1

MILITARY PREVENTIVE MEDICINE:

MOBILIZATION AND DEPLOYMENT

Volume 1

Section 1: A Historic Perspective on the Principles of

Military Preventive Medicine

Many of the medical challenges of deployment have not changed in the centuries since Washington and Lafayette rode

out among the soldiers at Valley Forge. Personnel still have to be protected from the elements, they still need safe food

and water, they still need properly located latrines, and they still must be given means to protect themselves from

disease and insects. General Washington’s innovations, such as army-wide smallpox vaccinations, strict camp hygiene

(instituted by Baron von Steuben), and command emphasis on preventive medicine measures, make him a hero of

modern military preventive medicine.

Art: Courtesy of Brown & Bigelow, St. Paul, Minnesota.

 John Ward Dunsmore Washington and Lafayette at Valley Forge 1907
2
Preventive Medicine and Command Authority—Leviticus to Schwarzkopf

3

Chapter 1

PREVENTIVE MEDICINE AND COMMAND

AUTHORITY—LEVITICUS TO

SCHWARZKOPF

CRAIG H. LLEWELLYN, MD, MPH

INTRODUCTION

LEVITICUS AND THE PREVENTIVE MEDICINE PARADIGM

The Book of Leviticus

The Paradigm

COMMAND AUTHORITY AND PREVENTIVE MEDICINE IN AMERICAN

MILITARY HISTORY

The Revolutionary War

The Civil War

World War I

Between the World Wars

World War II

The Korean War

The Vietnam War

Operations Desert Shield and Desert Storm

THE PREVENTIVE MEDICINE CONCEPT FOR COMMANDERS

The Commander’s Principal Staff and Operational Planning

The Medical Threat Estimate

SUMMARY
Military Preventive Medicine: Mobilization and Deployment, Volume 1

4

C. H. Llewellyn; Colonel, Medical Corps, US Army, (Retired); Professor of Military Medicine; Professor of Preventive Medicine

and Biometrics; Professor of Surgery; Director, Center for Disaster and Humanitarian Assistance Medicine (CDHAM), Uniformed

Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814-4799
Preventive Medicine and Command Authority—Leviticus to Schwarzkopf

5

INTRODUCTION

Throughout history under a variety of titles—

cleanliness, field hygiene, environmental sanitation,

preventive medicine, force protection—activities

and programs have been developed to maintain the

health and operational performance of military

forces and to prevent disease, injury, and disability. Legters and Llewellyn describe military

medicine as “a unique brand of occupational medicine, one that deals with the prevention and treatment of diseases and injuries resulting from work

in military occupations and operational environments.”1(p1141) Bayne-Jones notes that through the

performance of inspectorial, advisory, and regulatory duties, military preventive medicine is concerned with the administration of the entire military force, thus having a scope that exceeds all

other elements of the military medical departments.2 Military preventive medicine is therefore

the central function of military medicine. Unlike casualty management of individual patients, military

preventive medicine is intimately involved with

military commanders, staffs, and units on a continuous basis.

The promotion and preservation of health and

the prevention of illness and injury can rarely be

accomplished solely through medical channels.

Responsibility for the health and welfare of the

members of a military unit falls on the commander,

as dictated by federal law and military regulation.

Law and regulation are the basis for command authority and military preventive medicine through

which unit commanders can influence the health of

their commands and thus gain command of health.

An understanding of these seemingly simple relationships among military preventive medicine,

military medicine, and command authority and

responsibility has been the essential foundation for

successful preventive medicine activities throughout

military history and continues to be so today.

Equally important are the relationships between

unit commanders and their staffs and the military

preventive medicine personnel advising and supporting them. This chapter will explore the historical

basis for these relationships and the generic lessons

that may be learned and applied in the current and

future practice of military preventive medicine.

LEVITICUS AND THE PREVENTIVE MEDICINE PARADIGM

The Book of Leviticus

As Commander-in-Chief of the Continental

Army during the American Revolutionary War,

General George Washington published a general

order on “The Means of Preserving Health” (Figure 1-1) in which he referred to Moses as “the wisest General that ever lived” and quoted elements

of the Mosaic Sanitary Code from the Old Testament. This echoed similar references by the leading military physicians of the 18th century, such as

Pringle,3 Brocklesby,4

 and Munro5 in England and

Rush6 and Tilton7 in the United States, and presaged

Wood’s book Moses, the Founder of Preventive Medicine.

8 Each of the above authors recognized that the

book of Leviticus is probably the earliest textbook

of preventive medicine.

In his “Notes on the History of Military Medicine,” Garrison9 analyzes Leviticus, chapters 8

through 15, and identifies several functions of the

Levites, or Jewish priests, whom he defined as hygienic police. Their functions included regulating

diet, food sources, water, and personal and sexual

hygiene; recognizing and investigating disease;

quarantining diseased persons and purifying contaminated articles and structures; educating the

community on these topics; advising leaders on the

community’s hygiene; and conducting a census of

the community. In addition, these priests accompanied the army into the field and into battle, providing guidance on all aspects of camp sanitation and

the health of the force.

The priests of Israel, while having wide-ranging

responsibilities to the leaders and members of the

community they served, are not identified as having responsibilities for treating the sick or injured.

Thus began a separation of those responsible for the

health and well-being of the group from those who

provided treatment in an attempt to restore health.

The Paradigm

From the five books of Moses found in the Old

Testament, a broad picture of preventive functions

emerges that has continuing relevance for military

preventive medicine. The nation, religion, and army

of Israel were inseparable during the 40 years in

the wilderness, and the activities of the priests, the

hygienic police, were intimately involved with all

three. The priests’ functions can be broadly charac-
Military Preventive Medicine: Mobilization and Deployment, Volume 1

6

INSTRUCTIONS for SOLDIERS in the Service of the

UNITED STATES, concerning the Means of preserving HEALTH

Of CLEANLINESS

I

T is extremely difficult to persuade Soldiers that Cleanliness is absolutely necessary to the Health of

an Army. They can hardly believe that in a military State it becomes one of the Necessaries of Life.

They are either too careless to pay Attention to this Subject, or they deceive themselves by reasoning

from Cases, that are by no Means similar. Hitherto they have enjoyed a good State of Health, tho’ they

paid little or no Attention to such Punctilios; hence they conclude, that, tho’ in the Army, they shall

continue to enjoy an equal Degree of Health, under the like Degree of Negligence: Such reasoning has

proved fatal to thousands. They do not consider the prodigious Difference there is in the Circumstances of

five or six People, who live by themselves on a Farm, and of thirty or forty thousand Men, who live

together in a Camp. The former chiefly subsist on vegetable Food; they lodge warm and dry, and they

breathe in pure Air, which is not contaminated by noxious Vapours: The latter in general subsist too much

on animal Food; they sleep frequently on cold and damp Beds, and they breathe foul Air, that is constantly injured by the very Breath of a Multitude; and is frequently rendered much more dangerous by the

Stench and Exhalations that arise from putrid Bodies. The Air is injured, as I have just said by the Breath

of a Multitude and the perspirable Matter that comes through the Pores of the Skin helps to extend the

Disorder. But the Blood and Offals of Cattle that are killed near the Camp, with the different animal

Substances that are daily thrown there by the Soldiers themselves, must soon fill the Air with a pestilential Smell, unless they are immediately removed or covered sufficiently deep. When the Soldier pours out

Water, in which Flesh has been boiled; when in a peevish Mood he throws away Part of his Ration,

because it is too much roasted, or because it is not roasted enough; or even when he throws away Bones

that are not well picked; he seldom considers that such Things must soon become putrid, and that he is

sowing the Seeds of Disease and Death for himself or his Companions. The Soldier should burn his Meat

rather than throw it away: History informs us that great Armies have followed this Rule. Soldiers are not

supposed to be acquainted with the Art of preserving Health; they are little versed in Books; but, to the

Honour of American Soldiers, it is allowed that no men in Christendom of the same Occupation are so

well acquainted with their Bibles: Let them, once more, read the History and Travels of the Children of

Israel while they continued in the Wilderness, under the Conduct of Moses; and let them consider at the

same Time that they are reading the History of a great Army, that continued forty Years in their different

Camps under the Guidance and Regulations of the wisest General that ever lived, for he was inspired. In

the History of these People, the Soldier must admire the singular Attention that was paid to the Rules of

Cleanliness. They were obliged to wash their Hands two or three Times a Day. Foul Garments were

counted abominable; every Thing that was polluted or dirty was absolutely forbidden; and such Persons

as had Sores or Diseases in their Skin were turned out of the Camp*. The utmost Pains were taken to Keep

the Air in which they breathed, free from Infection. They were commanded, to have a Place without the

Camp, whither they should go, and have a Paddle with which they should dig, so that when they went

abroad to ease themselves, they might turn back and cover that which came from them†.

Besides these general Regulations, it is also necessary for the Preservation of Health, that every Soldier be particularly attentive to his own Person. The Straw on which he sleeps should be frequently dried;

and he should never spread it on damp Ground, when he can get Hurdles, Bark, Boards, Leaves, or any

other dry Substance to put under it. A Soldier should change his Shirt and Stockings once every two or

three Days: Though his Stock of Linen is small, a Shirt is soon washed. Little Attention is due to the

Colour, provided it be clean. Women are never wanting in a Camp for such Offices. A Man is seldom

aware of the Quantity of noxious Matter that comes through his own Skin and is deposited on his Shirt;

but if he takes up a Shirt that has been worn a few Days by another Person, he is frequently offended by

the disagreeable Smell.

These are some of the reasons why CLEANLINESS of every kind is necessary towards preserving Health

in an Army: They are Reasons which every Soldier may understand; but should he neglect to regulate

himself accordingly, the Regimental Surgeon will doubtless attend to the Neglect, and his Officers will

see that he does his Duty. For every Soldier by his Neglect not only endangers his own Life, but the Lives

of his Companions. Nature, or the God of Nature, has commanded, that men who live in Camps should be

cleanly: Whoever proves too obstinate, or too slothful to obey this Command, may expect to be punished

with Death, or suffer under some dangerous Disease.

W.

*Numb. 5. i. †Deut. 23 xii.

Fig. 1-1. The text of General George Washington’s broadside: Instructions for Soldiers in the Service of the United

States Concerning the Means of Preserving Health: Of Cleanliness. Source: Bayne-Jones S. The Evolution of Preventive Medicine in the United States Army, 1607–1939. Washington, DC: Office of the Surgeon General, Department of the

Army; 1968: 190–191.
Preventive Medicine and Command Authority—Leviticus to Schwarzkopf

7

terized as advisory, educational, inspectorial, investigational, and interventional. Focus was placed

equally on individual and community behavior in

attempting to prevent and control threats from disease, the natural environment, and food and water.

In the absence of scientifically grounded medical

knowledge, these efforts were based on pragmatic,

experiential, or ritualistic actions. Elements of these

practices can be found later in the successful military medicine that supported the Roman legions. A

strong case can be made for these five functions—

advice to leaders, education of unit members, inspection to ensure compliance, investigation of noncompliance, and intervention to protect the group—

as the continuing core functions of military preventive medicine.

COMMAND AUTHORITY AND PREVENTIVE MEDICINE IN AMERICAN MILITARY HISTORY

The Revolutionary War

During the 18th century, two outstanding English

surgeons general, Sir John Pringle3 and Dr. Richard

Brocklesby,4 drew on their own extensive experience

and that of van Swieten10 in Austria, among others,

to publish several books on military hygiene and

the preservation of the health of troops. The doctrine and practices described were known to George

Washington from his service in the colonial militia

alongside regular British troops during the French

and Indian Wars. Many of the American physicians

who provided the medical leadership during the

Revolutionary War had received their medical degrees from Edinburgh, read Brocklesby’s and van

Swieten’s books and knew Sir John Pringle personally. Thus from the beginnings of the republic, both

the commander in chief and the leading physicians

who served with him shared a view of the importance of preserving the health of troops and the fundamental responsibility of command at all levels to

accomplish this mission by relying on sound medical advice.

In his writings, Pringle addressed the officers as

well as the physicians because of his conviction that

the maintenance of the health of troops is the responsibility of command and, therefore, line officers. In addition, he noted that prevention cannot

be based on anything that a soldier can avoid but

must be governed by regulations and orders he is

required to obey. Each of Pringle’s themes appeared

in the publications of the leading American physicians during the Revolution. Dr. John Jones11 specifically referred to Pringle, and Dr. Benjamin Rush,

in Directions for Preserving the Health of Soldiers, addressed his book equally to Army line officers and

to physicians, while clearly stating that the health

of troops is a command responsibility.6 In a letter

they wrote to President John Adams, Rush and thenretired General Washington described the relationship of the physician general to the commander-inchief as having the closeness of a family member;

the physician general was an essential element of

the Army staff who should be aware of and concur

with all orders and plans for the Army.2

Recognition of the role of command authority in

preventive medicine is seen in many of Washington’s letters and general orders but is nowhere more

clearly indicated than in his decision in 1777 to order the inoculation of the entire Army against smallpox, describing it as “the greatest enemy to the

Continental Army.”2(p52) This decision was based on

the recommendation of his Physician in Chief, Dr.

John Morgan. Many historians point to the subsequently smallpox-free condition of the Continental

Army as a major contribution to winning the war.

Also of importance was the work of Baron von

Steuben, first Inspector General of the Continental

Army, who wrote and published, with Congressional approval, Regulations for the Order and Discipline of Troops of the United States12 in 1779. This

document contained many directions for the preservation of health and prevention of disease. Congressional approval made these legal regulations

that required compliance and execution by all

officers.

By the end of the American Revolutionary War,

then, nearly all the basic concerns of preventive

medicine had been identified and, in many cases,

made mandatory by the commander in chief and

the Congress:2(184–185)

• Responsibility of command for the health

of troops

• Medical officers as advisors to line officers

• Discipline

• Personal hygiene

• Diet and nutrition

• Clothing and shoes

• Threats from extreme heat, cold, fatigue,

and wetness

• Morale building and recreation

• Health education

• Immunization

• Environmental hygiene

° Location and design of campsites and
Military Preventive Medicine: Mobilization and Deployment, Volume 1

8

shelters

° Avoidance of crowding

° Sanitation of camps

° Disposal of excreta and waste

° Protection of water supplies

• Reduction of disease-transmitting human

contacts

• Rudimentary medical intelligence

Further progress depended on developments in the

biological and medical sciences during the late 19th

century and throughout the 20th century.

The Civil War

The relationship between command and military

preventive medicine during this period was

strongly influenced by the abysmal sanitation and

disease experience of the Mexican War (1846–1848)

and more directly by the British and French experience in the Crimea (1854–1856). Press reports made

these experiences common knowledge. In Britain,

the government responded by establishing the

Royal Sanitary Commission. This body was composed of leading civilians who exerted enormous

influence directly on commanders and their chief

medical officers, forcing the former to pay more

attention to medical advice. Equally important

among the commission’s work were the establishment of the specialty of Army Health in the British

Army; the publication of a new British Army regulation giving medical officers the power to advise

commanders on all matters pertaining to the health

of troops; the establishment of the Royal Army

Medical School in 1860, with specific courses of instruction in military hygiene; and the publication

of the sanitary history of the Crimean War, the first

medical war history published by a government.

Thus, at the outbreak of the American Civil War,

knowledge of these experiences and accomplishments was available and exerted a significant influence in the United States on government officials,

military leaders both medical and nonmedical, and

the general population.2(p89–92)

The incompetence of the US Army Medical Department in the earliest days of the war led President Lincoln to follow the British model and appoint the United States Sanitary Commission. The

Commission’s initially circumscribed inspectorial

and advisory powers rapidly expanded to true operational agency status, with the authority to conduct preventive services for the Army and authorization to communicate directly with the Surgeon

General, medical officers, commanders of troops at

all levels, the Secretary of War, and the President.

As evidence of its power, the Commission played a

major role in Congressional legislation directing the

reorganization of the Medical Department and

forcefully influencing the appointment of Lieutenant William A. Hammond as Surgeon General and

Surgeon Jonathan Letterman as Medical Director for

the Army of the Potomac.2(p102–104)

Among the myriad activities of the Commission,

several stand out. First was capturing the attention

of command, from the commander in chief down

to divisions in the field, concerning its responsibilities for the health of troops. Second was establishing the highly efficient Camp Inspection Service,

with a heavy emphasis on sanitation and hygiene.

Third was publishing material by distinguished

physicians and surgeons to educate both medical and nonmedical officers with such titles as

“Military Hygiene and Therapeutics,” “Rules for

Preserving the Health of Soldiers,” “Control and

Prevention of Infectious Diseases,” “Quinine as a

Prophylactic against Malarious Diseases,” and

“Scurvy.”2(p104) Each of these topics was recognized

as requiring medical advice and command action.

These publications introduced a new model for

health education and set the standard for several

decades.

Perhaps the most important action influenced by

the Commission was the appointment of LT

Hammond as Surgeon General in 1862. Enormously

talented, he attracted and appointed equally able

medical officers, such as Letterman, John Shaw Billings, and Joseph Janvier Woodward, each of whom

had proven ability to work well with field commanders. Hammond doubled the number of medical inspectors supervising sanitary matters, established the Army Medical Museum for educational

purposes, compiled and issued the pamphlets of the

Sanitary Commission, and established a comprehensive system of sanitary reports.

The command-directed and then Congressionally

dictated inoculation of troops against smallpox during the Revolutionary War continued during the Civil

War.A major medical innovation during the Civil War

was the official introduction of quinine sulphate as

prophylaxis for malaria. Recommended by the US

Sanitary Commission and enthusiastically promoted

by Hammond, oral quinine prophylaxis (given daily

as a whiskey bitters drink) was mandated by the command (Figure 1-2) and enforced by line officers. The

alcohol content reportedly made this a troop favorite.

During the Civil War, the initial chaos of mobilization was replaced by a military establishment within

which commanders were made to take responsibil-
Preventive Medicine and Command Authority—Leviticus to Schwarzkopf

9

Headquarters, Army of the Mississippi,

I UXA , AUGUST 25 T H , 1862.

GENERAL ORDERS,

NO. 117.

The season for billious and intermittent fevers in this region and

climate is at hand. The Medical Officers of this Army will, therefore, take

the most prompt and efficacious measures to counteract the effects of

malaria on our troops. To this end, their attention is again called to the

Circular of the Medical Director of the Department, dated, July 13th, 1862.

In addition to which, the following directions will be strictly carried out,

viz:

1st. All working parties will invariably be supplied with rations of

bitters, prepared as prescribed below, and to be given twice a day to the

individuals of each party under the direction of a commissioned officer

in quantities not to exceed half a gill at a time.

2nd. All guides and scouting-parties out at night, will, likewise, have

administered to them, under the direction of a Medical officer, a halfration of bitters. It will be given to them between Retreat and Tattoo.

3rd. The bitters to be issued, will be made, as follows:

96 grains of Sulp. Quinia,

100 " "Cinchinoa,

to each gallon of whisky; or, for each barrel of 40 gallons:

8 ounces of quinine,

13 " "Sulp. Cinchinoa;

this will make about thirteen hundred full rations.

4th. Medical Directors of Divisions will make prompt requisitions for

the necessary supplies to carry this Order into effect.

5th. Division, brigade and detachment commanders will see to the

execution of this order, and direct the issues under it to be accurately

stated in the weekly Sanitary and Inspection Report.

BY ORDER OF GENERAL ROSECHANS.

H.G. KENNETH,

Lieut.-Col and Chief of Staff

[OFFICIAL]

Fig. 1-2. Army of the Mississippi’s General Order No. 117 concerning the use of quinine bitters for the prevention of

malaria. Source: US Archives
Military Preventive Medicine: Mobilization and Deployment, Volume 1

10

ity for the health of troops and to accept the advice

of both the US Sanitary Commission and their own

military physicians. In spite of the fact that there

was still no scientific basis for preventive medicine

interventions and that disease remained the major

cause of morbidity and mortality in the military,

great improvements had been made. As reported

by Duncan,13 this experience was significantly better than that recorded during the Mexican War or by

the French in the Crimea, as is shown in Table 1-1.

Mexican War (United States)† 25 Apr 1846-5 Jul 1848 11,155 1,721 6.48:1

Crimean War (French) 1854-1856 70,000 7,500 9.33:1

Civil War (North) 15 Apr 1861-1 Aug 1865 199,720‡ 138,154 1.45:1

Danish War 1864

German 310 738 0.42:1

Danish 820 1,446 0.57:1

German War (German) 1866 5,219 4,008 1.30:1

Franco-Prussian War (German) 1870-1871 14,904 17,225 0.86:1

Russo-Turkish War 1877-1878 80,000 20,000 4.00:1

Sino-Japanese War (Japanese) 1894-1895 15,850 1,311 12.09:1

Spanish-American War 1 May 1898-31 Aug 1898 1,939 369 5.25:1

Philippine Insurrection Feb 1899-Dec 1902 4,356 1,061 4.11:1

Boer War (British) 1899-1901 11,377 6,425 1.77:1

War in Southwest Africa (German) 1904-1907 689 802 0.86:1

Russo-Japanese War 1904-1905

Japanese 21,802 58,257 0.37:1

Russian, less Port Arthur 18,830 23,008 0.82:1

World War I 1 Apr 1917-31 Dec 1918

Total United States Army 51,447 50,510§ 1.02:1

American Expeditionary Forces 16,951 50,105§ 0.34:1

World War II 7 Dec 1941-31 Dec 1945

Total United States Army 15,779 234,874 0.07:1

United States Army in Europe 1,779 135,576 0.01:1

*Includes deaths due to disease or nonbattle injury while captured or missing in action

†Data are derived in part from Historical Register and Dictionary of the United States Army, 1789-1903. Vol 2. Washington, DC: Government Printing Office;1903: 282, and are somewhat understated

‡

Includes disease deaths among the relatively small number of volunteers remaining in federal service subsequent to 1 Aug 1865

§

Includes gas casualties

Source: Communicable Diseases Transmitted Chiefly through Respiratory and Alimentary Tracts. Vol 4. In: Preventive Medicine in World

War II. Washington, DC: US Army Medical Department, Office of the Surgeon General; 1958: 11.

TABLE 1-1

DEATHS FROM DISEASE AND BATTLE DEATHS IN PRINCIPAL WARS, FOREIGN ARMIES

AND U.S. ARMY, 1846-1945

Ratio of deaths

from disease to

deaths from

battle injuries

War Date and wounds

Deaths from

Battle injuries

and wounds Disease *
Preventive Medicine and Command Authority—Leviticus to Schwarzkopf

11

World War I

The US military entered World War I better prepared from the preventive medicine standpoint than

at any other time in its history. Several factors produced this situation. The medical debacle of the

Spanish–American War, with typhoid fever outbreaks at many military camps causing extraordinary morbidity and mortality, focused attention on

these problems and led to governmental attention

in the post-war period. This resulted in Congressional legislation to reorganize the Army Medical

Department and empower it by giving it direct communication with the newly established Chief of Staff

and General Staff Corps.

More importantly, the emergence of medical microbiology, the growth of diagnostic laboratory capabilities, and the expanding understanding of vector-borne diseases (eg, malaria, yellow fever) and

disease causation in general provided the tools

needed for scientific military preventive medicine.

The success of the Army Medical School and the

Army Medical Research Board in Cuba, Puerto Rico,

and the Philippines led to the development of an

extraordinarily competent and experienced cadre

of military physicians. These physicians earned

national and international respect for their medical

research, thus greatly enhancing the status of military medicine and demonstrating to line officers the

potential contributions of military preventive medicine. New immunizations (eg, typhoid fever vaccine) and field hygiene innovations (eg, chlorination of water using the Lyster bag) from the Army

Medical School were matched by the publication

of outstanding manuals and textbooks of military

preventive medicine by Munson,14 Ashburn,15

Havard,16 Vedder,17 and Dunham.18

Against this background, most of the US Army

had developed significant field experience during

annual maneuvers beginning in 1910 and culminating in the 1916 expedition into Mexico led by General Pershing. Troop hygiene and health were excellent during the latter part of this period due to

the experience gained by commanders and their

supporting medical officers. So when the United

States entered the war in 1917, the operational experience of the past 7 years and the bioscientific and

medical knowledge base developed over the preceding 3 decades produced a highly competent and

ready force. The commanders who went to Europe

shared General Pershing’s view of the commander’s

responsibility for troop health and the essential role

of sound medical advice and technical expertise.

The Medical Department benefited not only from

the field experience and intimate staff relationships

of the preceding 7 years but also from the experiences of allied British and French forces during the

first 3 years of the war in Europe.

General Pershing set the tone for his expeditionary force by placing his chief surgeon and a small

group of medical officers on his general staff. This

intimate involvement of medical officers in all staff

actions and operational planning provided the essential foundation for command responsibility and

support for preventive medicine activities throughout the American Expeditionary Forces. Sanitary

inspections by medical officers, first established by

Surgeon General Lovell in 1818 and vigorously

employed by Surgeon General Hammond in the

Civil War, were reintroduced. The model for activities of sanitary inspectors had been developed during field exercises and the expedition into Mexico.

It was now implemented throughout the US Army

in the United States and Europe with exceptional

results—the health of the American Expeditionary

Forces was as good as that of troops in the United

States.

Perhaps the most important outcome of this period was the official recognition that the activities

of military preventive medicine extend well beyond

the limits of the Medical Department and are, in

fact, concerned with the administration of the whole

Army. This valuable lesson had been and continues to be difficult to learn and retain when the mission of military medicine seems to focus solely on

the hospital-based care of sick troops and combat

casualties. Military physicians are often the first to

forget this fundamental point and thus contribute

to the misunderstanding and ignorance of their line

officer colleagues.

Between the World Wars

The 2 decades preceding World War II saw enormous advances in microbiology and medical science

in general. Many of these emanated from ongoing

research at the Army Medical School and the overseas medical research boards. Perhaps more important was the broadening of epidemiology as a discipline in both civilian and military preventive

medicine. From focusing almost solely on infectious

disease and its causative agents, epidemiology expanded to encompass noncommunicable diseases,

with the recognition that host, environmental, occupational, cultural, and social factors are influential elements in health and disease. This broadened

scope fit the increasingly broad scope of military

operations and supporting activities as new
Military Preventive Medicine: Mobilization and Deployment, Volume 1

12

technologies were rapidly introduced into the

servicemembers’ environment.

Preventive medicine and public health educational resources, such as schools, courses, and institutes, increased rapidly during this period. Impressive also was the publication of many notable

textbooks for practitioners of preventive medicine

and the revisions of military preventive medicine

texts. Atabrine was introduced and tested as a quinine substitute for prophylaxis and treatment of

malaria. During this same time, sulforamides were

shown to cure and prevent many bacterial infections, thus expanding the concept of chemoprophylaxis.

World War II

The volumes published by the Army Medical

Department covering preventive medicine in World

War II are a rich source of information on the fundamental principles of military preventive medicine, which endure in spite of changes in the biomedical sciences. They should be read by anyone

seeking to become or claiming to be a specialist in

military preventive medicine. From them come two

major examples of command authority and preventive medicine—one successful and one not.

The successful example involves the control of

malaria in the Pacific theater of operations. Malaria

was incapacitating the US Army with attack rates

of 1,781 per 1,000 on Guadalcanal and 4,000 per

1,000 at Milne Bay. This led General MacArthur to

comment “This will be a long war if for every division facing the enemy I must count on a second division in hospital with malaria and a third division

convalescing....”19(p2) General MacArthur recognized not only the threat to his forces but also the

need to change the attitude of his subordinate commanders. This attitude was exemplified by a general officer with 40% of his troops incapacitated

with malaria who said playing with mosquitoes in

wartime was a waste of time while he was busy

preparing to fight. MacArthur grasped the basic

concepts: (a) command from highest to lowest levels must be educated about malaria and its prevention and understand that command authority must

be used to enforce malaria discipline; (b) there must

be a highly trained and competent malaria control

organization operating with the full support and

authority of the chain of command; and (c) malaria

control supplies, equipment, and personnel must

have a high priority for transportation ordered by

the command. MacArthur realized that technical

competence and advice of medical specialists was

essential, but command must recognize its responsibility and use its authority to accomplish this mission. The medical establishment acting alone will

fail. Recognition and application of these principles

greatly reduced the strategic medical threat from

malaria in this theater.

Cold injury has been recognized as a substantial

threat to troops, at least since the time of Napoleon,

and was even described in the armies of Alexander

the Great. The World War II volume entitled Cold

Injury—Ground Type20 provides lasting lessons on

this strategic medical threat, successful prevention

strategies, and painful examples of failures such as

occurred during the winter of 1944–1945 in Western Europe. The threat had been recognized by operational and medical staffs in 1943, but plans for

educating and training commanders and troops in

foot care were not implemented. While the planners recognized that cold weather uniforms and

footwear were essential to prevent a disaster, only

inadequate amounts of marginally acceptable items

were procured.

The price paid was 90,000 cold injury casualties,

with a preponderance among combat infantrymen—the equivalent of losing seven divisions of

riflemen at a time when no replacements were available. General Patton described the situation: “The

most serious menace confronting us today is not the

German Army, which we have practically destroyed, but the weather which, if we do not exert

ourselves, may well destroy us through the incidence of trench foot.”20(p168)

The knowledge was available and the threat had

been recognized, but neither the commanders nor

their staffs had been energized. This was partially

due to a failure in the relationships between commanders and their Chief Surgeons and medical

staffs. It was also attributable to the attitude engendered by the seeming total collapse of the German

forces and the rapid Allied advances that raised

hopes for a German surrender and an end to the

war before cold weather arrived. General Bradley

wrote after the war that in September he responded

to a crisis in supply and transport by deliberately

bypassing winter clothing in favor of ammunition

and gasoline.21 The command gambled and lost.

There is no evidence that the medical staff estimated

or presented the possible casualty numbers before

this apparently uncalculated risk was taken.

The Korean War

The Korean War is notable in that medical officers recognized the threats posed by infectious dis-
Preventive Medicine and Command Authority—Leviticus to Schwarzkopf

13

ease, such as malaria, and the environmental extremes of the Korean winters. Drawing on the recent lessons of World War II, malaria discipline was

successful, with commanders actively involved at

all levels.

In contrast, the first year in Korea saw a repetition of command ignoring medical advice about

cold injury, leading to devastating effects on improperly clothed, shod, and trained troops.22 After

the experience of the first chaotic year, the military

made significant improvements in the prevention

of cold injury in such areas as command and medical planning training, provision of appropriate uniforms, and enforcement of foot care down to the

individual level. In spite of these advances, the tactical situation frequently overcame the best prevention efforts, again taking a toll primarily on riflemen in forward exposed areas.

The Vietnam War

During the 12 years between Korea and the introduction of large US units into the Republic of

South Vietnam in 1965, many experienced preventive medicine officers left active duty, taking with

them hard-earned expertise. In addition, chloroquine-resistant falciparum malaria emerged, requiring renewed attention to basic malaria discipline.

Prophylaxis now required chloroquine–primaquine

on a weekly basis and Dapsone taken daily, thus

increasing the requirement for command supervision of compliance. Preventive medicine assets supported command supervision through urine testing of randomly selected field units to confirm the

presence of prophylactic drug metabolites.23

A highly significant example of command attention to preserving the health of soldiers can be

found in the experience of the 9th Infantry Division commanded by Major General Julian Ewell.

Operating in the inundated Mekong Delta area,

troops were continuously exposed to environmental conditions leading to bacterial and fungal skin

infections and warm-water immersion foot. General Ewell documented staggering losses from these

conditions among his riflemen—in some cases, reducing company strength by 50%.24

COL Alfred Allen in Skin Diseases in Vietnam,

1965–7225 documents the comprehensive preventive

medicine program of field research, field surveillance, training, and education brought to bear in

response to Ewell’s request for assistance. Appropriate prophylaxis and treatment helped, but the

major impact was achieved by gathering and presenting data related to the most significant problem—warm-water immersion foot. The data

showed that prevention depended on restricting

field operations to 48 hours of troop exposure, followed by a 24-hour drying period. General Ewell

implemented this policy through a command directive, holding subordinate commanders at each level

responsible for its vigorous implementation. In response, the rates of “paddy foot” and troop losses

declined significantly.

Operations Desert Shield and Desert Storm

The deployment of US Central Command forces

to the Saudi Arabian desert under the command of

General Norman Schwarzkopf raised the specter of

previous military operations in the same locale,

which were associated with large servicemember

losses because of disease and environmental conditions.26 Schwarzkopf’s force sustained the lowest

disease and nonbattle injury rates seen in US forces

during the 20th century (Figure 1-3).

This success was due in considerable measure to

the willingness of commanders at all levels to include in their deployment and campaign plans the

important medical threats and command policies

based on sound medical advice to control their impact. Well-prepared military preventive medicine

officers established essential surveillance activities

down to the battalion level to monitor preventable

disease. This allowed them to respond rapidly with

appropriate recommendations and essential interventions to control identified breakdowns and outbreaks.

Fig. 1-3. Disease and nonbattle injury rates in World War

II, Korea, Vietnam, Desert Shield, and Desert Storm,

showing the particularly low rates in Operations Desert

Shield and Storm (number of hospital admissions/1,000

soldiers/d). Source: Briefing slides, Office of the Surgeon

General, US Army, Washington, DC, 1992.

2.5

2

1.5

1

0.5

0

WW II Korea Vietnam Desert

Shield

Desert

Storm

Division

Nondivision

Combined
Military Preventive Medicine: Mobilization and Deployment, Volume 1

14

The success of these activities led to the Joint

Chiefs of Staff requirement that surveillance for preventable disease at the small-unit level be implemented in all future deployments of US forces.27 Preventive medicine activities during the subsequent

deployment of US forces to Somalia followed this

model of command recognition of responsibility for

preserving the health of servicemembers. The message reproduced in Figure 1-4 demonstrates the concern and attention of the Somalia Task Force commander to these issues. Again, command policies,

preventive medicine advice and surveillance, and

rapid investigation and intervention when outbreaks

occurred successfully preserved the fighting strength.

ADMINISTRATIVE MESSAGE

PRIORITY

P 08I621Z DEC 92 ZYB PSN 277700S23

FM CJIF SOMALIA//J–4/MED//

TO USCINCCENT MACDILL AFB FL//CCSG

CG FIRST FSSG// G-1// CG FIRST MARDIV//G-1//

CG THIRD MAW//G-1// FIRST SRI GROUP//S-1//

INFO BUMED WASHINGTON DC//JJJ// CMC WASHINGTON DC//MED//

COMMARFURPAC//G4/MED//

B T

UNCLAS //NO6200//

MSGID/GENADMIN/CG I MEF G4 MED//

SUBJ/COMMAND RESPONSIBILITIES IN MAINTAINING TROOP HEALTH//

RMKS/1. THE MEDICAL THREAT IN OPERATION PROVIDE HOPE IS

AMONG THE HIGHEST EVER FACED BY US FORCES, PROBABLY MUCH GREATER

THAN IN THE VIETNAM CONFLICT. THE PREVENTION OF FORCE DEGRADING ILLNESS IS A COMMAND RESPONSIBILITY.

2. PREVENTIVE MEDICINE PERSONNEL HAVE PROVIDED VERY SPECIFIC

RECOMMENDATIONS WHICH WILL PRESERVE COMBAT READINESS BY KEEPING PERSONNEL HEALTHY. IT IS UP TO INDIVIDUAL COMMANDERS TO

IMPLEMENT THESE RECOMMENDATIONS IN THE MOST AGGRESSIVE MANNER.

3. SPECIFICALLY, UNIT COMMANDERS ARE RESPONSIBLE TO INSURE

THE FOLLOWING:

A. ALL PERSONNEL ARE TO EXERCISE COMPLETE MALARIA AND

MOSQUITO DISCIPLINE, INCLUDING KEEPING SLEEVES DOWN AT ALL

TIMES, PROPER USE OF DEET INSECT REPELLENT ON ALL EXPOSED SKIN,

AND THE FULLEST USE OF BEDNETS. PERMETHRINE SPRAY SHOULD BE

ISSUED, AND ALL UNIFORMS AND BEDNETS SHOULD BE TREATED.

B. MALARIA MEDICATION WILL BE TAKEN AS PRESCRIBED, AND

MONITORED BY UNIT COMMAND STRUCTURE. IF MEFLOQUINE IS USED, IT

WILL BE TAKEN ON SUNDAYS BY ALL UNITS. IF DOXYCYLINE IS USED,

IT WILL BE TAKEN WITH THE MORNING MEAL BY ALL UNITS. ACCOUNTABILITY IS REQUIRED.

C. HAND WASHING AFTER USE OF LATRINE AND BEFORE MEALS

IS REQUIRED. UNIT LEADERS WILL INSURE THAT ALL TROOPS UNDERSTAND AND COMPLY WITH THIS REQUIREMENT. HAND-WASHING STATIONS

ARE TO BE PROVIDED AT THE EARLIEST POSSIBLE TIME. WHEN CHOW

HALLS ARE ESTABLISHED, NO TROOP WILL BE PERMITTED TO ENTER

WITHOUT WASHING HANDS. ENFORCEMENT IS REQUIRED.

D. ABSOLUTELY NO FOOD, WATER, OR ICE WILL BE CONSUMED

FROM THE LOCAL ECONOMY. FAILURE TO COMPLY WITH THIS RESTRICTION

CARRIES THE HIGH POTENTIAL OF EPIDEMIC DIARRHEA AND HEPATITIS.

UNIT COMMANDERS SHOULD INSURE THAT ALL TROOPS UNDERSTAND THE

TREMENDOUS THREAT ASSOCIATED WITH EATING FROM THE ECONOMY.

(Fig. 1-4 continues)
Preventive Medicine and Command Authority—Leviticus to Schwarzkopf

15

Fig. 1-4. The text of the Joint Task Force Somalia commander’s administrative message outlining the responsibilities

of unit commanders in maintaining their troops’ health. Source: Commander Joint Task Force Somalia. Command

Responsibilities in Maintaining Troop Health. Washington, DC: US Central Command; December 1992.

E. COMMANDERS WILL INSURE THAT HUMAN WASTE IS HANDLED

IN STRICT ACCORDANCE WITH PREVENTIVE MEDICINE RECOMMENDATIONS,

SPECIFICALLY, LATRINES ARE TO BE CONSTRUCTED AND MAINTAINED IN

FLY-PROOF CONDITION, TO PREVENT FLY CONTACT WITH HUMAN FECES

AND SUBSEQUENT DIARRHEA EPIDEMICS

F. WHEN CHOW HALLS ARE ESTABLISHED, THEY ARE TO BE

OPERATED IN FULL ACCORDANCE WITH PREVENTIVE MEDICINE RECOMMENDATIONS. AN IMPROPERLY RUN CHOW HALL CAN RESULT IN EPIDEMIC

DIARRHEA. THE PRIORITY ON “GETTING A HOT MEAL TO THE TROOP”

SHOULD AT NO TIME OVERRIDE PROPER PROCEDURES IN CHOW PREPARATION. INATTENTION IN THIS AREA HAS RESULTED IN MASSIVE EPIDEMIC DIARRHEA IN PAST OPERATIONS.

G. COMMANDERS WILL INSURE THAT HEAT INJURIES ARE PREVENTED BY ALLOWING A PERIOD OF ACCLIMATIZATION, ADJUSTING WORK

SCHEDULES TO AVOID THE HOTTEST PARTS OF THE DAY, AND ENFORCING

AGGRESSIVE WATER DRINKING (UP TO 1 CANTEEN PER HOUR).

H. HIV AND AIDS ARE EXTREMELY COMMON IN EAST AFRICA,

INCLUDING SOMALIA. PROSTITUTES ARE REPORTED TO BE 50% OR MORE

HIV INFECTED. COMMAND CLIMATE SHOULD ACTIVELY DISCOURAGE ANY

SEXUAL CONTACT WITH LOCAL PERSONNEL THROUGH POSITIVE LEADERSHIP AND EDUCATION.

4. PREVENTIVE MEDICINE PERSONNEL ARE AVAILABLE FOR UNIT

TRAINING. ALL TROOPS ARE TO BE THOROUGHLY BRIEFED AS EARLY AS

POSSIBLE IN THE EXERCISE, AND RE-BRIEFED AS NEEDED.

5. DISEASE AND INJURY TREND WILL BE AGGRESSIVELY MONITORED

THEATER-WIDE TO IDENTIFY PROBLEMS IMMEDIATELY AND TAKE CORRECTIVE ACTION. ACCURATE DISEASE REPORTING IS A HIGH INTEREST

ITEM.

B /

THE PREVENTIVE MEDICINE CONCEPT FOR COMMANDERS

The Commander’s Principal Staff and

Operational Planning

The preceding review presents a deceptively

simple picture that intentionally ignores the major

obstacles to preventive medicine and command interaction. It is imperative to identify these issues,

which originate both from commanders and their

staffs and from the military preventive medicine

personnel advising and supporting them.

Prevention activities lack the glamour and immediacy of saving the lives of combat casualties.

Prevention is focused on potential threats, requires

considerable investment of resources (eg, money,

personnel, supplies, equipment, time), and involves

modifications of behavior by units and individuals. And if prevention is successful, nothing happens. In this situation, the command emphasis

required for successful prevention programs may

easily be replaced by command resistance.

Commanders and their principal staff officers—

chief of staff, G/J1 Personnel, G/J2 Intelligence, G/

J3 Operations, G/J4 Logistics—may be ignorant of

the historical impact of medical threats. They may

not have been exposed earlier in their careers to

military medical officers with competence in and

understanding of military preventive medicine.

Common attitudes of staff are reflected in the statements “If it ain’t broke, don’t fix it” and “Come back

when there is a clear need or problem, Doc.” Of

course by the time it is “broke” or the need is clear,

it is too late for prevention. Other attitudes focus

on the dangers of death or dismemberment in combat and ridicule efforts to maintain health and prevent disease. Another negative attitude is reflected

in using operational security (OPSEC or the “need

to know”) considerations to avoid sharing essential mission information and intelligence with medical staff sections. Commanders foster these attitudes

and exacerbate the obstacles to successful preven-
Military Preventive Medicine: Mobilization and Deployment, Volume 1

16

tive medicine programs if they do not provide emphasis and support for these activities through both

personal and corporate behavior.

Commanders can make preventive medicine a

part of their daily personal behavior and a consistently

high-ranked item on the list of things they vigorously

check on. From a corporate standpoint, commanders

can make clear to their senior staff and subordinate

commanders the importance they attach to having

preventive medicine involvement in all aspects of

operational planning and mission execution. The

commander’s model should include centralized

planning and decentralized execution, with priority for resources given to combat units. Subordinate

commanders must be given adequate resources so

they can make prevention work. Good data gathering systems are required to enable the commander

to constantly check up on this area and to have a

basis for rewarding success and punishing failure.

As important as these command-centered problems are the barriers to successful preventive medicine from within the medical staff. Preventive medicine is the reverse of the usual clinical medicine

paradigm where the individual patient goes or is

taken to the provider of care. In preventive medicine, the provider and the intervention must go to

the “patient,” who in this case is the military unit.

Some medical personnel, while they have excellent

clinical skills, have only the most rudimentary understanding of preventive medicine in general and

of military preventive medicine in particular. This

lack of understanding may be matched by a similarly abysmal lack of knowledge of or experience

in nonmedical military matters, such as military

planning, the operational environment, and the

functioning of military organizations.

Medical staff sections must establish strong relationships with all nonmedical principal staff well

before planning for a major military operation

starts. The medical personnel must be able to recognize the essential elements of the operational plan

options being developed. They can then provide

information early in the planning process regarding possible medical threats and estimates of their

impact on the force and mission accomplishment.

Military preventive medicine officers must participate in the planning process by proactively coordinating with the Personnel, Intelligence, Operations,

and Logistics staff sections; they must not remain

confined with the Medical Staff section. They must

bring to bear knowledge of the history of successes

and failures in military preventive medicine and a

detailed technical knowledge of all the elements of

the multi-disciplinary preventive medicine team.

The point must be clearly made that no war has

been won because one side had the superior medical treatment and casualty care capability, but

throughout military history, battles and entire campaigns have been lost because of the impact of preventable disease. Preventive medicine also has a

role in reducing other types of medical threats. Of

equal importance is the education of commanders and

staff officers, both nonmedical and medical, that preventive medicine plays a major, officially recognized

role in health hazard assessment of weapons systems;

transportation platforms; toxicity of fuels, propellants, and obscurants; and changes in operational

doctrine that cause potential decrements in servicemember performance (eg, continuous operations).

A similar role for preventive medicine is also defined within force protection programs, which have

become a major focus during post–Cold War military deployments and operations.

Recognition of the staff and command context

within which preventive medicine activities affect a

specific operational plan is as important as skill in and

technical knowledge of preventive medicine and military operational planning. During a recent multinational military exercise in the United States, the

medical threat from the tick vector of Lyme disease

was identified. One allied force ordered permethrin

for treating field uniforms after arrival in the United

States. The G4 (Logistics) executed the order, which

was delivered exactly on time and rapidly distributed

to the allied force. However, there had been no coordination with the G3 (Operations) and G1 (Personnel) staff sections, and thus no time was allowed in

the exercise schedule for training troops in the use of

permethrin, nor was there time or a suitable area for

application. Very few troops accomplished even partial treatment of one of their three field uniforms. A

high percentage of the force sustained tick bites, and

more than 24 cases of Lyme disease were diagnosed.28

Even with recognition of the threat and appropriate

procurement and distribution, prevention may fail if

the actual implementation is not completely coordinated with each staff section, integrated into the operational plan, and understood by commanders and

leaders at all levels.

The Medical Threat Estimate

The fundamental planning tool for medical staffs

in general and preventive medicine officers in particular is the medical threat estimate. Appropriate

analysis and development of the medical threat estimate provide the basis for interaction with the principle staff sections as the operational plan is developed.
Preventive Medicine and Command Authority—Leviticus to Schwarzkopf

17

All staff planning activity, including medical, fundamentally starts with the commander’s mission

statement and the operational options being considered by the staff to accomplish this mission. For each

option considered, there should be an estimate of supportability from each staff section. For the medical

staff, this begins with the generic elements of the medical threat, as documented in Joint Publication 4-02,

Doctrine for Health Service Support in Joint Operations,

1994.

29 These elements, as shown in Exhibit 1-1, are

used in making an assessment of medical threats that

potentially apply to the specific operational setting

and are a composite of ongoing or potential enemy

action and environmental conditions that could reduce the operational effectiveness of military units.

The medical threat assessment is then applied to

each of the operational planning options under consideration. An estimate is made of the potential

threat to the health of the force and mission accomplishment: first, if policies and programs are not

implemented for maximum reduction and control

of these threats and, second, if policies and programs are given appropriate resources, integrated

into the operational plan, and supported by command at all levels. This medical threat estimate must

be developed in close consultation with each principle staff section, and cost-benefit estimates should

be made before the estimate is presented to command as part of the decision package. This process

is outlined in Exhibit 1-2.

An essential element of both the medical threat

assessment and the medical threat estimate is the absolute requirement for consistent and accurate medical reporting, sick-call surveillance, and rapid investigation of any breakdowns in program execution or

outbreaks of disease. All of this must be

accomplished within all units of the command, reaching down to the battalion or company level. Routine

hospital reports will not accomplish this goal.

Only by having these tools at hand can the commander make informed choices during the planning

process based on a sound estimate of the medical

threats, the policies and programs to counter the

threats, and the data gathering requirements for monitoring and rewarding success and identifying and

correcting failure.

EXHIBIT 1-1

THE MEDICAL THREAT: GENERIC ELEMENTS TO CONSIDER IN REGULAR

OPERATIONS AND OPERATIONS OTHER THAN WAR

Elements of Regular Military Operations

• Infectious disease • Directed energy weapons

• Extremes of environment • Blast effect weapons

• Conventional munitions • Flame and incendiary weapons

• Biological weapons • Mobilization, deployment, and battle stress

• Chemical weapons • Nuclear weapons

Elements of Operations Other Than War

• Medical threats to the indigenous population

• General stability of the country (eg, social, political, economic, security), within which the operation is

conducted

• Specific type of military operation

• Scenarios for use of force

• Application of Geneva Convention protection

• Logistical support, host-nation infrastructure, and other support considerations

Adapted from: Doctrine for Health Service Support in Joint Operations. Joint Staff: Washington, DC; 15 November 1994: A-1

through A-7. Joint Publication 4-02.
Military Preventive Medicine: Mobilization and Deployment, Volume 1

18

EXHIBIT 1-2

THE MEDICAL THREAT ESTIMATE PROCESS

1. Identify the medical threat categories that apply to the military operation being planned.

2. Assess within these medical threat categories, the specific threats that may be encountered. Rank these

within each threat category (eg, disease, environmental) by probable time of occurrence (before, early in,

during, or after deployment). This results in a prioritized medical threat assessment.

3. Apply this medical threat assessment to each of the operational planning options. Estimate the potential

impact on the force and mission accomplishment in both the absence and presence of appropriate command policies, programs, and resource commitments for threat reduction. This is the medical threat estimate; it provides the command with decision-making information regarding operational plan options and

costs for threat reduction.

Source: Medical Threat Estimate. Bethesda, Md: Department of Military and Emergency Medicine and Department of Preventive Medicine and Biometrics, Uniformed Services University of the Health Sciences; 1995. PMO580.

SUMMARY

The core functions of military preventive medicine have remained constant from the book of

Leviticus to the present. So too has the inescapable

relationship between preventive medicine and command authority. Obstacles exist to the successful development of these relationships, from both the nonmedical and the medical points of view, but they

can be overcome. The medical threat estimate can

be used as a tool and a process for integrating preventive medicine into the military planning process.

This chapter and the rest of this text are dedicated

to assisting military preventive medicine officers in

their efforts to support the commanders, who are

responsible for the health of their commands, by

providing them the means to gain command of

health.

REFERENCES

1. Legters LJ, Llewellyn CH. Military medicine. In: Last JM, Wallace FB, eds. Maxcy-Rosenau-Last Public Health and

Preventive Medicine. 13th ed. Norwalk, Conn: Appleton & Lange; 1992: Chap 71.

2. Bayne-Jones S. The Evolution of Preventive Medicine in the United States Army, 1607–1939. Washington, DC: Office

of the Surgeon General, Department of the Army; 1968.

3. Pringle J. Observations on the Diseases of the Army in Camp and Garrison. London: A. Millar, D. Wilson, T. Payne;1752.

4. Brocklesby R. Oeconomical and Medical Observations, in Two Parts, from the Year 1758 to the Year 1763, Inclusive.

Tending to the Improvement of Military Hospitals and to the Cure of Camp Diseases Incident to Soldiers. London: T.

Becket and P.A. DeHoudt; 1764.

5. Munro D. An Account of the Diseases Which Were Most Frequent in the British Military Hospitals in Germany from

1761 to 1763. London: A. Millar, D. Wilson, T. Durham, and T. Payne; 1764.

6. Rush B. Directions for Preserving the Health of Soldiers. Recommended to the Consideration of the Officers of the Army

of the United States. Published by Order of the Board of War. Lancaster: John Dunlap; 1778.

7. Tilton J. Economical Observations on Military Hospitals; and the Prevention and Cure of Diseases Incident to an Army.

Wilmington, Del: J. Wilson; 1813.

8. Wood P. Moses, the Founder of Preventive Medicine. New York: The Macmillan Co; 1920.

9. Garrison FH. Notes on the History of Military Medicine. Washington, DC: Association of Military Surgeons, 1922.

Reprinted from: Mil Surg. 1921–1922, Vols 49–51.
Preventive Medicine and Command Authority—Leviticus to Schwarzkopf

19

10. van Swietan G. A Short Account of the Most Common Diseases Incident to Armies. 2nd ed. London: T. Becket and

P.A. DeHonde; 1767.

11. Jones J. Plain Concise Practical Remarks on the Treatment of Wounds and Fracture. Philadelphia: R. Bell; 1776.

12. von Steuben F. US Inspector General’s Office: Regulations for the Order and Discipline of the Troops of the United

States. Part I. Philadelphia: Stuver and Cest; 1779.

13. Duncan LC. The comparative mortality of disease and battle casualties in the historic wars of the world. J Mil

Serv Inst US. 1914;54:140–177.

14. Munson EL. The Theory and Practice of Military Hygiene. New York: William Wood and Co; 1901.

15. Ashburn PM. The Elements of Military Hygiene: Especially Arranged for Officers and Men of the Line. 2nd ed.

Boston: Houghton Mifflin Co; 1915.

16. Havard V. Manual of Military Hygiene for the Military Services of the United States. New York: William Wood and

Co; 1917.

17. Vedder EB. Sanitation for Medical Officers. Medical War Manual No. 1. Authorized by the Secretary of War and Under the

Supervision of the Surgeon-General and the Council of National Defense. 2nd ed. Philadelphia: Lea & Febiger; 1918.

18. Dunham GC. Military Preventive Medicine. 3rd ed. Carlisle Barracks, Penn: Medical Field Service School; 1938.

19. Hoff EC, ed. Communicable Diseases: Malaria. Vol 6. In: Preventive Medicine in World War II. Washington, DC:

Office of the Surgeon General, Department of the Army; 1963.

20. Whayne TF, DeBakey ME. Cold Injury, Ground Type. Washington, DC: Office of the Surgeon General, Department of the Army; 1958.

21. Bradley ON. A Soldier’s Story. New York: Henry Holland Co; 1951.

22. Cowdrey AE. The Medic’s War. In: United States Army in the Korean War. Washington, DC: Center of Military

History, US Army; 1987.

23. Neel S. Medical Support of the U.S. Army in Vietnam 1965–1970. In: Vietnam Studies. Washington, DC: Center of

Military History, Department of the Army; 1973.

24. Ewell JJ, Hunt IA. Sharpening the Combat Edge. In: Vietnam Studies. Washington, DC: Center of Military History,

Department of the Army; 1974.

25. Allen AM. Skin Diseases in Vietnam, 1965–72. Vol 1. In: Internal Medicine in Vietnam. Washington, DC: Office of

the Surgeon General and Center of Military History, US Army; 1977.

26. Scales RH. Certain Victory. The U.S. Army in the Gulf War. Brassey’s: Washington, DC; 1994: 80, 121.

27. Department of Defense. Joint Medical Surveillance. Washington, DC: DoD; 1997. DoD Directive 6490.2.

28. Royal Army Medical Corps Preventive Medicine presentation. Presented at: Royal Society of Medicine United

Services Section Meeting; 1996; London.

29. Joint Chiefs of Staff. Doctrine for Health Service Support in Joint Operations. Joint Staff: Washington, DC; 15 November 1994. Joint Publication 4-02.