases required hospitalization for observation. Serious cases of scorpion stings have been 

reported elsewhere during OIF and OEF deployments. 

In 2006, a US Army entomologist in Kuwait was stung 

by the deadly scorpion Androctonus crassicauda and 

had to be airlifted for medical treatment.11 This 

Figure 3. Dogs resting next to a Soldier’s work area.

(Photo provided by the author.) 

Figure 2. Fox resting next to a military central housing unit.

(Photo provided by the author.) 

Figure 4. Rat and mouse droppings collected outside a 

food storage room. (Photo provided by the author.) 

a. NSN 6840-01-359-8533 

b. NSN 6840-01-474-7706 
 April – June 2010 61

THE ARMY MEDICAL DEPARTMENT JOURNAL

scorpion sting report is not an isolated incident. From 

2005 to 2006, 9 cases of snakebites and 85 cases of 

scorpion stings and spider bites were reported among 

3,265 Soldiers deployed to Iraq and Afghanistan.12

Filth flies are not only nuisance pests but are also 

important in mechanical disease transmission and may 

act as intermediate hosts for a number of 

helminthes.13,14 Flies in dining facilities frequently 

came into contact with food. This can enhance 

mechanical transmission of disease pathogens. Flies 

play a significant role in the spread of diarrheal 

diseases that contribute to reduced military 

effectiveness during deployments. Cases of 

gastroenteritis associated with Norovirus, Shigella, and 

Eschericia coli (Migula), Castellani and Chalmers 

(Gamma Proteobacteria: Entorobacteriaceae) have 

remained a problem among deployed forces. In a study 

conducted in 2003 at Doha, Qatar, on US Soldiers 

during rest and recuperation leave, 70% of Soldiers 

reported at least one episode of diarrhea while 54% 

reported multiple incidences during deployment to Iraq 

and Afghanistan. Among these individuals, 43% 

reported a decline in performance for 2 days, while 

17% indicated they had to take bed rest for 2 days due 

to a diarrhea episode.15 A study in 2004 found that 

66% of US Soldiers in Iraq experienced diarrhea, with 

50% reporting more than one episode.16

Fly larvae sometime invade human organs and tissues, 

a condition referred to as myiasis. Fly larvae in the 

human eyes results in ophthalmomyiasis or ocular 

myiasis. Common cause of ocular myiasis is 

deposition of the sheep nasal bot fly (Oestrus ovis 

Linnaeus (Diptera: Oestridae)) or human bot fly (Dermatobia hominis Linnaeus (Diptera: Oestridae)) larvae 

in the cornea of the human eye. Ocular myiasis 

patients complain of red watery eyes, swollen conjunctiva, and sometimes a sensation of foreign body in the 

eye. One case of ocular myiasis occurred on Contingency Operating Base Speicher in March 2008. A 

male Soldier reported to the optometry clinic complaining of painful, watery eyes and a feeling of “sand 

in his eyes.” He reported that a day before this visit, a 

fly had hit his eye while it was buzzing around his 

face. The optometrist observed and removed 4 small 

worms from over the cornea of his left eye. Antibiotic 

and antihistamine drops were prescribed and the patient was asked to report back after 2 days. He did not 

return for his follow-up appointment. The worms were 

sent to the base entomologist for identification. They 

were identified as the first instar larvae of the sheep 

nose bot fly. This case accounts for the second report 

of O. ovis ocular myiasis in the northernmost part of 

Iraq. Bot fly ocular myiasis cases from Iraq have been 

reported from the Baghdad area with only one other 

case reported north of Baghdad at Mosul.17 Other cases 

have been reported elsewhere in Iraq18 and Afghanistan.19 Ocular myiasis is not only medically important 

but is also traumatizing to the affected individual. 

Large numbers of birds roosting in buildings constitute 

health hazards. Bird nests harbor ectoparasites such as 

pigeon fleas (Ceratophyllus columbae Gervais 

(Siphonaptera: Ceratophyllidae)), chicken mites 

(Dermanyssus gallinae De Geer (Acarina: 

Dermanyssidae)), ticks (Argas reflexus Fabricius 

(Acari: Argasidae)), and biting lice. Although these 

parasites may not transmit diseases, their bites could 

cause allergic reaction and discomfort.20 Bird 

droppings attract filth flies and may carry disease 

pathogens. Soil contaminated with bird droppings 

accumulated over a long period of time may contain 

spores of the fungi Histoplasma capsulatum Darling 

(Ascomycetes: Onygenaceae) or Cryptococcus 

neoformas (San Felice) Vuillemin (Tremellomycetes: 

Tremellaceae). Inhalation of these spores may cause 

diseases such as Histoplasmosis and Cryptococcosis. 

Although these diseases are mild in healthy 

individuals, they may become fatal in a person with a 

compromised immune system. 

Cohabitation of rodents and humans may potentially 

expose individuals to various rodent diseases. 

Worldwide, rodents transmit over 35 diseases. Mice 

may transmit diseases to humans through their bites, 

droppings, and urine. Rat bite fever is an infectious 

bacterial disease caused by Streptobacillus moniliformis Levaditi, Nicolau, and Poincloux (Fusobacterales: Fusobacteriaceae) and Spirillum minus

Carter (Spirochaetales: Spirillaceae) and transmitted 

mostly through bites and scratches from rats and mice. 

Eating food contaminated with mice urine or feces 

could cause salmonelosis or leptospirosis. Rodents 

carry ectoparasites such as fleas. Bites from fleas 

infected with the bacterium Yersinia pestis (Lehmann 

& Neumann), Van Loghem (Enterobacteriales: 

Entorobacteriaceae) cause plague, a disease that 

caused millions of deaths in Europe during the Middle 

Ages21 and is still endemic in some countries.22

Close association of humans with feral and wild 

animals could potentially expose service members to 

zoonotic diseases. Over 75% of emerging and re-
62 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

Observed Noncompliance with Implementation of Vector-Borne Disease Preventive Measures 

Among Deployed Forces 

emerging pathogens are reported to be zoonotic.23 Feral dogs and other canids that roam the military camps 

in search of food may transmit numerous disease 

pathogens to humans. Of importance are diseases such 

as rabies, helminthes, and bacterial and fungal 

infections.24 Close contact with dogs and cats may facilitate transmission of ectoparasites which may cause 

prurities and secondary infection from scratching.25

Bites from fleas could potentially transmit diseases. Of 

all the diseases transmitted from animals to humans, 

rabies is the most severe. It has worldwide distribution 

and causes over 55,000 deaths every year.26

Although bed bugs do not transmit diseases, their bites 

may cause allergic reactions that could range from 

pruritic papules27 to hemorrhagic vesicular lesions and 

urticaria.28 Bed bug infestation may result in loss of 

sleep due to persistent biting and itching, ultimately 

affecting an individual’s quality of life and combat 

readiness. Repeated bites may cause individuals to 

become constantly agitated and nervous, resulting in 

substantial psychological problems.29 

RECOMMENDATIONS

The first line of defense against vector-borne diseases 

and annoying arthropods is the proper use of personal 

protective measures (PPM). It is the responsibility of 

the individual service member to implement recommended PPM. Soldiers must educate themselves on the 

importance of the use of PPM. Strict adherence to 

PPM will only occur when service members understand the serious consequences of noncompliance. 

This knowledge will promote development of confidence in the effectiveness of the personal protective 

equipment, thereby minimizing the disease threat. 

Commanders at all levels have direct responsibility for 

the protection of the health of Soldiers under their 

command. It is, therefore, imperative that unit leaders 

receive aggressive training on importance of PPE use 

and remain informed of all possible medical threats in 

various regions. Proper PPE use should be included as 

a required training task in the mission essential task 

list and should be part of predeployment training. 

Distribution of PPE to service members should be 

completed early in the predeployment phase whenever 

possible. Unit leadership should ensure that Soldiers 

are educated and motivated on the importance of PPM 

and are equipped with all required resources. They 

should remain vigilant, continuously emphasize the 

use of PPM, and perform unscheduled welfare visits to 

Soldier living quarters to ensure compliance. When 

possible, unit leadership should minimize unnecessary 

outdoor activity at dusk and dawn when disease 

vectors are most active. Also, trousers and long-sleeve 

shirts may give better protection than shorts and teeshirts during physical training. Deet should be applied 

to exposed skin at all times. 

Proper sanitation must be continuously emphasized. 

Unit leadership should enforce proper waste disposal. 

Waste bins should be emptied and cleaned daily or 

when filled. Segregation of waste at the source to 

allow proper burning should be enforced. Food storage 

or consumption in living areas should be discouraged 

and pest breeding habitats should be eliminated where 

possible. Leaders should enforce the US Army 5th 

Corps General Order Number 1 (GO-1) (March 19, 

2003), with all its modifications, as it pertains to the 

adoption of wild and feral animals as pets and mascots 

and feeding or caring of these animals. GO-1B prohibits “adopting as pets or mascots, caring for, or feeding 

any type of domestic or wild animal.” Individuals who 

keep or feed animals, regardless of their rank or 

position, should be subject to discipline under the Uniform Code of Military Justice* as specified in GO-1. 

Entrances to food service facilities should be equipped 

with adequate mesh screening and/or air curtains. 

Holes and cracks in the walls, doors, and windows 

should be sealed through the use of materials available 

on the base. Vegetation should be cleared and debris 

removed from around living and work areas. 

At higher command levels, authorities should ensure 

that all mandatory PPE is available to deploying 

personnel. The responsibility of acquiring PPE should 

not be left entirely to individual units. It should be 

distributed through a centralized process such as 

central issue facility, rapid fielding initiative (RFI), or 

other means that ensure that every unit receives all 

required resources before deploying. This is more so 

for mobilized USAR units which had more difficulty 

obtaining PPE than did Active Army units. Similar 

findings have been reported elsewhere among military 

services and branches of each service.31 In a study 

*The Uniform Code of Military Justice (UCMJ), a federal law,30

is the judicial code which pertains to members of the United 

States military. Under the UCMJ, military personnel can be 

charged, tried, and convicted of a range of crimes, including 

both common-law crimes (eg, arson) and military-specific 

crimes (eg, desertion). 
 April – June 2010 63

THE ARMY MEDICAL DEPARTMENT JOURNAL

within the Army, 40% of Active Army and Army 

National Guard personnel reported receiving issued 

deet compared with 21% of personnel from the USAR. 

Marked differences were observed in numbers of 

personnel having at least 3 permethrin-treated 

uniforms. The USAR units fared poorly with only 

6.2% of personnel having 3 permethrin-treated 

uniforms, compared to 54% of personnel in the Active 

Army units.32,33 The basis for this difference should be 

established and efforts made to ensure that all 

deploying personnel receive recommended PPE. If for 

any reason equipment cannot be issued to Soldiers 

before they deploy, RFI teams may be forwarddeployed, and it may be advantageous to preposition 

required PPE in different locations in theater. 

CONCLUSION

The military continues to commit considerable 

resources to FHP. Because of this, the Department of 

Defense FHP effort has made massive strides in 

combating environmental health threats during 

contingency operations, especially in disease endemic 

regions. However, despite this success, military 

personnel continue to be plagued by preventable 

diseases not related to combat. We observed poor 

implementation of PPM among individual Soldiers as 

well as serious failure by commanders at all levels of 

responsibility to emphasize the use of PPM. This 

indicates the need for reevaluation of current 

regulations, such as GO-1 and Army Regulation 40-5 34

which specifies the responsibilities of individual 

Soldiers and commanders in the implementation of 

PPM. Governing regulations and orders should clearly 

spell out disciplinary consequences for failure to 

strictly adhere to the use of required PPM. Military 

leadership should ensure that leaders at all levels face 

serious consequences if they fail to enforce use of 

PPM. Leaders should understand that they are 

responsible for the health of their troops and that they 

will be held accountable for DNBI among Soldiers 

under their command. It is therefore imperative that 

unit leaders strictly enforce PPM use and lead by 

example. Command discipline is indispensable. In the 

words of then Lieutenant General Sir William Slim, 

the commander of the British XIV Army in Burma 

during World War II: 

Good doctors are no use without good discipline. More 

than half the battle against disease is fought not by 

doctors, but by regimental officers.35 

General Slim sacked commanders who failed to 

enforce malaria prophylactic treatment. His aggressive 

leadership resulted in the enforcement of malaria 

chemo-prophylactic drug use, which dramatically 

reduced the number of malaria cases among his troops. 

This demonstrates that combined efforts from military 

policy makers, the medical community, leadership at 

every level of command, and the individual Soldier are 

needed to combat DNBI among deployed US forces. 

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United States Military. Med Trop. 2001;61(1):67-76. 

2. Bellamy RF, Llewellyn CH. Preventable casualties. 

Rommel's haw, Slim's edge. Army Mag. 1990;40:52-

56. 

3. Sanders JW, Putnam SD, Frankart C, et al. Impact of 

illness and noncombat injury during Operation Iraqi 

Freedom and Enduring Freedom (Afghanistan). Am J 

Trop Med Hyg. 2005;73(4):713-719. 

4. Kotwal RS, Wenzel RB, Sterling RA, Porter WD, 

Jordan NN, Petruccelli BP. An outbreak of malaria in 

US Army Rangers returning from Afghanistan. 

JAMA. 2005;293(2):212-216. 

5. Wojcik BE, Humphrey RJ, Czejdo B, Hassell LH. US 

Army disease and nonbattle injury model, refined in 

Afghanistan and Iraq. Mil Med. 2008;173(9):825-

835. 

6. Update: cutaneous leishmaniasis in US military personnel, southwest/central Asia, 2002–2004. MMWR 

Morb Mortal Wkly Rep. 2004;53(12):264–265. 

7. Myles O, Wortmann GW, Cummings JF, et al. 

Visceral leishmaniasis: clinical observations in 4 US 

army soldiers deployed to Afghanistan or Iraq, 2002-

2004. Arch Intern Med. 2007;167(17):1899-1901. 

8. Seyedi-Rashti MA, Nadim A. Attempt to control 

zoonotic cutaneous leishmaniasis in the Isfahan area, 

Iran. Proceedings of the 9th International Congress 

on Tropical Medicine and Malaria. Athens, Greece: 

14-21 October 1973:135. 

9. Fonseca-González I, Cárdenas R, Quiñones ML, 

McAllister J, Brogdon WG. Pyrethroid and 

organophosphates resistance in Anopheles (N.) 

nuneztovari Gabaldón populations from malaria 

endemic areas in Colombia. Parasitol Res. 2009;105

(5):1399-1409. 

10. Foil LD, Coleman P, Eisler M, et al. Factors that influence the prevalence of acaricide resistance and tick 

borne diseases. Vet Parasitol. 2004;125(1-2):163-

181. 
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Among Deployed Forces 

11. Scully S. Army scorpion expert in Kuwait stung by 

insect, irony. Armed Forces Press Service. November 

2, 2006. Available at: http://www.defense.gov/news/

newsarticle.aspx?id=1999. Accessed March 24, 2010. 

12. Shiaud DT, Sanders JW, Putnam SD, et al. Selfreported incidence of snake, spider, and scorpion 

encounters among deployed US military in Iraq and 

Afghanistan. Mil Med. 2007;172(10):1099-1102. 

13. Graczyk TK, Knight R, Tamang L. Mechanical 

transmission of human protozoan parasites by insects. 

Clin Microbiol Rev. 2005;18:128-132. 

14. Graczyk TK, Knight R, Gilman RH, Cranfield MR. 

The role of nonbiting flies in the epidemiology of 

human infectious diseases. Microb Infect. 2001;3:231

-235. 

15. Sanders J, Putnam S, Riddle M, Tribble et al. The 

epidemiology of self-reported diarrhea in Operations 

Iraqi Freedom and Enduring Freedom. Diagn 

Microbiol Infect Dis. 2004;50(2):89-93. 

16. Aronson NE, Sanders JW, Moran KA. Emerging 

infections: in harm’s way: infections in deployed 

American military forces. Clin Infect Dis. 2006; 43

(8): 1045-1051. 

17. Gregory A, Andrew R, Schaltz S, Laubach H. 

Ophthalmomyiasis caused by the sheep bot fly 

Oestrus ovis in northern Iraq. Optom Vis Sci. 2004;81

(8):586-590. 

18. Dunbar J, Cooper B, Hodgetts T, et al. Emerging 

infections: an outbreak of human external 

ophthalmomyiasis due to Oestrus ovis in southern 

Afghanistan. Clin Infect Dis. 2008;46(11):124-126. 

19. Stacey MJ, Blanch RJ. A case of external 

ophalmomyiasis in a deployed UK Soldier. J Roy 

Army Med Corps. 2008;154(1):60-62. 

20. Haag-Wackernagel DH, Spiewak R. Human 

infestation by pigeon fleas (Ceratophyllus columbae) 

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(2):343-346. 

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23. Taylor LH, Latham SM, Woolhouse ME. Risk factors 

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2):129-133. 

25. Skerget M, Wenisch C, Daxboeck F, Krause R, 

Haberl R, Stuenzner D. Cat or dog ownership and 

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27. Elston DM, Stockwell S. What’s eating you? Bed 

bugs. Cutis. 2000;65:262-264. 

28. Thanakaram S. Bullous eruption due to Cimex 

lectularius. Clin Exp Dermatol. 1999;24:241-242. 

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of phlebotomine sand flies on US military operations 

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situation, and development of a leishmaniasis control 

program. J Med Entomol. 2006;43(4):647-662. 

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Deployed US Army soldier’s knowledge and use of 

personal protection measures to prevent arthropodrelated casualties. J Trav Med. 1998;5:217-220. 

33. Gambel JM, Brundage JF, Burger RJ. Survey of US 

Army soldier’s knowledge, attitudes, and practices 

regarding personal protection measures to prevent 

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Med. 1998;163:695-701. 

34. Army Regulation 40-5: Preventive Medicine. 

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AUTHOR

CPT Wanja is Chief, Department of Immunodiagnostics, Division of Entomology, Walter Reed 

Army Institute of Research, Silver Spring, Maryland. 
 April – June 2010 65

In 2007, Army Audiology transformed from a program 

focused on hearing conservation to one focused on 

maximizing operational capabilities.1

 This new 

program centered on systems and strategies enabling a 

Soldier to maintain and, in some cases, improve 

auditory awareness. These goals were achieved 

through the 4 elements of the Army Hearing Program: 

hearing readiness, clinical hearing services, 

operational hearing services, and hearing 

conservation.2,3 Hearing readiness is the metric applied 

to annual audiometric testing that enables tracking of 

the audiologic health of Soldiers. Army Regulation 40-

501 4 outlines the categories of readiness, which are 

reflected in the Army Medical Department Medical 

Protection System (MEDPROS) medical readiness 

database. The MEDPROS categories are indicative of 

medical readiness, and thus better ensure achievement 

and maintenance of a deployment-ready force. 

Operational hearing services focus on battlefieldrelevant solutions to communication and protective 

systems that enable a more effective force. An 

example of this component is integration of a variety 

of noise-cancelling headsets with ear-level 

microphones that enable a Soldier to monitor his or her 

environment while reducing ambient noise. Hearing 

conservation is a garrison-based mission with the goal 

of hearing loss prevention in industrial-based 

operations.5

 Clinical hearing services determine the 

extent of audiologic and otologic illness or injury and 

can provide treatment strategies. Both the hearing 

conservation and clinical services components have 

been well established since 1978 as outlined in 

Department of Defense Instruction 6055.12.

3

 The need 

to incorporate all components of the Army Hearing 

Program in-theater has existed for a number of years, 

however, the priority of the clinical mission and 

complexities of transportation within the Iraq Joint 

Operational Area limited the services available. 

Historically, the role of the deployed Army 

Audiologist (Area of Concentration 72C), involved a 

predominately direct clinical care mission. Located in 

Baghdad’s International Zone, the audiologist 

was sole provider of audiological diagnostic care in 

the US Central Command’s Iraq area of operations. 

The audiologist’s primary duties involved evaluation 

and treatment of otologic and audiologic injuries and 

illness, and was therefore heavily engaged in the 

evaluation and treatment of blast injury. The role also 

involved supporting clinics throughout Iraq that 

conducted abbreviated hearing testing, either for the 

purposes of inclusion in physical examinations or to 

evaluate a need to evacuate to higher echelons of care 

for diagnosis and treatment. With the sole 

otolaryngology clinic located at Joint Base Balad 

(JBB), medical management of otologic injury proved 

cumbersome. Fortunately, the handover of Ibn Sina 

hospital to the Government of Iraq in October 2009 

presented the opportunity to expand the hearing 

program to a more active role in prevention. This also 

enabled collocation with the otolaryngologist to 

provide more expeditious evaluation and treatment. 

These developments combined with the gradual 

reduction of the clinical mission (patient encounters 

decreased by half from 2007 to 2008) and allowed the 

program’s efforts to shift towards the preventive and 

education mission. In essence, the move enabled the 

Theater Audiology Consultant to incorporate all 

components of the Army Hearing Program into daily 

practice, rather than serving in a primarily clinical role. 

Although the proposed collocation with the 

otolaryngologist at the Air Force Theater Hospital 

initially seemed ideal, space requirements precluded 

this move. Instead, the audiology clinic moved to a 

level II clinic on JBB, which presented new prospects 

for the program. Of note, the generous space in the 

level II clinic doubled as a classroom. The clinic could 

accommodate instruction of up to 6 hearing technician 

students who not only used the training systems 

(Figures 1 and 2), but also were able to use the 

diagnostic booth for more realistic training. During 

Evolution of the Army Hearing Program in a 

 Deployed Environment 

CPT Kara M. Cave, MS, USA 

CPT Edward O. Price, MS, USA 
66 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

one of the courses conducted in the midst of a premove site inspection at JBB, the Environmental 

Science and Engineering Officer (author E.O. Price) 

from the adjacently located 223rd Medical Detachment 

(Preventive Medicine) (PM DET) volunteered to teach 

a section of the course on noise 

hazard evaluation. This block of 

instruction presented information 

about the improvements in noise 

surveillance and noise-induced 

injury prevention resulting from the 

symbiosis of the 2 specialties of 

audiology and environmental 

science. 

The first opportunity to blend the 

capabilities of the 2 fields arose with 

the identification of a trend of 

worsening test results noted by the 

a u d i o l o g i s t d u r i n g a n n u a l 

audiometric testing of a JBB 

aviation unit. So informed, but not 

having full equipment capabilities, 

staffing, or experience, the 

audiologist combined forces with 

the 223rd PM DET to conduct a 

presurvey inspection. After 

collaborating on areas identified as 

potentially hazardous and creating a 

schedule to allow capture of the 

most representative sampling, the 

PM DET conducted noise dosimetry 

of the aviators’ environment 

spanning several days, while the 

audiologist conducted area noise 

sampling. Since adequate crew rest 

is a particular safety concern to aviation operations, a 

portion of the dosimetry involved measuring noise 

within sleeping quarters. The audiologist provided the 

unit with a report of the findings and recommendations 

on how to improve communication in the noise hazard 

environments and mitigate the noise exposure in their 

sleep areas. As the final piece to the study, the unit 

received a health education briefing, which included 

information about the threat of noise exposures in 

theater and how to mitigate some of these threats, and, 

most important, the results of the unit’s noise survey. 

All unit members were offered an opportunity to be 

otoscopically examined and refitted with hearing 

protection devices at the conclusion of the briefing. 

These fittings also identified aviators who had difficult 

to fit ear canals for whom custom devices were 

ordered for their communication earplugs to ensure 

better noise attenuation and improved communication. 

The briefing also provided an 

opportunity to advertise the recently 

expanded audiological capabilities at 

JBB. 

The PM DET’s experience with 

conducting noise surveys proved 

invaluable. In garrison, the industrial 

hygiene section of preventive 

medicine will often perform the 

noise surveys in conjunction with 

the environmental science section. 

Therefore, the audiologist’s role in 

noise assessment and abatement is 

usually a consultative one. The 

audiologist’s role often does not 

involve interpretation of results and 

noise measurement. In theater, this 

role became key to the success of the 

program. The PM DET had regular 

missions to remote forward 

operating bases in a vast area of 

operations which limited staffing 

resources available to conduct this 

noise monitoring. The environmental 

science and engineering officer and 

the audiologist collaborated to devise 

a system to successfully cover the 

requests for noise surveillance 

(Figure 3). Generally, noise 

monitoring was initiated by a 

complaint of suspected noise hazards reported by the 

unit safety officer or commander to the PM DET. The 

PM DET would notify the audiologist, who would 

then conduct a preinspection assessment. The 

audiologist would assess the equipment and staffing 

needs for the study and request resources from the PM 

DET accordingly. In the case of occasional equipment 

shortages, the Bioenvironmental Engineering Section 

of the USAF 332nd Expeditionary Aerospace Medical 

Squadron, also assigned to JBB, provided the 

equipment. This afforded the opportunity for 

specialists of both services to compare notes on noise 

hazardous areas identified around the base. The Air 

Force provided a key resource of aircraft-related noise 

Evolution of the Army Hearing Program in a Deployed Environment 

Figure 1. Medics practicing earplug fitting 

during Theater Medic Hearing Program 

training at Camp Taji, Iraq. (Photo provided 

by CPT Cave.) 

Figure 2. Medic performing otoscopy 

during Theater Medic Hearing Program 

training at Camp Taji, Iraq. (Photo provided 

by CPT Cave.)
 April – June 2010 67

THE ARMY MEDICAL DEPARTMENT JOURNAL

data. This data could be incorporated into the reports, 

given that not all aircraft to which the service members 

were exposed were present during the study. After data 

collection, the audiologist would generate the report of 

findings and recommendations. Of note, the report 

included specific recommendations not only for noise 

abatement, but for personal protective equipment, 

often implemented clinically. The audiologist also had 

access to research relevant to improved speech 

understanding amidst background noise among various 

types of integrated hearing protection and 

communication devices. Presented with these findings, 

the noise-monitored unit could often justify the 

expense of personal protective equipment compatible 

with more tactically relevant solutions beyond passive 

earplugs. Each unit was offered a briefing to review 

the findings of the results of the noise survey. 

CONCLUSION

Through the coordination of preventive medicine 

assets in theater, the scope of services afforded the deployed Soldier expanded to include noise surveillance, 

education, and tactically relevant hearing protection. 

This allowed continuation of prevention of noiseinduced hearing injury despite the constant threat of 

noise exposure. Positioning these assets among denser 

living areas also improved access to care. 

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. Cleveland L. Fort Carson: An Army Hearing 

Program Success Story. Army Med Dept J. April-June 

2009:67-75. 

3. Department of Defense Instruction 6055.12: DoD 

Hearing Conservation Program (HCP). Washington, 

DC: US Department of Defense; March, 2004. 

4. Army Regulation 40-501: Standards of Medical 

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

September 10, 2008:80. 

5. 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 January 24, 2010. 

AUTHORS

CPT Cave is Chief of the Hearing Program at Fort 

Bliss, Texas. When this article was written, she was 

the Audiology Theater Consultant with the 10th 

Support Hospital, Joint Base Balad, Iraq. 

CPT Price is the Commander of the 223rd Medical 

Detachment (Preventive Medicine), Fort Carson, 

Colorado. When this article was written, he and his 

unit were deployed to Joint Base Balad, Iraq. 

Figure 3. The noise hazard identification and mitigation model which 

was developed and applied in Iraq. 
68 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

According to the Department of Defense (DoD) 

Medical Surveillance Monthly Report, the number of 

troops diagnosed with weight issues has doubled since 

the start of the Iraq war in 2003.1

 Stress from long 

deployments and unhealthy habits such as too much 

fast food or playing video games for extended periods 

of time have been identified as possible causes for this 

increase. Although the causes may have been 

identified, human factors such as the health and career 

implications of obesity are often overlooked. This 

article examines one program that the Army uses to 

battle body fat, with the ultimate goal of stopping and 

reversing the spread of obesity among both Soldiers 

and Family members. 

In a collaborative effort, the US Army Medical 

Department Activity in Heidelberg, Germany, 

partnered with the US Army Center for Health 

Promotion and Preventive Medicine-Europe 

(USACHPPM-EUR) to develop the Heidelberg Army 

Wellness Center. The Center implemented a 

comprehensive wellness program that answered the 

question, “How is the Army battling body fat?” and 

became the model for wellness centers throughout the 

Army. Although wellness has had its share of 

definitions, historically, the concept was first 

suggested by Halbert Dunn, MD, who began using the 

phrase “high level wellness” in the 1950s.2

 Since then, 

wellness has been generally accepted to mean a 

healthy balance of mind, body, and spirit that results in 

the overall well-being of an individual.3

 The leading 

causes of death in modern society have been linked 

largely to the behavior choices a person makes each 

day. The change from the 19th century to the 20th 

century brought with it a transition in the focus of 

health concerns from infectious diseases to those 

mediated by lifestyle. It became prudent to seek 

methods to increase the homeostasis of life and to find 

a balance with mind, body, and spirit. Wellness has 

illustrated the impact that a slight change in 

perspective can have on both an individual’s health 

and the bottom line of organizations. Medical 

application of wellness emerged based on the works of 

Kenneth Cooper, MD, and Andrew Weil, MD, both of 

whom demonstrated the profitability of prevention.3

The Army Medical Department Activity in Heidelberg 

examined the basic constructs of wellness and devised 

a process that integrated health promotion and a 

wellness program into clinical care practice. An 

important factor was the research by Logsdon et al4

into the effect of physician intervention in the 

adaptation of healthier lifestyle changes, such as 

exercise compliance among patients. They found that 

individuals who received physician-initiated 

counseling were more likely to report positive 

behavior changes regarding exercise than were 

reported by matched controls. Therefore, key to the 

development of the wellness process at Heidelberg 

was the encouragement of physicians to counsel 

patients on the benefits of engaging in positive health 

behaviors, such as exercise and diet. After a physician 

suggested lifestyle modification to the patient, he or 

she would be referred to the Heidelberg Army 

Wellness Center. Establishment of a process that 

linked the physicians to the Center was our first step in 

creating the model for successful wellness 

applications. 

The DoD notes that physical fitness, which includes 

components such as aerobic and anaerobic fitness, 

body composition, and weight management, “...is a 

vital component of combat readiness and is essential to 

the general health and well being for Armed Forces 

personnel.”5

 In 2008, approximately 60% of all DoD 

services personnel, male and female, were classified as 

overweight.6

 In a percentage of these cases the excess 

body weight can lead to degradation in performance 

for the Soldier. Problems can arise from the amount of 

time a Soldier may spend on a medical profile, or from 

Battling Body Fat 

Todd Hoover, MA 

COL Kyle D. Campbell, MS, USA 
 April – June 2010 69

other health care needs associated with the excess 

weight and body composition, all of which contribute 

to a reduction in operational readiness. Indeed, this is 

not an exclusive concern of the US Army. Each of the 

armed services has physical fitness programs, each 

with its own specific focus to test and maintain each 

individual’s body composition and physical fitness. 

According to regulatory guidelines of Army Regulation 

AR 600-9,

7 Army Regulation 350-1,8

 and Army Field 

Manual 21-20,

9

 failure to meet physical fitness 

standards or weight control standards can have a 

detrimental effect on a Soldier’s career. The primary 

objective of the Army Wellness Centers is the 

prevention of such occurrences in the first place. To 

assess the effectiveness of this concept, the Heidelberg 

Army Wellness Center and USACHPPM-EUR began 

a collaborative effort with the Seventh Army’s 

Noncommissioned Officer Warrior Leader Course to 

address a disturbing situation among the students. The 

noncommissioned officer instructors noted a trend in 

students reporting for the course who were either 

overweight, over body composition, unfit, or a 

combination of those conditions. The Warrior Leader 

Course trains 432 Soldiers over 30 days, 8 times a 

year. During each class in 2007 and 

2008, 10% of the Soldiers were not 

able to meet body fat standards at the 

end of the training cycle. Working 

together, the Heidelberg Army 

Wellness Center and the USACHPPMEUR developed a new program to 

reduce the number of those body fat 

failures at the end of the Warrior 

Leader Course. 

The purpose of the weight reduction 

initiative was to determine if metabolic 

testing, or indirect calorimetry, 

combined with a 4-week dietary 

intervention would result in decreased 

body weight within a selected cohort of Soldiers 

judged as overweight. All Soldiers who did not meet 

body fat standards were directed to participate in the 

health education program at the beginning of the 

Warrior Leader Course. Metabolic testing was used to 

measure daily caloric needs. Body fat was measured 

using bioelectrical testing, which also provided 

information on intracellular hydration. Data on each 

Soldier’s total body weight and body fat were 

collected within 3 days of reporting to the course, and 

again at the end of the training. After the initial 

evaluation, each participant received an individualized 

meal plan based on their metabolic results. An 

educational class was provided to review test results as 

well as to illustrate effective principles of proper 

nutrition and exercise for weight reduction. 

Metabolic testing using indirect calorimetry is an 

advanced method for measuring the resting metabolic 

rate of individuals. Identification of a Soldier’s resting 

metabolic rate is the first step in designing an 

individualized intervention that meets the needs of the 

person. The process of metabolic testing is rather 

simple to complete. It is important to note that anyone 

receiving a metabolic analysis must not have eaten or 

exercised for at least 4 hours before testing. 

Consumption of any type of food or drink, engaging in 

physical activity, or smoking can elevate the resting 

metabolic rate, which would result in an inaccurate 

reading. The scientific principle used in indirect 

calorimetry is based on the metabolic requirement of 

oxygen to produce energy. For each 208 mL of oxygen 

consumed, the body burns one calorie of energy.10

Therefore, measuring the amount of oxygen ingested 

into the body and then exhaled 

determines the oxygen absorption rate. 

During testing, the nose is clipped with 

a special clamp. Inhaled and expired 

air is isolated through a single use, 2-

way breathing valve. The valve is 

designed to allow air to enter, but 

closes in the reverse direction when air 

i s e x p i r e d , w h i c h p r e v e n t s 

contamination of the air sample. The 

metabolic measurement device has an 

oxygen sensor and flow meter which 

are used to analyze both the 

concentration of oxygen and its 

volume (Figure 1). 

It is important to understand the resting metabolic rate 

because if the human body does not receive enough 

calories per day to maintain basic life function, the 

body literally “thinks” it is starving to death. The 

human body is a complex organism that requires key 

things from the environment—air, water, and food—in 

order to survive. Without them, life could not exist. 

Food can be greatly manipulated, and a person could 

survive without water for 2 to 10 days depending on 

Figure 1. Metabolic measurement device in use. 
70 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

temperature. Without air, however, life ceases to exist. 

The resting metabolic rate represents between 60% 

and 75% of the body’s total energy needs for the day 

and shows the minimum amount of calories the body 

needs per day just to survive, ie, to be able to breathe 

and think. Resting metabolic rate is vital for basic life 

function. Throughout human evolution, the body has 

been able to adapt to times of both famine and 

abundance. The problem in modern times is that food 

is plentiful, but the body does not know this. If the 

body experiences prolonged periods of less food 

consumption than it needs, a starvation response is 

triggered that prompts the body to become extremely 

conservative in energy expenditure. In some cases of 

extreme dieting, the body will even metabolize lean 

muscle tissue to be used as energy, just to protect fat 

cell stores. Therefore, an understanding of a person’s 

resting metabolic rate can help the development of 

programs specific enough to avoid triggering the 

starvation response in the body. 

Upon arrival, Soldiers report to the evaluation 

center at the Warrior Leader Course. Each student completes a simple questionnaire that asks 

for weight, height, and age. Special dietary concerns are addressed by evaluating specific health 

needs of the Soldiers. For example, if a Soldier 

was under treatment for high blood pressure, an 

appropriate meal plan would be provided to meet 

this medical need. All meal plans at the 

Noncommissioned Officer Academy programs 

have been developed by dietitians registered with 

the American Dietetic Association. 

Body fat is assessed using a process called 

bioelectrical impedance assessment. Bioelectrical 

impedance assessment is based on the principle of 

conductivity of electrical current and resistance. First, 

the basic data of weight, height, and age are entered 

into the bioelectrical impedance assessment machine. 

Using the weight and height measurements, a body 

surface area is determined. The Soldier is placed in a 

supine position on an exercise mat with hands and feet 

extended straight out. Small electrodes are placed on 

the wrist, hand, foot, and ankle (Figure 2). The 

electrodes are coated with a sticky gel substance that 

adheres to the skin, which creates a seal between the 

skin and the bioelectrical impedance assessment 

contacts. Wires are attached to the electrodes. A low 

current, which is completely painless, is applied and 

the resistance of the body is evaluated. Since water is 

an efficient conductor of electricity, the current applied 

to muscle, which contains about 70% water, just 

passes through. However, resistance occurs when the 

current encounters fat. The amount of resistance (in 

ohms) is measured and helps determine how much fat 

mass is in the tested body surface area. 

When correctly performed, bioelectrical impedance 

assessment can provide an accurate and safe measurement of body fat. In fact, if the Soldier is hydrated 

enough (55% to 65% for males and 50% to 60% for 

females) the test yields impressive results. Identification of the ratio of fat mass to lean tissue will help 

determine if the intervention is having a positive effect 

on total body fat reduction. By comparing results 

before and after the program, an accurate assessment 

can be made as to whether the intervention was a 

success or failure. Body fat testing provides a very 

crucial analysis of the program’s true effectiveness in 

meeting the Army’s physical fitness standards. 

The final component in weight reduction intervention 

is education, not only about the test results and what 

they mean, but also how the Soldier can successfully 

apply them in his or her environment. To accomplish 

this, a class called “Upping Your Metabolism” was 

developed. Soldiers learn about metabolism and how 

simple changes, such as frequency of intake of food, 

can elevate the resting metabolic rate. In addition, 

teaching Soldiers how to modify their dietary habits 

whether they are in the field, at home, or deployed is 

key to long-term success. The class provides a heavy 

emphasis on the application in real world settings of 

what the metabolic test reveals. After all, the entire 

program would be virtually worthless if nobody could 

sustain or maintain the plan for the long haul. 

Assisting Soldiers to understand how the body 

Figure 2. Bioelectrical impedance assessment data collection. Note the 

electrodes attached to the subject’s right foot and ankle. Other electrodes 

are attached the to the subject’s right hand and wrist (not visible). 

Battling Body Fat 
 April – June 2010 71

THE ARMY MEDICAL DEPARTMENT JOURNAL

processes energy and what environmental changes can 

be made to achieve a better balance in caloric needs 

has resulted in some impressive outcomes. 

CONCLUSION

The results achieved by the Heidelberg Army 

Wellness Center and USACHPPM-EUR indicate the 

wellness program was relevant to improve functioning 

and human performance at the Noncommissioned 

Officer Academy’s Warrior Leader Course. Eight class 

cycles were completed in the 12 months from August 

2007 to August 2008. Aggregate data collected (N =

154) indicates that 99% of Soldiers participating in the 

program met body fat standards at the end of the 

intervention. At the end of the 4-week program, the 

average body weight loss per Soldier was 9.9 lbs with 

a reduction of 3.6% body fat. Longitudinal data 

collected after 6 months to ascertain the long-term 

effectiveness showed that more than 86% of 

participants had maintained or continued their weight 

loss. This data appears to indicate that this wellness 

program is very effective for active duty Soldiers. 

Further studies would be needed to assess the 

effectiveness of the program for active duty Family 

members, Army civilians, and members of the general 

population. 

REFERENCES

1. Armed Forces Health Surveillance Center. Diagnoses 

of overweight/obesity, active component, US Armed 

Forces, 1998-2008. Med Surveill Mon Rep. 2009;16

(1):2-6. Available at: http://www.afhsc.mil/

viewMSMR?file=2009/v16_n01.pdf#Page=02. 

Accessed April 9, 2010. 

2. Dunn HL. What high level wellness means. Health 

Val. 1977;1(1):9-16. 

3. Coleman RA, Ritch JM. The business of integrative 

medicine. ACSM's Health Fit J. 2008;12(6):29-32. 

4. Logsdon DN, Lazaro CM, Meier RV. The feasibility 

of behavioral risk reduction in primary medical care. 

Am J Prev Med. 1989;5(5):249-256. 

5. Department of Defense Directive 1308.2: Joint DoD 

Committee on Fitness. Washington, DC: US Dept of 

Defense; 2005:2. 

6. Department of Defense Survey of Health Related 

Behaviors Among Active Duty Personnel. 

Washington, DC: Office of the Assistant Secretary of 

Defense (Health Affairs), et al; 2008: 134-135. 

Available at: http://www.tricare.mil/2008Health 

Behaviors.pdf. Accessed April 22, 2010. 

7. Army Regulation 600-9: The Army Weight Control 

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

November 26, 2006. Available at: http://

www.apd.army.mil/pdffiles/r600_9.pdf. Accessed 

April 9, 2010. 

8. Army Regulation 350-1: Army Training and Leader 

Development. Washington, DC: US Dept of the 

Army; December 18, 2009. Available at: 

www.army.mil/usapa/epubs/pdf/r350_1.pdf. 

Accessed April 9, 2010. 

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

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

1998. Available at: https://akocomm.us.army.mil/

usapa/doctrine/DR_pubs/dr_aa/pdf/fm21_20.pdf. 

Accessed April 9, 2010. 

10. Kang, J. 2008. Bioenergetics Primer for Exercise 

Science. Champaign, Illinois: Human Kinetics 

Publisher. 

AUTHORS

Mr Hoover is the Director, Army Wellness Centers–

Europe, US Army Public Health Command Region–

Europe, Landstuhl, Germany. 

COL Campbell is Deputy Commander for Administration, US Army Medical Department Activity and 

Martin Army Community Hospital, Fort Benning, 

Georgia. When this article was written, he was 

Commander, US Army Medical Department Activity, 

Heidelberg, Germany. 
72 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

Alcohol abuse has been a problem for armies ever 

since the first sip of barley malt passed the lips of a 

Sumerian spearman. The problem continues to 

challenge both commanders and health care providers 

alike in the modern United States Army as the 21st 

century begins. There is a certain irony in Fort Sam 

Houston’s status as the home of Army medicine, for 

the post’s namesake was an alcoholic for much of his 

adult life. Furthermore, the Republic of Texas began 

its quest for independence and eventual statehood 

under his leadership in the midst of a war which saw 

alcohol abuse play a significant role in the near-defeat 

of the Texian forces in the very battle which came to 

symbolize heroic martyrdom in the cause of freedom. 

If the Republic of Texas was born in the priming pan 

of a flintlock rifle, it was most certainly baptized with 

a dipperful of white lightning. The impact of alcohol 

abuse upon the opening stages of one of the most 

fateful conflicts in American history still carries useful 

insights for the Army Medical Department of today. 

(Sam Houston’s struggle with alcoholism has been 

documented in a number of studies, two of which are 

referenced herein.1,2) 

“...send no more ardent spirits...” 

The North American colonists who revolted against 

Mexican misrule of the province of Texas in late 1835 

came from a society which was generally characterized by hard drinking. In 1830 the consumption of 

whiskey in the United States averaged five gallons per 

person per year. By 1835 it was estimated that excessive drinking figured in the deaths of 56,000 citizens 

each year even as a growing temperance movement 

began to find adherents in the populace. The ScotsIrish and Anglo-Celtic Southerners who comprised a 

large portion of those who settled in Texas from the 

early 1820s onward, and who initially took up arms in 

defense of the rights originally promised to them by 

Mexico, were even more culturally predisposed to 

tipple than the average American of the time.3,4

Alcohol consumption among Southerners often 

exceeded the national norm, “if only because of the 

relative slowness of the temperance crusade to cut the 

rate as it did in the Northern states after 1830,” noted 

historian Bertram Wyatt Brown. In the antebellum 

South from the Potomac to the Sabine the consumption 

of alcohol was viewed as a function of masculinity, an 

important social ritual enacted among males, intended 

to display virility and “show affection and group 

solidarity in permissible fashion,” for the practice 

served to “validate male friendships and incorporation 

into the male tribe, so to speak, particularly in Celtic 

regions, of which the South was one.”3,5,6

The proclivity for tapping the cask cut across social 

and economic class lines on the Southern frontier, 

where the rural patrician was just as likely to imbibe 

freely as the yeoman farmer or the “chaw-bacon” 

backwoodsman. A number of contemporary observers 

commented upon the Texian tendency to engage in 

rowdy drinking bouts. In 1822, young emigrant Robert 

Hancock Hunter and his family arrived at a new 

settlement on San Jacinto Bay (near modern Houston) 

to find a group of 31 men reeling about the shoreline, 

“all drunk on Pa’s rum.” Virginian Fairfax Gray was 

present 14 years later when a convention mustered in 

the hewn-log hamlet grandly named “Washington-onthe-Brazos” to provide political leadership for the 

restive Anglo-American settlers in their confrontation 

with the Mexican government. Gray sneered that the 

assembly was “run by besotted minds” after hearing 

provisional Secretary of War (and future US senator) 

Thomas Jefferson Rusk exhort his colleagues to “take 

one more drink of whiskey and then saddle up and go 

to the rescue of the boys in the Alamo.” A leading 

This article is derived from the monograph, “Offensive to Humanity”: Medical Issues in the Texas War for 

Independence, 1835-1836. 

Aguardiente at the Alamo: 

 Alcohol Abuse and the Texas War 

 for Independence, 1835-1836 

Wayne R. Austerman, PhD 
 April – June 2010 73

social historian of the Republic of Texas has 

characterized it as “a masculine world, a hard place of 

toil occasionally relieved by rough carousing, an 

uninhibited place where most men often drank too 

much. Drinking inevitably exaggerated the obstinate 

streak of argument-prone Texans, which led to further 

uproar.” A captured Mexican officer waspishly 

observed in the wake of the great Texian victory at San 

Jacinto in April 1836 that “The gatherings of those 

besotted people are invariably more or less influenced 

by mean liquors.”7-10

The truth of the matter is that the troops who fought 

for Texas independence were an undisciplined and 

intractable lot, who were hard to keep under control 

even under the best of circumstances. A decade later 

during the Mexican War of 1846-48 a bemused 

General Zachary Taylor of the US Army confessed 

that “on the day of battle I am glad to have Texas 

soldiers with me, for they are brave and gallant, but I 

never want to see them before or afterwards, for they 

are too hard to control.” Even in the midst of the 1836 

struggle for independence a harried provisional 

Governor David G. Burnet lamented that the 

“intemperate and irrational” natures of his volunteer 

troops taxed the skills and patience of their 

commanders. Historian Paul D. Lack observed in his 

study of the revolution that 

No single manifestation of disciplinary problems 

among Texas soldiers attracted more condemnation 

from the authorities than alcohol consumption, [for 

among the ranks] the potential for excess increased 

substantially when the army found an opportunity 

to indulge its thirst for whiskey. Consumption of 

alcohol comprised such a regular part of camp routine that it attracted little comment except when it 

spilled over in the form of disorderly behavior.11,12

The existing cultural propensity for heavy drinking 

manifested itself among the earliest American 

volunteers to reach Texas as war fever grew during the 

waning months of 1835. On November 4, for example, 

a party of 30 men belonging to a larger contingent of 

volunteers recruited from the Ayish Bayou settlements 

in the Louisiana-Texas border country passed through 

the village of Gonzales on the Guadalupe River, east 

of San Antonio. There they punctuated a drinking bout 

by staging a riot which saw stores looted, men beaten, 

and women subjected to insult and abuse before more 

sober comrades intervened to restrain the drunken 

troops. “Savage Indians would not be guilty of such 

conduct,” complained one angry resident.13

Gonzales had already been the scene of the first armed 

clash between angry Texians and Mexican troops 

during the preceding month, and by the following 

December its settlers had provided many members of 

the self-designated “Army of the People” which was 

besieging Brigadier General Martin Perfecto de Cos 

and his garrison in San Antonio. Led by the mildmannered Stephen F. Austin, this volunteer force was 

soon drinking to the detriment of good order and 

discipline after encamping within sight of the enemyheld town and neighboring Alamo mission. “The army 

had been assembled only a few days before Austin 

began suggesting that whiskey be eliminated from its 

list of supplies,” noted Lack. “Soon he wrote to the 

civil government: ‘In the name of Almighty God send 

no more ardent spirits to this camp—if any is on the 

road turn it back, or have the head knocked out.”14,15

Despite Austin’s pleas for shattered kegs and strict 

sobriety, the liquor continued to lubricate the 

volunteers’ vigil against Cos. “Many sought relief 

from their boredom by reaching to the bottom of a 

brown jug,” Stephen L. Hardin observed in Texian 

Iliad. “Austin complained that drunks roared through 

camp, shooting off rifles and wasting precious powder 

and ball.” The passage of little more than a month saw 

a combination of inaction, loose discipline and potent 

libations that very nearly destroyed the Texians’ 

always unstable sense of unit cohesion. 

Between 250 and 300 volunteers departed for home; 

others berated their officers; and more than a few got 

blind drunk ... the siege of Bexar, at last so close to 

success, was in danger of being abandoned. Texian 

volunteers had been encamped around the town for 

about seven weeks, during which time they had 

defeated the Mexicans in every engagement, switched 

commanders and consumed inordinate amounts of corn 

liquor.... For the first time since the fighting began at 

Gonzales, Texians had to admit that they were beaten, 

not by the enemy, but by their own disorganization and 

discord.15(pp56,68)

The prevalence of alcohol abuse among such 

undisciplined troops had served only to exacerbate all 

of the problems normally associated with maintaining 

units composed of such untrained citizen-soldiers on 

protracted active duty. None of Cos’ cannon and 

muskets had done a fraction as much potentially fatal 
74 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

damage to the Texian cause as had the numbing sluice 

of corn squeezings down the throats of the restless 

men who held the Mexican regulars besieged in San 

Antonio and the Alamo. 

A Texian assault and two days of grim house-to-house 

fighting resulted in Cos’ surrender on December 10, 

1835. A boozy round of celebration followed the 

parole and release of the enemy troops, and then the 

majority of the volunteers departed homeward, leaving 

a small garrison of both newly enlisted “regulars” and 

fellow volunteers behind them to secure the Alamo 

and its artillery. As 1836 opened, a second Mexican 

expeditionary force was poised to invade Texas and 

crush the rebellion. Meanwhile, the Anglo colonists 

and their native Tejano allies struggled to form a 

standing army and organize a workable government to 

direct what was still simply a petition of rights by arms 

and not yet a formal bid for independence. The stage 

was set for that fateful progression of events which 

would come to form the great creation myth of Texas 

history—the siege and battle of the Alamo. Not 

surprisingly, alcohol abuse played a nearly decisive 

role in that action as well.15(pp77-91)

“...drunken irregularities...” 

The alcoholic history of the Alamo highlighted the 

liquor abuse problems which afflicted both common 

soldiers and their commanders as the struggle with 

Mexico entered its fifth month of open warfare. The 

crumbling “mission fortress” hosted a garrison which 

was apparently prone to tippling at every opportunity, 

and at least one senior officer’s drinking habits directly 

contributed to the internal dissension and slipshod 

discipline which threatened to fragment the defenders 

in the face of an impending Mexican invasion. 

By early February 1836 command of the Alamo had 

devolved upon young Lieutenant Colonel William 

Barret Travis, who had formal charge only of the 50 

“regulars” assigned to the post. The hundred-odd 

volunteers who comprised the balance of the station’s 

strength had elected Colonel James Bowie as their 

commander. A renowned adventurer and duelist, he 

was by that time medicating an advancing case of 

tuberculosis by frequent recourse to the bottle.* 

Irritated at Travis’ attempt to assert overall command 

authority by virtue of his status as an officer of the 

regular Texian forces, the ailing Bowie actively 

interfered in the functioning of the command. On 

February 13 the post adjutant complained in official 

correspondence that Bowie had sought to assume 

overall command by his own authority, ordered the 

garrison to parade through the streets of San Antonio 

while under arms, and used their intimidating presence 

to compel the release of prisoners from the municipal 

juzgado (jail). The adjutant reported that Bowie and 

many of the troops were drunk at the time of these 

disturbances. An indignant Travis informed the 

provisional government that he refused to be “held 

responsible for the drunken irregularities of any man.”†

 

The quick-tempered attorney-soldier was so disgusted 

with Bowie’s drunken intrigues and rivalry that he 

assembled his 50 regulars and marched them out of the 

Alamo to establish a new camp located several miles 

distant on the Medina River on February 13. Although 

Travis and his men remained there only a day or two at 

most before returning to San Antonio, it was still an ill 

considered action on his part, for there had already 

been a spate of warnings concerning enemy activity 

along the Rio Grande. The division of the Alamo’s 

garrison in the face of a possible invasion of Texas 

was itself an index to the virulency of the liquor-fueled 

antipathy between Travis and Bowie.13(p82)

Even after Travis’ men rejoined the garrison the 

excessive drinking continued. Most of the troops were 

quartered in town in private lodgings and not within 

the walls of the post proper. This made it virtually 

impossible for their officers to maintain proper 

discipline and control their access to liquor. Such 

laxity came very close to destroying the Alamo’s 

defenders before they could ever mount its ramparts. 

The speed of the Mexican advance northward into 

Texas took Travis and his superiors by surprise, for he 

had persistently discounted reports that enemy troops 

had crossed the Rio Grande as early as February 18 

and were closing on San Antonio. A cavalry vanguard 

had reached the Medina River ford to the west of town 

(in the vicinity of modern Castroville and Lacoste) by 

the night of the 20th. When Santa Anna and the lead 

division of his army arrived at the river at 1:45 PM on 

the 21st, he found Brigadier General Joaquin Ramirez 

y Sesma and his horsemen awaiting further orders.18,19

Sesma might have already sent his cavalry forward to 

scout the town and its approaches, but he had *References 13(pp52,56,60-61,71-72,76-78,80-81),16(pp62-

63,119),17,18 †References 13(p82),15(pp119-120),17(pp55-56)

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cautiously chosen to keep his dragoons on the west 

bank of the Medina. Soon after Santa Anna’s arrival 

on the scene, he met with local sympathizers from San 

Antonio who informed him that the “Norte 

Americanos” were preparing to hold a grand fandango 

that night in celebration of George Washington’s 

birthday. He quickly ordered Sesma to take his best 

mounted men across the Medina to mount a surprise 

attack upon San Antonio in a bid to catch the rebels by 

surprise. A heavy rain swept down on the ford that 

afternoon and rising water kept the cavalry from 

crossing until early on the morning of the 22nd. At that 

time the dragoons were barely 25 miles from the 

Alamo. Even when traveling on the muddy trace 

which served as a road, the cavalry force had time 

enough to stage a forced march and surprise attack 

upon the unsuspecting enemy.18(p67),20

When Sesma’s dragoons finally cleared the floodswollen ford and neared San Antonio in the predawn 

darkness of February 23, the Texians were either still 

carousing in the cantinas or seeking to sleep off the 

night’s debauchery. An aggressive commander could 

have filled the streets with carbine and saber wielding 

troopers before the befuddled enemy could do so much 

as lift a powderhorn, but Sesma was anything but 

aggressive. The timorous cavalryman advanced no 

farther than the banks of Alazan Creek, a stream 

running hardly a mile and a half from town. There he 

halted to confer with local sympathizers. One of Santa 

Anna’s senior staff officers lamented that when Sesma 

came within sight of the town, 

the enemy was still engaged in the pleasures of a dance 

given the night before.... Several (of the citizens) came 

to inform him, indicating to him the points through 

which he might enter and the orders he should give, and 

urging him earnestly.... At the very moment that 

General Ramirez y Sesma was advised to enter Bejar, 

there were only ten men at the Alamo, and it would 

have required an equal number to take it. Had he just 

placed himself at the bridge over the San Antonio that 

connects the fort to the city, as he was advised, he 

would have prevented the enemy from taking refuge 

there, thus avoiding the painful catastrophe that we 

witnessed.18(pp67,70),20(pp67,70),21

There can be no doubt that a surprise descent by Mexican cavalry early on that morning could have had 

catastrophic results for the Texians. Cut off from the 

sanctuary of the Alamo and finding the narrow streets 

of the town filled with enemy horsemen, the hung-over 

or still inebriated men would have faced several bleak 

prospects: barricading themselves in their lodgings; 

dashing into the streets to confront Sesma’s troopers 

by ones and twos as they sought to escape to their 

walled post; or fleeing to the open plains, where they 

would have been ridden down and lanced or sabred 

like cattle. Capitalizing upon the element of surprise 

and the liquor-muddled wits of the enemy, Sesma 

could have butchered a fleeing rabble at his leisure. 

Conceivably, it would have been the worst defeat 

inflicted upon American troops by an enemy cavalry 

force since British Lieutenant Colonel Banastre Tarleton’s horsemen had massacred 350 Continental troops 

at the Waxhaws, South Carolina in May of 1780.22,23

Sesma chose instead to hold his position on Alazan 

Creek and await the arrival of Santa Anna and a 

column of infantry at 12:30 PM. Even after their arrival 

it took another two hours to initiate their movement 

toward San Antonio. Even so, Sesma had enjoyed 

incredibly good luck that morning, despite his 

inexplicable squandering of the sort of opportunity of 

which all good cavalry men dreamed. Travis had 

prudently posted a sentinel in the belltower of San 

Fernando church that morning after daybreak, and at 

about 10 AM he had seen Sesma’s cavalry moving 

through the brush along Alazan Creek and quickly 

gave the alarm. None of the enemy horsemen were still 

visible from the tower by the time Travis arrived at the 

lookout post, and most of the men who had been 

aroused by the alarm bell’s strident peals went back to 

bed or bottle in disgust at what they dismissed as a 

false alarm. 

Travis wisely sent two riders westward from town to 

scout the muddy road which led ultimately southward 

to the Rio Grande. It was nearing noon when they 

spurred their mounts eastward in a hasty retreat after 

nearly blundering into some of the breastplated enemy 

dragoons. Thus it was not until almost midday that the 

Texians finally took alarm at the presence of Mexican 

cavalry on the outskirts of town and began a 

precipitate retreat to the walls of the Alamo. Even 

then, Sesma’s mere presence in the area helped to 

impair the ultimate effectiveness of the garrison’s 

defense, for he later reported that upon entering town 

at 3 PM, his men seized 50 rifles which had been left 

behind by fleeing Texians in their haste to reach 

safety. Surely those weapons were a loss which the 

rebels could ill afford when faced with an enemy force 
76 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

of such strength. Travis must have keenly felt their 

absence on the morning of March 6, when the Mexican 

assault columns came over the walls of the Alamo to 

finally end the contest.13(p87),17(pp9-10,17-26),18(pp67-72)

Sesma’s failure to take aggressive action against the 

enemy on the fateful morning of February 23, 1836, 

had a profound impact upon the remaining course of 

Santa Anna’s entire campaign. The unhindered 

assembly of the rebel garrison in the Alamo that 

afternoon presented the Mexican commander with the 

choices of either leaving a portion of his forces behind 

in San Antonio to contain and thus neutralize the 

garrison, or to mount an eventual assault upon it with 

the major part of his command before moving 

eastward to pursue and confront the rebel army being 

raised by Houston. That Santa Anna chose to waste 13 

days and sacrifice the future services of an estimated 

1,500 dead or wounded troops in order to destroy the 

Alamo garrison was his error. However, he selected 

that option as a result of Sesma’s major failures—to 

capitalize on his commander’s attainment of strategic 

surprise; to use his own army’s superior tactical 

intelligence; and to exploit the enemy’s lax discipline 

and ludicrous lack of security.15(p155),21(pp42-56)

Such potentially decisive action by Sesma would 

obviously have been successful against an enemy who 

had been rendered temporarily incapable of swift and 

concerted action following even minimal advance 

warning or initial contact with the enemy. What Sesma 

needed, and would have had, to make a successful 

cavalry strike into the streets of San Antonio was 

nothing less than total surprise. Otherwise, a battalion 

of even bleary-eyed Texian riflemen firing from 

behind hastily barricaded streets could have turned a 

cavalry charge into a bloody shambles in short order. 

The enemy’s physical condition on that morning of 

February 23 would have clearly been the key to the 

operation’s success. The exhaustion induced by two 

successive nights of aguardiente-laced celebration was 

enough to have put the odds solidly in Sesma’s favor, 

had he struck at first light on the 23rd. 

“...so far as it is possible to do so.” 

Suppose that a Mexican cavalry raid had destroyed the 

Alamo garrison while it was still in its collective cups 

on that midwinter dawn. Santa Anna would have been 

free to establish a base of operations in San Antonio 

without delay. On February 23 the overall Texian 

defense effort was still in serious disarray. Sam 

Houston, the nominal commander of all Texian forces, 

was not then with any assembly of troops, but rather 

far to the northeast in the vicinity of Nacogdoches, 

negotiating a treaty ensuring the neutrality of resident 

Indian tribes during the ongoing war. Perhaps 500 

volunteers were mustering under different 

commanders in the Goliad-Copano Bay area at that 

time. When Houston arrived in Gonzales on March 11 

(five days after the fall of the Alamo) to assume active 

command of the force being assembled, only 374 men 

were present for duty. Coupled with the approximately 

500 men then serving with Colonel James Fannin at 

Goliad, the Texians had less than one-fourth as many 

troops in the field as did their adversary. By March 20 

Houston was reduced to only the men under his 

immediate command, for on that day Fannin’s force 

was defeated by a detachment of Mexican troops on 

the open plains east of Goliad, and a week later almost 

every one of them was executed on Santa Anna’s 

personal order.13(pp101-103,106-108),15(pp156-157)

Had Santa Anna begun an advance eastward from San 

Antonio prior to the end of February, he would have 

caught the Texian forces in even more disarray than 

when he actually did commence such movement on 

March 10. Houston’s force did not reach its peak 

strength of approximately 1,400 men until the week of 

March 24, when he spent a week confronting Sesma 

and a detachment of 1,200 troops across the rainswollen Colorado River. He then resumed his retreat 

eastward to the Brazos and beyond. Within a few more 

weeks, disease and desertion had reduced his effective 

strength to a little over 800 men when he finally turned 

to confront the enemy in battle at San Jacinto (just east 

of what is now the city of Houston).10(pp51,135),13(pp110-111)

It was the high water which had allowed Houston to 

avoid battle on the Colorado, and which hampered the 

Mexican pursuit throughout so much of the campaign, 

but the rainy weather did not commence until March 

18, with the wettest period falling between March 28 

and April 14. Had Santa Anna commenced a pursuit of 

Houston in late February or early March, his troops 

would have enjoyed generally dry weather and firm 

roads by which to reach easily fordable river crossings. 

The Texian force might well have been overtaken and 

forced to stand and give battle amid three converging 

columns of the enemy army. Given such a scenario, 

the Texian bid for independence might well have been 

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crushed somewhere west of the Colorado in the 

vicinity of modern-day Flatonia or Schulenburg.* 

Of course all of these scenarios remain conjecture 

only, for Sesma failed in his mission on February 23, 

and the liquor-addled Alamo garrison slept largely 

undisturbed through the critical hours of danger. Yet it 

had been a very close call, and in the struggle to come 

much less serious faults than drunken laxity would 

spell defeat and annihilation for commands far larger 

than that of Travis and Bowie. Sesma’s vacillation and 

a benevolent fortune had saved the Texians in San 

Antonio on that brisk winter morning, and Santa 

Anna’s myopic lack of strategic vision coupled with 

his leisurely sense of operational urgency further 

militated events in the rebels’ favor as the conflict 

continued. Unfortunately, the enemy’s errors proved 

serious enough only to delay the inevitable outcome 

for the defenders of the Alamo in the uneven 

confrontation in San Antonio de Bexar. 

Neither the deaths of 185 men nor the occupation of a 

crumbling adobe edifice in distant San Antonio posed 

a potentially decisive threat to the main Texian war 

effort on March 6. If anything, news of the Alamo’s 

fall and the butchery of its defenders galvanized public 

opinion in the United States in favor of the revolution 

and produced a flood of volunteers to fight for the 

Texian cause. San Antonio itself was the most 

populous town in Texas, but it was located well to the 

west of the main foci of Anglo-American settlement in 

the region, and Mexican possession of it had already 

been conceded by Houston as he planned his defense 

of the infant republic. 

The defense of the Alamo assumed operational 

importance to the Texian war effort essentially 

because it was a fortuitous, if unplanned, diversion of 

enemy attention and resources on the cusp of an 

unusually wet spring. Santa Anna’s fixation on a 

protracted siege of the Alamo served to delay the start 

of his offensive campaign against the Texian’s main 

force until the weather intervened to work decisively 

to their advantage. The arrival of the Texas monsoon 

season fatally retarded the Mexicans’ mobility when 

their pursuit of Houston’s army finally commenced 

during the second week of March 1836. (Santa Anna’s 

distraction with the Alamo defenders is not uncommon 

in military history. A parallel circumstance with 

similar disastrous consequences was Hitler’s fixation 

on Greece and the Balkans (1940) to the detriment of 

the imminent invasion of Russia.25) 

The Alamo garrison, of course, had no way of 

knowing that any of this would ultimately come to 

pass. Their concern was with the immediate defense of 

their post, and in this they came within a whiskey glass 

of failing abysmally due to indiscipline and fondness 

for John Barleycorn’s company. The question remains 

as to whether the ultimate fault for this lay with the 

post’s commanders or was rooted in the essential 

nature of the revolutionary army in which they served. 

Armed forces reflect the broader values and cultural 

characteristics of the societies which furnish their 

soldiery. The volunteers who comprised the backbone 

of the 1836 revolutionary army of Texas were largely 

(80%) newly arrived from the United States or Europe. 

They averaged 27 years of age and were typically 

(60%) unmarried. Roughly two of every three came 

from the South, and few owned any substantial amount 

of land or property. Men of such age, marital, 

socioeconomic status, and geographic origin were 

precisely the type who were most strongly predisposed 

to drink to excess, given the opportunity. Their 

resistance to discipline, unfamiliarity with 

conventional military life, and isolation from both the 

physical comforts and behavioral restraints of life at 

home produced an army which “had a manicdepressive quality,” which obliged its earliest 

commander, Stephen F. Austin, to preface a general 

order with the remarkable explanation that “the 

interests of the Country, the success of the Campaign 

and the Safety and Honor of the Army require that 

order and discipline should be observed so far as it is 

possible to do so.”11(pp122-124,138-139)

Austin’s successor, Sam Houston, had served as an 

officer in the 39th US Infantry and had seen for himself over 20 years earlier how badly the indiscipline of 

volunteers and militiamen had impeded the conduct of 

Andrew Jackson’s campaign against the Creek Indians 

in northern Alabama. His Fabian strategy of avoiding 

battle by trading space for time stemmed in large part 

from his own distrust of the volunteer troops he 

commanded. His refusal to hold a council of war until 

the very day of the climactic battle at San Jacinto 

demonstrated just how little confidence he had in the 

judgment of his own officers.15(pp205-208),26,27

*

References 10(pp25,46,52,65,69-70,75,80-81,93), 

20(pp25-29),21(pp97,100,102-104,113-114),24.
78 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

The phrase, “so far as it is possible to do so” almost 

became the epitaph of the Republic of Texas. Austin’s 

early injunction to “send no more ardent spirits” 

should have been stitched onto a banner and flown 

from the Alamo’s jackstaff. Surely Travis and Bowie 

knew fully well the weakness of their men when it 

came to drinking. It was their solemn obligation as 

commanders to enforce discipline and curb 

drunkenness among their troops. In this they failed 

miserably. The key to this failure lay in James Bowie. 

BEER IN THE MUG

James Bowie possessed unquestionable command 

presence and great physical vigor in his earlier years, 

having become a man of property and survived 

wounds in personal encounters which would have 

killed most men. By 1836 he was clearly in decline, 

but his reputation and force of personality were still 

such that most of the Alamo’s garrison enthusiastically 

followed his lead instead of that of the younger and 

personally austere Travis. The loss of his wife and 

both young children in the cholera epidemic of 1833 

had coincided with a lengthy spell of his own severe 

illness while on a trip to Mississippi, and the twin 

physical and emotional ordeals had taken a heavy toll 

upon him. He became a chronically heavy drinker, 

using the liquor to both dull his spiritual pain and ease 

the discomfort from his advancing tuberculosis. When 

he cast his lot with the revolution, he was undoubtedly 

an alcoholic.17(p56)

As Lon Tinkle observed in The Alamo, 

Whiskey was the standard frontier remedy against 

sickness—and everybody knew Bowie since the loss of 

his wife was a man sick unto death, now living on his 

nerves. There is a difference, however, between 

companionable gaiety and besottedness, as Travis well 

knew.17(p56)

The tension between the two commanders was 

essentially rooted in the alcoholic Bowie’s declining 

self-image, for, as Tinkle analyzed his personality, 

All Bowie now had left was his pride—and his ability, 

he would have called it his manhood, for holding liquor. 

The entire quarrel had been no more than a middle-aged 

man’s need to prove himself again at the threat of 

youthful competition.... and the loyalty of the men 

went out, not to the regular army man, but to the ailing, 

hard-drinking Bowie.17(p56)

Thus it was that James Bowie’s individual flaws 

intersected with the ingrained cultural proclivities of 

the men he commanded. The tragic result was that the 

real commanders at the Alamo became Bowie’s inner 

demons. The sober and conscientious Travis had set a 

perfect example of temperance for the men. But that 

was irrelevant, for the man who exercised the genuine 

reins of command by the power of his personality 

during this critical period at the Alamo was Bowie. His 

popularity and past reputation had won the troops’ 

confidence, even as his failure to master his own appetites nearly spelled an early doom for both them and 

the cause for which they ultimately gave their lives. 

Santa Anna’s defeated army took home at least one 

trophy from its abortive campaign above the Rio 

Bravo del Norte. Stripped from its staff at the Alamo, 

the flag of the First Company of the New Orleans 

Greys was carried southward to eventually repose in 

the national museum in the castle of Chapultepec. In 

the center of its gold-fringed azure field, a rampant 

eagle spread its pinions in a militant stance, flanked by 

the black-lettered legends of “FIRST COMPANY OF

TEXAN VOLUNTEERS! FROM NEW ORLEANS” and 

“GOD & LIBERTY.” The men who had originally carried 

that flag to the Alamo had entered Texas while 

marching to the tap of a drummer’s stick beating the 

rhythm to a popular tune of the day, Beer in the Mug.

Given the Texians’ often ill-timed and poorly 

considered thirst for liquor, that song might well have 

served as a fitting funeral dirge for the stillborn 

Republic of Texas. Had Sesma not halted to take 

counsel of his fears on the banks of Alazan Creek, and 

had Daniel Cloud, Travis’ bell tower sentry, celebrated 

too enthusiastically at the preceding night’s fandango, 

the Mexican-American border might today rest on the 

Sabine and not the Rio Grande, and the home of US 

Army medicine might be at Fort Sill (Oklahoma) or 

Fort Polk (Louisiana) instead of Fort Sam Houston. 

Although the ashes of the Alamo’s dead were cast 

upon the wind 174 years ago, and the arts of both 

medicine and war have changed greatly since then, 

human nature and frailty remain immutable. Alcohol 

abuse and the myriad physiological and psychological 

factors which precipitate its occurrence are still with 

us, and every unit in the United States Army contains 

Soldiers who suffer from this personally destructive 

and organizationally erosive practice. In 1836 a 

common soldier had little individual responsibility 

beyond keeping his musket clean and his cartridge box 

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THE ARMY MEDICAL DEPARTMENT JOURNAL

dry. His officers fully expected him to get drunk at 

every opportunity, for that was one of the very few 

forms of recreation available to him at many posts. 

The ten doctors who served in the Alamo garrison 

were all doubtless familiar with a variety of hangover 

nostrums, but none of them would have found in their 

comrades’ propensity for alcohol abuse an unusual 

pattern of behavior for the time and place. The average 

American Soldier of today, be he rifleman, computer 

operator, or laboratory technician, lives in an 

immensely more sophisticated world and regularly 

deals with concepts and technologies which would 

have staggered the best minds in the era of Travis and 

Bowie. The leaders of today’s Soldiers carry the same 

essential burdens of command in an environment 

which demands incomparably more of them and their 

Soldiers, while remaining just as mercilessly unforgiving of error on the battlefield. There is no longer 

any place for the “traditional” vices of the soldier. 

The US Army Medical Department (AMEDD) has 

waged a continuingly successful battle against disease, 

which has historically been the greatest killer of 

Soldiers until comparatively recent times. AMEDD 

surgeons have become so skillful, and the technology 

which supports them so effective, that since the days 

of Gettysburg and Belleau Wood wounds have been 

robbed of much of their traditional lethality. All too 

many of the injuries and losses suffered by the army 

which it serves today in peace or war are essentially 

self-inflicted. Perhaps some day we will be able to 

screen all personnel before induction and identify 

potential alcoholics so that they may be somehow 

inoculated against the effects of the drug forever. 

Concurrently, we must discover a way to terminate the 

existing addictions of all who are already afflicted with 

the disease. Until that time we can only seek to set the 

example by providing good leadership to blunt our 

Soldiers’ desire to abuse alcohol. Unavoidably, there 

must also be the provision of compassionate and 

effective care for those who succumb to its attraction. 

The lessons of history warn us of the disasters which 

may overtake armies which tolerate old ills simply 

because they are common and enduring. 

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AUTHOR

Dr Austerman is the Historian at the Leader Training 

Center, US Army Medical Department Center and 

School, Fort Sam Houston, Texas. 

Aguardiente at the Alamo: Alcohol Abuse and the Texas War for Independence, 1835-1836 

This drawing of the chapel  the Alamo appeared in The Illustrated London News in 1844.  

Courtesy of the Library of Congress Prints and Photographs Division, Washington, DC.
SUBMISSION OF MANUSCRIPTS TO THE ARMY MEDICAL DEPARTMENT JOURNAL

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

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

convey clinical and health service support information; and provide a professional, high quality, peer reviewed print medium to encourage 

dialogue concerning health care issues and initiatives. 

REVIEW POLICY

All manuscripts will be reviewed by members of the AMEDD Journal’s Editorial Review Board or forwarded to appropriate subject matter 

experts for further review and assessment. 

IDENTIFICATION OF POTENTIAL CONFLICTS OF INTEREST

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

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

whether potential conflicts do or do not exist. Authors should do so in the manuscript on a conflict‐of‐interest notification section on 

the title page, providing additional detail, if necessary, in a cover letter that accompanies the manuscript.

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

assistance, if any.

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

manuscript.

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

interpretation of data; writing the report; and the decision to submit the report for publication. If the supporting source had no such 

involvement, the authors should so state. 

PROTECTION OF HUMAN SUBJECTS AND ANIMALS IN RESEARCH

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

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

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

explain the rationale for their approach and demonstrate that the institutional review body explicitly approved the doubtful aspects of the 

study. When reporting experiments on animals, authors should indicate whether the institutional and national guide for the care and use of 

laboratory animals was followed. 

GUIDELINES FOR MANUSCRIPT SUBMISSIONS

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

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

no longer than 24 double‐spaced pages. However, exceptions will always be considered on a case‐by‐case basis. In general, 4 double‐

spaced MS Word pages produce a single page of 2 column text in the AMEDD Journal production format.

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

conform to those guidelines as closely as possible. Abbreviations/acronyms should be limited as much as possible. Inclusion of a list of 

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

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

Medical Association reference format: 

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

publication, volume, and page numbers. 

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

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

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

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

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

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

are preferred. Prints of photographs are acceptable. Please do not send photos embedded in PowerPoint. Images submitted on slides, 

negatives, or copies of X‐ray film will not be published. For clarity, please mark the top of each photographic print on the back. Tape 

captions  to  the  back  of  photos  or  submit  them  on a  separate  sheet.  Ensure  captions and  photos are indexed  to each  other.  Clearly 

indicate the desired position of each photo within the manuscript. 

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

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

6.  Submit manuscripts to: 

EDITOR, AMEDD JOURNAL 

ATTN MCCS HT 

2419 HOOD ST STE C 

FORT SAM HOUSTON, TX 78234-7584 

DSN 471-6301 

Comm 210-221-6301 

Email: amedd.journal@amedd.army.mil