The Bug Stops Here

Force Protection and

Emerging Infectious Diseases 

Donald F. Thompson, Joel L. Swerdlow, and Cheryl A. Loeb 

Center for Technology and National Security Policy 

National Defense University

November 2005 
The views expressed in this article are those of the authors and do not reflect the official 

policy or position of the National Defense University, the Department of Defense, or the 

U.S. Government. All information and sources for this paper were drawn from

unclassified materials. 

Dr. Donald F. Thompson is a senior research fellow in the Center for Technology and 

National Security Policy at the National Defense University. He is a Colonel and a Senior 

Flight Surgeon in the United States Air Force and specializes in Family Medicine and 

Preventive Medicine. Dr. Thompson may be contacted via email at 

thompsond1@ndu.edu or by phone at (202) 685-2406. 

Dr. Joel L. Swerdlow is an author and researcher whose work has been translated into

more than three dozen languages. He spent nearly ten years as an Assistant Editor and 

Senior Writer at National Geographic magazine and is currently an Adjunct Professor at 

Johns Hopkins University. Dr. Swerdlow may be contacted via email at 

joel@jswerdlow.com or by phone at (202) 549-8111. 

Cheryl A. Loeb is a research associate at the Center for Technology and National 

Security Policy at the National Defense University and is also pursuing a Ph.D. in 

Biodefense at George Mason University. Ms. Loeb may be contacted via email at 

loebc@ndu.edu or by phone at (202) 685-2397. 

Contents Defense & Technology Papers are published by the National Defense University Center 

for Technology and National Security Policy, Fort Lesley J. McNair, Washington, DC. 

CTNSP publications are available online at http://www.ndu.edu/ctnsp/publications.html. 

 ii
Contents 

Executive Summary.....................................................................................................v 

Introduction..................................................................................................................1

Infectious Disease through History ............................................................................3

Emerging Infectious Diseases............................................................................4

Infectious Disease and Force Protection....................................................................8 

Preventable Disease and Non-Battle Injuries ....................................................9 

Force Protection Measures........................................................................................13 

Emerging Infectious Diseases and Regional Combatant Commands...................19

United States Central Command......................................................................19 

United States European Command ..................................................................34 

United States Northern Command...................................................................37

United States Pacific Command ......................................................................44

United States Southern Command...................................................................49 

Special Operations Command & Transportation Command ...........................54

Strategic Recommendations for Worldwide Force Protection..............................55 

Environmental Surveillance and Mitigation ....................................................55 

Surveillance and Management.........................................................................56 

Clinical Diagnosis and Treatment....................................................................59 

Historical Perspective ................................................................................................61 

Conclusion ..................................................................................................................63 

 iii
 iv
Executive Summary 

Throughout history, emerging and reemerging infectious disease have plagued human 

populations. From the earliest recorded epidemics of bubonic plague and smallpox more 

than 2,500 years ago to the deadly 1918 pandemic of the Spanish Flu, infectious diseases 

have helped to shape human history. Despite significant advances in medical research

and treatment in the past century, infectious diseases remain among the leading causes of 

death worldwide. These diseases are appearing in places they have never been seen 

before or were thought to have been eradicated, are spreading faster and more frequently, 

and are posing an increasing global health threat that will affect national and international 

security in both the near- and long-term future, even affecting the success of U.S. military 

missions and operations. 

Force health protection is an urgent priority for the Department of Defense (DOD), as 

increasing threats of natural outbreaks of infectious disease could seriously undermine 

mission readiness and success. U.S. national security might be impacted by military 

operations in regions with endemic and epidemic occurrences of infectious disease, 

where disease activity may prevent the successful completion of a mission or operation or 

may even result in infected soldiers carrying a contagious disease back to the United 

States. 

Changing military doctrine and tactics call for a fresh approach to force protection. Rapid 

deployment of military forces, revised distribution of medical resources in theater, 

improved body armor, and modern combat casualty care efforts are leading to different 

illnesses and injuries from those seen in previous conflicts. Emerging infectious diseases 

in the context of urban warfare, low-intensity conflict, and the rapid movement of service 

members and civilians, have made a new approach to military medical support 

imperative. Despite improvements in combat-injury protection and wound management, 

disturbing trends are developing in infectious diseases in military forces. 

The purpose of this paper is to review important lessons that have been learned in the 

past, and to revisit the older but proven principles of force protection that are in danger of 

being forgotten in today’s technology-focused military environment. Recognizing that 

infectious diseases could have a significant impact on military operations, this report 

provides a series of case studies that analyze health threats to each regional combatant 

command and presents both tactical and strategic recommendations that will better 

prepare the entire DOD for future outbreaks of disease. These recommendations focus on 

procedural changes that will allow the U.S. military to regain its competitive advantage. 

Line commanders may herein learn what their predecessors have learned and avoid the 

same fatal mistakes. Medical officers will better understand operational decision making 

and take the initial steps in becoming trusted advisors to line commanders. Senior 

policymakers will recognize that they must take action to restructure line-medical 

interactions to improve collaboration across bureaucratic barriers. 

 v
These recommendations largely deal with more effective management of casualties from

the time of injury or illness through recovery and rehabilitation. Once implemented, they 

will support better identification of service members at increased risk, either from

geographic location, or exposure to known or unknown hazards. Disease prevention and 

clinical management will be improved, civilians far removed from the combat theater 

will not be exposed to exotic diseases, and early detection and warning systems will 

enable DOD to continue to move forces worldwide without the risk of transmitting 

diseases. Recommendations to reduce the operational risk to DOD can be grouped into a 

few key areas: 

• Advanced Technology Development 

o Develop rapid field tests for diseases of military operational importance. 

o Develop molecular-based assays for environmental samples. 

o Develop a topical field antibiotic or improved field wound dressing. 

o Identify promising insect repellants to provide long-term uniform protection. 

o Cost—moderate; Timeline—mid-term; Difficulty—moderate 

• Improved Procedures and Policies for Expeditionary Medical Support 

o Improve infection-control practices, cohorting, and isolation in field hospitals, 

during medical evacuation to the United States and in U.S. hospitals. 

o Reevaluate the size, locations, and capabilities of deployed medical support. 

o Improve understanding of local disease and vector patterns. 

o Link known environmental and population data to identify high-risk areas for 

diseases of military operational importance. 

o Develop policies to prevent misuse of antibiotics in theater. 

o Cost—low; Timeline—short; Difficulty—easy 

• Improved Civil-Military Cooperation on Epidemic Prevention and Response 

o Develop cooperative disease response and control strategies in conjunction 

with Federal, state, and local public health officials. 

o Link civilian and military medical research and intelligence experts to military 

operational needs at geographic Combatant Commands. 

o Develop a DOD/VA antibiotic susceptibility surveillance system. 

o Cost—low; Timeline—short; Difficulty—easy 

• Improved Monitoring, Surveillance, and Management of Service Members. 

o Develop systems to enable tracking of service members worldwide, especially 

combat casualties being returned to the United States. 

o Monitor healthcare workers as a sentinel population of disease outbreaks. 

o Improve tracking of potentially infected service members by fusing disease 

surveillance systems with other data sources. 

o Cost—low; Timeline—short; Difficulty—easy 

 vi
Introduction 

 

As the United States prepared for World War in 1917, experience in the 

cantonments, the temporary camps thrown up to train thousands of draftees, and 

in the sanitation of active troops showed that war is as much as ever 75% an 

engineering and sanitary problem, and less than 25% a military one. The wise 

general will do what the engineers and sanitary officers let him. 

Hans Zinsser, Rats, Lice and History 1 

Hans Zinsser, a preventive medicine consultant to the Allied Expeditionary Force in 

France in World War I, penned these comments to underscore the devastating effects of 

disease on military forces throughout history. He added that “the tricks of marching and 

shooting and the game called strategy constitute a minor part of war, and are only the 

terminal operations engaged in by those remnants of the armies which have survived the 

camp epidemics.”2

Military medicine and combat casualty care have made tremendous advances in the 70 

years since Zinsser’s review. The typical warfighter today often experiences a lower rate 

of disease and non-battle injuries while deployed than in garrison. Personal protective 

equipment, such as body armor, provides a much greater degree of force protection in 

today’s combat environment of urban warfare and low-intensity combat. Forward 

deployment of surgical teams and rapid evacuation of casualties allow injured service 

members to receive advanced care within just a few hours of injury. 

Despite these advances in combat-injury prevention and wound management, there are 

some disturbing trends in the development of infectious diseases in military forces 

deployed overseas, suggesting that line commanders and their medical advisors may be 

forgetting some of the most basic elements of disease prevention. Known and unknown 

illnesses are emerging and spreading, both in theater and in hospitals far removed from 

areas of combat. The smaller and more mobile military of today accepts some operational 

risk due to its increased dependence on civilian transportation, supplies, and healthcare

delivery, and may find its ability to move forces limited by the outbreak of a 

communicable disease, such as influenza or severe acute respiratory syndrome (SARS). 

The purpose of this paper is to review important lessons from the past and to revisit the 

older but proven principles of force protection that are in danger of being forgotten in 

today’s technology-focused military environment. Case studies are presented that focus

on challenges to each geographic Combatant Command, though many of these challenges 

are relevant to line commanders around the world. Recommendations are provided at the 

joint and strategic levels, with a focus on the procedural changes that will allow the U.S. 

military to retain its competitive advantage. 

1

 Hans Zinsser, Rats, Lice and History (Boston: Little, Brown, and Company, 1935), 132. 2

 Ibid., 152. 

 1
Current and future line commanders should read this paper with the intent of learning 

what their predecessors have learned without repeating the mistakes that lead to loss of 

life and combat capability. Current and future medical officers should note how 

operational issues and decisions made in combat go far beyond what is learned in the 

classroom or in a peacetime clinic, and how they must change their approaches to 

protecting their forces. Senior policymakers should take action to strengthen line-medical 

interactions, and should force, if necessary, collaboration across service stovepipes and 

organizational bureaucratic barriers. Recommended solutions are not expensive—most 

deal with processes, procedures, communication, and coordination. 

 2
Infectious Disease Through History 

The first stanzas in The Iliad describe a “fatal plague” that swept through the Greek army 

on the beaches near Troy. Homer tells us “men were dying” at the hands of a “deadly 

distant Archer” who 

Cut them down in droves 

And the corpse fires burned on, night and day, no end in sight.

In this epic poem, never again did the Greeks have to light corpse fires, let alone keep 

them going day and night. Combat with spears and swords could not kill as effectively as 

disease. 

Throughout recorded history, emerging and reemerging infectious disease have plagued 

human populations. Smallpox, a deadly disease known for its high mortality rate and 

propensity to leave survivors with disfiguring facial and body scars, can be traced back as 

far as 1157 B.C. to the mummy of Pharaoh Ramses V, who many historians believe had 

been infected with smallpox. First described in Chinese texts in the 4th century A.D., 

smallpox was not eradicated until 1977, and the World Health Assembly did not 

officially declare the world smallpox-free until 1980. 

In The History of the Peloponnesian War, Thucydides wrote about a “plague” that laid 

waste to the Athenian armies in 430 B.C., killing thousands of the population of the 

walled city of Athens, troops and civilians alike.3

 The first recorded outbreak of bubonic 

plague, known as the Plague of Justinian, occurred in 531, killing thousands of people in 

Constantinople, Egypt, and along the eastern Mediterranean. Nearly 800 years later, the 

bubonic plague, better known as “Black Death,” traveled across the European continent 

and Asia. Beginning in Europe in 1367, the plague epidemic continued for more than 60 

years, killing as much as a quarter of the European population. Spread by the bite of 

infected fleas, the Black Death traveled rapidly through overcrowded cities with poor 

sanitation. 

In the early 1800s, outbreaks of cholera, an acute intestinal infection derived from food or 

water contaminated with the bacterium Vibrio cholerae, were first recorded. In the winter 

of 1818-1819, cholera killed 3,000 soldiers of a 10,000 soldier British army contigent 

operating in India. Shortly after, outbreaks of cholera began to surface throughout Europe 

and Asia, leading to five epidemics between 1857 and 1923. The third such outbreak, 

from 1852-1860, killed more than one million Russians.4

 

One of the deadliest and best-known pandemics in the 20th century was the 1918-1919 

outbreak of influenza, better known as the Spanish Flu. The deadly Spanish flu began in 

the spring of 1918, causing mild occurrences of flu both in the United States and across 

 3

 Christine A. Smith, “Plague in the Ancient World: A Study from Thucydides to Justinian.” Available 

online at: <http://www.loyno.edu/~history/journal/1996-7/Smith.html>. 4

 “Pandemic,” Wikipedia, 26 June 2005. Available online at: <http://en.wikipedia.org/wiki/Pandemic>.

 3
the globe, including France, Spain, and later in England. In the fall of 1918, at the end of 

World War I, a second wave of outbreaks erupted around the globe, spreading along trade 

routes and shipping lines, and following troop movements. By the end of the pandemic, 

an estimated 500,000 people had died in the United States, and upwards of 50 million 

people had died worldwide. More people died of influenza in a single year than in four 

years of the Black Death Bubonic Plague from 1347-1351.5

 

The struggle to understand infectious diseases has been well documented for over 2,500 

years. Scientists have studied the types of people affected, the clinical appearance of the 

disease in individuals, the association with war and large population movements, and 

possible associations with transmission vectors, such as rats, lice, mosquitoes, and water. 

Advances in science and technology have led to great improvements in health and have 

answered many questions about the bacteria, viruses, and parasites that cause disease, the 

vectors that transmit disease, and the body’s response to disease. However, the 1969 

proclamation by the U.S. Surgeon General that it was “time to close the book” on 

infectious disease was indeed premature. 

Bacteria— A microscopic one-celled organism that is able to survive in a wide 

range of environments, subdivides rapidly, and is self-sufficient; depending on 

circumstances, may be beneficial or detrimental to the host. 

Virus— An organism, smaller than bacteria, which contains genetic material——

RNA or DNA——and replicates within its host for survival. 

Parasite— A single or multicellular organism that lives on or in its host, which is 

usually a larger organism that provides physical protection and nourishment. The 

relationship may be beneficial or detrimental, depending on the circumstances. 

Emerging Infectious Diseases 

Over the past 30 years, more than three-dozen new and frightening diseases have been 

identified.6 These include: the hepatitis C, Ebola, and other hemorrhagic viruses; 

hantaviruses; Legionnaires’ disease; Nipah encephalitis; SARS; and most pervasively, the 

human immunodeficiency virus (HIV/AIDS).

At the same time, all-too-familiar diseases have surged. The global tuberculosis mortality 

rate is rising for the first time in 40 years. Malaria is returning to areas from which it had 

been eradicated and is spreading into new areas, such as Central Asia and Eastern 

Europe. Worldwide, there are now 350-500 million acute cases annually. 

Infectious diseases, furthermore, have been appearing in places they have never been 

seen before. In 1999, the West Nile virus appeared in the New York City metropolitan 

area, its first appearance in North America; by the end of 2003, it had appeared in 46 

 5

 Molly Billings, “The Influenza Pandemic of 1918,” June 1997. Available online at: 

<http://www.stanford.edu/group/virus/uda/index.html.> 6

 Robin A.Weiss and Anthony J. McMichael, “Social and Environmental Risk Factors in the Emergence of

Infectious Diseases,” Nature Medicine, December 2004, vol. 10, no. 12, Supplement, S70-76. 

 4
states. Worldwide outbreaks and epidemics of diseases like dengue, meningitis, 

influenza, cholera, and malaria have become increasingly common. Despite remarkable 

progress in fighting infectious diseases, the American Society of Microbiology recently 

reminded a congressional committee that such diseases remain the leading cause of death 

worldwide and the third leading cause of death in the United States.7

 Infectious diseases 

are spreading faster and more frequently than ever before. The era of anti-disease 

optimism is ending and health communities are acknowledging defeat in the vaunted

“war” on microbes. 

Louis Pasteur initiated the era of optimism in the late 19th century with his proclamations 

that modern science could “make parasitic maladies disappear from the face of the 

globe.”8

 Such optimism reached its peak in the two decades immediately following 

World War II, when antibiotics and other “wonder” drugs caught the public imagination, 

and health leaders thought that even tropical diseases, such as malaria, would soon be 

eradicated. Macfarlane Burnet, who won the 1960 Nobel Prize in medicine for his work 

on the human immune system, said in 1972 that “the future of infectious diseases will be 

very dull.” Successful vaccines against smallpox and polio only furthered belief that the 

health threat from infectious diseases was diminishing. This optimism, it turns out, was 

premature. 

Expectations among experts are now much more modest, especially in light of increasing 

antibiotic resistance of pathogens and the resistance of insect vectors to insecticides. 

Many microbes reproduce every 20 minutes— three generations per hour—which means 

that they can adapt quickly to the environment and develop resistance to medications like 

penicillin. Such resistance, first noticed by physicians in the early 1950s shortly after 

antibiotics were introduced, is now accelerating at an alarming rate.9

 According to the

Centers for Disease Control and Prevention (CDC), “drug resistance of bacteria, 

parasites, viruses, and fungi is swiftly reversing advances of the previous 50 years.”10 

Strains of the bacteria Staphylococcus aureus, to cite only one of many possible 

examples, are now resistant to virtually every known antibiotic. At the same time, 

pharmaceutical researchers do not promise many new antibiotics. While several new 

classes of antibiotics have been discovered in the past 30 years, bacterial resistance 

quickly develops. Despite increasing investments in new drug discovery, the output of 

new drugs is dropping.11 

 7

 The actual figure is probably higher. Mounting evidence implicates microbes in heart disease, rheumatoid

arthritis, diabetes, multiple sclerosis, autism, chronic lung diseases, and other conditions and diseases 

previously thought to be unrelated to infection. Researchers have also documented in recent years that at

least 25 percent of all kinds of cancers (but not cases of cancer) have a proven microbial involvement. 8

 Quoted in Jimmy Carter, “A Tale of Two Worlds,” in Impact: From the Frontiers of Global Health. 

(Washington, DC: National Geographic, 2003), 7. 9

 DDT resistance first noticed in Greece in 1951; quickly reported in Lebanon, Saudi Arabia, and Costa 

Rica. Andrew Spielman and Michael D’Antonio, Mosquito (New York: Hyperion, 2001). 10 Centers for Disease Control and Prevention, “Preventing Emerging Infectious Diseases: A Strategy for 

the 21st Century–Overview of the Updated CDC Plan,” 11 September 1998. Available online at: 

<http://www.cdc.gov/mmwr/preview/mmwrhtml/00054779.htm>. 11 “Despite Billions for Discoveries, Pipeline of Drugs is Far From Full,” New York Times, 19 April 2002, 

C1. 

 5
Along with increasing antibiotic resistance, a number of interconnected reasons have led 

to the emergence and reemergence of a number of deadly infections: 

• Population and demographics: There are now roughly 6.45 billion people in the 

world, and most experts believe that there will be 8 or 9 billion by 2025. 

Changing human demographics can lead to an increase in the occurrence of 

infectious disease. Population dislocation, migration, and overcrowding in 

cities—often without adequate clean water, sanitary facilities, and public 

healthcare systems—are all factors in this change. 

• International travel and commerce: Rapid advancements in international travel

allow for persons incubating diseases to move around the globe before they even 

realize they are sick. Furthermore, growth in international commerce and an 

increasingly internationalized food supply, coupled with a decrease in trade 

restrictions between neighboring countries, makes it easier for microbes and 

disease-causing insects to travel around the world in as short a time as 24 hours. 

• Economic development and changing agricultural practices: As populations 

increase and animal husbandry occurs in urban and suburban locations, many 

more people come into contact with livestock than when farms were rural. The 

great increase in pig and chicken farming in China has allowed more exchange of 

avian and human influenza viruses. 

To cite only two of the innumerable examples of how the above factors interact with each 

other, the current global epidemic of dengue fever began with ecological and 

demographic changes caused by combat in the Asian and Pacific theaters during World 

War II. Closer to home, the Aedes albopictus, or Asian tiger mosquito, which contributes 

to the spread of West Nile virus and other diseases, arrived in Houston in the 1970s 

inside worn tires that were shipped to the United States for recapping with new treads.

12

A. albopictus brings yet another threat to the United States, because it, along with its 

cousin A. aegypti, is also a vector for yellow fever. If travelers who are sick with yellow 

fever come to the southern United States in the summer, outbreaks are possible because 

of these two mosquito vectors. 

As we try to maintain effective weapons against microbes, scientists are learning 

microbes do far more than simply evolve through random mutations. As part of the 

survival strategies that they have been developing for billions of years, bacteria and 

viruses can swap genes—“capturing DNA from other microbes, plants, and animals and 

passing this DNA to their progeny.”13 For example, genes from a virus that afflicts 

poultry may combine with genes from a human influenza virus subtype, causing an 

infection that can be spread person-to-person and against which the human immune 

system may have no adequate defense. This is what most worries international health 

 12 Andrew Speilamn and Michael D’Antonio, Mosquito (New York: Hyperion, 2001), 30-45. 13 See, for example, Bruce R. Levin, “Noninherited Resistance to Antibiotics,” Science, September 10, 

2004, vol. 305, 1578-79, and Howard Ochman, et al., “Lateral Gene Transfer and the Nature of Bacterial 

Innovation,” Nature, 18 May 2000, vol. 405, pp. 299-302.

 6
authorities as they try to contain the H5N1 avian influenza subtype now emerging in 

Asia, where many farmers and their families live in close proximity to the poultry and 

swine they raise. 

This new era of emerging and reemerging diseases will continue to pose an increasing 

global health threat that will affect national and international security in the near- and

long-term future. Infectious diseases are a major contributor to poverty and disorder. 

Worldwide, six infectious diseases—influenza, HIV/AIDS, intestinal infections, 

tuberculosis, malaria, and measles—cause nearly half of all deaths before age 44.14 The 

U.S. National Intelligence Council and other government agencies warn that outbreaks of 

such diseases destabilize poorer nations, slow economic growth, create refugee 

emergencies, and impede the development of democracy, thereby sowing the seeds of 

military conflict.15 

 14 Quoted in Jimmy Carter, “A Tale of Two Worlds,” in Impact: From the Frontiers of Global Health

(Washington, DC: National Geographic, 2003), 53. 15 Central Intelligence Agency, “The Global Infectious Disease Threat and Its Implications for the United

States,” January 2000. Available online at: <http://www.cia.gov/cia/reports/nie/report/nie99-17d.html>.

 7
Infectious Disease and Force Protection 

Throughout history trade and conflict have played large roles in spreading diseasecausing microbes. Ships in ancient Greece, for example, could travel up to a 100 miles a 

day, covering the entire Mediterranean in a week. With past conflict and wars, it was 

almost always the case that soldiers were more likely to die from disease than from

combat-related injuries. Military commanders have long struggled with the decimation of 

their fighting forces because of disease. Crowding, inadequate food and rest, mixing of 

soldiers from urban and rural backgrounds, and the difficulty in balancing prevention 

costs with the unnecessary loss of combat troops to disease perplex line commanders to 

this day. 

George Washington, facing the British troops that occupied Boston shortly after the 

Battle of Bunker Hill in 1775, reported in writing to the Continental Congress that 

smallpox was his “most dangerous enemy.”16 During the Valley Forge winter of 1778-79, 

Washington decided that all of his men had to be inoculated against smallpox, even 

though as a direct result of the procedure about two percent of them would die.17 18 This 

decision kept his fighting forces effective when smallpox later incapacitated and killed 

British soldiers before and during crucial battles. 

During the Spanish-American war, only a little more than a century ago, commanders did 

not feel it was their responsibility to prevent or combat diarrhea, even when it laid waste 

to their troops; only rarely were orders given to move mess areas away from latrines, a 

simple action that would have significantly decreased the occurrence of disease.19 

“Though the percentage actually on the sick list never got above 20, 

there was less than 50% who were fit for any kind of work.” 

Colonel Theodore Roosevelt on the Battle of Santiago, 1898. 

Source: R. Major, Fatal Partners: War and Disease. (New York: Doubleday, Doran,

and Company, 1941)

 16 Donald R. Hopkins, Princes and Peasants: Smallpox in History (Chicago: University of Chicago Press, 

1983), 258. 17 Elizabeth A. Fenn, Pox Americana: The Great Smallpox Epidemic of 1775-1782 (New York: Hill and 

Wang, 2001), 93. 18 The smallpox virus is Variola major, so inoculation against smallpox is called variolation. In 1796, 

Edward Jenner discovered that inoculation with the cowpox virus (Vaccinia) provided cross protection 

against smallpox. Louis Pasteur later adopted the word ‘vaccination’ for immunization against any disease. 19 “History of Military Medicine: Lessons from Today’s Vaccines,” CTNSP/NDU Senior Level Seminar 

Series, Vaccines Workshop, National Defense University, 17 March 2005. 

 8
The importance of other anti-infectious disease efforts has become a lesson that military 

commanders have to learn over and over again. On Guadalcanal, in late 1942, as control 

of the South Pacific island hung in the balance, and diseases such as malaria reduced 

some 200-man rifle companies to 65 men,20 a top Marine officer insisted, “We came here 

to kill Japanese, not mosquitoes.” 

Fortunately, his commander, General Douglas Macarthur, thought otherwise. From Pearl 

Harbor to the summer of 1943, malaria caused eight U.S. casualties for each one caused 

by the Japanese military, and six out of ten malaria-carrying mosquitoes came from manmade sources like tire tracks.21 Then, thanks to stringent mosquito control efforts that had 

General Macarthur’s direct, personal support, the malaria rate dropped by 95 percent. A 

June 1944 press release from Pacific headquarters reported that Macarthur had won “one 

of the greatest victories—in the Southwest Pacific Areas—a victory of Science and 

discipline over the anopheles mosquito.”22 

“The mosquito is little but has bugs in her spittle.

Repellents and spray will keep her away! 

Antimalaria jingle broadcast on the “Mosquito Network” to Allied 

forces in the World War II Pacific theater. A monthly pin-up calendar 

and Sunday cartoon used “Mosquito Moe” and “Anopheles Ann” to 

remind troops to roll down their sleeves, use repellents, and take other 

precautions. The “Atabrine Cocktail Hour” of recorded music always 

began with a “commercial” urging malaria control. Atabrine was the 

daily medication taken to protect from malaria infections. 

Source: Leon Warshaw, Malaria: the Biography of a Killer (New York: Rinehart & 

Company, 1949), 298. 

Preventable Disease and Non-battle Injuries 

In today’s rapidly changing disease threat environment, it is crucial to anticipate likely 

risks and to rapidly develop and implement preventive countermeasures to enable 

warfighters to survive these threats. Such health threats rarely come to the attention of the 

public but are vitally important, nonetheless, because of their detrimental impact on 

combat effectiveness. Prevention and response to such threats deserves in-depth analysis 

during combat operations and should not be delayed until after the conflict, when 

researchers can pore over disease and injury data after troops have returned home. The 

U.S. military publicly announces the number of uniformed personnel killed in action, the 

number of “non-hostile deaths,” and the number wounded. The low numbers who 

actually get sick in theater and the numbers of service members who are so sick that they 

 20 Robert T. Joy, “Malaria in American Troops in the South and Southwest Pacific in World War II,” 

Medical History, 1999, 43: 196. 21 Edmund Russell, War and Nature (Cambridge, U.K.: Cambridge University Press, 2001), 114. 22 Ibid., 117. 

 9
must be airlifted out of the war zone, are rarely identified during military operations, even 

though the military preventive medicine and public health community has made 

considerable progress over the past 20 years in preventing disease and maintaining the

health of each service member. 

Historically, disease and non-battle injury (DNBI) rates have rivaled those from battle 

injuries.23 24 Aggressive commander attention to reduce preventable injuries has reversed

this pattern since World War II. Non-battle injury rates now account for a much smaller 

proportion of DNBI—one fourth of the combined DNBI total, down from half just 50 

years ago. 

 

Comparable disease and non-battle injury data are not available from earlier conflicts 

because of differences in category definitions, completion of data, and other 

methodological issues. Data from the Crimean War in 1854 to 1856, one of the earliest 

wars in which accurate records were kept, show how much more destructive disease was

than combat.25 The opposing armies suffered almost equally from diarrhea and dysentery 

caused by cholera and other organisms, epidemic typhus (an infection transmitted from 

man to man by the body louse, especially common in refugee camps and during war, 

famine, and disasters), and other diseases.26 The French and Russian armies lost 50,000 

and 37,000 men, respectively, to disease; they lost 20,000 and 38,000 to wounds. 

Figure 1 Figure 2

Crimean War, 1854-1856

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

French English Russian

Died of Disease

Recovered

Crimean War, 1854-1856

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

90,000

100,000

French English Russian

Died of Wounds

Survived Wounds

Figure 1 & 2— Hans Zinsser, Rats, Lice and History (Boston: Little, Brown, and Company, 

1935). 

 23 Non-battle injuries include non-combat related motor vehicle accidents, training injuries, and recreational 

injuries. 24 Institute of Medicine, Strategies to Protect the Health of Deployed U.S. Forces (National Academy 

Press, 1999), 23-24. 25 Zinsser, 165. 26 A notable exception was the lower rates of disease and death from combat wounds in the English forces, 

probably because of the efforts of Florence Nightingale, who introduced nursing care into combat casualty 

care. 

 10
Data collected during U.S. conflicts are consistent with these findings. Deaths due to nonbattle causes exceeded those due to battle from the Revolutionary War until World War 

II. 

Figure 3

U.S. Army Battle Deaths vs. Other Deaths, Mexican War through 

Vietnam

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

400,000

Mexican

War

Civil War

(Union)

SpanishAmerican

War

World War

I

World War

II

Korea Vietnam

Other Deaths

Battle Deaths

Figure 3—James James, Alyce Frelin, and Robert Jeffery, Disease and Nonbattle Injury 

Rates and Military Medicine, Medical Bulletin of the U.S. Army, Europe 39 (8):17-27, 

August 1982. 

Figure 4 

Disease/Nonbattle Injury Rates* for Selected U.S. Deployments

0

10

20

30

40

50

60

70

80

90

ODS/DS OJE OJG OEF-War OEF-Stab OIF-War OIF-Stab

Injury

Disease

 11
*Incidence rates per 1000 service members per week 

ODS/DS— Operation Desert Shield/Desert Storm 1990-1991 

OJE— Operation Joint Endeavor— Balkans ’95-96 

OJG— Operation Joint Guard— Balkans ’97-98 

OEF/OIF— Operation Enduring Freedom and Operation Iraqi Freedom

• War phase—15 Mar 03— 3 May 03 

• Stabilization phase— 4 May 03— 26 Mar 05 

Sources: Jose Sanchez, et al, Health Assessment of U.S. Military Personnel Deployed to

Bosnia-Herzegovina for Operation Joint Endeavor, Military Medicine 166 (2001):470-474; 

Kelly McKee, et al, Disease and Nonbattle Injury among United States Soldiers Deployed 

in Bosnia-Herzegovina during 1997: Summary Primary Care Statistics for Operation Joint 

Guard, Military Medicine 163 (1998): 733-741; Air Force Institute for Operational Health, 

“Historic and Recent DNBI Rates”, 4 April 2005. 

Much of this improvement has been due to the general decrease in many infectious 

diseases over the past century, as well as improved preventive and medical treatment 

measures, but closer examination indicates that there continues to be troop loss due to 

preventable illness and injuries. 

As the data from the past decade demonstrate, cases of diseases and non-battle injuries 

have fallen to record lows in recent force deployments. Greatly improved tracking and 

recording of types of illnesses and non-battle injuries have allowed preventive efforts to 

be targeted at the point where illnesses and injuries can best be prevented, but all this 

laudable effort is at risk if military line commanders and their medical advisors allow the 

emphasis on force protection and anticipating emerging disease patterns to decay. 

 12
Force Protection Measures 

For commanders and warfighters at all levels, responsible preparation for military 

operations and force health protection requires an understanding of basic disease 

concepts, risks, and trends, and what threats can be reasonably anticipated in any 

geographic area. Scientific progress in molecular biology, biotechnology, and other, new 

fields has led to great progress in our understanding of disease, in the medical capabilities 

at our disposal, and just as essentially, in commander priorities. 

Control methods against most illnesses are notoriously low-tech and do not fit the 

“Warfighter of the 21st Century” stereotype. While hand washing, head-to-toe sleeping 

arrangements, “sneeze” barriers between beds, improved air exchanges, and air 

sterilization with ultraviolet light are all proven to reduce respiratory illnesses in service 

members in-garrison, these measures are obviously not as high a priority during combat 

operations as body armor and night vision goggles, and often are not technically feasible 

in the field.27 There are, however, many measures that can and should be taken in the 

field to protect warfighters from avoidable infectious disease threats. 

Once the decision has been made to engage in a military operation, commanders should 

first define the mission, resources, and parameters for the operation, then task medical 

staff to gather and examine pre-engagement medical and environmental intelligence and 

provide advice for protection against any threats. This can be as simple as asking 

questions: Is malaria in the area, and if so, what type? What prophylactic combination of 

drugs works best against it? What preventive countermeasures, such as mosquito 

repellant or bed nets, will warfighters need? More complex questions may include: Do 

other infectious diseases put the mission at risk? Are there geographic, environmental, 

climatic, vector, or population factors requiring risk management efforts? Soon, remote

sensing of global ocean temperatures may make it possible to predict rain and subsequent 

mosquito levels with some accuracy.28 Satellite imagery also may help identify potential 

geographic, environmental, and vector-borne disease risks. 

Trusted professional relationships between commanders and their medical experts are 

essential so that the best scientific advice may be shared in an operationally relevant 

context. The field environment is no place for a civilian physician who does not 

understand the operational military culture, warfighting mission, and risk management

process. Combat casualty care in Vietnam required a degree of expertise that was not 

developed in a civilian practice in the United States. New surgeons arriving in Vietnam 

were attached to experienced teams for orientation, and they learned new techniques in 

 27 Terrence Lee, et al, “Selected Nonvaccine Interventions to Prevent Infectious Acute Respiratory 

Disease,” American Journal of Preventive Medicine, April 2005, 28: 305-316. 28 See, for example, D.A. Focks, et al., “Transmission Thresholds for Dengue in Terms of Aedes Aegypti

Pupae per Person With Discussion of Their Utility in Source Reduction Efforts,” American Journal of

Tropical Medicine and Hygiene, January 2000, 62: 11-18.

 13
the operating room.

29 The effective Joint Task Force Surgeon will have the best scientific 

solutions to protect combat forces from preventable threats and will know which of these 

are possible, given local operational requirements. He or she must succinctly present to 

the line commander those threats that may impact mission completion and the available 

preventive countermeasures, and must clearly state the risks and benefits of the various 

courses of action. 

Once the responsible line commander selects a course of action, the surgeon continues to 

assist subordinate commanders as they implement countermeasures, and monitors for 

unanticipated events that may call for rapid responses. If the unit medical officer is not an 

effective operational advisor and is unable to provide appropriate courses of action to 

protect warfighters, the unit commander must relieve him or her and find a trusted, 

forward-leaning medical officer who can be relied upon to provide the best available, 

operationally relevant, medical advice to protect the forces. If, on the other hand, the unit 

commander does not request, understand, accept, or implement operationally relevant, 

preventive medical advice, then it is appropriate to elevate the issues to a higher 

command level. British Field Marshall Sir William Slim, who rebounded from a 

catastrophic loss in Burma in 1942 to win an overwhelming victory over the Japanese in 

1944 and 1945, took aggressive action when his line commanders failed to implement his 

command guidance—he relieved them from command. Concerning compliance with the 

requirement to take a daily mepacrine pill, the medication taken to prevent malaria, Slim

had surprise checks of whole units. “If the overall result was less than ninety-five per cent 

positive, I sacked the commanding officer. I only had to sack three; by then the rest had 

got my meaning.”30

Training and education are essential, especially when medicines, such as those that 

combat malaria, must be taken for weeks after an individual’s last exposure to diseasecarrying mosquitoes. The malaria-causing parasite can live dormant for months and even 

years in an infected individual’s liver without causing symptoms. Failure to take 

prescribed prophylactics until the threat of disease has been eradicated can allow 

parasites to multiply and cause disease and death to troops even after they return from

overseas deployment. Discipline is crucial to assure that troops comply with command 

guidance and direction to take medications, use personal protective equipment, such as 

bed nets and insect repellant, and use common-sense protection, such as sleeping in 

uniforms that cover the skin rather than leaving skin exposed to biting insects. The 

medical officer has no role in such command discipline; only the unit commander can 

enforce compliance. 

Troop movement becomes more complicated if the potential deployment site involves 

areas designated by the CDC as having “repeated experience with outbreaks of diseases 

once thought to be archaic or obscure.” Included in recent years are outbreaks of plague 

in India and leptospirosis in Nicaragua and the Malaysian portions of Borneo. In late 

2004–early 2005, reports emerged that pneumonic plague had infected workers at a 

 29 Spurgeon Neel, Medical Support of the U.S. Army in Vietnam, 1965-1970 (Washington, DC: Department

of the Army, 1973). 30 Sir William Slim, Defeat Into Victory (London: Cassell and Company, 1956), 180.

 14
diamond mine in the Congo. Microbes that cause this plague are airborne, more virulent 

and dangerous than the bubonic plague, and spread by the same kind of rat-borne fleas 

that were responsible for the Black Death epidemics in the Middle Ages.31

Leptospirosis is a disease caused by the bacterium Leptospira 

interrogans, found in the tissues and urine of infected dogs, swine, and 

rodents. It is transmitted to man upon contact with infected tissues, or 

more commonly by contact with contaminated water. It causes fever, 

meningitis, and liver and kidney infections and is common in the 

Southern United States and in the tropics. Its military operational 

association is obvious, since one of its names is Fort Bragg fever. It is 

also known as European swamp fever, mud fever, and swineherd 

disease. It is easily treated with antibiotics, once a correct diagnosis is 

made. 

Plague is an infection caused by the bacterium Yersinia pestis. The 

disease usually presents in three clinical forms in humans: bubonic, 

pneumonic, and septicemic. Bubonic plague was the cause of the Black 

Death epidemics that wiped out one quarter of the population of Europe 

in the Middle Ages. Bubonic plague is transmitted by infected fleas that 

infest rats and has historically spread quickly in urban and suburban 

areas with poor sanitation systems where plague-infected rats flourish. 

The infection is transmitted when a person is bitten by the infected flea, 

and the plague bacterium migrates to the lymph nodes in the arm pits or 

the groin, where it causes the classic swollen buboes that give the 

disease its name. The infection then spreads throughout the body via the 

bloodstream. It can be transmitted from person to person once it reaches 

the lungs. Pneumonic plague occurs when the bacteria are inhaled in an 

aerosol form when a person with pneumonic plague coughs (or when the 

bacteria are intentionally released in a bioterrorism attack). This route of 

infection causes illness within one to two days and quickly leads to 

death, unless promptly treated with antibiotics. 

 15

 31 “Pneumonic Plague Seen in Congo Outbreak,” Washington Post, 15 February 2005, A19.
Commander’s Pre-Deployment Operational Checklist32

Issue Office of 

Primary 

Responsibility 

Information 

Source 

What are the known infectious disease threats? SG CDC, WHO, 

Armed Forces

Medical 

Intelligence Center 

What is the civilian experience with infectious diseases 

in this area? 

SG WHO 

What are the environmental hazards in this area? J2, SG NOAA, USGS, 

AFMIC 

Are my troops adequately protected with vaccines? SG CDC, AFMIC 

Do my troops need to take any medications to protect 

from malaria? 

SG CDC, AFMIC 

Do I have sufficient personal protective equipment (bed 

nets, DEET insect repellant, permethrin repellant to treat 

uniforms) to protect from insects?

J4, SG 

Are there any environmental control measures that will 

reduce exposure risks to my troops? 

J2, J4, SG NOAA, USDA, 

AFMIC 

Have I issued operational orders to my line commanders 

to assure troops use personal protective equipment while 

exposed?

J3, Chief of 

Staff 

Have I established an inspection system to see that my

preventive medicine orders are obeyed? 

J3, Chief of 

Staff 

Are environmental and medical threat surveillance 

systems in place to monitor changes in environmental 

and disease threats?

J2, J4, SG 

Are systems in place to detect any changes in infectious 

diseases in nearby civilian populations? 

POLAD, SG Dept of State, 

WHO, CDC 

Is there a risk of unexpected civilian population 

displacement that may inadvertently expose my troops 

to increased infectious disease risk?

J2, SG, 

POLAD 

Dept of State, 

NGOs, UNHCR 

Are there additional precautions I must take to protect 

against such risks?

J2, SG 

Are medical surveillance systems in place to monitor, 

detect, and warn of any unexpected disease occurrence 

in my troops? 

J4, SG 

 32 Definitions: The Joint Staff Directorates : J1— Manpower and Personnel; J2—Intelligence; J3— 

Operations; J4— Logistics; J5— Strategic Plans and Policy; J6— Command, Control, Communications & 

Computer System; J7— Operational Plans and Interoperability; J8— Force Structure and Resources and 

Assessment; POLAD – Political Advisor; SG— Command Surgeon; CDC— Centers for Disease Control 

and Prevention; WHO— World Health Organization; AFMIC— Armed Forces Medical Intelligence 

Center; NOAA— National Oceanic & Atmospheric Administration; USDA— United States Department of

Agriculture; USGS— U.S. Geological Survey; NGO— Non-Government Organization; UNHCR—United 

Nations High Commissioner for Refugees. 

 16
International agencies, such as the World Health Organization (WHO) have regional 

rapid response networks—trained personnel, protective equipment, and data analysis 

capability—capable of investigating and, if necessary, managing suspected cases of 

infectious disease if the host nation permits. Although these agencies work closely with 

the CDC, their close cooperation with a military operation is not assured.33 DOD partially 

addresses this shortfall by providing deployable laboratory and diagnostics capability for 

each mission to an area where known infectious diseases are prevalent. 

Post-combat capacity to diagnose and treat diseases is another shortcoming. Even for 

common and familiar infections like malaria, symptoms may not appear until weeks or 

months after exposure. Fewer than a dozen returned travelers now die of malaria in the 

United States each year, but more than 1,000 get sick with malaria that is often not 

diagnosed until they are near death. Symptoms from a virus, such as hepatitis C, may not 

appear for decades, so commanders may never know the health consequences of 

particular operations.34 Zinsser observed that the average professional officer thinks of 

the military doctor as an “unwillingly tolerated noncombatant who takes sick call, gives 

cathartic pills, makes transportation trouble, complicates tactical plans, and causes the 

water to smell bad. He is useful after an action to remove the debris, but otherwise he is a 

positive nuisance.”35 Historical experience shows otherwise—the commander ignores 

medical advice at his own peril. 

Good medical intelligence is not enough to reduce the effect of infectious disease on 

warfighters. The ability to fight at night has become a significant U.S. tactical advantage, 

yet nighttime is when many disease-carrying mosquitoes are most active. Such 

mosquitoes and other insects can also affect urban fighting during the day. There is no 

known way to prevent dengue fever—known as “breakbone fever” because of the 

debilitating pain it causes—other than to avoid being bitten by A. aegypti mosquitoes that 

carry the dengue-causing virus. These mosquitoes, which are most active during daylight 

hours, have adapted well not only to cities, but also to the damage caused by urban 

warfare. In the wild, A. aegypti breed in small bodies of water, such as the few raindrops 

that may accumulate in a broken bamboo shoot. In cities, they thrive in anything in which 

water can collect, like broken dishes, pieces of glass, and abandoned tires. 

The tendency today is to believe that infectious diseases are a thing of the past, thanks to 

advances in science and technology. However, infectious diseases have a huge—and 

perhaps a growing—role in military affairs. Indeed, emerging infectious diseases seem to 

permeate every aspect of military operations, from the broad circumstances that make the 

use of armed forces necessary, to the detailed decisions made by individual warfighters 

during an action, to new processes, procedures, and technologies that must be developed 

to manage combat casualties and diseases that may be acquired outside the United States. 

 33 Centers for Disease Control and Prevention, “Protecting the Nation’s Health in an Era of Globalization:

CDC’s Global Infectious Disease Strategy,” 2002. Available online at: 

<http://www.cdc.gov/globalidplan/global_id_plan.pdf>. 34 See, for example, , Sandt L. St John TM, “The hepatitis C Crisis,” Ethnicity and Disease, Spring 2005, 

15 (2 Suppl 2):S52-7. 35 Hans Zinsser, Rats, Lice and History (Boston: Little, Brown, and Company, 1935), 152. 

 17
Force protection and freedom of troop movement may be directly curtailed by emerging 

infectious diseases. Geographic disease patterns and operational requirements may put 

military personnel at such risk that combat operations may need to be cut short. The next 

section of the paper identifies realistic health threats in relation to the Regional 

Combatant Commands, where the force protection issue is most relevant and provides 

recommendations for addressing these threats, not only for the Combatant Commands, 

but for the entire DOD. 

 18
Emerging Infectious Diseases and Regional 

Combatant Commands 

United States Central Command (CENTCOM) 

The CENTCOM area of responsibility (AOR) has multiple sites 

where U.S. and coalition military forces will be in place for a 

prolonged period of time. Operation Enduring Freedom and 

Operation Iraqi Freedom (OEF/OIF) both required rapid 

development of forward operating locations to support combat 

operations. As operational requirements stabilize and mobility 

becomes less of a priority, actions should be taken to improve 

troop protection from emerging infectious disease risks. The 

following two case studies show how infections with 

Acinetobacter baumannii and Leishmania spp. in warfighters calls for a reevaluation of 

in-theater distribution of medical resources given the constraint of minimizing the 

footprint of combat support personnel and assets in country. Such resource constraints, 

including supplies, equipment, personnel, and facilities, require anticipation of, and 

planning for, possible alternatives. These case studies provide examples of emerging 

infectious threats and the resulting operational impacts, and offer opportunities to make 

substantive changes to military medical doctrine, plans, and policies to improve the 

combat effectiveness of today’s lighter, faster forces. 

Case Study I—Acinetobacter: Urban Warfare, Low-Intensity Conflict, and 

Emerging Infections

Changing ground combat tactics, equipment, and conditions have led to different patterns 

of wounds in U.S. warfighters. Combat wounds during World War II and the Vietnam 

War were often high-velocity bullet wounds and low- velocity grenade fragment wounds 

to the chest, with injuries that were quickly fatal. Body armor developed, improved, and 

deployed over the past 30 years has saved many lives, and has led to different patterns of 

wounds in the survivors. In Somalia in 1993, soldiers wore heavy body armor that 

shielded the chest from many direct wounds, so a higher percentage of injuries and deaths 

resulted from pelvis and extremity wounds.36 Since then, body armor has become lighter 

and has provided additional protection to the abdomen, groin, and throat, so the numbers 

of immediately fatal injuries from both bullets and grenade fragments have decreased. 

Compared to full-scale field combat, like that of World War II and Vietnam, lowintensity conflict in the urban environment leads to more use of close-in weapons, for 

example, rifles used by snipers, explosive charges, such as improvised explosive devices 

(IEDs), and rocket-propelled grenades. These weapons create a much smaller lethal zone 

 19

 36 Robert L. Mabry, et al. “United States Army Rangers in Somalia: An Analysis of Combat Casualties on

an Urban Battlefield,” Journal of Trauma, September 2000, 49 (3): 515-52. 
that may be survivable if the warfighter is properly protected. Low-intensity military 

conflict between the Israeli Defense Forces and the Palestinian Armed Forces during the 

Al-Aqsa Intifada beginning in September 2000 showed combat injury patterns where 75 

percent of wounds were to the extremities, head, face, and neck, thanks to the use of 

Kevlar helmets and ceramic body armor.37 Low-intensity conflict in Iraq, such as the 

recent urban offensives in Fallujah and Al-Anbar province, show similar injury patterns, 

but injury patterns are changing somewhat in the stabilization phase of the conflict. 

During the stabilization and reconstruction period in Iraq, patrolling forces are more 

likely to be ambushed by IEDs, such as suicide bombers in cars. The resulting lowintensity-conflict injury pattern is reflected in a higher proportion of extremity wounds. 

 

Figure 5 

Figure 5 demonstrates the complex injuries caused by IEDs in urban warfare. The

armored vehicle often provides enough protection so the service member survives the 

initial blast, but multiple types of injuries resulting from other mechanisms require

aggressive surgical and medical management. 

Source: David Lounsbury and Ronald Bellemy, Emergency War Surgery, 3rd Edition

(Washington, DC: Borden Institute, 2003). 

 20

 37 Dror Lakstein and Amir Blumenfeld, “Israeli Army Casualties in the Second Palestinian Uprising,” 

Military Medicine, May 2005, 170: 427-430.
Figure 6

Figure 6 demonstrates the mechanism of injury and severe lower extremity damage from 

a land mine or from a small IED. The vital structures within the chest and abdomen are 

relatively shielded by body armor and by the rest of the service member’s body, so 

prompt control of bleeding by a combat medic enables many warfighters to survive these

injuries. 

Source: David Lounsbury and Ronald Bellemy, Emergency War Surgery, 3rd Edition

(Washington, DC: Borden Institute, 2003). 

The real success of body armor is in the wounds prevented, because many explosive 

fragments are deflected by the armor and never cause any wounds. In urban warfare and 

low-intensity conflict, however, low-velocity fragments are injuring unprotected areas of 

the face and extremities, because the vital structures within the chest and pelvis are 

relatively protected. Thanks to better personal protection, warfighters are surviving 

attacks that would have been fatal in previous conflicts, but this creates an emerging issue 

of infections caused by microorganisms. 

Warfighters in field combat conditions carry a heavy amount of bacterial contamination 

on their clothing and skin, and any wound allows this contamination to enter the body. 

Delays in resuscitation, evacuation, and surgical wound care increase the chance that this 

contamination will develop into infection, because the longer bacteria are in a wound 

with poor blood supply and dead tissue, the more likely a serious infection will develop.38 

 21

 38 Rodney Peyton, Carl Griffiths, and Daniel Rignault, “Terrorist Injury,” in Ballistic Trauma: Clinical

Relevance in Peace and War, James M. Ryan, Ed. (Oxford University Press, 1997), 277-282. 
Figure 7 

Mechanism of Injury*

OEF/OIF Battle and Non-Battle Injuries

23

33 Grenade**

IED

Gunshot

Motor Vehicle 22

10 Other

12

* Casualties may have more than one mechanism of injury. 

**Includes fragmentation grenades, mortars, and bombs. 

Figure 7 indicates that 45 percent of the casualties in the first two years of OEF and OIF 

were injured by munitions that produced low-velocity fragments: IEDs, grenades, mortars, 

and bombs. These fragments cause multiple penetrating wounds that damage extensive

amounts of tissue and introduce much more contamination than a single gunshot wound. 

Source: Joint Theater Trauma Registry Report, 13 April 2005. 

Changing enemy combat tactics calls for changing the tactics not only of coalition forces, 

but also of those responsible for force protection, and for managing these changing 

casualty patterns. Military combat casualty care is adapting to these shifting injury forms, 

but the logistical support, medical evacuation, and referral healthcare structure must 

adapt as well. The U.S. military moved to a much smaller in-theater footprint after the 

success of Operation Desert Storm in 1991, but this shift has not come without costs. The 

focus of this case study is to describe some of the effects that this change in doctrine has 

had on combat casualty care and to provide recommendations as to how some of these 

newly identified deficiencies could be addressed. 

Many service members who were severely injured in Iraq are returning to the United 

States with bloodstream infections caused by the bacterium Acinetobacter baumannii, an 

organism found in soil and water in many parts of the world known to cause pneumonia 

and bloodstream infections. An isolated case of this infection might not be an issue, but 

the emerging pattern is one of a cluster of infections among a high proportion of 

personnel in an identifiable group and is a clinical issue that needs resolution. Moreover, 

ongoing transformation of the military to a light-weight, highly mobile, combat force 

with a small support infrastructure that has limited immediate medical support suggests 

that such types of infections are just the tip of the iceberg for military medics. Military

medical doctrine has changed from providing definitive treatment in theater with large 

 22
field hospitals to rapid stabilization as close to the fighting as possible, with rapid 

aeromedical evacuation out of the theater of combat. For casualties from Iraq and 

Afghanistan, for example, additional surgical care is provided en route at Landstuhl 

Regional Medical Center in Germany. These casualties are then returned to the United 

States for definitive surgery and rehabilitation. This concept of operations is not ideal for 

wound management because complete initial management of combat injuries is not 

always possible and in-theater diagnostics and treatment are limited by resources. One 

consequence is a growing number of infections with A. baumannii. 

Current doctrine for combat casualty care focuses on rapid stabilization of casualties by 

Forward Surgical Teams, where the emphasis is on controlling bleeding and rapid 

aeromedical evacuation. This practice results in minimal debridement of contaminated 

wounds, which allows the development of infection, putrefaction, gas gangrene, and 

bloodstream infections. The cornerstone of combat casualty care is debridement within 

six hours so that foreign bodies—dirt, clothing, debris, bone splinters—and obviously 

dead tissue are removed before serious tissue infections can develop.39 During the 

Vietnam conflict, service members underwent full debridement by a surgeon in a hospital 

close to the area of combat, sometimes for five to seven days, until the wounds were 

clean. According to one study, the mean time of hospitalization in Vietnam was 9.2 

days.40 In Iraq and Afghanistan, wounded service members are being evacuated in as 

little as 12 hours; the fact that sand from Iraq is still being washed out of wounds in 

Germany and in Washington, D.C suggests that debridement in theater is inadequate. 

While rapid stabilization and transport policy allows lives to be saved with a smaller 

military medical footprint in theater, under-debridement of combat wounds appears to be 

shifting the burden of medical care to portions of the military and civilian healthcare 

system not yet prepared for the added precautions necessary to prevent infection. 

The result is that wounded service members who may be harboring dangerous infections 

are being returned to the United States to medical treatment facilities (MTFs) that are 

unprepared for them. In the combat theater, these casualties are a well defined group in a 

setting focusing on combat casualty care, but once they return to the United States, they

become a group requiring special monitoring and handling, because they are mixed with 

other DOD beneficiaries receiving general medical and surgical care in military MTFs. 

Many of these other beneficiaries are seriously ill retirees with significant medical 

conditions, such as diabetes, pulmonary disease, and other diseases that compromise their 

ability to fight off infection. Effects of this mixing of recent combat casualties from Iraq 

with other DOD beneficiaries have been considerable. There have been at least 43 

episodes of person-to-person transmission of A. baumannii at Walter Reed Army Medical 

Center in Washington D.C., leading to deaths of at least three elderly patients who were 

infected while hospitalized at Walter Reed. There have been two cases of person-toperson transmission at the National Naval Medical Center in Bethesda, Maryland, with 

 39 Simon Mellor, Charles Easmon, and Jay P. Sanford, “Wound Contamination and Antibiotics,” in 

Ballistic Trauma: Clinical Relevance in Peace and War, James M. Ryan, Ed. (Oxford University Press,

1997), 61-71. 40 Elliot Jacob and Jean Setterstrom, “Infection in War Wounds: Experience in Recent Military Conflicts 

and Future Considerations,” Military Medicine, June 1989, 154 (6): 311-315. 

 23
the death of one elderly patient. There have also been outbreaks at a Combat Support 

Hospital in Baghdad, the U.S. Navy Hospital Ship USNS Comfort, and the U.S. Army 

Landstuhl Regional Medical Center in Germany, where another elderly patient died from

an infection contracted in the intensive care unit from a wounded solder from Iraq. 

Additional cases have been identified at Brooke Army Medical Center in San Antonio, 

Texas.41 The infections with A. baumannii initiated in-theater are thus causing medical 

concerns in a much broader medical setting. 

A significant complicating factor for A. baumannii and many other wound-infecting 

organisms is antibiotic resistance. The A. baumannii bacterium is readily divided into two 

main groups: one group that is sensitive to many antibiotics but can rapidly develop 

resistance when exposed to antibiotics, and another group that is already resistant to most 

antibiotics. Regardless of grouping, these bacteria represent a challenge to treatment with 

conventional antibiotics. The A. baumannii observed in returning U.S. service members 

is already resistant to multiple antibiotics and requires treatment with an extremely 

expensive antibiotic (Primaxin) that is usually reserved for rare infections. Pharmacy 

spending on Primaxin increased from $43,000 to $226,000 in the first two years of 

OEF/OIF at the two military medical centers treating most of these combat casualties.42 

Figure 8 

Primaxin Drug Costs

$0

$50,000

$100,000

$150,000

$200,000

$250,000

2002 2003 2004

WRAMC

NNMC

Figure 8: Accurate treatment costs for combat casualties are very hard to determine. 

Military medical treatment facilities do not have data systems that support easy

identification of patients admitted from various conflicts, or for the routine or 

extraordinary costs associated with treating them. Costs for the gowns, masks, and 

gloves necessary to maintain strict hospital infection could only be estimated. During 

the four year period from 2001-2005, pharmacy data systems changed in two facilities, so 

actual costs for these antibiotics could only be estimated based on average costs and 

antibiotic usage before 2002 compared to costs and usage in 2005. The authors greatly 

appreciate the efforts made by Pharmacy, Medical Supply, Safety, Infection Control, and

Infectious Diseases personnel at Walter Reed Army Medical Center, National Naval 

Medical Center, and Brooke Army Medical Center. 

 41 Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, 19 November 2004, 

vol. 53 (45): 1063-1066. 42 Major Kimberly Moran, Walter Reed Army Medical Center; Lieutenant Commander Kyle Petersen, 

National Naval Medical Center, personal communication, 09 August 2005. 

 24
A. baumannii is a known pathogen in the United States, but in the patient population 

represented by service personnel, these unusual presentation and transmission patterns 

are cause for concern. While the bacterium is known to cause hospital-acquired cases of 

pneumonia and bloodstream infections in the United States, it is usually seen in severely 

ill patients whose immune systems are compromised. Despite being the cause of 50 

percent of wound infections in Vietnam casualties, it was not seen during the Persian 

Gulf War in 1990-1991. Some speculate that the cause for this is that there were so few 

casualties in Operation Desert Storm, and urban warfare was not a factor, so injury 

patterns and combat casualty care practices did not create the right environment for A. 

baumannii to become noticeable. It was the cause, however, of 31 percent of hospitalacquired infections in earthquake victims in Turkey in 1999, and at least eight cases of 

hospital-acquired infections in Perth, Australia, among 29 of the persons injured in the 

October 2000 Bali bombing.43 It therefore represents an opportunistic pathogen that, once 

established in a location or environment, can become a significant infectious agent with 

problematic outcome and treatment concerns.

Military epidemiological investigations to date suggest that most infections with A. 

baumannii are associated with severely injured soldiers who are resuscitated at one of the 

U.S. Army Combat Support Hospitals in or around Baghdad.44 The bacterium has been 

detected on hospital equipment in operating rooms and intensive care units in several 

deployed field hospitals. Genetic fingerprinting of organisms collected from 58 patients 

has identified five distinct clones that match the organisms collected from the field 

hospitals, suggesting that the hospitals may be the underlying source of the infections. As 

previously stated, antibiotic resistance is a serious problem with A. baumannii infections. 

The only effective antibiotics (Primaxin and Polymyxin B) are used only rarely because 

of their toxicity and cost, and to preserve their effectiveness in treating life-threatening 

infections. 

The mechanism of colonization, infection, and person-to-person transmission are not yet 

understood.45 The source of the initial infection may be from soil or other environmental 

sources of contamination, or may result from continued transmission within field surgical 

hospitals in Iraq. Transmission seems to occur more frequently in combat casualties with 

severe soft-tissue and orthopedic injuries, but it is unknown whether transmission occurs 

during the initial trauma, following resuscitation, during surgery, or while Soldiers and 

Marines with blood stream infections are recovering at Walter Reed Army Medical 

Center and the National Naval Medical Center. The fact that it is not known whether 

wounded service members are infected when they depart the theater allows the possibility 

of another source of infection: exposure while in the U.S. Air Force medical evacuation 

system. An initial evaluation of two aeromedical evacuation flights in January and 

 43 Christopher Heath, et al., “A review of the Royal Perth Hospital Bali experience: an infection control 

perspective,” Australian Infection Control, 2003:8(2) 43-54. 44 U.S. Army Center for Health Promotion and Preventive Medicine, Interim Report, Epidemiological 

consultation on the investigation of Acinetobacter baumannii infections in U.S. military treatment facilities, 

11 November 2004. 45 Colonization is the growth of organisms on or in the body, while infection develops when these 

organisms begin to cause a disease that harms the body. 

 25
February 2005 raised concerns about adherence to infection-control practices but did not 

identify any obvious A. baumannii transmission.46

The practice of forward surgical treatment may contribute to the risk of antibiotic 

resistance. Warfighters who may already be colonized or infected with A. baumannii or 

other organisms are having orthopedic surgical appliances (pins and rods used to stabilize 

fractures) emplaced in theater or at Landstuhl Regional Medical Center. This aggressive 

surgical management may seem to provide better care for the immediate battlefield 

wounds, but when these service members later develop bloodstream infections, the 

surgical appliances act as foreign objects that sequester bacteria, allowing them to evade 

both the body’s natural defenses and the antibiotics that are administered to treat the 

wound and bloodstream infections. These service members are often being treated for six 

weeks with very strong antibiotics, yet still must have the appliance surgically removed 

when the bloodstream infection fails to clear. They are then treated with antibiotics for a 

second six weeks to eliminate the infection. These treatments are not only expensive, but 

they also breed resistant bacteria at other sites, such as the respiratory tract and the 

bowels. In an attempt to prevent these infections, some injured casualties from Iraq are 

having Primaxin and other powerful, broad spectrum antibiotics administered 

prophylactically. While on the surface this may seem like a good practice, it is likely 

causing the development of resistance that will quickly make the antibiotics useless. 

Although vascular surgeons may occasionally place plastic grafts on injured arteries intheater, this is only done to keep the injured limb alive and is understood to be a 

temporary measure that needs to be surgically corrected once the wound is completely 

debrided and all infection is eliminated. Few military combat casualty care experts are 

advocates of placing internal orthopedic surgical appliances in-theater. Orthopedic 

surgery guidelines in World War II prevented this practice by prohibiting the internal 

placement of any metallic devices forward of an evacuation or general hospital. 

 

A potential partial solution to this dilemma is to revisit the short-lived World War II 

notion of topical application of antibiotics to combat wounds. American studies at the 

time concluded that initial topical application of sulfonamide antibacterial agents to 

severe, contaminated wounds was of little value, and the correct doctrine of immediate 

surgical debridement was developed. German soldiers, on the other hand, were provided 

with packets that also contained mafenide hydrochloride, a different form of sulfonamide 

that was not inhibited by wound fluids and pus as are the sulfa derivatives tested by the 

United States.47 Germany used mafenide hydrochloride powder in the field to prevent gas 

gangrene associated with combat wounds. The United States turned instead to the newly 

discovered penicillin, which was thought to be 60 times more effective against the 

organisms causing gas gangrene. 

 46 Paul Doan and James Stewart, The Environmental Surveillance for Acinetobacter baumannii in the Air 

Evacuation System, United States Air Force School of Aerospace Medicine, 12 May 2005. 47 Janice Mendelson, “Topical Mafenide Hydrochloride Aqueous Spray in Initial Management of Massive

Contaminated Wounds with Devitalized Tissue,” Prehospital and Disaster Medicine, July-September 2001, 

16 (3): 172-174. 

 26
Local administration of antibiotics in combat wounds offers other advantages over the 

current practice of intravenous administration. War wounds often have large amounts of 

dead and devitalized tissue, and systemically administered antibiotics do not penetrate 

areas where local blood vessels are damaged.48 The doctrine of the past 50 years should 

be revisited, not to replace prompt surgical debridement with the administration of 

antibiotics, but to add early application of a topical antibiotic or antiseptic to severe, 

contaminated wounds, perhaps as early as when the injured warfighter is first seen by the 

combat medic in the field. 

In summary, a number of factors may be causing or contributing to problems with A. 

baumannii. First, normal bacteria that colonize the human body and keep dangerous 

bacteria in check are being destroyed by Primaxin and other antibiotics that are overused 

in-theater or while casualties are evacuated. Second, A. baumannii is an opportunistic 

infectious agent that infects wounds where the body’s usual healing mechanisms are 

severely compromised by large amounts of tissue damage, devitalized tissue, and poor 

blood flow. Third, there may be cross-contamination between U.S. troops and Iraqi 

casualties treated in the same medical facility. Extensive studies are underway to collect 

more data that may answer some of these questions. Pending the results of these studies, 

prompt action is required. Actions should be taken that will help to reduce the levels of 

infection in service personnel and diminish the transfer of bacteria to other clinical 

settings and third-party patients. 

Case Study II—Leishmaniasis: Battle Scars of the 21st Century? 

Until recently, the malaria parasite and the mosquito have been the pathogen-vector pair 

most detrimental to military forces in the past few centuries. They have been replaced by 

the protozoan parasite Leishmania and its insect vector, the sand fly of the genus 

Phlebotomus (see figure 11). This pair causes three clinical syndromes in humans: 

cutaneous Leishmaniasis, mucosal Leishmaniasis, and visceral Leishmaniasis. There are 

at least 13 species of the Leishmania parasite, divided into Old World and New World 

categories. Leishmaniasis is found widely in Central and South America, Africa, around 

the Mediterranean Sea, and in the Middle East and Central Asia. 

Some of these species have an animal reservoir in nature (burrow-dwelling rodents, 

dogs), while others are transmitted only from human to human by the female sand fly. 

The primary syndrome seen in U.S. service members in the Middle East is the Old World 

cutaneous form, where a dry ulcer slowly begins to grow several weeks after a sand fly 

bite. The person may first notice only “an infected insect bite,” but typically becomes 

concerned when a chronic, painless ulcer continues to grow over several months. The 

ulcers caused by the Old World parasite often resolve spontaneously over months to 

years, but can leave behind a disfiguring scar called an “oriental sore” or “Baghdad boil.” 

Infections caused by the New World parasites are more aggressive and often require 

treatment to prevent the more serious visceral or mucocutaneous form from developing. 

 48 Charles Heisterkamp, et al., “Topical Antibiotics in War Wounds: A Re-Evaluation,” Military Medicine,

January 1969, 13-18. 

 27
Figure 9 

Source: COL Naomi Aronson, Uniformed Services University of the Health Sciences, 24

Jun 05. 

The visceral form is called kala-azar, and is much more dangerous. The infected person 

may not get sick for months after the sand fly bite, but then typically develops fever, loss 

of appetite, weight loss, muscle wasting, enlargement of the liver and spleen, and anemia. 

Visceral leishmaniasis can be life threatening if not treated. 

Management of these infections has been a challenge for the medical community due to 

difficulties in diagnosis and treatment. The cutaneous lesions are rarely properly 

diagnosed on the first visit to a health care professional.49 Antibiotics are often prescribed 

and have little or no effect. An initial diagnosis of cutaneous leishmaniasis is often made 

upon finding the parasite from tissue scrapings or a skin biopsy of the edges of the ulcer, 

and from bone marrow or liver biopsies for visceral leishmaniasis. No clinically useful 

blood or skin screening test exists. Effective treatment often requires intralesional or 

intravenous sodium stibogluconate, an antimony compound in investigational new drug 

status available only from the CDC. This medication causes well-known toxic reactions 

that include weakness, fatigue, headaches, muscle aches, joint stiffness, nausea, vomiting, 

and elevation of liver and pancreatic enzymes. Treatment takes from three to four weeks, 

and patients require another two to three weeks of convalescence after treatment before 

resuming demanding physical activity.50 Alternative medications, such as amphotericin B 

and pentamidine, are used primarily when the parasite is resistant to antimony, but must 

 49 Alan Magill, Cutaneous Leishmaniasis in the Returning Traveler, Infectious Disease Clinics of North 

America, March 2005, 19: 241-266. 50 Samuel Martin, et al., Leishmaniasis in the United States Military, Military Medicine, December 1998, 

163 (12): 801-807. 

 28
also be administered intravenously and have significant toxicity. A new lipid complex 

form of amphotericin B has been approved by the Food and Drug Administration for 

visceral leishmaniasis, but does not appear to be effective for cutaneous leishmaniasis.51

Alternative treatment options have been examined for cutaneous leishmaniasis, based on 

the infecting parasite strain, the immune status of the patient, and the locations of the 

ulcers.52 On September 10, 2004, the U.S. Army released management guidance for 

suspected cases of cutaneous leishmaniasis that summarize when intravenous treatment is 

appropriate and when no treatment is appropriate, for example, if lesions are small and

already starting to improve, are not located in sensitive areas of the body, such as over 

joints, on the face, ears, nose, or feet, and are not bothersome to the patient or family. 

Leishmaniasis was a minor problem for the U.S. military during Operation Desert 

Shield/Desert Storm, when only 32 cases were seen in service members.53 Twenty of 

these cases were the cutaneous form, but military medical experts were surprised when 

there were 12 cases of a visceral-like leishmaniasis in an area that was not known to have 

visceral leishmaniasis.54 This new presentation of the infection was called viscerotropic 

leishmaniasis. Treatment costs to the U.S. military are significant. Until recently, most of 

the evaluation and treatment of leishmaniasis took place at Walter Reed Army Medical 

Center, where about 420 cases were seen between 1967 and 1998, mostly in soldiers 

deployed to Panama. Providing proper care for these active duty and reserve service 

members was a long, costly, and complex process: direct costs for treatment were 

estimated to exceed $17,000 per patient and to result in an average of 92 lost duty days

per patient.55 Current treatment costs are about $11,000 per soldier and involve about 40 

days lost from duty.56

There has been an explosion of cases of leishmaniasis since OEF/OIF began. There have 

been almost 1,000 cutaneous cases and five visceral cases in the first two years. The low 

number of cases in Operation Desert Storm may have lulled DOD into a false sense of 

security. Most infected service members did not understand the risk of the disease or their 

need for personal protective equipment (PPE). Many shared the misperception from 

Operation Desert Storm that DEET insect repellant and permethrin-treated uniforms were 

more toxic than useful.57 PPE was often unavailable, as combat movements early in the 

war outstripped supply lines. There also has been more urban and peri-urban deployment 

of U.S. forces, compared to Operation Desert Storm, during which most forces were in 

open desert, where the sand fly vector is less common. Sand fly activity is greatest in Iraq 

in the fall, and in some areas of Iraq where large troop populations were conducting their 

 51 Glenn Wortmann, et al., “Failure of Amphotericin B Lipid Complex in the Treatment of Cutaneous

Leishmaniasis,” Clinical Infectious Diseases, April 1998, 26:1006-7. 52 Magill, 241-266. 53 Martin, et al., 801-807. 54 Alan Magill, et al., “Viscerotropic Leishmaniasis in Persons Returning from Operation Desert Storm— 

1990-1991,” Morbidity Mortality Weekly Reports, February 28, 1992, 41 (8): 131-134. 55 Martin, et al., 801-807. 56 COL Naomi Aronson, Uniformed Services University of the Health Sciences, 24 June 05. 57 One of the rumored causes of Gulf War Illness was the use of DEET insect repellent and permethrintreated uniforms. A Google search provides over 6,600 web pages on this subject. 

 29
missions, roughly two percent of sand flies were infected with the Leishmania parasite.58 

Early in the combat phase of the war, troops slept outside their armored vehicles with as 

little clothing as possible, leading to hundreds of sand fly bites in some cases, as 

illustrated by figure 11. As security became more of an issue, more service members 

were housed in secure, air-conditioned buildings, so sand fly exposure was greatly 

reduced. 

 Figure 10 

 

 

 

Figure 10 – Sand Fly Bites 

Source: COL Naomi Aronson, Uniformed 

Services University of the Health Sciences, 24

June 2005. 

Sand flies and rodents breed in accumulations of garbage and debris and in the rubble 

around airstrips, so the poor sanitary conditions associated with urban warfare increase 

the risk of troop exposure. Sand flies are weak fliers and only travel about 100 meters 

from their dark, moist resting places. These characteristics result in focal areas of very 

high transmission, especially near Talifar and Tallil Air Base where PPE is still not being 

used properly. Two Stryker Brigades accounted for over 250 cases in the first six months 

of 2005. 

A concern is that many of these cases are not being reported via the military disease 

surveillance systems and may be lost to follow-up. Many of the infected service members 

do not need the intensive intravenous treatment at Walter Reed Army Medical Center or 

Brooke Army Medical Center and are managed locally with heat treatment or 

cryotherapy. Often their diagnoses are made based on clinical findings rather than 

laboratory identification of the parasite and are not captured by disease surveillance 

systems. Unless a comprehensive disease surveillance system is in place that tracks all of 

these service members, military medical personnel will only learn about their cases when 

they get sick enough to seek care. 

The puzzling aspect of leishmaniasis in OIF is why so many troops are getting infected 

when much is known about its prevention. As with malaria prevention, insect bites can be 

 30

 58 Dennis White, Survey of Repellent Use by Service Members Arriving in Kuwait for Operation Iraqi 

Freedom 2, Military Medicine, June 2005, 170(6): 496-500.
greatly reduced if specific steps are taken to reduce the warfighter’s exposure. It is 

possible to identify resting and breeding sites of sand flies and avoid these areas or take 

steps to eliminate them as much as possible. Geographic information system technology 

and remote sensing using commercially available satellite environmental data have been

used for many years to identify insect vectors of diseases, allowing intervention efforts to 

be targeted at the highest risk areas.59 Numerous methods have been described for 

applying insecticides and baits that can suppress sand fly attacks for two to four months 

with each application.60 Personal protection is essential to prevent sand fly and mosquito 

bites, and has been incorporated into military doctrine. Despite its effectiveness, service 

members’ adherence to prescribed measures is often inadequate, and the logistical 

support for providing personal protective supplies is questionable.61 DOD is

reemphasizing the risks of leishmaniasis to heighten awareness on the part of service 

member, but a recent report indicated that only one-third of an Army Reserve unit that 

arrived in Kuwait in March 2004 received the appropriate education and protective 

supplies.62 This suggests that the reason for infection in these troops is not mysterious at 

all, but reflects failure to consider all the appropriate logistics and personal protective 

measures. 

The card shown in figure 11 is provided to all soldiers deploying in OEF and OIF.63 The 

reverse side of the card reminds them to seek medical assistance if they develop a fever 

or sore that will not heal, to tell the doctor that they have been deployed to an area with a 

high risk of leishmaniasis exposure, and to show the card. The card contains names and 

phone numbers of Army experts who can provide diagnostic kits and clinical 

management assistance. 

 59 Donald Thompson, et al., “Bancroftian Filariasis Distribution and Diurnal Temperature Differences in

the Southern Nile Delta,” Emerging Infectious Diseases, July-September 1996, 2 (3):234-235. 60 Martin, 801-807. 61 White, 496-500. 62 Ibid. 63 Permission to use card given by COL Naomi Aronson, Uniformed Services University of the Health

Sciences, 24 June 2005. 

 31
Figure 11 

Joint Recommendation: Improve Infection-Control Practices in the Field and in 

Fixed Hospitals 

• Military planners should plan for fixed medical care facilities that allow better 

infection control. Planners should rapidly identify fixed structures for patient care 

areas in-theater to provide suitable infection-control environments for operating 

rooms and intensive care units. These structures should be converted for hospital use 

as soon as major combat operations and the security situation permits. Alternatively, 

fixed structures with concrete floors should be built as part of deployed field hospitals 

for these important patient care areas. Difficulties with maintaining infection control 

and preventing transmission early in OIF, in both field hospitals and the U.S. Navy 

hospital ship USNS Comfort, included shortages of hand hygiene products, sinks, 

gowns, and repeated shortages of antibiotics, and an inability to properly cohort 

casualties. The Air Force emphasized improving hospital structures by pouring 

concrete pads for field hospitals and constructing doors between wards to reduce 

environmental contamination and spread, but other field hospitals in Iraq still had 

canvas tents and dirt floors two years after the war began. 

• Evaluate and reinforce infection-control practices throughout the continuum of 

combat casualty care. This is especially important in military, civilian, host nation, 

and Veterans Health Administration facilities where combat casualties and civilians 

are treated in the same institution. There were many more cases of nosocomial 

infections at Walter Reed Army Medical Center than at the smaller Landstuhl 

Regional Medical Center in Germany, despite the much higher proportion of infected 

 32
patients being admitted at Landstuhl. While this is probably due in part to the 

younger, healthier patient population at Landstuhl and relatively short 

hospitalizations, infection-control practices must be reemphasized, particularly in 

these high-risk hospital settings. Patients with immunocompromised family members 

and with very young children may need special attention. 

• Reevaluate the size and capabilities of the medical footprint within the combat 

theater. Medical experts must determine what force structure changes are necessary 

to provide adequate debridement of severe soft tissue wounds, and what are the 

logistics and resource costs of improved early diagnostics and treatment for 

potentially communicable diseases before aeromedical evacuation. Medical, logistics, 

and personnel planners must determine the best balance between in-theater surgical 

care for the highest risk injuries and the logistics cost of providing these capabilities. 

Joint Recommendation: Cooperative Iraqi-American Disease Investigation 

• Undertake a cooperative scientific investigation with Iraqi medical authorities of 

infections in injured Iraqi service members so that disease prevalence and 

transmission risks can be better characterized. Many Iraqi casualties are being treated 

in U.S. Combat Support Hospitals for a period of many weeks, and have positive A. 

baumannii respiratory and wound cultures, suggesting that the organism is much 

more common in Iraq than thought. A collaborative U.S.-Iraqi study could provide

considerable lessons learned that might improve combat casualty care for both 

nations. 

 33
United States European Command (EUCOM) 

The EUCOM AOR includes many geographic areas that have 

limited fixed medical facilities with advanced diagnostic 

capabilities. There is significant political instability in some

African countries, rising concern over failed states, and a high 

incidence of intrastate conflict with subsequent internal refugee 

crises. U.S. military forces deployed into these countries have 

often encountered major infectious disease threats that have 

reduced combat effectiveness. The following case study 

describes an operational dilemma that could be faced by 

EUCOM today. 

Case Study III—Hemorrhagic Fever Viruses: Hot Zones 

In early 2005, person-to-person transmission of Marburg virus infection was reported in 

Angola, where the fatality rate approached 80 percent. As of August 24, 2005, the 

Ministry of Health in Angola had reported a total of 374 cases and 329 deaths 

countrywide. New infections continued to develop despite intensive intervention by 

WHO and other international aid organizations. In many cases, due to a lack of adequate 

knowledge of virus transmission and control measures, hospital staff and family members 

of patients infected with the virus became victims of the virus. Another hemorrhagic 

fever virus, the Ebola virus, caused 12 infections and nine deaths as of June 16, 2005 in 

the Republic of Congo. 

DOD policymakers have paid little attention to Ebola and Marburg hemorrhagic fever 

virus because the chance is remote that warfighters would deploy to Angola and the 

Republic of Congo. The fear of these illnesses is strong, however, because of popular 

books, such as The Hot Zone by Richard Preston, and the Dustin Hoffman movie 

“Outbreak.”64 A more significant danger is another pathogen called Crimean-Congo 

hemorrhagic fever virus. This virus is present in many areas, including some locations 

where the U.S. military has been involved. Cases have been reported in many countries in 

Africa, as well as Turkey, Iraq, Iran, Pakistan, United Arab Emirates, Kuwait, Oman, 

Kosovo, Albania, Bulgaria, Kazakhstan, Uzbekistan, Tajikistan, Russia, and China.65 

Crimean-Congo hemorrhagic fever (CCHF) develops between three and nine days after a 

person is bitten by an infectious tick or comes into direct contact with blood or infected 

tissues from a person or from livestock. Symptoms include sudden onset of fever, chills, 

muscle aches, nausea, vomiting, and headache. These symptoms are similar to those seen 

in many other infections, including influenza and malaria. Advanced symptoms include 

bleeding into the skin, causing skin rashes, and bleeding from the upper bowel, blood in 

 64 Richard Preston, The Hot Zone: A Terrifying True Story (New York: Random House, 1994). 65 Multiple sources including ProMED (International Society for Infectious Diseases); Control of

Communicable Diseases Manual, 18th Edition, (American Public Health Association); Health Information

for International Travel (Centers for Disease Control and Prevention); and Emerging Infectious Diseases

(Centers for Disease Control and Prevention). 

 34
the urine, nosebleeds, and bleeding from the gums. An additional risk for U.S. military

forces is from nosocomial (hospital-acquired) transmission. CCHF is easily transmitted 

by blood and body fluids, so the risk to healthcare workers and others who come into 

contact with ill persons is significant. The antiviral medication Ribavirin is effective, but 

is not FDA approved for CCHF treatment. Untreated, CCHF has a case fatality rate 

between 5 and 50 percent, with an average case fatality rate of 30 percent. 

Transmission to another service member could take place during the incubation stage,

early in the clinical stage during the few days before an infected service member seeks 

medical attention, either in the field or in transit, or during the two-week hospitalization 

required for patients while the infection runs its course. Effective infection-control 

measures in the hospital setting (blood and body fluid precautions) largely prevent inhospital transmission of CCHF, but practices recommended for care of civilian patients in 

civilian hospitals may not be possible in a field setting, in the aeromedical evacuation 

system, or in a fixed military MTF where there are multiple casualties from combat 

injuries or infectious diseases. 

Seoul Hemorrhagic Fever, which causes hemorrhagic fever with renal syndrome, 

develops from one to five weeks after exposure to aerosols from fresh urine of infected 

rodents (specifically, the Norway rat, which is found worldwide), often when dust 

contaminated by rodent excreta or urine is stirred up. This exposure usually occurs in 

rural settings, though it has been found in urban settings in Seoul, Korea, in persons who 

had not traveled outside the city. Symptoms include fever, shock, and kidney failure. 

While Seoul Hemorrhagic Fever does not pose the risk of transmission from person to 

person, it cannot be treated with Ribavirin, as can CCHF. 

In a deployed setting, all service members who are suspected of having a hemorrhagic 

fever must be strictly isolated to protect healthcare workers and other patients from

infection. Once a laboratory diagnosis is made, infection-control measures may be 

tailored for the particular infection, but until this additional diagnostic information is 

obtained and confirmed, such patients must be managed as if they are carrying the most 

contagious virus. 

Standard infection-control recommendations include a private room, face shields or

surgical masks, eye protection, gowns and gloves, plastic aprons, leg and shoe coverings 

for protection from large amounts of blood and vomit, restriction of non-essential contact 

with others, and careful removal and disposal of protective gear upon leaving the 

patient’s room. Many of these infection-control procedures are difficult in a field setting. 

In the event that a diagnosis has not yet been made, care for these types of infections is 

complicated by airborne precautions for respiratory diseases. Influenza, SARS, plague, 

and many other infectious respiratory diseases, as well as hemorrhagic fever viruses, will 

be under consideration as possible causes of symptoms until a definitive clinical and

laboratory diagnosis is made. Such respiratory precautions are difficult, if not impossible, 

in field conditions. These precautions include negative air flow, sealed isolation rooms, 

high-efficiency air filters, and an anteroom for personnel to don and doff personal 

protective equipment and to prevent respiratory aerosols from escaping into the corridor. 

 35
Respiratory precautions will by necessity be minimal until service members reach large 

medical centers, so a lowered threshold for suspicion of such infections and careful 

tracking of other service members who may have been exposed is crucial to prevent 

disease outbreaks. The ability to move highly infectious patients by the military aeroevacuation system will face formidable obstacles jeopardizing patients, staff, and the 

military patient movement equipment. International patient movement of highly 

infectious patients across non-U.S. borders may incite fears leading to denial of 

permission to enter the airspace of other countries. 

Even in fixed medical facilities, costs of infection control are significant. Direct costs of 

disposable supplies for multiple patient visits each day may add thousands of dollars to 

the cost of each hospitalization. Efforts to decrease unnecessary instances of patient 

contact, on the other hand, lead to lower quality of medical care.66 A recent study 

indicated that isolated patients had half as many hourly contacts with healthcare 

personnel, had fewer medications prescribed, and were more likely to experience 

preventable adverse events, such as falls and inadequate management of disorders of 

fluid and electrolytes.67 

Joint Recommendation: Develop a rapid field diagnostic capability for diseases of 

military operational importance

• Fast-track the development and implementation of a rapid field diagnostic capability 

for diseases of military operational importance. Diseases associated with fevers are 

major causes of illness and death in military and civilian travelers to Africa. There are 

dozens of possible causes for a fever in a service member in and after returning from

Africa, including malaria, Crimean Congo hemorrhagic fever, Ebola and Marburg 

hemorrhagic fevers, Lassa fever, Rift Valley fever, yellow fever, influenza, plague, Q 

fever, leptospirosis, African trypanosomiasis (African Sleeping Sickness), African 

tick bite fever, and tuberculosis. Some of these possibilities are very unlikely in 

certain geographic areas, and several (yellow fever, measles, mumps, rubella, 

diphtheria, polio) are prevented by up-to-date immunizations. Most, however, can 

only be diagnosed with advanced clinical laboratory testing equipment after the 

service member is evacuated to Germany or the United States. The development of a 

rapid, gene-based diagnostic testing capability that can be deployed into the field is 

essential to allow in-theater diagnostics and treatment. Such diagnostics should detect 

organisms in wounds and on environmental surfaces, should provide crucial antibiotic 

susceptibility data, and should provide genetic fingerprinting analysis that will permit 

identification and disruption of person-to-person transmission of pathogens currently 

affecting combat operations in the EUCOM command region. Knowledge of speciesspecific information will permit military physicians to properly stratify infected 

service members based on risk from the particular parasite. 

 66 Henry Stelfox, David Bates, and Donald Redelmeier, “Safety of Patients Isolated for Infection Control,”

Journal of the American Medical Association, 8 October 2003, 290(14):1899-1905 67 Persons with serious medical conditions such as congestive heart failure or diabetes require close 

attention to protect from over- and under-hydration, and to monitor and correct the sodium, potassium, and

other electrolytes in their blood. 

 36
United States Northern Command (NORTHCOM)

The NORTHCOM AOR contains the greatest challenges for the 

Department of Defense. North America has some of the most 

advanced medical diagnostic, treatment, and research capabilities, 

has seemingly endless resources, and has outstanding ground and 

air transportation networks and communication and computer 

infrastructure. While each of these factors taken in isolation would 

seem to ease the control of infectious diseases and provide a 

reprieve in force protection efforts, the complex interaction 

between the different components within DOD, the as-yet-undefined homeland security 

roles and responsibilities at the Federal, state, and local levels, and the lack of a strategic 

national game plan precludes any meaningful planning for controlling infectious disease 

transmission in the Continental United States. At the point where warfighters come into 

contact with civilians in the United States, whether healthcare workers or other 

beneficiaries in DOD MTFs, their own family members, or the general public, the control 

of any infectious disease transmissible from person to person is beyond the influence of 

the military, and is instead up to the civilian public health system, which is not prepared 

or resourced for unfamiliar diseases. 

These issues will assume critical importance in the event of an outbreak of highly 

contagious influenza. The current outbreaks of avian influenza in Asia and continued 

human cases suggest that concerns of a worldwide pandemic are valid. The following 

case study looks at the impact of the 1918-1919 outbreak of influenza and the possibility 

that troop movements directly contributed to its worldwide spread. It describes some of 

the military equities in such an epidemic and identifies areas where NORTHCOM must 

engage in order to be prepared to respond effectively in the case of such an event. 

Case Study IV—Pandemic Influenza 

The Spanish Flu of 1918-1919 was the single most deadly outbreak of disease in the 20th

century, perhaps in the entire world history of disease. The first wave of influenza began 

in the spring of 1918, causing mild occurrences of flu in the United States and across the 

globe. Some historians believe that the first instance of the disease erupted as early as late 

January and early February 1918 in Haskell County, Kansas, where it is believed to have 

spread to Camp Funston, the second largest army camp in the country, housing an 

average of 56,000 troops. In the spring of 1918, thousands of soldiers became sick with 

influenza-like symptoms, resulting in 237 cases of pneumonia and 38 deaths.68 The first 

unusual outbreaks of influenza in Europe occurred in Brest in early April 1918 with the 

arrival of American troops, followed by mild occurrences of the virus in France, 

Germany, England, and Spain. 

 37

 68 John M. Barry, The Great Influenza: The Epic Story of the Deadliest Plague in History (Penguin Books:

2004), 96. 
Beginning in August 1918, a highly virulent and lethal strain of the virus began to sweep 

the globe, appearing on the Indian subcontinent and in China, Japan, and Southeast Asia, 

killing thousands. Cases of influenza in the United States from this second wave first 

appeared in Boston, Massachusetts, and in Camp Devens, Massachusetts, in late August 

and early September, then rapidly appeared in military bases and cities up and down the 

East Coast,69 including Camp Dix, New Jersey, and Camp Meade, Maryland. “In a single 

day, 1,553 Camp Devens soldiers reported ill with influenza. On September 22, 19.6 

percent of the entire camp was on sick report, and almost 75 percent of those on sick 

report had been hospitalized.”70

At Camp Sherman, Ohio, every third man reported ill. At Camp Meade, 27 percent of the 

42,300 troops were hospitalized. The hospital had a capacity of about 1,000 beds, but in 

just one day had to admit 875 flu patients.71 The influenza virus continued to spread to 

military bases and cities throughout the country, causing massive illness and thousands of 

deaths. In a single day at Camp Custer, outside Battle Creek, Michigan, 2,800 troops 

reported that they were sick.72 Relief and medical efforts to stop the spread of the disease

in many of the cities was severely hampered due to a lack of supplies and volunteers 

healthy enough to care for those infected with the influenza virus. Hospitals were quickly 

overfilled with the sick and dying, and ill people lined up for countless hours in hopes of

receiving medical care. There were not enough medical supplies, doctors, or nurses to 

care for the sick. Businesses were closed throughout the country, public gatherings were 

cancelled, and bodies were left in the streets once hospitals and morgues were filled up, 

often being buried in mass graves because of a shortage of caskets. 

The deadly influenza pandemic reached Camp Lewis, Washington, in mid-September 

following the arrival of a ship carrying soldiers from Philadelphia, then traveled along the 

West Coast, eventually reaching Alaska, where it decimated small communities, in some

cases, killing all the inhabitants of remote Eskimo villages. 

The second wave of the pandemic influenza outbreak peaked and began declining 

worldwide by the end of December 1918. Some countries, however, continued to 

experience a third wave of disease in the early months of January and February 1919. 

Because many countries that experienced the 1918-1919 influenza pandemic did not have 

reporting measures in place for the occurrence of disease, the exact number of deaths 

worldwide is not known. What is known is that the Spanish Flu killed more people 

worldwide than recorded combat deaths in World War I. Conservative estimates place the 

number of deaths at upwards of 50 million people worldwide, with 500,000 deaths in the 

United States and as many as 6 million deaths in India alone.73 Since 1918, two more 

 69 Ann H. Reid et al., “1918 Influenza Pandemic Caused by Highly Conservative Viruses with Two 

Receptor-Binding Variants,” Emerging Infectious Diseases, October 2003, vol. 9, no. 10. 70 John M. Barry, The Great Influenza: The Epic Story of the Deadliest Plague in History (Penguin Books:

2004), 87. 71 Carol Byerly, Fever of War: The Influenza Epidemic in the U.S. Army during World War I (New York:

New York University Press,2005), 76. 72 Barry, 217. 73 David Parsons, “The Spanish Lady and the Newfoundland Regiment.” Available online at:

<http://www.ku.edu/carrie/specoll/medical/parsons.htm>. 

 38
significant influenza pandemics have occurred, in 1957-1958 and 1968-1969, although 

neither of them had as high a mortality rate as the 1918 influenza outbreak. 

The 1957-1958 influenza epidemic originated in February 1957, in the Kweichow 

province of China and spread from China into the rest of Asia, the Middle East, and 

Europe, reaching North America in June 1957.74 In 1968, a new flu strain, H3N2, 

originated in the Guangdong Provence in southern China and quickly spread around the 

world.75 Pandemic influenza has not occurred since 1968, and it is widely believed that 

another pandemic influenza is overdue. 

One recent concern is that the latest outbreak of avian influenza H5N1 virus in Asia will 

lead to the next influenza pandemic in the very near future. Identified in Italy more than 

100 years ago, avian influenza is an infectious disease of birds caused by type A strains 

of the influenza virus.76 In 1996, a strain of avian influenza was first detected in geese in 

China’s Guangdong province, and by 1997, a massive epidemic of avian influenza virus 

in poultry had broken out in Hong Kong, leading to the mass culling of an estimated 1.5 

million chickens. 

Avian influenza viruses can be transmitted to humans in two ways: directly from infected 

birds or avian virus-contaminated environments (poultry farms, poultry slaughter areas, 

poultry markets), or through an intermediate host, often pigs.77 The H5N1 virus is of 

particular concern because it mutates rapidly, can cause severe disease in humans, and 

has demonstrated resistance to known influenza antiviral medications. Since 1997, 

outbreaks of pathogenic avian influenza caused by the H5N1 virus have continued to 

cause fatal disease in humans throughout Asia. Over 115 human cases of avian influenza 

A (H5N1) have occurred throughout Cambodia, Indonesia, Thailand, and Vietnam. It is 

also believed that limited human-to-human transmissions have occurred, raising the fear 

in the international health community that the H5N1 virus could lead to the next 

influenza pandemic as human-to-human transmission increases. 

 74 The Office of the Public Health Historian, The Lister Hill National Center for Biomedical 

Communications, “Influenza: A Short History of the Disease,” 7 December 2004. Available online at: 

<http://lhncbc.nlm.nih.gov/apdb/phsHistory/health_news_text.html>. 75 Ibid. 76 United Nations Food and Agricultural Organization, “Avian Influenza— Background.” Available online 

at: <http://www.fao.org/ag/againfo/subjects/en/health/diseases-cards/avian_bg.html>. 77 Centers for Disease Control and Prevention, “Transmission of Influenza A Viruses Between Animals and 

People.” Available online at: <http://www.cdc.gov/flu/avian/gen-info/transmission.htm>.

 39
Figure 12 

Figure 12 - Source: Photo by Larry Rana, USDA, Image Number: 95cs6917, CD2958-011. 

Although estimates have varied, health experts from the CDC and from WHO have 

predicted that a new influenza pandemic could kill from two to fifty million people, 

depending on the pathogenicity of the virus, how fast it can spread, and if large enough 

supplies of an effective antiviral drug can be produced in time to stop a widespread 

infection.78 

The threat of a rapidly spreading influenza within the United States will likely lead to

irrational behavior and even panic as people try to protect themselves and their families 

from such a threat. Government authorities at all levels will be inundated as they try to 

allocate scarce medical resources. Freedom of movement will likely be reduced in an 

effort to limit disease spread. As movement of people is reduced, so will movement of

goods and services. This will degrade the ability of military installations to resupply and 

to move service members and combat equipment from base to base or from the United 

States to an overseas location. As global power projection is key to U.S. military strength, 

these movement limitations must be considered and overcome before a pandemic hits. 

 40

 78 Martin Enserink, “WHO Adds More ‘1918’ to Pandemic Predictions,” Science, 17 December 2004, vol. 

306, 2025. 
DOD must proactively engage with Federal, state, and local authorities, and with private 

sector entities involved in freedom of movement. The military should be an active 

participant in any homeland security forum where prevention or response of a 

communicable biological weapon is an issue. There is an erroneous perception that the 

military would be involved in enforced restriction of movement. In actuality, the military 

is more likely to be used in maintaining movement of critical goods and services. 

NORTHCOM should begin to close the preparedness and response gap by improving 

disease and personnel surveillance and response networks. Monitoring disease prevalence 

and tracking service members within the United States has largely been an afterthought, 

and the development of rapid decision-making and disease-control strategies has been 

nonexistent. DOD has recently developed policies for enforcing quarantine on military 

installations in response to a public health emergency, has begun to put in place a global 

emerging infectious disease surveillance system, and has been proof-testing a process that 

collects disease information from military installations in the United States and shares

results with several civilian public health agencies. However, efforts are largely scattered 

between the services, and the resources applied to these efforts have been minimal. A 

timely, responsive capability that is likely to anticipate and prevent outbreaks is greatly 

needed to balance the considerable reductions of in-theater medical diagnostics and 

treatment capacity in recent years. 

Perhaps the most crucial task for NORTHCOM is to engage with civilian medical and

public health officials, and Federal, state, and local emergency planners to identify how 

and where a communicable disease will spread in the United States and what actions

should be taken by whom to manage an outbreak. This is especially important with the 

growing threat of pandemic influenza. People will adapt to a crisis or a perceived crisis, 

with many unanticipated, undesirable consequences. For example, they may choose to 

stay home when it would be better for them to get antibiotics at a certain location, or they 

may leave home and travel to an area that puts them at increased risk for an infectious

disease. 

Joint Recommendation: Improve Civil-Military Cooperation on Epidemic 

Prevention and Response 

• Create a cooperative response system to respond to a communicable disease 

outbreak, such as pandemic influenza. Build a core group of military, Federal, state, 

and local disease control officials to develop requirements for rapid disease 

investigation, contact tracing, movement and activity restrictions, and medical surge 

capacity. A strategy for national solutions should include identification of capabilities 

to meet each of these requirements, all possible military, Federal, state, local, private 

sector, and civil society organizations that can fill the gap between states and 

societies, to meet manpower and resource requirements, and proofs of concept to 

evaluate potential solutions in urban, rural, and regional settings. The primary role of 

DOD personnel should be to facilitate in the civilian sector the deliberative planning 

process that has been so successful within the military. 

 41
• Create a Joint Operational Bioresponse Center that directly links civilian biodefense

expertise with Combatant Commanders. The Department of Homeland Security is 

developing a National Biodefense Analysis and Countermeasures Center at Fort 

Detrick, Maryland, in cooperation with the National Institutes of Health. The Center 

is staffed by personnel on detail from NORTHCOM and U.S. Pacific Command, 

assisted by medical intelligence analysts assigned to the Armed Forces Medical 

Intelligence Center, and the U.S. Army Medical Research Institute for Infectious 

Diseases at Fort Detrick. An operational DOD official attached to the Center will 

provide an essential link during a national epidemic control effort. 

Joint Recommendation: Develop Improved Service Member and Disease 

Surveillance Process 

Improved Management of Warfighters Evacuated from the Combat Theater 

• Carefully monitor and separately manage casualties from combat operations such as 

Iraq and Afghanistan because of the potential risk of transmitting infection. When

they return to the United States, injured soldiers should be kept separate from nonactive-duty beneficiaries until risks for disease transmission have been identified and 

controlled. Concerning infection with A. baumannii, for example, the service 

members of concern should include severely injured warfighters, service members 

who have been in the operating room or intensive care unit in Combat Support 

Hospitals where A. baumannii transmission has occurred, and other service members 

who have been in contact with these first two groups. Service members injured or 

possibly contaminated with an infectious disease should be carefully monitored and 

managed when they are medically evacuated from the field, when they are stabilized 

and treated at Landstuhl Regional Medical Center in Germany or another location, 

and when they are hospitalized in the United States. They should be managed apart 

from elderly persons and those with other disease conditions that make them more 

susceptible to infection. The model should be the National Naval Medical Center, 

where a trauma service was established on one ward of the hospital, with all the other 

services (Orthopedics, Vascular Surgery, Neurosurgery, Internal Medicine) acting as 

consultants to this focused trauma service. This organizational modification 

effectively groups injured Marines in one geographic location, greatly reducing the 

opportunity for nosocomial infections to develop in other beneficiaries. These 

measures are serious and will require a significant commitment from DOD to provide

aircraft for transportation and sufficient staffing for separate wards in hospitals. While 

one option is to close the intensive care units at, for example, Walter Reed to military

dependents and retirees until the transmission is understood, better staff education and 

strict compliance with infection-control procedures may reduce the risk of 

transmission sufficiently until other measures are developed and put in place to 

prevent and manage these infections. In the case of A. baumannii, since these soldiers 

may develop drug resistant bacteria during their course of treatment, the possibility 

exists for them to transmit these other bacteria when they are moved to other 

hospitals. To protect patients in VA and other hospitals from drug resistant bacteria, 

the infected warfighters should not be moved beyond Walter Reed and the National 

 42
Naval Medical Center until it can be verified that they are not infected. This may 

occasionally compete with the desire to return the recovering warfighters to their 

home to be with their families as soon as possible, so decisions must be made based 

on the pertinent facts for each case and the capability for suitable risk mitigation. 

Enhanced Syndromic Surveillance of Healthcare Workers

• Monitor healthcare workers as a high-risk population that may provide advance 

warning of an infectious disease outbreak like influenza. Such monitoring should 

become routine and might include thermal scanning at the beginning and end of each 

shift. Constant occupational exposure to potentially infectious persons in ambulatory 

clinical settings suggests that they will be the first exposed to an unknown infectious 

disease, including pandemic influenza, and so might show nonspecific signs, such as 

a mild fever in the first four to eight hours after exposure. Because they might also 

develop respiratory symptoms soon after exposure, they should not simply be allowed 

to stay home if they show early signs of an illness. This was the case in eight 

healthcare workers in Hong Kong when SARS first began to spread. These healthcare 

workers called in sick the day after they were exposed to a SARS patient at work. 

When an astute supervisor told them to come in to the hospital to be evaluated, they 

were all found to be infectious and were immediately isolated. Such careful daily 

monitoring of healthcare workers could provide 1 to 2 days additional early warning 

of a new or spreading communicable disease, and would allow these high-risk 

persons to be identified, isolated, and tested before they could transmit a potentially 

lethal communicable illness to family members, co-workers, and friends. 

 43
United States Pacific Command (PACOM)

The PACOM AOR contains the largest geographic region of the 

U.S. Combatant Commands and depends on rapid air travel for 

force projection. The Asian Pacific region contains multiple, 

strategic security partners of the United States, and the nontraditional security threat of infectious diseases, such as SARS 

and avian influenza, threaten many of the features of 

globalization—free trade, free travel, and free information flow. 

As international and regional preparedness efforts continue, 

PACOM must take steps to assure that strategic air transport remains unthreatened as a 

tool of global power projection. 

PACOM shares many of the equities described for NORTHCOM concerning tracking of 

service members. Moving troops into and around the theater to meet security needs is 

paramount, and PACOM will depend on NORTHCOM to assure that troops moving from

the continental United States during an influenza epidemic or pandemic, for example, are 

not incubating a communicable disease that could spread to PACOM forces and 

compromise combat effectiveness, and vice versa.79 

Both commands will need to work with civilian health agencies to identify the most 

appropriate contagious disease control practices. As in controlling an influenza pandemic, 

enforced quarantine is unlikely to be considered today due to concerns about civil 

liberties. Voluntary movement and activity restrictions are likely to provide the added 

time required for extensive case tracking and identification, but civilian and military 

public health officials must be prepared for the rapid contact tracing and decisionmaking 

that will be required. 

Case Study V—Severe Acute Respiratory Syndrome 

The emergence of SARS in 2002 surprised international public health experts and 

showed how vulnerable the world had become to contagious disease. The SARS 

epidemic of 2002-2003 demonstrated the ease with which a local outbreak can quickly 

become a worldwide epidemic. The virus ultimately spread to more than two dozen 

countries and administrative regions within six months, generating a massive global 

public health response. Hospitals in Singapore, Hong Kong, Vietnam, and Canada 

struggled to contain the virus when people unknowingly infected with SARS gave it to 

dozens of other people with whom they came in contact, including family members, 

hospital workers, and other travelers. As of the end of 2003, there had been 8,096 cases 

 79 In the field of epidemiology, an outbreak is a large number of cases of a disease occurring in a short 

period of time. An epidemic is a more scientific description after an investigation is begun that confirms

numbers based on a specific case definition and the usual numbers of such cases expected in the particular 

area in a defined period of time. A pandemic is a global epidemic. 

 44
worldwide and 774 deaths.80 The epidemic had dramatic effects on the global economy, 

with one model estimated that the short-term global cost of lost economic activity was 

approximately $80 billion.81 

SARS is a viral respiratory illness caused by a coronavirus, called SARS-associated 

coronavirus (SARS-CoV). The virus that causes SARS is thought to have been 

transmitted from civet cats, small wild mammals that were taken from their native 

environment to local markets, where they were sold for human consumption. Human 

exposure is likely to have occurred in the crowded and unsanitary market conditions.82

The first recorded case apparently occurred in mid-November 2002, in the city of Foshan, 

Guangdong Province, China. However, the Chinese Ministry of Health did not report to 

WHO that there had been 300 cases and 5 deaths in an outbreak of “acute respiratory 

syndrome” until February 2003. Confusing the response to these initial cases was the 

presence of cases of H5N1 avian influenza, with three deaths among members of a Hong 

Kong family who had traveled to Fujian Province. 

The SARS virus was carried out of southern China on February 21, 2003, when a 64-

year-old medical doctor who had treated patients in Guangzhou and was himself 

suffering from respiratory symptoms checked into a room of the Metropole Hotel in 

Hong Kong. He subsequently transmitted the SARS virus to at least 16 other guests, who 

carried the disease to Toronto, Singapore, and Hanoi, as well as hospitals in Hong Kong. 

Despite its low transmission rate and the relatively low number of deaths compared to 

other infectious diseases, SARS had a very powerful and negative psychological impact 

worldwide. The newness of the disease, the speed of its global spread, the identification 

of several superspreaders who transmitted the infection to dozens of others, and public 

uncertainty about the ability to control its spread probably contributed to public alarm.

This alarm led to behavior that worsened the economic impact by reducing travel and 

tourism to affected countries. Other behaviors reduced the ability of governments to 

control transmission of the disease. For example, in late March 2003, when Hong Kong 

officials quarantined the Amoy Gardens apartment complex, where over 300 residents 

became ill, they found that two thirds of the approximately 1,000 residents had already 

fled. 

Extensive study of compliance with quarantine control measures in Toronto revealed a 

number of obstacles to compliance that will likely reoccur in the event of a contagious

disease epidemic in the United States. Barriers to compliance with voluntary quarantine 

measures/movement restrictions included: fear of loss of income; inconsistencies in the 

application of quarantine measures between jurisdictions; spotty monitoring of 

 80 World Health Organization, “Summary of probable SARS cases with onset of illness from 1 November 

2002 to 31 July 2003.” Available online at: 

<http://www.who.int/csr/sars/country/table2004_04_21/en/index.html>. 81 Jong-Wha Lee and Warwick J. McKibbin, “Estimating the Global Economic Costs of SARS,” in

Learning from SARS: Preparing for the Next Disease Outbreak, workshop summary, (Washington, DC:

National Academies Press, 2004), 11. 82 Ibid., 4.

 45
compliance; difficulties with logistical support for infection-control supplies, 

medications, and food; psychological stress as a result of social distancing and 

stigmatization; and unclear government communication to the public.83 

A number of lessons from the SARS outbreak can be applied to future outbreaks of 

disease. A wide variety of traditional health methods, coupled with modern technology, 

allowed for countries to better contain the outbreak and eventually stop the spread of the 

virus. PACOM should carefully consider these methods to better prepare for a future 

infectious disease outbreak, including: isolation of patients, quarantining contacts, 

canceling mass gatherings and closing schools, recommending that the public augment 

personal hygiene and wear masks, issuing travel advisories and screening travelers at 

borders, and using infrared and thermal scanning of travelers at borders to detect an 

elevation in body temperature that could be indicative of a fever.84 

Furthermore, the interaction of public health needs and national security needs were 

studied in the context of the SARS epidemic by a recent Defense Science Board Task

Force on SARS Quarantine.85 The findings and recommendations from this task force 

apply in general to public health emergencies and disease outbreaks and should be 

considered not only by PACOM but the entire DOD: 

• Many quarantine and isolation procedures exist, and they need not be perfect to 

reduce disease transmission. The military must not be seen to be responsible for 

pandemic spread of a disease. Costs of extensive quarantine are very high and 

provisions would be needed to care for those immobilized by quarantine restrictions. 

• A comprehensive national and international civilian-military exercise program should 

be developed that addresses trans-jurisdictional quarantine issues, establishes 

mutually agreed upon protocols, and tests these plans through tabletop and actual 

exercises. Systems and tools should be developed to collect, organize, and provide for 

real-time tracking of an outbreak. 

• Military force protection strengthens civilian defense from and response to an 

outbreak. DOD capability to perform its mission could be limited if there is no plan 

for immediate protection of the force. DOD caution in adopting a supporting role in 

response to an outbreak and related consequence management may result in delayed 

action when immediate action is demanded. 

• Lack of suitable isolation facilities in the event of a large outbreak will be a limiting 

factor. DOD should consider new technologies and alternative approaches to 

isolation. 

 83 Clete DiGiovanni, et al., “Factors Influencing Compliance with Quarantine in Toronto during the 2003

SARS Outbreak,” Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science, 2004, 2 (4):

265-272. 84 David M. Bell, World Health Organization Working Group on Prevention of International and 

Community Transmission of SARS, “Public Health Interventions and SARS Spread, 2003,” Emerging

Infectious Disease, 2004, 10(11). 85 Office of the Under Secretary of Defense for Acquisition, Technology, and Logistics, Interim Report of

the Defense Science Board Task Force on SARS Quarantine, December 2004. Available online at: 

<http://www.acq.osd.mil/dsb/reports/2004-12-SARS_Memo_Final.pdf>. 

 46
Joint Recommendation: Improve Aeromedical Evacuation of Communicable 

Disease Casualties 

Evaluation of Disease Transmission Risks during Aeromedical Evacuation 

• Perform comprehensive studies of the aeromedical evacuation process to minimize 

risks of disease transmission. Infections passed to other casualties during medical 

evacuation flights by person-to-person, surface contact, or contaminated medical 

instruments or equipment must be controlled. Aeromedical evacuation will remain a 

key link to global power projection and mobility. Aeromedical evacuation 

enhancements in the last decade are largely responsible for the transformational 

changes in combat casualty care supporting a small but effective forward deployed 

medical support structure. The use of the Army Forward Surgical Teams, the Navy 

Forward Resuscitative Surgery System, and the Air Force Small Portable 

Expeditionary Aeromedical Rapid Response Team, and the reconfiguring of aircraft, 

staff, and equipment to provide critical medical care in flight have revolutionized 

expeditionary medical support for the warfighter. Aeromedical evacuation remains 

one of the greatest challenges while moving potentially infectious casualties. Limited 

air filtration and circulation, low humidity, low cabin pressure, and close contact 

between passengers all raise the risk for person-to-person transmission by both 

respiratory droplets and blood or body fluids. Several biocontainment “modules” 

exist for the single patient with a highly contagious infectious disease, such as Ebola 

or smallpox, but the logistics system is not available for multiple patients.

Enhanced Tracking of Casualties Aeromedically Evacuated from the Theater 

• Develop tools and processes to enhance casualty tracking on aeromedical evacuation 

flights and upon return to the Unites States. These improvements should make the 

existing U.S. Transportation Command (TRANSCOM) aeromedical evacuation 

tracking system, TRANSCOM Regulating and Command & Control Evacuation 

System (TRAC2ES), database available for prompt queries by public health disease 

investigators, and the system should be enhanced to collect data on all passengers. 

Due to their occupational exposure, healthcare workers are at the highest risk of 

infection. Infection control, personal protection, and vigorous hand washing are 

regularly emphasized to minimize transmission of infections but are difficult in 

transit. The aeromedical evacuation system has established protocols for transporting 

casualties with known communicable diseases, but largely accomplishes this by 

dedicating an entire airframe to move a very small number of infectious cases. Since 

disease transmission may occur if a service member is unknowingly incubating an 

infection, such as influenza, CCHF, SARS, or A. baumannii, it will be crucial to 

identify all other service members who may have been exposed during the flight. This 

effort should be done in conjunction with a similar effort in the commercial airline 

industry, because many service members travel on commercial airlines within the 

short incubation period of many of these infections. Flight manifests are a critical part 

of contact tracing when an infectious person travels on a commercial aircraft, but they 

are not currently available in an electronic format in either the commercial or military 

 47
sectors. Once in the United States, DOD could utilize Radio Frequency Identification 

Technology (RFID) to track service personnel movement. An RFID tag is a small 

object that can be attached to or incorporated into a person, animal, or product, and is 

already used by DOD to track supplies and equipment. This would allow DOD 

healthcare personnel to keep track of and quickly locate service personnel who might 

have been exposed or are at risk of infecting others with an infectious disease. Such 

an effort would obviously have to take into consideration the need for operational 

security, but such data security issues can be easily addressed. 

 48
United States Southern Command (SOUTHCOM) 

The SOUTHCOM AOR includes several countries where lowintensity conflict has been ongoing for many years. Current U.S. 

military involvement does not include large numbers of service 

members, but travel distance from fixed medical facilities can be 

great, and service members may need to be self sufficient for 

prolonged periods of time. Logistical support for such missions can 

be minimal, but exposure to disease-carrying insect vectors can be 

prolonged during the humanitarian assistance operations common in 

the AOR. 

Good military order and discipline is not as much the issue in SOUTHCOM as is the 

need to improvise solutions when the full logistical support tail that accompanies large 

troop movements is lacking. Service members often must be skilled in more than one 

primary area, and creative thinking to extemporaneously and quickly manage difficulties 

is a requirement for success. The more preventive measures that can be designed into the 

gear at a service member’s disposal, the more likely these measures will be used. The 

SOUTHCOM region faces a number of important health threats, including malaria, 

yellow fever, and dengue fever, which can and will affect combat operations. Military 

doctors and service members need to be prepared to combat these health threats, which 

often include infections from disease-carrying mosquitoes. 

Case Study VI—Malaria and Force Protection 

Malaria has been an important health threat to military operations for centuries and 

continues to be an issue for SOUTHCOM forces. In humans, malaria is caused by a onecelled parasite called plasmodium, transmitted by the female Anopheles mosquito. It 

appears to have lived “in the guts of reptiles” and—like many other disease-causing 

microbes—to have moved into humans around the time that organized agriculture began, 

10,000-20,000 years ago.86 Other forms of plasmodia still live in birds, reptiles, rodents, 

and nonhuman primates. 

Only certain species of mosquitoes of the Anopheles genus, and only females of those 

species, transmit malaria. Female Anopheles pick up the parasite from infected people 

when they bite to obtain blood needed to nurture their eggs. Inside the mosquito, the 

parasites go through a life-cycle change and enter the stage that is infective to humans 

and migrate to the mosquito’s salivary glands. When the mosquito bites again, the 

parasites pass into the blood of the person being bitten. Transfusion of infected blood can 

also spread malaria, which is why all potential blood donors are screened to see if they 

have been in a malaria-infested area. 

Plasmodia have a complex life cycle, reproducing sexually inside mosquitoes and 

asexually inside both human red blood cells and the human liver. At one stage of their 

 49

 86 John Reader, Africa: Biography of a Continent (New York: Vintage Books, 1997), 244. 
life cycle, they nest deep within the human liver, which is one key reason why malarial 

infections can be difficult to detect and treat. 

Malaria has probably killed more people than any other disease in history. Today it is 

endemic—high levels of infection are permanent—in more than 90 countries. 

Approximately 40 percent of the world’s population live in areas where malaria is 

transmitted, resulting in 350-500 million acute cases of malaria a year and 1-3 million 

deaths a year. 

Figure 13 

Figure 13 - Source: Centers for Disease Control and Prevention, “Geographic Distribution 

of Malaria,” 23 April 2004. Available online at:

<http://www.cdc.gov/malaria/distribution_epi/distribution.htm>.

Four types of malaria can cause infections in humans: Plasmodium falciparum, 

Plasmodium ovale, Plasmodium malariae, and Plasmodium vivax. P. malariae is the 

least common of the four types and both P. vivax and P. ovale can cause recurrent illness. 

P. falciparum is the most severe and life-threatening form of the disease and can cause 

organ failure and, in severe cases, can lead to cerebral malaria. 

Most often, the first symptoms of malaria begin to appear about two weeks after a person 

is infected. The time period varies from 9 to 30 days, depending on the type of 

 50
Plasmodium infection. These symptoms are usually fever, headache, chills, and vomiting. 

If not treated promptly with effective medicine, malaria can kill by destroying red blood 

cells and by clogging the capillaries that carry blood to vital organs. 

Many antimalarial drugs come from nature. The first and most famous is quinine, which 

scientists first isolated in 1820. Quinine is found in the bark of the Cinchona tree, which 

is native to certain mountainous areas of Peru. Local people, remnants of the Inca empire, 

drank teas made with this bark to combat fevers, and Spanish colonial officials began to 

use and write about it in the mid-17th century. Scientists recently determined that quinine 

kills P. falciparum by disrupting its food vacuoles, and the other three types of malaria by 

killing the parasites at the stage of asexual reproduction.87 By the late 19th century, 

physicians and researchers had documented that quinine can also work as an effective 

prophylaxis, keeping people safe from malaria. 

Several important antimalarial compounds have been synthesized de novo, including 

chloroquine and primaquine, developed as part of the U.S. Army drug screening program

during World War II, and mefloquine, developed in collaboration between the U.S. 

Army, WHO, and Hoffman-LaRoche, Inc.88 Several promising new compounds are in the 

final stages of testing, but further development is hampered by resource constraints. 

The only major new malaria drug in the past 30 years is artemisinin, a chemical derived 

from one particular type of wormwood plant.89 Chinese scientists rediscovered this agent 

in the late 1960s, when Chinese dictator Mao Zedong instructed them to use ancient 

herbal pharmacopoeia to find an antimalaria drug that could help North Vietnamese and 

Viet Cong soldiers then fighting the Americans and South Vietnamese.90 Virtually all 

artemisinin in the world today comes from plants grown in China and Vietnam. Efforts to 

grow it in India, Brazil and other countries have failed. The plants prosper there, but for 

some reason—perhaps the soil or the weather—do not produce a consistent supply of the 

needed chemicals. Due to current worldwide shortages of artemisinin, in 2003 the Bill 

and Melinda Gates Foundation granted $42.6 million to develop a biotechnological 

technique that synthesizes artemisinin.91

Much research on malaria now focuses on genetics. Scientists, for example, have 

sequenced the genomes of the P. vivax and the Anopheles mosquito.92 What practical 

results this will produce have yet to been seen. 

 87 Joel G. Hardman and Lee E. Limbird, eds. Goodman & Gilman’s The Pharmacological Basis of

Therapeutics, Ninth Edition (New York: McGraw-Hill, 1996), 979. 88 Institute of Medicine, Malaria, Obstacles and Opportunities (National Academy Press, 1991), 150-153. 89 Artemisinin is extracted from the dry leaves of the Chinese herb artemisia annua (qinghaosu, or sweet 

wormwood), which the Chinese used more than 2,000 years ago to control malaria. 90 See Chinese Cooperative Research Group on Qinghaosu and Its Derivatives as Antimalarials, “Chemical

Studies on Qinghaosu,” Journal of Traditional Chinese Medicine, 1982, 2 (1): 3-8. 91 Vincent JJ Martin, et. al., “Engineering a Mevalonate Pathway in Escherichia Coli for Production of

Terpenoids,” Nature Biotechnology, July 2003, vol. 21, no. 7, 796-802. 92 See, for example, a series of articles on plasmodium genomics in the October 3, 2002 Nature, and a 

series of articles on the genome of the Anopheles mosquito in the 4 October 2002 issue of Science.

 51
Recent and ongoing military missions indicate that a lack of attention to disease 

prevention continues to be an important but often overlooked issue. With adequate 

medical intelligence and strict discipline regarding mosquito control and use of

prophylactic drugs, malaria, for example, should be a 100 percent preventable disease. 

Nonetheless, 131 U.S. Armed Forces personnel who served in Somalia during 1992-93 

contracted malaria.93 Marines contracted malaria in late 2003, after 133 were carried by 

helicopter into Liberia to protect U.S. diplomats during a civil war that threatened to 

dissolve into urban anarchy. No hostile action was ever directed at the Marines, yet more 

than one-third of them (53), some near death, had to be medically evacuated back to the 

ship due to malaria. Tests subsequently proved that none of the Marines had been taking 

their malaria medicine properly, including the 80 who were lucky enough not to get 

sick.94 The perception that faulty generic drugs may have played a role was addressed, 

leaving the impression that there was failure by the command to supervise the use of 

malaria countermeasures, and failure by medics to assure that the command was 

supervising. 

The wars in Afghanistan and Iraq, currently the highest priority for U.S. military 

planners, are recent examples of how the occurrence of disease and lack of discipline can 

affect military operations on foreign soil. One study of 725 Rangers who served in 

Afghanistan from June to September 2002 discovered that five percent became infected 

with malaria during their tour. 95 Interviews revealed that 48 percent of the Rangers did 

not take their prophylactic medicine, and 71 percent did not use insect repellant. 

Furthermore, 59 percent did not continue to take medicine after leaving malaria-infested 

areas, which is essential to eliminate any possibility of infection. 

 

Because of side effects, whether real or imagined, troops often resist taking drugs, such 

as those that provide protection against malaria. During World War II, many U.S. troops 

serving in the Pacific did not take antimalarial medicines because their skin often turned 

yellow and there were rumors that they would become impotent. Today, many 

warfighters resist malaria prophylaxis because side effects—still not well understood—

can include psychoses and seizures.96

One of the key threats to force protection and health in combat operations in malarial 

endemic regions is that drug-resistant Plasmodium strains are widespread. Coupled with 

an increasing number of mosquitoes that are insecticide-resistant, malarial infections 

have a significant tendency to affect combat operations in SOUTHCOM regions. 

 93 Centers for Disease Control and Prevention, “Malaria Among U.S. Military Personnel Returning From

Somalia, 1993,” Morbidity and Mortality Weekly Report, 16 July 1993, 42(27), 524-526. Available online 

at: <http://wonder.cdc.gov/wonder/PrevGuid/m0021173/m0021173.asp>. 94 “Officials Say Malarial Marines Didn’t Take Medication Properly,” N.Y. Times, 5 December 2003, A 27. 95 S. Russ, et al., “An Outbreak of Malaria in U.S. Army Rangers Returning From Afghanistan,” Journal of

the American Medical Association, 12 January 2005, 293, no. 2. 96 See, for example, DOD, Armed Forces Epidemiological Board, “Armed Forces Epidemiological Board 

(AFEB) Select Subcommittee to Develop Mefloquine Study Options,” 21 May 2004. 

 52
Joint Recommendation: Develop Improved Combat Uniform Insect Repellant 

• Identify promising insect repellants to provide long-term uniform protection. Military 

logistics planners should enhance the capacity of personal protective equipment to 

protect from vector-borne diseases. Future uniform modifications should improve 

upon the current loosely enforced requirement for each warfighter to periodically 

spray their uniform with permethrin to repel insects. Ideal repellant characteristics 

would include long term bonding to uniform fabric that resists being washed away 

when uniforms are laundered. Such efforts usually become a low priority during 

times of increased operational tempo, and are therefore neglected during the acute 

combat phases when warfighters depend on such protection the most. Such a 

capability is of added import to service members who are involved in peacekeeping 

or humanitarian assistance operations. 

 53
United States Special Operations Command (SOCOM) and 

Transportation Command (TRANSCOM)

SOCOM and TRANSCOM have unique worldwide responsibilities that raise distinct 

vulnerabilities to emerging infectious diseases. Both commands support missions of the 

geographic combatant commands in addition to their own unique missions. 

U.S. Special Operations Forces (SOF) are particularly mobile throughout the world and 

may be required to travel to geographic locations with dangerous and unknown disease 

threats. Even though attached medical support prepares for known infectious disease 

threats, it is impossible to fully predict what health threats SOF may encounter. 

TRANSCOM provides airlift and sealift of cargo and personnel around the world. Airlift 

assets are essential tools to support the worldwide projection of U.S. military power. 

These assets will be called upon to move military and civilian personnel during an 

infectious disease outbreak, such as influenza or SARS. Transportation from an area of 

increased risk, such as from Asia during the SARS epidemic, calls for the utmost 

precautions to prevent contributing to the international spread of an emerging infectious 

disease. 

Such precautions were developed to support the movement of a U.S. citizen with 

suspected SARS from Vietnam. Infectious disease experts from both civilian and military 

agencies developed interim guidance for the air medical transport of SARS patients to 

support this patient movement.97 The current problem centers around what steps must be 

taken to routinely disinfect or decontaminate an airframe that may have inadvertently 

transported someone who is incubating a disease or has such mild symptoms that the 

disease is unrecognized. 

It is important for both SOCOM and TRANSCOM to coordinate and work in conjunction 

with regional combatant commands in infectious disease preparation and response. These 

commands operate in many geographical regions and are thus susceptible to multiple 

disease threats, including A. baumannii, leishmaniasis, Crimean-Congo hemorrhagic 

fever, malaria, SARS, and pandemic influenza. 

 97 Centers for Disease Control and Prevention, “Guidance for Air Medical Transport for SARS Patients,” 3 

May 2005. Available online at: <http://www.cdc.gov/ncidod/sars/airtransport-sarspatients.htm>. 

 54
Strategic Recommendations for Worldwide Force 

Protection 

Complex and changing threat conditions require proactive, anticipatory consideration of 

force protection requirements. These requirements will vary with changes in combat 

settings and tactics, enemy threats, and geographic environments. Military medical and 

combat casualty care experts must carefully but quickly consider the likely consequences 

for warfighters of any of these variations, alter existing force protection techniques, and 

develop new processes to maintain and enhance the combat forces. 

Strategic recommendations from recent experiences in urban warfare and low-intensity 

conflict build upon those already described. They include: 

• more in-depth evaluation and mitigation of environmental threats before troops enter 

an area; 

• better monitoring and tracking of troops within the theater and, after leaving, their 

ongoing health status and changing vulnerabilities; 

• more proactive measures to protect service members from environmental and disease 

threats and from each other when a contagious disease threat surfaces; 

• more advanced diagnostic and treatment modalities that consider the threat 

environment and the in-theater force structure. 

A theme of these recommendations is the need to take advantage of digital and wireless 

technology in force protection. Service member exposure depends on tracking their 

locations, and nothing short of fully entering the electronic age will address most of the 

surveillance needs cited above.

Environmental Surveillance and Mitigation 

The geographic and climatic environment has long been the greatest noncombatant threat 

to the warfighter. Heat and cold, lack of water, sun, and insect vectors of infectious 

diseases will continue to require the highest degree of attention by military planners and 

medical and environmental experts. More and more information about local 

environments is available from commercial satellites, and more detailed disease vector 

threat information can be obtained by monitoring the disease burden in the local 

populations. 

Remote Sensing of Environmental Threats 

• Link known environmental (terrain, vegetation, rainfall) and population data (urban 

vs. rural) to identify high-risk areas for transmission of leishmaniasis, malaria, 

dengue, and other vector-borne diseases of military operational importance. Remote 

sensing of environmental threats is especially important in preventing disease in 

troops operating in Iraq. The actual disease prevalence in Iraq should be determined 

 55
in collaboration with the Iraq Ministry of Health, and joint vector control efforts 

should be undertaken to reduce the burden of disease in Iraqi citizens and in coalition 

military. Known and possible environmental threats will then guide force placement 

and prevention countermeasures in the initial phase of combat operations, and will 

identify the types of specialists required to further define and reduce threats, such as 

entomology teams to eliminate mosquito or sand fly breeding sites, or air or soil 

contamination sampling teams to identify toxic industrial chemicals that must be 

avoided. 

Improve Environmental Sampling and Surveillance 

• Fast-track the development of molecular-based assays for environmental samples.

Proper management of potentially infected casualties requires all casualties to be 

managed as if they are infected until clinical test results are negative, a process that 

takes 3 to 6 days. The Air Force, for example, has established protocols at one 

deployed location that require all high-risk combat casualties to be managed as if they 

are infected with A. baumannii until they have been proven to be infection-free by 

laboratory cultures. Current environmental sampling and culturing methodologies 

may miss A. baumannii: they often fail to detect the organism in soil and water 

samples. Basing infection-control practices on negative environmental results using 

laboratory tests designed for clinical specimens may provide a false sense of security. 

In-theater field diagnostic technology should be developed rapidly to accurately 

detect A. baumannii in soil, water, and surface samples from equipment and skin. 

This will permit realistic, risk-based infection-control practices that are based on 

injury severity, location of in-theater care, presence or absence of the pathogen in the 

environment, and exposure to other sources of infection to be linked to in-theater and 

CONUS-based clinical surveillance results. Environmental surfaces in aeromedical 

evacuation aircraft should be sampled and tested before and after all medical 

evacuation flights, and careful monitoring of patients and medical personnel after 

flights should be done routinely to detect if transmission may be occurring in flight. 

Surveillance and Management 

Military decisionmakers require rapid situational awareness to warn them of a changing 

threat environment so they may evaluate potential courses of action, implement their 

decisions, and monitor outcomes so decisions may be modified as circumstances change. 

Effective disease surveillance systems allow the most timely and accurate assessment of 

the impact of environmental and infectious threats on combat troops. These systems 

generate data from a variety of sources that must be fused, mined, and analyzed to 

generate timely, actionable information upon which effective courses of action may be 

developed by medical personnel and line commanders. 

Operational decisions will be made based on available data. Unknown or undefined 

disease threats can lead to wide-ranging and burdensome countermeasures, such as 

excessive personal protective equipment, personnel movement restrictions, isolation, and 

quarantine. As additional information becomes available, these countermeasures may be 

 56
safely relaxed to a degree. The sooner that actionable information is collected, analyzed, 

and presented to decisionmakers, the quicker operational restraints that were imposed to 

protect from disease threats can be reduced. 

Improved Tracking of Service Members 

• Fast track the development and deployment of data-capture systems that allow realtime visibility of service members as they move around the world. Such a system

would provide real-time, accurate, location data so that each service member’s 

exposure risk could be quickly determined, whether to an environmental disease 

threat or to another service member who may have been exposed and be at risk for 

transmitting an infection. A proof of concept pilot project that supports prompt 

contact tracing for disease investigation would use technology that is currently 

available, for example, RFID. This technology could quickly give DOD a system to 

track personnel coming out of theater and capture their movement to their home

stations in the United States. 

Enhanced Warfighter Disease Surveillance 

• Enhance and merge disease surveillance systems with other data sources so diseases 

acquired in theater may be detected and tracked once the warfighter returns home.

Until the data-capture system is developed, disease surveillance systems must include 

the ability to track warfighters from their home station to the theater and back to their 

home stations, must include their geographic location, and must support electronic 

capture of clinical disease data short of an actual laboratory diagnosis in-theater. For 

example, if a soldier is diagnosed after return to his home station with cutaneous 

leishmaniasis, the surveillance system should allow rapid identification of all other 

service members who were in the same geographic area in the same time period so 

these personnel and their medical providers can be notified of the increased likelihood 

that they could be infected. Since many of the combatants are guard and reserve 

members, the system must be able to reach those who return to inactive guard or 

reserve status once they demobilize. 

Aggressive Infection Control Cohorting, Isolation, and Quarantine 

• Aggressive infection control, isolation, and quarantine are especially important in the 

case of highly communicable diseases, including influenza viruses and some

hemorrhagic fever viruses. Infection-control procedures in-theater should be 

improved by cohorting persons at risk. This should include a complete evaluation of 

patient and staff cohorting procedures to provide for the best infection control 

possible in field conditions and in fixed medical facilities, and should lead to policies 

and procedures that implement the practices to best protect injured service members 

and medical staff, given operational tempo limitations. Strict infection control is 

difficult and costly at all levels of care. It requires gowns and gloves for each and 

every person who comes into contact with the individual, and sinks for good hand 

washing near the bedside. In deployed settings, a common compromise in place of the

 57
U.S. standard of private isolation rooms might be to cohort, or group, these patients in 

one ward, large room, or area of the field hospital or hospital ship. With strict 

infection-control procedures, this arrangement protects healthcare workers and 

provides reasonable protection for other patients in the facility, though it does not 

protect these service members from each other. 

Policies to Support Appropriate In-Theater Use of Antibiotics 

• Develop policies to prevent misuse of the only antibiotic effective against multi-drug 

resistant bacteria. While prophylaxis with broad spectrum antibiotics is a well proven 

measure in preventing wound infections from common bacteria that are found on the 

skin,98 unnecessary use of Primaxin (imipenem/cilastatin) promotes antibiotic 

resistance in A. baumannii, for example, which is known to rapidly develop resistance 

in the presence of antibiotics. Prophylactic antibiotic administration should be limited 

to those antibiotics used to treat the usual bacterial causes of wound infections. 

Infectious disease experts have developed policy guidelines for in-theater use of 

antibiotics, but implementation has been hampered by inadequate supplies of the 

lower cost, first-line antibiotics that are less likely to contribute to antibiotic 

resistance. 

Development of a Tri-service Antibiotic Susceptibility Surveillance System 

• Develop a DOD/VA surveillance system to collect and disseminate antibiotic 

susceptibility information. Antibiotic resistance patterns detected should be linked to 

both the patient from whom they are collected and to the geographic source of the 

organism so prompt force health protection countermeasures may be developed and 

implemented. The current lack of such a system limits collection and dissemination of

this information to each individual military MTF. 

In-Theater Joint Disease Investigation Expertise 

• Military disease management experts should be available in-theater to provide 

surveillance and analysis expertise as soon as disease early warning systems detect 

an anomaly. Each service has specialized teams to perform such analysis and 

response,99 but these teams are largely staffed and deployed according to servicespecific doctrine rather than theater-wide needs. Administrative barriers prevent quick

redeployment of personnel and laboratory equipment within theater to respond to 

outbreaks. A true joint team of disease experts and diagnostic laboratory equipment 

should be developed to cross service and geographic boundaries and be truly 

responsive to the needs of the Joint Task Force Surgeon. 

 98 David Burris, et al., editors, Emergency War Surgery, Third United States Revision, (Washington, DC:

The Borden Institute, 2004), 103. 99 The U.S. Army Theater Area Medical Laboratory, the U.S. Navy Forward Deployed Laboratory, the U.S. 

Air Force Theater Epidemiology Team. 

 58
Clinical Diagnosis and Treatment

Diseases caused or complicated by emerging infectious pathogens often require novel 

treatment regimens as more is learned about their disease course and transmission to 

others. Doctors must use available medications to treat these conditions and often choose 

antibiotic or antiviral treatments that are not in widespread use, because many organisms 

develop resistance to medications that are used commonly. These medications, when 

available, are often those that have more dangerous side effects or are in short supply. 

Occasionally treatments for rare conditions use medications that have never been 

approved by the Food and Drug Administration (FDA), since such approval requires 

rigorous trials in many patients to prove effectiveness and safety. These drugs must be 

administered under special administrative rules called Investigational New Drug 

protocols, and require that much additional paperwork be collected and reported to the

FDA. Current treatment options are greatly limited for the conditions of military 

operational importance described in this paper, A. baumannii, Crimean-Congo 

hemorrhagic fever, and Leishmania infections. 

The difficulties encountered in treating emerging infections require the best possible 

diagnostic technology so treatments can be expeditiously and efficiently targeted. A 

presumptive diagnosis is first made on the basis of clinical signs and symptoms, and the 

infectious diseases known to be present in the geographic location. Laboratory diagnostic 

testing is often necessarily to identify the cause of an infection early in its course and to 

provide the most appropriate treatment regimen. 

Recent advances in molecular diagnostics can provide genetic fingerprinting of 

organisms so military medical experts know not only the pathogens causing a particular 

disease, but the antibiotics to which it is susceptible. As more genetic information is 

obtained about different strains of pathogens, it will be possible to identify common 

geographic sources and even patterns of virulence. This additional information will 

greatly enhance the military physician’s ability to treat these service members, and will 

enhance the capabilities of military disease investigators as they track persons exposed to 

a contagious disease. 

Improve Clinical Surveillance of Combat Casualties 

• Comprehensive tracking and disease surveillance should be undertaken on all injured 

warfighters after they depart from the theater. In-depth disease investigation by intheater clinical testing should become part of the standard procedures for military 

actions in Iraq and Afghanistan. As long as rapid diagnostic technology is not in 

place, wound and skin cultures of high-risk casualties should become a routine part of

entering the air evacuation system until infections are under control. Currently, 

wound and skin cultures for A. baumannii are collected upon arrival at Landstuhl 

Regional Medical Center in Germany, but initial results are not available for 72 

hours, and antibiotic resistance patterns require another 72 hours. Results from

cultures could provide line and medical decisionmakers with important data to help 

identify injured service members needing aggressive surgical, antibiotic, and 

 59
rehabilitative treatment. Timely results will allow military physicians to quickly 

respond to changing patterns of infection, and improve outcomes and return-to-duty 

rates. 

Develop a Topical Field Antibiotic or Improved Field Wound Dressing 

• Fast-track the development of a topically applied field antibiotic/protectant dressing.

Such a powder or spray could be used at the earliest levels of care, and could even be 

carried by warfighters or combat medics to be applied in the field at the time of

injury, especially if combat actions prevent prompt evacuation and treatment. 

Characteristics of such an antibiotic or bandage would include topical application by 

spray or powder, rapid passage through intact skin and necrotic tissue so it 

immediately exerts its antibacterial effect without depending on blood supply, and 

effectiveness against all pathogens likely to be encountered—bacteria normally found 

on the skin and organisms found in soil and water—effectiveness against infection in 

adjacent living tissue, rapid metabolization, and rapid elimination from the body 

without side effects. This agent should be easy to store in field conditions and readily 

available in sufficient quantities. It should also be one to which pathogens will not 

quickly develop resistance.100 A controlled-release formulation, where antibiotics are 

incorporated into biodegradable polymers designed to release sustained drug 

concentrations in wounds, may add protection for many days, a useful characteristic 

when medical treatment resources in-theater and aeromedical evacuation out of the 

theater are limited.101 

 100 Konrad Hell, “Characteristics of the Ideal Antibiotic for Prevention of Wound Sepsis Among Military 

Forces in the Field,” Reviews of Infectious Diseases, 1991, 13 (Suppl 2): S164-169. 101 Elliot Jacob and Jean Setterstrom, “Infection in War Wounds: Experience in Recent Military Conflicts 

and Future Considerations,” Military Medicine, June 1989, 154 (6): 311-315. 

 60
Historical Perspective 

Military leaders have struggled with disease for millennia, before any understanding of 

the human body, before discovery of pathogens, before the development of antibiotics to 

treat infections, and before the availability of the diagnostics and treatment capabilities 

we have come to expect today. 

Operational dilemmas faced in the past, consideration of courses of action, and ingenuity 

demonstrated in the face of uncertainly are a reminder that the predicament of emerging 

infections should not be thought of as overwhelming. Leaders should instead recognize 

the importance of continuously seeking opportunities to improve force protection 

practices. This requires proactive consideration of innovative steps to monitor and 

improve combat casualty prevention and treatment, of which history provides multiple 

examples. 

Importance of describing symptoms, the course of a disease, and its patterns of 

transmission

Peloponnesian War (431-404 B.C.) The first disease investigator may have been 

Thucydides (471-400 B.C.), who used the best diagnostic technology available—his 

powers of observation. His eye-witness account of the plague at Athens has a detailed 

clinical presentation of signs and symptoms and the course of the disease over several 

weeks. He describes transmissibility by noting that “the birds and animals which feed on 

human flesh, although many bodies were lying unburied, either never came near them, or 

died if they touched them.”102

Military operations in a resource-constrained environment call for improvised 

solutions 

Siege of Turin (1537) Ambroïse Paré first gained fame as an army surgeon. He struggled 

with the standard treatment for gunshot wounds, cautery by pouring boiling oil into the 

wounds. One day while treating large numbers of combat casualties, Paré ran out of 

boiling oil, and said, “I was forced, that I might not leave (the wounds) undressed, to 

apply a digestive made of the yolk of an egg, oil of roses, and turpentine.” The next day 

he unexpectedly found these casualties free from pain, well rested, and their wounds 

uninflamed.103 

Importance of understanding the local operational environment to protect forces 

from diseases 

Spanish-American War Colonel Theodore Roosevelt wrote of the havoc that poor 

sanitation, vile food, and swarms of mosquitoes were wreaking on the American Army in 

Cuba. When he received impossible recommendations from the War Department, he 

 102 Logan Clendening, Source Book of Medical History (New York: Dover Publications, 1942), 27. 103 Ibid., 192. 

 61
complained that the War Department “unfortunately knew nothing of the country nor of 

the circumstances of the Army.” 

Importance of trusted communication of operation advice from the medical officer 

to the commander 

Revolutionary War General George Washington made and changed his command 

judgments based on staff advice. His initial operational order against smallpox 

inoculation in 1775 was based on advice from Dr. Benjamin Church, a prominent Boston 

physician who served as Washington’s Chief Physician until he was accused of 

treason.104 William Shippen, a Philadelphia land owner trusted by Washington, was later 

appointed Director General, and provided what appeared to be more appropriate 

operational advice.105 He later advised Washington to variolate the Continental Army

against smallpox while they were in garrison and could be isolated from other soldiers, so 

person-to-person transmission of smallpox was greatly reduced, and the death rate was 

minimal.

Spanish-American War “No matter how many recommendations were made..., only 

those recommendations were carried out which the commanding officer desired.” As Dr. 

Walter Reed expressed it, “The Army Medical Corps has received a black eye because of 

the neglect and incompetence of men who did not really belong to it.”106

Leaders must develop and enforce procedures and policies to protect forces 

Revolutionary War Poorly disciplined troops neither built adequate latrines and sanitary 

facilities nor used the available ones, with the result that in short order they contaminated 

their water supply. The lesson of strictly enforcing regulations on the use of sanitary 

facilities has had to be relearned in every war.107

How perception of inequitable treatment quickly leads to civil disturbance 

Mexican Revolution of 1910 The use of quarantine to control disease transmission has 

had a jaundiced history in the United States. Any involuntary restriction of movement 

infringes on personal liberty, as any disobedient child can attest. Efforts to restrict 

movement to control disease have been associated with racist and anti-immigration 

movements. 

 104 John Duffy, The Healers: A History of American Medicine (Chicago: University of Chicago Press, 

1976), 81. 105 Mary Gillett, The Army Medical Department: 1775-1818 (Washington, DC: US Army Center of

Military History, 1981). 106 Ralph Major, Fatal Partners: War and Disease (New York: Doubleday, Doran, and Company, 1941), 

197. 107 Duffy, 79. 

 62
Conclusion 

Newly emerging and reemerging infectious diseases, coupled with increasing resistance 

of both pathogens and vectors, pose a risk to U.S. national security because they threaten 

the military’s ability to protect its forces. Infectious diseases associated with urban 

warfare or low-intensity conflict, coupled with the challenges of providing treatment for 

combat casualties and nonbattle injuries and illnesses, will continue to strain the abilities 

of military medicine to preserve and restore the fighting strength of U.S. military forces. 

DOD must cultivate a culture of innovation in force protection and develop a Joint cadre 

of military medical and combat casualty care experts who will follow the shifting patterns 

of illnesses and injuries, both during and between conflicts, and bring the full weight of

advanced research and development to bear on rapidly solving these threats to health and 

national security. These experts must understand the culture and environment of military 

operations, so that their advice to the line commander is relevant and realistic. They 

should not encourage or allow their commander to think that the medics have all the 

answers and are responsible for the outcomes. This responsibility rests with the unit 

commander. 

The emergence of urban warfare and low-intensity conflict as the focus for military 

operations in OEF/OIF, taken together with the emergence of new enemy tactics, is 

leading to transformation of U.S. and coalition military tactics. Transformation of

military casualty-care processes is leading to improved surgical and medical care. There 

is a critical need to examine and respond to the impact on society of infectious disease 

challenges introduced when warfighters return home for definitive treatment and 

rehabilitation. Such challenges will continue as the U.S. military reduces its presence

overseas and relies on rapid deployment of forces. 

The recommendations for special monitoring and management of injured and potentially 

infectious warfighters may seem aggressive. The systematic actions necessary to address 

these complex challenges, however, require reexamination of deployed force structure, 

targeted advanced technology research, and improved coordination and information 

sharing among DOD, the Veterans Health Administration, and the civilian healthcare 

systems. Perhaps the greatest challenge to implementing many of these recommendations 

is the difficulty of working across organizational cultures. Military medical officers and 

line commanders must understand their mutual responsibilities to protect the fighting 

force. Military experts must work with their counterparts in the civilian community, at 

the Federal, state, and local levels, and in the private sector. 

Technological advances have multiplied the effectiveness of warfighters, allowing a 

smaller force to be much more effective. Military medical and line leaders must create an 

environment in which developing problems may be identified and addressed before they 

result in combat ineffectiveness. Future line and medical leaders must be developed in 

such a forward-leaning setting. 

 63
 64

 

Colonel Ron Bellamy, one of the preeminent experts in combat casualty care, pointed out 

more than 20 years ago that there is an ongoing need to keep an open mind toward 

unorthodox and even outlandishly futuristic proposals for combat casualty care.108 Such 

seemingly unorthodox thinking must include operational planning and policymaking, 

thereby allowing DOD to undergo a transformation that provides the best possible force 

protection for warfighters of today and tomorrow. After combat operations were well 

underway in World War II, military strategic planners finally realized that a wellcoordinated and successfully executed military campaign demands a mastery of diseases 

of operational importance.109 It should not be necessary to relearn this lesson. 

108 R.F. Bellamy, “The Causes of Death in Conventional Land Warfare: Implications for Combat Casualty 

Care Research,” Military Medicine, 1984, 149: 55-62. 109 Robert Bwire, Bugs in Armor: A Tale of Malaria and Soldiering, (Lincoln, Nebraska: iUniverse.com, 

Inc., 2001), 155.