Report to the Chairman, Subcommittee

on National Security, Veterans Affairs,

and International Relations, Committee

on Government Reform,

House of Representatives

United States General Accounting Office

GAO

October 2001 CHEMICAL AND

BIOLOGICAL

DEFENSE

DOD Needs to Clarify

Expectations for

Medical Readiness

GAO-02-38
Page i GAO-02-38 Chemical and Biological Medical Readiness

Letter 1

Results in Brief 2

Background 4

Scope and Methodology 8

DOD and the Services Have Not Systematically Reviewed the

Adequacy of the Medical Specialist Mix for the Treatment of CB

Casualties 9

Levels of Training, Testing, and Exercising for Medical

Management of CB Casualties Remain Low 19

Conclusions and Recommendations 36

Agency Comments and Our Evaluation 38

Appendix I Specific Signs, Symptoms, Diagnoses, and Treatment

for Some Common Chemical and Biological Agents 41

Appendix II General Distinguishing Features of Chemical and

Biological Terrorism 43

Appendix III U.S. Military CB Warfare Medical Training Summary

Tables, Fiscal Years 1997–2000 44

Appendix IV Comments From the Department of Defense 46

Appendix V GAO Contacts and Staff Acknowledgments 49

GAO Contacts 49

Staff Acknowledgments 49

Related GAO Products 50

Tables

Table 1: Military Officers and Enlisted Personnel Trained in

Courses on CB Medical Treatment, Fiscal Years 1997–2000 22

Contents
Page ii GAO-02-38 Chemical and Biological Medical Readiness

Table 2: Fiscal Years 1997–2000 4-Year Medical Personnel CB

Warfare Training Totals as a Percentage of Fiscal Year

2000 End Strength 26

Table 3: Officers and Enlisted Personnel Trained in MCBC Courses,

Fiscal Years 1997–2000 44

Table 4: Officers and Enlisted Personnel Trained in FCBC Since

Fiscal Year 1999 44

Table 5: USAMRIID Biological Warfare Satellite Broadcasts, Fiscal

Years 1997–2000 44

Table 6: Military Health Service Total End Strength, Fiscal Year

1999 45

Figures

Figure 1: Proficiency Measures From the Army Study Medical

Training 2000, Slide from Medic Training 2000 Briefing

Presented by Major General James B. Peake 29

Figure 2: Numbers of Planned CINC Exercises, Fiscal Years 1993–

2005 34
Page iii GAO-02-38 Chemical and Biological Medical Readiness

Abbreviations

ASD-HA Assistant Secretary of Defense for Health Affairs

CB chemical and biological

CBW chemical and biological warfare

CBO Congressional Budget Office

CMRT Continuing Medical Readiness Training

CINC Unified Commander in Chief

CREST Casualty and Resource Estimation Tool

CUD Common User Database

DOD Department of Defense

FCBC Field Management of Chemical and Biological Casualties

JCAHO Joint Commission on the Accreditation of Healthcare

Organizations

JRCAB Joint Readiness Clinical Advisory Board

JSCAP Joint Strategic Capabilities Plan

MAT Medical Analysis Tool

MCBC Medical Management of Chemical and Biological Casualties

NBC nuclear, biological, and chemical

OEP Office of Emergency Preparedness

PACOM U.S. Pacific Command

TAA Total Army Analysis

THCSRR Total Health Care Support Readiness Requirement

USAMRICD U.S. Army Medical Research Institute of Chemical Defense

USAMRIID U.S. Army Medical Research Institute for Infectious

Diseases

USFK U.S. Forces Korea

WMD weapons of mass destruction
Page 1 GAO-02-38 Chemical and Biological Medical Readiness

October 19, 2001

The Honorable Christopher Shays

Chairman, Subcommittee on National Security,

 Veterans Affairs, and International Relations

Committee on Government Reform

House of Representatives

Dear Mr. Chairman:

The U.S. strategy against chemical and biological (CB) weapons is based

largely on deterrence. In the event deterrence fails, medical response

planning will be essential. However, following the 1991 Gulf War, reviews

that we and the Inspector General of the U.S. Department of Defense

(DOD) completed in 1992 and 1993 identified a number of shortcomings in

DOD’s capacity to provide medical support for the numbers of

contaminated casualties that were predicted, and in 1996 we found that

many of the problems identified in these reports persisted.1

 In the 10 years

since Desert Storm, DOD has implemented a mandatory immunization

program for anthrax, but, despite statements from defense officials

emphasizing the seriousness of these threats, questions remain about

DOD’s overall medical readiness for the full array of chemical and

biological warfare threats that have been identified. The attack on the

United States, on September 11, 2001, underscores the need for medical

readiness should deterrence fail.

You asked us specifically to determine how DOD has adapted its medical

corps to emerging CB threats. As we agreed with your office, our

objectives in this review were to assess (1) the efforts of DOD and the

services to incorporate CB threats in medical personnel planning and to

 1

Operation Desert Storm: Full Army Medical Capability Not Achieved

(GAO/NSIAD-92-175, Oct. 18, 1992); Operation Desert Storm: Problems With Air Force

Medical Readiness (GAO/NSIAD-94-58, Dec. 30, 1993); Operation Desert Storm:

Improvements Required in the Navy’s Wartime Medical Care Program

(GAO/NSIAD-93-189, July 28, 1993); Chemical and Biological Defense: Emphasis Remains

Insufficient to Resolve Continuing Problems (GAO/NSIAD-96-103, Mar. 29, 1996); and

Inspector General, DOD, Medical Mobilization Planning and Execution (93-INS-13, Sept.

30, 1993).

United States General Accounting Office

Washington, DC 20548
Page 2 GAO-02-38 Chemical and Biological Medical Readiness

adapt its medical specialty mix accordingly and (2) the extent of medical

personnel training in the treatment of CB casualties.

Public assessments by defense officials have emphasized the seriousness

of the military threat from chemical and biological weapons. However, we

found that neither DOD nor the services have systematically examined the

adequacy of the current specialty mix of medical personnel for chemical

and biological defense. While some of the services have begun to review

the staffing of deployable medical units for the capacity to manage the

consequences of certain chemical warfare scenarios, they have not done

so for biological warfare scenarios. In general, DOD has not successfully

adapted its conventional medical planning to CB warfare. For example,

the software, evaluations, and review processes it used in medical

planning did not incorporate these threats as they did conventional ones,

and they have lacked the information on casualty rates or qualified care

providers required to address the appropriateness of the current mix of

expertise and competencies.

Although joint protocols for treating CB casualties have recently been

completed, as recommended by DOD studies, agreement has not been

reached among the services on which health care providers are

appropriate to provide treatment. DOD officials attributed the weakness of

CB medical planning to several factors, including failure to establish this

as a medical priority in Defense Planning Guidance (particularly for

biological warfare), data and methodological constraints that complicated

the task, disagreements among the services about the capacity to

implement evacuation policy, and pessimism that medical support could

effectively treat substantial numbers of CB casualties. Joint, unified

command, and service planners charged with addressing these issues all

expressed frustration with inaction on the part of others. In particular, the

medical planners for the unified commands stated that, in the absence of

better planning support from the services, they had reluctantly adopted a

rough method of estimating the medical support required for CB

scenarios—applying a fixed multiplier to the support required for

conventional ones. This method presumes that the individual medical

units currently possess the appropriate mix of health care providers.

Relatively few military health care providers are trained to a standard of

proficiency in providing care to CB casualties. Service medical planning

officials generally maintained that their medical units had to be prepared

to handle a broad range of casualties and that even specialists would have

to serve as generalists when they were in theater. They believed that

Results in Brief
Page 3 GAO-02-38 Chemical and Biological Medical Readiness

specialized military medical training was the appropriate way to address

any additional medical skills needed to deal with CB casualties rather than

adjusting the mix of health care specialists. However, while progress has

been made since the Gulf War in increasing the availability of such

specialized training, these courses are essentially voluntary. On the basis

of the number of students who have taken the various courses, we found

that no more than 19 percent of uniformed health services personnel had

completed any specialized CB military medical training. No more than 2.2

percent of medical officers had completed the full 7-day course in the

Medical Management of Chemical and Biological Casualties. Even the

individuals who have been trained cannot be readily identified in the event

of an emergency because either the tracking systems do not exist or they

are not currently functioning. Except for the Army’s Medic 2000 study,

which found that the lowest proficiency scores among medics were for

nuclear, biological, and chemical (NBC) skills, the services have not

rigorously tested proficiency in assessing and treating CB warfare

casualties. This study and other indirect evidence indicate that proficiency

is low, partly because of weak or absent requirements for training, testing,

and certification.

Although the service surgeons general have begun integrating chemical

and a few biological scenarios into their medical exercises, medical

planners from each of the five regional unified commands told us that to

their knowledge no realistic field exercise of medical support for chemical

or biological warfare had been conducted. Additional data provided by

DOD showed that only two joint military exercises planned since 1993 had

included both medical response and chemical or biological warfare.

Similarly, key readiness evaluations used to advise the President on

readiness to implement the national security strategy had never set a

scenario for the unified commanders requiring medical support for

weapons of mass destruction. Officials told us CB medical support is

rarely exercised because of conflicting priorities encountered by both

warfighters and medical staff and because it is very difficult and

expensive.

In sum, DOD and the services had not fully addressed weaknesses and

gaps in modeling, planning, training, tracking, or proficiency testing for the

treatment of CB casualties. The resulting medical structure has not been

rigorously tested for its capacity to deliver the required medical support.

As a consequence, medical readiness for CB scenarios cannot be ensured.

The persistence of this situation suggests a disagreement about the

significance of the threat, a failure of leadership, or an acceptance of a

high level of risk.
Page 4 GAO-02-38 Chemical and Biological Medical Readiness

We recommend that the Secretary of Defense address the gap between the

stated CB threat and the current level of medical readiness by clarifying

DOD’s expectations regarding medical preparation for CB contingencies

and, as appropriate, integrating chemical and biological medical readiness

in Defense Planning Guidance. To the extent that DOD continues to regard

CB threats as serious in its areas of operations and expects its medical

forces to prepare for them, the Secretary of Defense should require that

the services and joint staff agree on evacuation capacity and the medical

providers qualified to provide specific wartime care, develop joint

planning models that include CB scenarios, develop training requirements

and assess their effectiveness with proficiency metrics and standards,

develop and maintain the systems to track CB training and proficiency,

and increase the realistic exercise of medical support for both chemical

and biological scenarios. DOD has reviewed a draft of this report. It

concurred with the recommendations and provided additional comments.

DOD officials and U.S. government reports have stated that CB warfare

must be considered a potential threat in future conflicts. Any reshaping of

the military medical force to respond to CB threats would occur in a

context including (1) a broad variety of CB agents that could produce a

range of effects from minor irritations to mass casualties and (2) a dual

medical mission with tensions between the needs of day-to-day peacetime

care and wartime operations. Within these constraints, the joint staff of

the Office of the Secretary of Defense and the services play distinct but

interrelated roles in ensuring medical readiness. The tools available to

them for this purpose include various types of training and exercises.

In June 1995, Presidential Decision Directive 39 declared that “the United

States shall give the highest priority to developing effective capabilities to

detect, prevent, defeat and manage the consequences of nuclear,

biological or chemical (NBC) materials or weapons use by terrorists.” The

former Secretary of Defense further emphasized at his confirmation

hearing in January 1997 that U.S. forces in theater face the threat of

chemical and biological weapons:

“I believe the proliferation of weapons of mass destruction presents the greatest threat that

the world has ever known. We are finding more and more countries who are acquiring

technology—not only missile technology—and are developing chemical weapons and

biological weapons capabilities to be used in theater and also on a long-range basis. So I

think that is perhaps the greatest threat that any of us will face in the coming years.”

Background

High-Level Officials Have

Emphasized the

Seriousness of CB Threats
Page 5 GAO-02-38 Chemical and Biological Medical Readiness

In 1998, the Chairman of the Joint Staff issued Master Plan Exercise

Guidance that identified NBC defense and force protection as his top

training issues, and DOD began its much-publicized Anthrax Vaccine

Inoculation Program. In fiscal year 2001, the budget for the Defense Health

Program, which includes financing for both peacetime and deployment

care, was approximately $18.2 billion. The President’s Budget Request for

the Chemical and Biological Defense Program was $836 million, an

increase from the $791 million in total obligations for fiscal year 2000.2 The

Defense Health Program budget for fiscal year 2000 incorporated at least

$137 million for medical training.3

 The Army Medical Department’s NBC

Defense Readiness Program uses about $17 million annually in operation

and maintenance funds to purchase countermeasures and provide

supplemental support for exercises and training of medical units for NBC.

Anticipating the medical personnel needs associated with chemical and

biological warfare is complicated by the wide array of such agents, the

differences in their effects, and the variety of ways they might be used.

The physiological effects of specific agents identified as potential threats

are extremely varied, as detailed in appendix I. In general, a chemical

attack would typically result in illness quickly, whereas biological agents

could result in illnesses with delayed onset. The distribution of victims

would usually be limited to the area downwind from a chemical attack but

could be more widely spread for contagious biological agents. First

responders to a chemical attack on a battlefield or in a war zone would be

soldiers, medics and corpsmen, but because of the delayed effects, the

first responders to a biological attack on military personnel in a war zone

would more likely be sick-call physicians. (See appendix II.)

Not only must medical personnel requirements be tailored to cover a

variety of potential threats; they must also be coordinated with the

medical personnel requirements of day-to-day care for military personnel,

dependents, and retirees. The military medical service has historically had

 2

Fiscal year 2000 funding data are based on total obligation authority. According to Army

Medical Department officials, this is the source for most CB warfare training funds. See

DOD, Chemical and Biological Defense Program: Annual Report to Congress, March

2000 (Washington, D.C.: 2000).

3

Additional amounts were used to support the Uniformed Services University of the Health

Sciences and to finance the Health Professional Loan Program that provides scholarships

to medical personnel in exchange for military service.

The Threat Is Composed of

Varied Agents

The Dual Medical Mission

Complicates Planning
Page 6 GAO-02-38 Chemical and Biological Medical Readiness

a dual mission—supporting the force during deployments and providing a

health care benefit to DOD personnel and their dependents. Some

mismatch naturally exists between the skills required by wartime and

peacetime care.4

 For example, some of the services most used by DOD

beneficiaries in peacetime, such as obstetrical care, are not likely to be in

high demand by a deployed force. Military surgeons train for wartime

inpatient care but currently practice mostly outpatient and pediatric care.

Similarly, the skills required for responding to a chemical or biological

attack may not be naturally encompassed in the demands of a peacetime

health care service. This is important insofar as any skills that are uniquely

required in wartime must be sustained in the absence of much direct use.5

Defense planning is led by the Office of the Secretary of Defense, which

sets overall policy and develops Defense Planning Guidance that is based

on the President’s national security strategy. Every 2 years, the Joint

Chiefs issue a Joint Strategic Capabilities Plan (JSCAP) based on this

formal guidance that gives missions to the nation’s unified combat

commands which have operational control of U.S. combat forces. Each

command is headed by a Commander-in-Chief (CINC). They are

responsible for fighting and winning the nation’s wars within a particular

area of responsibility, usually geographic. The CINCs develop war plans

and requirements that specify the combat troops that will be needed to

meet the threat and mission assigned by the JSCAP.

 4

See W. M. Hix and S. Hosek, Elements of Change in Military Medical Force Structure: A

White Paper (Santa Monica, Calif. RAND, 1992), and Congressional Budget Office,

Restructuring Military Medical Care (Washington, D.C.: July 1995). For example, CBO

reported that “the care furnished in military medical centers and hospitals in peacetime

bears little relation to many of the diseases and injuries that medical personnel need to be

trained to deal with in wartime.”

5

The services have handled this mismatch historically by developing substitution rules to

determine which peacetime specialties can be employed to fulfill the various wartime

medical needs. For example, the Navy permits obstetricians to fill certain field surgical

positions because it must meet the need for fully qualified obstetricians in peacetime, and

Navy medical officials told us that these specialists are familiar with basic abdominal

surgery. However, the risk of such substitutions is not clear, and service officials identified

no formal process for determining their effect on standards of care. Recognizing that not all

physician specialties are substitutable, a study of medical requirements by DOD’s Office of

Planning, Analysis, and Evaluation recommended a follow-on effort to determine the mix

of physician skills required to support the wartime effort, in order to ensure that adequate

care is provided. See DOD, Office of Planning, Analysis, and Evaluation, 733 Update

Wartime Medical Report (Washington, D.C.: July 24, 1997), p. ESii.

Department, Joint Staff,

and Services Play Different

Roles in Ensuring Medical

Readiness
Page 7 GAO-02-38 Chemical and Biological Medical Readiness

Each service then calculates the additional number of troops it will need

to support the combat force. The total number of combat and support

troops determines the military population at risk. On the basis of the

threat, the population at risk, and previously developed doctrine, the

service medical planners project the required hospital and unit

assignments. Each of the services has the responsibility to work within the

budget identified by DOD to train and equip its forces and to staff the

needs identified by the CINCs. Specifically, in the context of medical

readiness, the services are responsible for ensuring that individuals and

units can perform the functions (such as medical assistance) to which they

are assigned.

The CINCs then review the services’ plans for filling their needs. For

example, a CINC medical planner would review the adequacy of service

components’ plans for medical support and would integrate their logistical

requirements. The Joint Staff helps the CINCs resolve any readiness

problems discovered in the context of the Joint Monthly Readiness Review

or through other means. Any systemic problems or shortfalls in readiness

the CINCs note are brought to the attention of the joint staff for medical

planning (J4), which works to resolve them. Finally, DOD finances the

services and reviews service expenditures (including those on medical

personnel and services).

The services and CINCs address their responsibilities to ensure readiness

partly through training and exercises. Training can be provided either to

individuals or units, and exercises are of several types, including (1)

tabletop exercises that test decision making in response to a single

problem; (2) command post exercises, in which multiple decision makers

respond to dynamic scenarios; and (3) full field exercises, in which

opposing armies compete to simulate a range of activities from combat to

medical response. Tabletop and command-post exercises are useful to the

extent that they identify important policy and operational issues, but they

do not demonstrate actual ability to provide effective medical care in a

forward setting. Field exercises may be further divided, based on the

specific capabilities they are intended to test, such as the ability to detect

agents and quickly don protective gear, the ability to function in protective

gear, or the ability to decontaminate exposed personnel.

(Decontamination is not a doctrinal responsibility of medical units,

although they may, in practice, be required to perform it.) Our focus was

on exercises that test the ability of medical units to correctly diagnose and

treat symptomatic patients.
Page 8 GAO-02-38 Chemical and Biological Medical Readiness

To assess the efforts of DOD and the services to adapt their medical

specialty mix to CB warfare threats, we examined medical personnel

planning processes, interviewed medical planners, and reviewed studies of

medical requirements. We also reviewed literature and interviewed

experts in the treatment of CB-related injuries and diseases.

To assess the extent of medical personnel training in the treatment of CB

casualties, DOD’s ability to track who has been trained, and the extent of

proficiency testing and readiness exercises, we interviewed service

trainers and medical administrative officers regarding related training

requirements, the availability of training opportunities, and the portion of

medical personnel who had completed such training. We also questioned

medical planners from the unified commands and queried the joint

exercise planning database regarding exercises incorporating both

medical components and chemical or biological warfare. We reviewed the

use of CB threats in medical personnel planning and compared it to the

stated threats and to methods used to plan, train, exercise, and test the

readiness and proficiency of medical support for conventional warfare as

well as methods the Office of Emergency Preparedness uses to develop

better trained medical personnel for domestic response to disasters,

including CB agents.

Specifically, we conducted interviews with the Office of the Secretary of

Defense for Health Affairs, the Office of Program Analysis and Evaluation,

and Joint Medical Planning Staff. We met with planning and training

officials at the Army Medical Department at Fort Sam Houston, the Navy

Surgeon General’s Office, the Navy Bureau of Medicine and Surgery, and

the Air Force Surgeon General’s Staff at Bolling Air Force Base. We

attended the annual Association of Military Surgeons and the Weapons of

Mass Destruction 2000 meetings. We also met with officials of the Joint

Readiness Clinical Advisory Board, the U.S. Army Medical Research

Institute of Infectious Diseases, and the U.S. Army Medical Research

Institute for Chemical Defense. We attended meetings between the unified

command medical planners and Joint Medical Planning Staff (J4), and we

conducted follow-on interviews by phone and e-mail.

Our inquiry was limited to medical personnel planning and training for CB

threats. The scope of our work covered active duty and reserve medical

personnel planning and training by the Army, Navy, and Air Force; we did

not separately examine the Marines, for whom the Navy provides medical

support and personnel. Our focus was on medical readiness to support the

armed forces in the event of chemical or biological warfare agent

exposure in areas outside the United States. Although we conducted some

Scope and

Methodology
Page 9 GAO-02-38 Chemical and Biological Medical Readiness

interviews with the Office of Emergency Preparedness to examine its

approach to medical personnel planning for CB consequence management,

we did not focus on DOD’s support of domestic preparedness efforts.

Similarly, we did not explicitly test alternative theories regarding the cause

of the current planning and training conditions, although we asked DOD

officials for their analysis of the underlying causes. We conducted our

study in accordance with generally accepted government auditing

standards between December 1999 and April 2001.

While some of the services have begun to review the staffing of deployable

medical units for the capacity to manage the consequences of certain

chemical warfare scenarios, they have not done so for biological warfare

scenarios. Similarly, DOD’s efforts to assess medical requirements, and

CINC and joint staff efforts to develop and review war plans, have not

addressed CB scenarios as they have conventional ones, and joint medical

planning tools lack the ability to do so. CB warfare planning failures were

attributed to service disagreement about evacuation capability, which

personnel were qualified to provide treatment, and the inherent difficulty

of such planning. In addition, with respect to medical planning for

biological warfare defense, service officials cited the absence of direction

in the Defense Planning Guidance. In the absence of effective formal

planning, combat medical planners expressed concern that they can make

only an educated guess about CINC requirements for specific medical

personnel in the event of a chemical or biological attack. Medical planners

stated that the planning process currently lacks the capability to

adequately estimate medical requirements in the event of chemical or

biological warfare.

Each service determines its medical personnel requirements by using one

or more models that predict the number and nature of casualties that

would ensue from scenarios incorporated in current Defense Planning

Guidance. However, service officials stated that these scenarios have not

included biological warfare. In addition, the services varied in the nature

and status of their efforts to incorporate chemical warfare in medical

personnel planning. The service-based efforts were largely reviews of the

DOD and the Services

Have Not

Systematically

Reviewed the

Adequacy of the

Medical Specialist

Mix for the Treatment

of CB Casualties

Service Methods for

Personnel Planning Do Not

Specify the Personnel

Required to Manage CB

Casualties
Page 10 GAO-02-38 Chemical and Biological Medical Readiness

staffing of medical units rather than more thorough reviews of the medical

force structure.6

For example, the Army is DOD’s executive agent for CB warfare support.

Yet Army officials stated that its medical structure, Medforce 2000, was

primarily based on cold war scenarios that assume many serious traumas

requiring surgical care, a high rate of fatalities, and few cases of nonbattle

injury and disease.7

 The Army force structure is planned through a

biannual assessment of the Army’s future requirements, known as the

Total Army Analysis (TAA). The Army Medical Department identifies the

medical personnel and equipment required to support the force in the

combat scenarios used in the TAA, determines the composition of medical

teams, and recommends an appropriate workload.8

Based in part on the TAA for 2005, the Army estimated the additional

number of beds that would be needed to cope with casualties from a

chemical attack but did not analyze the specific skill mix needed.

Following Defense Planning Guidance, TAA had not incorporated

biological warfare scenarios. Army Medical Department officials indicated

both that they were not authorized to structure medical care for biological

contingencies and that battlefield CB scenarios causing mass casualties

would overwhelm current medical capabilities. Not until 1998, for TAA for

2002 through 2007 did the Army fully integrate general medical

requirements and begin to use chemical casualty scenarios (involving a

liquid nerve agent and mustard) to drive force requirements. To support a

periodic adjustment of rank structure within particular specialties, the

Army is reviewing 39 medical staff functions to assess whether the need

for them has changed.9

 Army officials told us that it would take about 3

 6

All the service medical planners are constrained by existing structures, including medical

centers, field hospitals, hospital ships, and mobile hospitals, and important parts of their

planning processes concern decisions about how best to staff these units.

7

Army medical officials told us that, during the Gulf War and in Bosnia, this emphasis on

surgical capability meant that medical units did not have the right specialty mix for the

general medical illnesses they encountered at sick call.

8

Specifically, the Army applies its Patient Generator Model to estimate casualty rates, using

the same patient condition categories as the Medical Analysis Tool (MAT) but with more

detailed specification of patient data. Then the Army uses these data to determine essential

medical personnel requirements.

9

Such reviews had been completed for podiatry, patient holding services, hospital litter

bearers, veterinary animal care, and ear, nose, and throat services. Functions such as

respiratory care, which could be affected by the introduction of chemical agents, were

reviewed just before the new TAA and are not likely to be revisited for another 2 or 3 years.
Page 11 GAO-02-38 Chemical and Biological Medical Readiness

years to complete this process for all medical functions. They explained

that under the present planning system, the number of billets for particular

medical specialties is based largely on the historical staffing of Army

treatment facilities.10

Similarly, according to the Navy, its medical requirements are not directly

set or affected by CB warfare scenarios. Navy medical planning efforts rely

primarily on analyses and methods such as DOD’s 733 Update report, the

Total Health Care Support Readiness Requirement (THCSRR) model for

developing medical requirements, and the Medical Analysis Tool (MAT),

which have limited utility for planning a medical specialty mix for CB

warfare. The 733 Update projected an upper bound for the number of beds

required in support of a chemical scenario, not a biological one, and

included no findings with respect to the nature of the personnel required.

The MAT—medical planning software approved by the joint staff and used

extensively by the Navy for planning and current operations—lacks

treatment protocols, casualty rates, and bed requirements necessary to

model specialty mix for CB warfare. Thus, the Navy has not identified the

specific personnel mix required to treat casualties exposed to CB warfare

agents. Without specific casualty rate estimates for chemical

contingencies, Navy medical planners estimate medical personnel

requirements for chemical contingencies by increasing the estimate for

conventional conflict by a specified percentage.11

The Air Force, like the Army, determines the expected distribution of

patients by condition and severity and then matches unit types to this

workload to arrive at personnel requirements. The Air Force also

periodically reviews medical unit composition. It has reviewed its array of

medical units and has added units for infectious diseases, theater

epidemiology, and preventive aerospace medicine within the past 3 years.

 10Another hindrance to planning medical requirements for CB scenarios has been the lack

of agreement on treatment protocols for injuries and illnesses attributable to CB

exposures. These protocols were not completed by the Joint Readiness Clinical Advisory

Board (JRCAB) until early 2000, too late to incorporate in this planning cycle.

11The Army has developed and is testing a new model, the Casualty and Resource

Estimation Tool (CREST), for estimating CB warfare casualties and bed requirements.

CREST is a plume model that can estimate need for various types of beds but cannot

determine need with respect to specific expertise or skill mix. Although CREST will

provide a means of estimating CB warfare casualties and bed requirements that MAT lacks,

some joint medical planners were critical of the model because it was not developed jointly

and because casualty rates can be highly sensitive to variations in assumptions. For

specific scenarios analyzed with CREST, casualties ranged up to 500,000.
Page 12 GAO-02-38 Chemical and Biological Medical Readiness

Air Force medical planners indicated that they were challenged to keep up

with the workload associated with predeployment examination and

immunization. However, officials told us they had not adjusted Air Force

medical units and personnel for biological warfare. Air Force officials

volunteered that mass casualty scenarios would inevitably cause

bottlenecks.12 In addition, they noted that medical requirements are quite

sensitive to presumed rates of evacuation and that the Army and Air Force

do not agree on the rates that would be achievable.13

While maintaining that the current specialty mix is generally appropriate

to these emerging threats, service planners did identify additional skills

that would be key to successful medical management of CB warfare

casualties. Some Army officials expected that chemical warfare readiness

would require an increase in respiratory therapy, ward nursing, and

internal medicine. Others noted that the Army did not have a lot of

infectious disease experts in deployed hospitals for surveillance and

prevention. Similarly, Air Force officials expected that chemical warfare

scenarios would require more respiratory technicians, pulmonologists,

critical care nurses, and intensive care beds. They stated that the threat of

biological warfare would increase the need for infectious disease and

preventive medicine personnel as well as personnel to collect baseline,

predeployment data. Air Force and Navy medical planners both

anticipated that chemical scenarios would require more emergency

personnel who could recognize and respond to symptoms quickly. (See

appendix II.) Although these informal assessments varied, they implied

that the current specialty mix needed revision.

DOD’s tools for planning medical requirements are highly structured and

scenario dependent, and the possibility of CB warfare presents a large

variety of potential scenarios and weapons. Many of the tools and studies

 12For information on service medical requirement models, see Defense Health Care: TriService Strategy Needed to Justify Medical Resources for Readiness and Peacetime Care

(GAO/HEHS-00-10, Nov. 3, 1999).

13Several Army officials were skeptical about Air Force capacity to evacuate at the rates

required and stated that the Army had not complied with the joint planning guidance based

on these concerns. Army officials were skeptical that the Air Force’s Critical Care in the Air

plan would work in mass casualty situations. Air Force officials noted that the Army’s

medical requirements were highly sensitive to assumptions about the speed with which

patients could be evacuated: Quicker evacuation drastically reduces the estimated need for

medical personnel in the field.

Medical Planning Methods

Have Not Been Adapted to

CB Warfare
Page 13 GAO-02-38 Chemical and Biological Medical Readiness

for planning conventional medical response lack features required to

adequately plan for CB support or to assess the effect of CB warfare on the

appropriate mix of medical specialties. The services also could not agree

on which health care providers should implement joint treatment

protocols.

CB warfare casualty estimation is highly complex and scenario-dependent

and therefore requires the consideration of many and varied factors. In

addition, the results can be highly sensitive to minor variations in some

assumptions. Potential biological warfare agents include anthrax,

botulinum toxins, viral encephalitis, enterotoxins, hemorrhagic fevers,

plague, Q fever, smallpox, and tularemia.14 Once a specific agent is known,

the method and quantity in which it is weaponized and delivered are just

two factors that can determine the kinds of resulting injuries and illnesses.

Additionally, the population at risk and troop configuration, where the

weapon hits relative to the population, the intensity of the conflict, the

likely air stability, humidity, temperature and sunlight, warning times, the

availability of protective equipment, and evacuation rates all potentially

affect exposure, casualty and medical workload rates. With more than a

dozen highly variable factors at play, casualty estimates can and do vary

from zero to more than half a million. Casualties could appear immediately

or much later at sick call and in hospitals. They may need simple

decontamination or they may be contagious. They may need to be

evacuated or they may need to be isolated. A precise planning process

based on highly specific scenarios may be challenged by a range of

scenarios this broad and uncertain.

Faced with similar issues and uncertainties, for instance, the Office of

Emergency Preparedness (OEP) takes a more qualitative approach to

focus its personnel planning efforts on ensuring a highly flexible response.

OEP officials stated that there are so many variables that it would be

impossible to predict casualties and mold a response. Instead, they plan

for a range of scenarios, from the relatively easy to mass casualty

scenarios involving thousands of cases. However, a flexible response is

predicated on the existence of adequate numbers of well-trained personnel

and teams that can be mobilized. OEP is supporting efforts to identify the

 14D. R. Franz and others, “Clinical Recognition and Management of Patients Exposed to

Biological Warfare Agents,” Journal of the American Medical Association, 278:5 (1997),

399–411.

Precise Medical

Requirements Planning

Confronts a Broad and

Uncertain Range of

Scenarios
Page 14 GAO-02-38 Chemical and Biological Medical Readiness

core competencies needed among physicians, nurses, and emergency

medical technicians and to encourage their incorporation in standard

board certification.

Compounding these problems, DOD officials characterized data on

chemical warfare casualty rates as limited and generally dated. They

stated that most of the available data were derived from warfighting and

medical care as practiced during World War I. These rates might be lower

in today’s more mobile, highly dispersed warfighting. For more novel

agents, even historical data are unavailable.

Similarly, while DOD experts believe that very good data are available on

the effects of biological agents once the nature and extent of exposure are

known, they stated that generally little was known about the exposures

that would result from weaponized agents. Computer models can help

generate estimates for purposes of testing their sensitivity to a range of

assumptions, but validating many of the assumptions may not be possible.

Two major reviews of medical personnel requirements were completed by

DOD’s Office of Program Analysis and Evaluation (PA&E) in the 1990s.

Section 733 of the National Defense Authorization Act for Fiscal Years

1992 and 1993 directed the Secretary of Defense to conduct a

comprehensive study of the military medical care system required to

support the Armed Forces during a war or other conflict.15 DOD completed

the study and in April 1994 issued a final report to the Congress, The

Economics of Sizing the Military Medical Establishment: Executive

Report of the Comprehensive Study of the Military Medical Care System,

generally known as the 733 Report. In August 1995, PA&E was directed to

update the report’s estimates to reflect changes in force levels and

planning scenarios and to better include rotational and training

requirements. This study, the 733 Update, was completed in May 1999.

Both reports found that DOD had programmed far more physicians than

were needed for the wartime missions associated with two nearly

simultaneous regional conflicts.16 Although the Office of Program Analysis

and Evaluation approved the 733 Update, DOD never issued it because the

Air Force disputed the results. The Air Force maintained that the

physician level recommended was too low because it did not reflect recent

 15Pub. L. No. 102-190, National Defense Authorization Act for Fiscal Years 1992 and 1993.

16In July, 2001, DOD dropped the two nearly simultaneous regional wars scenario as the

principal basis for military planning.

DOD Evaluations of Medical

Requirements Have Not Fully

Assessed CB Scenarios and

Lacked Data for Assessing

Specialty Mix
Page 15 GAO-02-38 Chemical and Biological Medical Readiness

joint guidance that expanded Air Force support of humanitarian civil

assistance and disaster requirements.

Neither the original 733 Report nor the update fully assessed the medical

requirements for CB warfare threats. In the absence of a standard

methodology for estimating theater casualties from such weapons, the 733

Update was based on a conventional conflict with a major excursion used

to estimate chemical casualties. The separate chemical warfare scenario

based on the results of the Joint WMD Analysis was used to estimate

medical workload.17 However, the scenario expected after the release of an

aerosol cloud of a biological agent would be quite different.

The 733 Update’s review of workload requirements was based on an

analysis of conflict scenarios from the Defense Planning Guidance (to

generate possible casualty streams) in conjunction with medical planning

factors (such as evacuation policy, dispersion factors, and the average

lengths of hospital stay). The authors of the updated study cited a lack of

approved data on the care requirements of victims of NBC agents and

noted that the study relied instead on the expert opinions of several

military medical professionals to generate estimates. The study

recommended DOD charter a medical panel to review various agents and

their associated health effects and medical requirements for future DOD

planning. The Joint Readiness Clinical Advisory Board was given this

assignment.

The 733 Update used the methodology developed for the original study to

identify the total number of physicians required but recognized that “not

all physician specialties are substitutable.” The study concluded that “the

current manning policy for deployable hospitals varies greatly from

the...identified 733 requirements for surgeons and other specialties.”

18 In

addition, the updated study found that the care factors necessary to

 17DOD, Joint WMD Analysis (J-8) (Washington D.C.: 1997).

18The analysis established requirements for facilities (surgical and medical beds, operating

rooms) and physicians at each echelon of care, including medical facilities in the

continental United States. It also developed estimates of peak loads for intra- and intertheater medical evacuations, recommended an active-reserve component mix that

minimized the number of active duty personnel required, and compared projected intratheater care requirements against the wartime capabilities currently programmed for

specific theaters. The analysis did not review the organization or staffing of patient hospital

care and basic medical units, and it did not review their ability to provide required medical

care.
Page 16 GAO-02-38 Chemical and Biological Medical Readiness

identify needs by physician specialty were last reviewed in a 1988 study.

The 733 Update’s first recommendation was that “A follow-on study should

be undertaken to update the common-use care factors and determine the

appropriate mix of physician specialties needed to support the wartime

requirements in deployable hospitals.”

19 Officials of DOD’s Office of

Program Analysis and Evaluation told us that they did not know if any

action had been taken on this recommendation that a study of physician

specialty mix be conducted.

We found that the Joint Staff lacked functional tools for planning medical

needs for CB warfare and that as a consequence, CINC medical planners

were concerned they could make only educated guesses regarding these

needs. The Medical Analysis Tool (MAT)—software CINCs use to identify

medical requirements, review war plans, assess the sufficiency of service

support, and develop schedules for deploying medical personnel and

equipment to the theater of war—has lacked capability to support

planning for the risks of CB warfare. This is significant in part because the

MAT is the only tool the Joint Staff has approved for medical planning.

The MAT uses casualty rates, patient types, and specific treatment

protocols to project medical requirements—that is, admissions,

evacuations, and beds required. When we reviewed the progress of CB

medical planning, the MAT had neither incorporated profiles identifying

the types of injuries and illnesses CB attacks would generate nor the

treatment protocols these injuries and illnesses would require. Booz-Allen

Hamilton, the contractor responsible for the MAT planning tool, was

taking steps to incorporate CB treatment protocols developed by the Joint

Readiness Clinical Advisory Board (discussed below), but the services

have not agreed on the medical personnel who are qualified to treat

patients with these protocols.

In addition, the medical planners at the CINCs, who do the day-to-day

medical readiness planning, voiced strong concerns about the adequacy of

service planning for CB and stated that they had neither appropriate

warfare planning factors nor service-approved casualty rates with which

to estimate medical requirements.20 In the absence of this information,

 19733 Update Wartime Medical Report, Executive Summary, p. ES-ii.

20While the Center for Army Analysis has conducted a joint study of chemical warfare

casualty rates, this was performed for the purposes of estimating protective equipment

needs and did not include the level of detail about specific types of casualties required for

determining medical personnel needs.

Joint Medical Planning Lacks

the Capability to Determine

Medical Personnel Needs for

CB Warfare
Page 17 GAO-02-38 Chemical and Biological Medical Readiness

medical planners stated that they estimated CB medical requirements by

using a rule of thumb: They supplemented the estimated number of

medical personnel required for conventional warfare with an additional

percentage to cover the undetermined medical need in the event of CB

warfare. However, this method assumes that the medical requirements for

CB support would exceed those of conventional war but would not differ

qualitatively. Both the Joint Staff for Medical Readiness and the theater

medical planners recognized that this estimation method was neither

precise nor well validated.

The Joint Staff for Medical Readiness reviews the estimates the CINC

planners produce without examining the mix of specialists. This suggests a

limited ability to conduct joint medical planning for CB scenarios. The

Joint Staff officials stated that they were reluctant to accept a CB planning

model unless the operations, intelligence, and WMD communities had fully

approved it.

The Joint Readiness Clinical Advisory Board (JRCAB) was assigned to act

on the 733 Update recommendation to develop treatment protocols for

injuries and illnesses associated with CB warfare. It oversaw the creation

of separate CB expert panels that recently completed 22 treatment

protocols for patient conditions that could result from biological warfare

and 20 for chemical warfare. The protocols include type of injury, type of

treatment facility needed, bed requirement, patient length of stay by

specific bed type, and specific treatment requirements (e.g., lab tests) for

each level of care. The task was given to JRCAB because it had already

been charged with the larger task of further standardizing medical systems

for war and peacetime operations in support of a joint approach to

medical planning. In particular, it was charged with developing a Common

User Database for MAT and future medical modeling tools that would

specify for each patient condition the treatment required, the time

required to provide the treatment, and the personnel who should provide

it. Without a common, up-to-date database using current clinical protocols,

all the service medical models use different assumptions about the

treatment needed, and the results are neither comparable nor readily

defensible.

JRCAB officials reported that achieving service agreement on treatment

providers was the most contentious issue they encountered; the advisory

board eventually had to settle for agreement on generic providers with

links to service specifics. Officials told us that the issue was that the

services, particularly the Army, did not want to give up flexibility in

deciding who would provide treatment in the field. Therefore, the ability to

The Services Lack Consensus

on Which Health Care

Providers Should Implement

Joint Treatment Protocols
Page 18 GAO-02-38 Chemical and Biological Medical Readiness

use these protocols to efficiently plan joint specialty mix requirements will

continue to be limited for both conventional and CB warfare.

In sum, although some progress has been made, DOD has not fully

assessed the effect of emerging CB threats on its overall medical

personnel or specialty mix requirements. CB medical planning is

complicated by several factors, and the weaknesses we observed had

several potential causes. First, as in conventional planning, planners are

constrained by a dual mission, existing medical facilities, and current

force structure. Second, some methodological constraints are more

particular to CB planning: Pertinent data are limited and often dated; CB

casualty estimation is highly complex and scenario-dependent and the

results can be highly sensitive to minor variations in assumptions;

computer models can help generate these estimates, but validating the

underlying assumptions is not always possible. Third, Army officials told

us that no direction had been given in the Defense Planning Guidance to

plan medical support for biological warfare scenarios—even though

biological warfare scenarios are different than those for chemical

warfare.21

Officials stated that exercises incorporating a more realistic, larger

number of casualties would overwhelm current systems and medical

capabilities. However, without realistic planning and exercises, being

overwhelmed by an actual CBW attack is all the more likely. In addition,

contentious issues such as the adequacy of medical personnel mix or the

appropriateness of evacuation plans may never be resolved without data

from credible exercises.

Over and above these constraints, joint, CINC, and service planners all

said they were constrained by lack of agreement or inaction on the part of

 21This mirrors the trend in civilian preparedness. According to D. A. Henderson, Johns

Hopkins Center for Civilian Biodefense Studies: “Of the weapons of mass destruction

(nuclear, chemical, and biological), the biological ones are the most greatly feared, but the

country is least well prepared to deal with them. Virtually all federal efforts in strategic

planning and training have so far been directed towards crisis management after a

chemical release or an explosion.... This exercise is not unfamiliar. Spills of hazardous

materials, explosions, fires and other civil emergencies are not uncommon events. The

expected scenario after release of an aerosol cloud of a biological agent is entirely

different.... Public health administrators would be challenged to undertake emergency

management of a problem alien to their experience and in a public environment where

pestilential disease, let alone in epidemic form, has been unknown.” D.A. Henderson, “The

Looming Threat of Bioterrorism,” Science, 284:5406 (Feb. 26, 1999).
Page 19 GAO-02-38 Chemical and Biological Medical Readiness

others. Service planners stated that they could not plan for biological

warfare defense if it was not included in the Defense Planning Guidance.

Joint Staff officials stated that they were reluctant to push CB planning

without an assessment tool that the operations, intelligence, and WMD

communities had fully approved. Although the approved joint planning

tools had yet to incorporate CB medical response, an NBC casualty

estimation tool the Army developed was being resisted by CINC medical

planners, who stated that they had not been involved in its development.

Joint planning has been further slowed by service disagreements on the

key issues of who is qualified to provide specific treatments and what

evacuation capabilities will be provided. In the end, the continuing

disagreements would seem to reflect a lack of high-level consensus and

leadership.

Several sources suggest that the effect of these planning shortfalls is that

the current mix may be wrong. The 733 Update concluded that the current

manning policy varies greatly from the 733 identified requirements for

surgeons and other specialties. More recently, RAND documented a

command-post exercise that found that the Assistant Secretary of Defense

for Health Affairs “must . . . redesign the medical facilities and force

structure to meet CBW medical requirements, as their current focus, on

trauma surgery in war, will not respond well to CBW casualties.”

22 Finally,

even in the absence of changes in formal planning, medical planners

within all three services informally anticipated a variety of specific

changes needed in specialty mix to adequately address CB scenarios.

However, Army medical planners said the need for specialized CBW skills

should be met through training rather than by specialty mix adjustment.

Although medical personnel generally receive instruction in such matters

as donning chemical protective gear, only the Army includes an

introduction to CB casualty management in basic training for medical

staff. Specialized courses have been developed and are available in various

formats. However, specific training to manage and treat CB casualties is

effectively voluntary, funding is unstable, and relatively few providers are

trained. The services also lack or do not use information systems for

tracking personnel who complete the training, and they do not conduct

regular standardized proficiency testing, even among the medical

 22Desert Breeze 5: Responding to WMD Threats in the CENTCOM AOR (Santa Monica,

Calif.: RAND NDRI, March 2000), p. xiv.

Levels of Training,

Testing, and

Exercising for

Medical Management

of CB Casualties

Remain Low
Page 20 GAO-02-38 Chemical and Biological Medical Readiness

personnel who would have early contact with potential CB casualties.

Although the service surgeons general have begun integrating chemical

and a few biological scenarios into their medical exercises, they remain

extremely rare.

The Army, Navy, and Air Force require medical personnel to receive some

familiarization with personal protection for NBC environments. Each

Army corps, including the Medical Corps, does its own basic training.

Enlisted personnel who will become medics take 8 hours of NBC training

as part of their Initial Entry Training course, which is 10 weeks long. Army

Medical Department officials said the course trains to the minimum

acceptable skill level because of the cost of training so many people. Army

officials stated that they were developing a longer basic training program

for medics but could not yet fund it.23 All new Medical Corps officers

(physicians, physician assistants, and nurses) take a 12-week basic course

that includes 39 hours of NBC training. They are also required to take the

Army Medical Department Officer Advanced Course, which includes 10

hours of additional NBC instruction as part of an 8-week correspondence

course.

All Navy field hospital personnel are required to learn decontamination

procedures and receive familiarization training in how to function in a

chemically and biologically contaminated environment. However, Army

Medical Department officials observed that this is just-in-time training and

meant that many Navy trainees coming to their programs had not had the

prerequisite training in donning protective gear that all Army trainees

complete in their initial training. Navy officials said that they were

unaware of any such problem.

All Air Force Medical Service personnel are required to take some basic

NBC defense training annually. However, in the past, both its subject

matter and duration were left to the individual installation commanders,

and Air Force officials indicated that as a result, the training has varied

from post to post. New guidance has specified that this will be a 1-day

course covering the basics of NBC treatment, donning protective gear, and

performing basic mission functions while wearing the gear. The Air Force

 23Like the medics, Army medical junior noncommissioned officers receive a basic course

with 8 hours of NBC training. A few noncommissioned officers go on to take the Army

Health Physics Specialty Course, which includes some additional NBC training.

Some Basic Training

Includes Personal

Protection and Very Basic

CB Warfare Medicine
Page 21 GAO-02-38 Chemical and Biological Medical Readiness

has refocused the available training on the mobile medical personnel most

likely to need it. Others will continue to get the training on a just-in-time

basis.

In addition to the services’ training efforts, the Defense Medical Readiness

Training Institute administers a triservice medical readiness program. Its

Combat Casualty Care Course for junior officers, medics, and first

responders is a 9-day course with 8 hours of NBC training. Institute

officials told us that the Army requires all medical personnel to take this

course but the Navy and Air Force do not. For staff in units that provide

definitive care, the Institute also offers a combat casualty management

course with a small NBC component.

The Army’s principal unit for training health care professionals in the

principles of chemical casualty care is the Chemical Casualty Care

Division of U.S. Army Medical Research Institute of Chemical Defense

(USAMRICD), which operates under the sponsorship of the Army Medical

Department Center and School. The Operational Medicine Division of the

U.S. Army Medical Research Institute for Infectious Diseases (USAMRIID)

at Fort Detrick is the Army’s principal authority on biological casualty

care. Medical Management of Chemical and Biological Casualties (MCBC)

is taught by both centers jointly.24 It was designed primarily for physicians

but is open to physician assistants and nurses and, with permission, to

senior medics and medical service corps officers of all three armed

services.

The 6-1/2 day MCBC course provides familiarization with the principles,

management, and treatment of CB warfare injuries in combat. It includes

lectures from expert researchers, with both clinical laboratory and handson field training. It is the only CB warfare medical course that meets the

criteria for entry on an officer’s permanent record, the Officer Record

Brief, and the only one that the Army Training Requirements and

Resources System tracks. According to Army training officials, this course

had 280 slots per year until 1998 and was heavily subscribed with waiting

lists, when it was doubled to up to 560 slots. In the 4 years between 1996

and 2000, a total of 1,375 service medical personnel (including physicians,

physician assistants, nurses, and medics) took the on-site MCBC course.

 24Before 1992, each ran its own training course, but the two courses were combined after

the Gulf War.

A Range of Specialized CB

Warfare Medical Courses

Has Been Developed
Page 22 GAO-02-38 Chemical and Biological Medical Readiness

(See table 1.) A disproportionate number of these were from the Army.

The Army has about 52 percent of service medical corps personnel but 68

percent of the MCBC on-site trainees.25

Table 1: Military Officers and Enlisted Personnel Trained in Courses on CB Medical

Treatment, Fiscal Years 1997–2000

Course

Days

training Army Navy Air Force

All

services

MCBC on-site 7 929 330 116 1,375

MCBC off-site 3 4,201 394 1,288 5,883

FCBC on-site 5 724 71 13 808

FCBC off-site 3 668 1 17 686

Biological Warfare Satellite

Course

1.5 6,863 3,177 12,617 22,657

Chemical Warfare Satellite

Course

1.5 1,692 371 1,524 3,587

Navy CBRE Familiarization 1 2,337 2,337

Navy CBRE Casualty

Management

3 463 463

Total 15,077 7,144 15,575 37,796

To better meet the demand for course information beyond the limited slots

available, the institutes have pursued other, less thorough training options.

During Operation Desert Shield, they developed emergency courses that

grew into an exportable off-site version of the medical management course

pared down to 3 days of training, with the biological care portion of the

class cut from 3 days to half a day. Army personnel again made up twothirds of those trained. The Air Force has shown far more interest in offsite training than the Navy (1,288 compared with 394).

As more combat medics asked to take the medical management course,

the Institute of Chemical Defense tailored a course for them. In fiscal year

1999, it began the new course, Field Management of Chemical and

Biological Casualties (FCBC), whose purpose is similar to that of the

medical management course but which is less clinically intensive and has

more emphasis on early care in the field. The focus is on prehospital

emergency treatment and casualty decontamination. It is offered four

times a year, and a reduced off-site version is also available. For both

 25Some of the remaining slots go to civilian personnel.
Page 23 GAO-02-38 Chemical and Biological Medical Readiness

versions of the course, 1,494 military personnel have taken the class, all

but 102 of whom were Army trainees.

Because the demand for this training had not been met by the resident and

exportable courses, several distance learning programs were developed to

offset the shortfall:

• In September 1997, the Army’s Institute for Infectious Diseases offered its

first satellite class on the medical management of biological casualties.

The live satellite video teleconference on biological casualty care

comprised 3 half-days of broadcast material. In 4 years, 22,657 military

health service officers have taken these courses, but attendance peaked in

1998 when, for the first time, the Air Force required all medical staff to

take minimum NBC training and approved this course as meeting the

requirement. (See table 1 and more detail in appendix III, table 5.) Nearly

8,000 Air Force personnel registered for the course in the year of the

directive.

• In April 1999, the Institute of Chemical Defense followed with a course

titled Medical Response to Chemical Warfare and Terrorism. Among the

reported worldwide audience of from 2 million to 3 million people

estimated to have viewed at least part of the broadcast, 3,587 military

personnel registered for the course.

• The Institute of Chemical Defense (ICD) has also developed several

distance learning products based on these courses that are available

through its Web site, distributed free each year at several military medical

conferences and shipped to military medical commands and treatment

facilities. It distributed about 13,300 educational products last year,

including handbooks, textbooks, CD-ROMs, and videos.

Navy officials told us that they have waiting lists for both the medical

management and field management courses and that there are not enough

seats to meet their requirements. Stating that they had had trouble making

enough seats available in Army courses, they indicated that they had

developed their own, simpler courses. Institute of Chemical Defense

officials administer enrollment for both institutes and strongly disagreed,

saying that the Navy and Air Force routinely ask for fewer slots than the

institutes offer.26 In fiscal year 1999, the Navy began offering a 1-day course

for general NBC awareness entitled Navy Familiarization Course in the

 26 In its comments on the draft, DOD reported that since our visit to USAMRICD Navy

participation had increased and that every Navy slot for the course had been filled.
Page 24 GAO-02-38 Chemical and Biological Medical Readiness

Medical Management of Chemical, Biological, Radiological, and

Environmental Casualties. This training focuses on all medical support

personnel, first responders, and support personnel. The Navy has also

started its own 3-day Chemical, Biological, Radiological, and Environment

Casualty Care Management course. Personnel from the Naval

Environmental Health Center and Naval Environmental Preventive

Medicine units conduct this training at the requesting command. Through

fiscal year 2000, 2,337 personnel have had the 1-day awareness course, 463

the 3-day casualty care course.

Considering all these forms of special CB warfare medical training,

approximately 37,000 military medical personnel have been trained in the

past 4 years. (See table 1.)

Although several courses are now available for interested personnel, this

alone does not ensure DOD’s medical readiness. There is no mechanism—

either joint or within a service—for defining the medical NBC training

requirements to support medical readiness. As a result, CB warfare

medical courses are generally voluntary, filled mostly by rank-and-file

interest rather than by command requirements. Most Army personnel who

take the medical management course take the off-site version, which

offers only a half-day of medical training for treatment of biological

warfare casualties. The Army is considering requiring all active-duty

physicians slated to join military units in time of war through the

Professional Officer Filler System to take either form of the medical

management course. Only medical officers at NBC weapons depots are

now required to take it, and only members of civil support teams are

required to take field management training. The Air Force had required

everyone to take a minimum familiarization course but has cut the

requirement back to mobile personnel and allows it to be met by the

satellite courses. The Navy requirements are that personnel deploying to

field hospitals learn decontamination procedures. Little else in the way of

NBC medical training is required of all other physicians, physician

assistants, nurses, medics, or corpsmen.

Target populations for the courses generally have not been well identified.

This is important because, without knowing who falls into the target

population, the services cannot size the classes appropriately to address

the population’s need. In contrast, many other Army Medical Department

courses are targeted to a defined population with an estimated attrition

rate. This determines the numbers of slots needed each year to train and

sustain the target group.

Courses Are Voluntary,

Target Populations Are Not

Fully Identified, Funding Is

Unstable, and Relatively

Few Military Health Care

Providers Are Trained
Page 25 GAO-02-38 Chemical and Biological Medical Readiness

Funding for components of this training has been unstable. Army training

officials told us that funding for CB warfare medical training actually

decreased after the Gulf War and then increased following the passage of

the Combating Proliferation of Weapons of Mass Destruction Act of 1996

(commonly known as the Nunn-Lugar-Domenici Act) and a report we

issued in 1996.27 Army officials indicated that, although the medical

management course had more stable funding as part of the budget for the

Army Medical Department Center and School, funding for the remaining

Institute of Chemical Defense courses had been reduced. This included the

field management course and all the distance learning programs, which

they stated was cut by more than half for fiscal year 2001 and had been

eliminated for fiscal year 2002.28

When specialized medical training is defined at its broadest, all the

attendees of all the medical courses in the past 4 years, including satellite

distance learning broadcasts and familiarization classes, totaled 37,796.

Even without adjusting for the attrition of trained personnel or trainees

taking more than one course, fewer than 18.6 percent of the 203,378 officer

and enlisted health care providers in fiscal year 1999 had completed any

specialized CB warfare medical training.

Considering just medical corps officers trained through both the on-site

MCBC course and its less rigorous off-site version means that 5,486 or 9.8

percent of current service end strength have been trained (see table 2).

The Army leads with 16 percent trained. The Navy had 3.3 percent, while

the Air Force trained 6 percent over 4 years.

However, only a small fraction of military medical officers have been fully

trained in the military’s “gold standard” resident Medical Management of

Chemical and Biological Casualties (MCBC). During the past 4 years, 611

service medical corps physicians have taken the resident course or, more

broadly, 1,375 medical corps personnel (physicians, physician assistants,

and nurses).29 With the current end strength of 55,978 active and reserve

 27Pub. L. No. 104-295, title VII, The Intelligence Authorization Act for Fiscal Year 1997;

Chemical and Biological Defense: Emphasis Remains Insufficient to Resolve Continuing

Problems (GAO/NSIAD-96-103, Mar. 29, 1996).

28Officials told us that funding for these classes was actually unspent funds for new CB

warfare equipment under development. They stated that since this equipment had now

been fully developed, the money had to be redirected to produce and field it.

29Only 4 years of comparable data were available for the various courses.
Page 26 GAO-02-38 Chemical and Biological Medical Readiness

duty medical corps officers (not correcting for attrition, which would

lower the estimate), fewer than 2.5 percent have received this training (see

table 2). The Army has not trained more than 3.7 percent of its physicians,

physician assistants, and nurses in the MCBC course, while the Navy has

trained 2.4 percent, and the Air Force less than 1 percent.

Table 2: Fiscal Years 1997–2000 4-Year Medical Personnel CB Warfare Training

Totals as a Percentage of Fiscal Year 2000 End Strength

Training and end strength Army Navy

Air

Force

All

services

Totals

CB warfare training 13,385 6,694 14,051 37,796

Officer medical corps end strength (physicians,

physician assistants, and nurses)

24,761 13,961 17,256 55,978

End strength enlisted medical personnel 81,588 33,768 32,044 147,400

Medical Health Service health care providers 106,349 47,729 49,300 203,378

Percentages

Medical Health Service health care providers

receiving any training

12.6% 14.0% 28.5% 18.6%

Medical Corps officers receiving MCBC training

either on or off site

16 3.3 6 9.8

Medical Corps officers receiving MCBC on-site

training

3.7 2.4 0.7 2.5

Tracking completed training would be necessary to quickly determine who

has received specific individual training or to quickly assemble teams of

fully trained personnel. Neither DOD nor any service has an operating,

centralized system to quickly identify who has received training. The

systems that exist do not consistently track all relevant CB warfare

courses. As a result, an accurate summary of current personnel who have

received any particular CB medical training cannot be given and DOD

cannot readily retrieve the identity of qualified and trained personnel.

The Army Training Requirement and Resources System tracks only the

completion of training for courses on its requirements lists. Although the

medical management course is tracked for Army personnel, the field

management course, the combat casualty course, and other mass casualty

courses such as Medical Effects of Ionizing Radiation and Radiological

Hazards Training are not. Army manpower requirement planners do not

track training either; they track only the basic area of concentration for

officers who are medical specialists. Training compliance checks still have

to be done through the unit or hospital commander. Officials told us that a

Tracking Is Too Weak to

Support Meaningful

Training Requirements
Page 27 GAO-02-38 Chemical and Biological Medical Readiness

centralized training and competency database like the one maintained by

the Joint Commission on Accreditation of Health Care Organizations for

civilian medical care is not available and cannot be implemented.

However, that they track only medical specialists’ area of concentration,

not their military training, is inconsistent with medical planners’

statements that it is training, not specialization, that ensures CB warfare

readiness.

The Navy stated that it had no way of tracking training throughout a career

but that Navy medicine needed a system to track it. Individual

commanders are supposed to track their unit’s training and combat

readiness, but officials told us that this is typically only a count of how

many personnel have had the required training and what percentage have

their shots or know how to wear protective gear. The commands are

supposed to use the Standard Personnel Management System to report

their information so that Navy Medicine can verify compliance with

training requirements. However, the system has not been working for

some time, and they were without aggregate data.

Similarly, the Air Force does not maintain a list of trained personnel. Most

of the task of ensuring Air Force wartime medical readiness falls on the

commanders of the Military Treatment Facilities, who are expected to

report on unit readiness to their major commands through the Medical

Readiness Decision Support System. It tracks officers’ current assignment,

primary training, and additional certifications. However, most Air Force

training consists of the Army satellite courses, which are not considered

part of Continuing Medical Readiness Training (CMRT) and are not

recorded by the CMRT system. The Air Force does not mandate or track

completion of MCBC training.

Proficiency testing is needed to ensure that personnel who have

completed training are actually able to perform key tasks. While the

Army’s courses conduct hands-on testing, trainees are not required to pass

a final test to receive credit for course completion or for Continuing

Medical Education. Although each service establishes proficiency and

currency standards for NBC defense training, most standards consist of

the local commander’s check on his or her unit’s readiness, not individual

proficiency. For example, Navy commanders are supposed to check their

units’ readiness, but we were told that they have no proficiency measures.

Moreover, Army officials stated that units do medical proficiency training

but would be very unlikely to train for NBC. They also said that no one

regulates medical operations to make sure they follow the standard

Proficiency Is Not

Systematically Tested
Page 28 GAO-02-38 Chemical and Biological Medical Readiness

doctrine and that lessons-learned observers need not be certified. Mastery

of subject matter and treatment receives insufficient systematic

verification in either the classroom or the field. Similarly, the elaborate

credentialing practices of peacetime medical care have no parallel in

wartime. While this yields substantial flexibility, it may also raise questions

about quality.

One general indication that unit NBC training is inadequate comes from

results at the Army Combat Training Centers. According to the March 2000

Annual Chemical and Biological Defense Program report, Army units at

the company, battalion, and brigade levels were unable to perform all NBC

tasks “to standard.” The 2000 report also concludes that this “less than

satisfactory performance at the Combat Training Centers is directly

attributable to lack of homestation NBC training (p.136).”

Another measure is an evaluation (Medical Training 2000) conducted by

the Army that included a criterion-referenced assessment of the

proficiency of its medical first responders—medics. According to the

Army, this is important because the skills that may be key to addressing a

CB attack, including rapid assessment of unusual symptoms, are not

typically practiced in garrison. The Army study of its active duty medics

found that only 16 percent passed a multiple choice test on assessing and

managing NBC casualties, and the Army concluded that this indicated a

very low degree of general medical readiness among medics. (See figure

1.) Their readiness to treat NBC casualties was lowest of all skills

measured. (Navy and Air Force officials told us that they had no

comparable assessments of proficiency among medical personnel.)
Page 29 GAO-02-38 Chemical and Biological Medical Readiness

Figure 1: Proficiency Measures From the Army Study Medical Training 2000, Slide from Medic Training 2000 Briefing

Presented by Major General James B. Peake

Source: Medic Training 2000 briefing presented by Major General James B. Peake, Commanding

General, AMEDD Center and School, at the Medic–WMD 2000 Conference, April 3–6, 2000. See

also U.S. Army Center for Healthcare Education and Studies, Medical Training 2000 (San Antonio,

Texas: Fort Sam Houston, Army Medical Department Center and School, n.d.).

The technical report of the Medical Training 2000 Study completed by the

U.S. Army Center for Healthcare Education and Studies concluded:

MEDIC TRAINING 2000

Outcomes at Baseline

Skill Medics*

perceiving they

can perform

the skill

Medics* passing

a cognitive test

(>=70%)

Medics* passing a

hands-on skill

test (>=70%)

Medics* passing a

hands-on skill test

(critical criteria

standard)

Assess

Casualty

69% 50% 17% 3%

Manage

Airway

84% 66% 51% 2%

Control

Bleeding

91% 54% 20% 8%

Insert IV 93% 89% 77% 29%

Treat NBC

Casualty

25% 16% not tested not tested

*Total military medical experience of medics tested in Phase I (N = 347)

LOW
Page 30 GAO-02-38 Chemical and Biological Medical Readiness

“Finally, special attention must be drawn to the problem of training combat medics to treat

NBC casualties. Data from self-ratings of proficiency, supervisors’ ratings of proficiency,

and written tests (Phases I, II, and III) indicated that 4 out of 5 combat medics had

significant deficits in this area. In every evaluation conducted in this study, the lowest

scores were always for treating NBC casualties. Both academic and unit training failed to

teach combat medics this essential skill. It is unlikely that there will be a simple solution to

this problem. Assessing and treating an NBC casualty is not a fundamental skill. Combat

medics must have a good grasp of the principles required to treat a conventional casualty

before they can begin to grasp the complexities involved in caring for NBC casualties.

Moreover, high fidelity NBC training is complex and resource-intensive. The ability to treat

an NBC casualty was not tested with a hands-on test in this study because the logistical

burden was too high. If the ability to treat an NBC casualty is critical to the role of a 91B10-

level combat medic, then new academic and unit training programs as well as adequate

logistical support must be developed to teach and sustain the skill.”

30

Given that medics had received only 8 hours of CB familiarization with

their basic training and that even the summaries available from Army field

manuals (as excerpted in appendix I) are necessarily rather technical,

these results are not surprising. These low proficiency scores come just as

the Army is preparing for more mobile combat where medics may be

deployed farther from higher-level support.

In May 1998, the Chairman of the Joint Staff published guidance for

exercise and training objectives that identified NBC defense and force

protection as the top training issues. Nevertheless, in March 2000, DOD’s

Chemical and Biological Defense Program Annual Report concluded that

CB scenarios are not adequately exercised. The report found that although

the Army had more than 750 models and simulations, very few combat

simulations incorporated the effects of NBC and none incorporated all

aspects.31

Officials told us that although medical response to a CBW incident has

been exercised domestically, outside the United States comparable

 30U.S. Army Center for Healthcare Education and Studies, Medical Training 2000 (San

Antonio, Texas: Fort Sam Houston, Army Medical Department Center and School, n.d.), p.

6.

31DOD, Chemical and Biological Defense Program Annual Report to Congress

(Washington, D.C.: March 2000), p. 133. Also see Chemical and Biological Defense: Units

Better Equipped, but Training and Readiness Reporting Problems Remain

(GAO/NSIAD-01-27, Nov. 14, 2000).

A Minority of Medical

Units Participate in Service

CB Exercises and the

CINCs Very Rarely

Exercise CB Medical

Readiness
Page 31 GAO-02-38 Chemical and Biological Medical Readiness

exercises of medical support have been minimal. Although the service

surgeons general have recently begun integrating chemical and a few

biological scenarios into their medical exercises, medical planners from

each of the five unified commands reported that these commands have not

conducted a realistic field exercise of medical support for chemical or

biological warfare. A key readiness review, which is used to advise the

president on readiness to implement the national security strategy, has

never set the unified commanders a scenario requiring medical support for

weapons of mass destruction.

Army medical officials stated that the Army generally does not exercise

casualty management, evacuation, triage, or decontamination for CBW

scenarios. The Army conducts training exercises for its field hospitals,

battalion aid stations, and medical companies at its three combat training

centers. Officials told us that in recent years they have generally included

a chemical scenario and that they piloted a biological scenario in 1999.

Although Army Health Care Operations officials told us these exercises

were more realistic than those that might be performed at their home

base, they exclude the more persistent chemical agents that could bring

the exercise to a halt. In general, most brigades go through the combat

training centers about every 2 years, with two or three companies of 130

troops from each brigade, or 10 percent of the troops being directly

involved in the chemical play. Simulated casualties range from 10 to about

150 of 260 personnel. Demonstrating the importance of field exercises,

Army officials told us that, in the first training exercise, casualty rates can

run as high as 75 percent, but as the units learn how to respond this drops

sharply to as low as 10 percent. However, according to Army health care

operations officials, it is not unusual to have 100 percent turnover in

personnel every 2 years.

The Army also has command post staff exercises that are limited to

decision making and do not involve units in the field. The AMEDDX

exercise, for example, involves units that volunteer to train in evacuation,

reception, and treatment, including CB casualties. Golden Medic is a

command post exercise for Army reserve units that includes some CB play

but does not exercise medical treatment. Even though personnel not

directly involved in CB play can learn from after-action reports, the

modest proportion of Army units annually participating in exercises

involving CB medical support (combined with the turnover rate among

medical personnel) raise questions about medical readiness for CB in the

Army, DOD’s lead agent for CB medical readiness.

The Services Train a Small

Minority of Units With Field

Exercises of CB Medical

Support
Page 32 GAO-02-38 Chemical and Biological Medical Readiness

Like all hospitals certified by the Joint Commission on the Accreditation of

Healthcare Organizations (JCAHO), Air Force hospitals are required to

exercise their ability to respond to mass casualties annually. In addition,

depending on local threat conditions, they are required to conduct

exercises in responding to an attack. It was not clear to Air Force

headquarters how many of these involve CB, as the hospitals are not

required to report the content or result to the major commands. Air Force

health care officials said that in the past they have had difficulty getting

medical care included in regular combat readiness exercises and even

then the medical play was often cancelled. However, they reported having

made significant strides since May 2000 with a considerable shift in their

organizational staffing. Army and Air Force officials told us that the

completion of the JRCAB protocols for the treatment of CB casualties has

allowed more meaningful exercise of CB medical care. The protocols were

loaded onto handheld computers as patient care algorithms that allow

exercise umpires to score how the simulated casualties fared. As a result,

the Air Force was able to include medical management of chemical or

biological casualties in three of its recent major field exercises—Pacific

Warrior, Consequence Island, and Golden Medic. Air Force officials

estimated that roughly 15 to 20 percent of medical staff have participated

in exercises of medical care of chemical or biological casualties.

Navy officials told us they had not conducted a field exercise of CB

medical support. They stated that a full response to CB would quickly

bankrupt the services. They argued that any full response plan would have

to be joint. The Navy reported that in general only a small percentage of

their exercises involve medical care. Officials told us that medical play

during routine combat readiness exercises often lacks a scenario involving

a CB event because it becomes “too hard,” or the CB portion that was

planned is eliminated because “it does not let the warfighter exercise his

needs.” They have recently begun to include chemical or biological care

tabletop exercises for medical staff. Their most recent Vanguard exercise

included a response to both chemical and biological agents (sarin and

plague). Another is planned with a biological agent for October 2001. Their

recent science and technology exercise included a response to a chemical

agent (sarin). Another tabletop exercise was played against chemical and

biological agents (smallpox). Two smaller tabletop strategic exercises for

the leaders of Navy medicine were held at Camp Lejeune and included a

response to plague.

Although the service surgeons general have begun integrating chemical

and a few biological scenarios into their medical exercises, validating any

of the services’ planning assumptions would require both realistic CB

Joint CB Medical Readiness Is

Rarely Tested
Page 33 GAO-02-38 Chemical and Biological Medical Readiness

scenarios and full medical participation in joint combat readiness

exercises. For example, Army officials voiced concern about the lack of

joint exercises to support key Air Force lift capacity assumptions. The

joint staff requires the unified commands to examine quarterly scenarios

of regional warfare. The focus of the review is determining the armed

forces’ current readiness to execute the full range of the national military

strategy, including peacetime engagement, deterrence, conflict prevention,

and winning the nation’s wars. Service and Joint Staff told us that as of

June 2000 this key review had never asked the CINCs to address a

scenario that incorporated medical support for CB contingencies. We were

told it might do so in the future.

Given the difficulty and expense of exercising realistic CB scenarios, some

service officials argued that more has to be done at the joint level. For

example, Army officials voiced concerns about the lack of joint exercises

to support Air Force lift capacity assumptions. The Joint Exercise

Management Program of the joint staff (J-7) maintains data on all

exercises planned by the various CINCs and major commands in order to

coordinate approval and funding of the exercises. These data provide a

rough approximation of pertinent CINC exercises based on keyword

searches of exercise abstracts. Overall, CINCs planned 2,714 exercises

between fiscal years 1993 and 2005 (figure 2). Of these, 278 (or about 10

percent) involved some medical play, and 38 (1 percent) involved chemical

or biological warfare scenarios. Only 4 exercises involved both medical

support and either chemical or biological scenarios.
Page 34 GAO-02-38 Chemical and Biological Medical Readiness

Figure 2: Numbers of Planned CINC Exercises, Fiscal Years 1993–2005

Source: J-7, Joint Exercise Management Program, April 2001.

Although the frequency of all planned CINC exercises rose after the Gulf

War and then gradually declined to 201 in 2000, the number of joint

medical exercises of all types peaked at 31 in 1995 and fell to 16 in 2000.

(See figure 2.) Exercises incorporating chemical or biological warfare

(CB), and in particular medical response to chemical or biological warfare

(CB Medical) have remained few and far between. Given that the threat

was said to be increasing, these trends are at odds. Indeed, the last joint

CB medical exercise that would have been completed was in 1994, and the

next one is not planned until 2005. Figure 2 shows the total number of

29 25 31

18 26 27 20 16 19 15 18 17 17

3 9 1 000 3 2 44444 0 2 0000000000 2

0

50

100

150

200

250

300

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Medical CB CB Medical Total
Page 35 GAO-02-38 Chemical and Biological Medical Readiness

planned joint exercises for 1993-–2005, as well as those involving medical

support and CBW.32

Overall, little exercising has been done above the level of unit

commanders. The CINCs do not track these unit exercises, and neither

they nor DOD could provide us with a summary of them. Essentially,

although there are more than 150 joint exercises planned annually,

relatively few include either CB warfare or medical matters, and virtually

no joint exercises include both CB warfare and field medical response.

Medical officials told us that in combat exercises the only roles generally

played by medical staff are to assist in recognizing a CB event and

planning the logistics required for handling it. Medical staff commented

that both CB warfare and medical support have to fight for inclusion in

combat readiness exercises. The problem they saw was that CB defense is

not the primary objective of any exercise. Medical planners argued that, on

the one hand, if CB defense were made the primary exercise objective

without direction from the Joint Chiefs, then it would be harder to get

broad participation in the exercise. On the other hand, when CB defense is

not the primary objective, then the threat tends to be watered down so

that other objectives will not be disrupted by showstoppers.

The term “mass casualties” refers to any level of casualties that

overwhelms the existing medical resources at a given site or level of care.

Army planners charged with the medical response to CBW told us that a

realistic mass casualty CB scenario had never been exercised. They stated

that “their realistic working assumption was that a genuine CB event in the

battlefield would overwhelm the medical system.” They said that given

 32 U.S. Pacific Command officials also confirmed that PACOM had conducted command

post CB exercises, but had not included a field exercise of medical support. U.S. Central

Command staff could not recall any field exercises of CB medical support. CENTCOM’s

Desert Breeze exercises had a tabletop CB warfare medical component. The Neon Falcon

exercises included CB warfare decontamination but not medical treatment. Central

Command officials also said that while field exercises are generally the responsibility of the

component commands, they did not have any knowledge of these exercises or their lessons

learned. They reported that the Joint Unified Lessons Learned System for reporting and

retrieving lessons learned from exercises had been down for a year and a half. Joint Forces

Command reported two exercises. In November and December 1999, it trained and

exercised to plan for the millennium celebration. No medical units were actually deployed.

In May 2000, it participated in the Top Officials (TOPOFF) exercise, whose purpose was to

prepare to conduct surveillance, decontamination, treatment, and evacuation of chemical

victims in Portsmouth, New Hampshire, and biological victims in Denver, Colorado. DOD

had no significant field role. No DOD medical units were deployed in a field role other than

a Chemical Biological Incident Response Force to assist with decontamination. U.S.

European Command also reported that it had not conducted CB exercises.
Page 36 GAO-02-38 Chemical and Biological Medical Readiness

that the medical system will be overwhelmed, mass casualty scenarios

should be exercised to prepare our medical force leaders to sustain

medical operations in the face of such an event. DOD health affairs

officials acknowledged that they did not know how many casualties they

could handle and agreed that they could have better knowledge of their

current capabilities.

In sum, DOD development of appropriate CB courses is an important

contribution to adequate readiness but may not be sufficient to guarantee

readiness. Treating CB casualties is an advanced medical skill, but without

requirements, relatively few military medical personnel receive advanced

training. Army testing of medics confirmed that proficiency was low.

Army officials characterized the funding for individual CB medical training

as unstable. Unit training appears insufficient because skills to ensure

readiness are rarely exercised due to conflicting priorities encountered by

both warfighters and medical staff and because it is difficult and

expensive. Even individuals who have been trained cannot be readily

identified because either the tracking systems do not exist or they are not

currently functioning. Certification based on proficiency standards in the

classroom or the field is not being done, in part because neither the

metrics nor the standards have been developed.

The President, Secretary of Defense, and Joint Chiefs have all emphasized

the importance of preparing U.S. military forces for emerging CB threats.

Last spring, DOD reported to the Congress that “the probability of U.S.

forces encountering CB agents during worldwide conflict remains high.”

33

However, we found that the likelihood of CB casualties receiving

proficient medical care remains low. Although we found efforts to plan

and train for these threats, there is a wide and longstanding gap between

DOD’s appraisal of CB threats and DOD’s medical preparedness to meet

them. This suggests a lack of consensus about the threat, a failure of highlevel leadership, or the acceptance of a potentially high level of risk.

DOD and the services have not adequately modeled or evaluated medical

specialty mix or fully resolved their differences. DOD has not developed

comprehensive, meaningful training requirements, adequate tracking

systems, or rigorous proficiency testing. The available evidence indicates

 33DOD, Chemical and Biological Defense Program Annual Report to Congress

(Washington, D.C.: March 2000), p. i.

Conclusions and

Recommendations
Page 37 GAO-02-38 Chemical and Biological Medical Readiness

that proficiency is low. From training only a fraction of personnel to failing

to conduct realistic, challenging combat field exercises that include CB

medical treatment, DOD has not fully responded to the threat as stated.

Consequently, 10 years following Operation Desert Storm, serious

concerns remain about DOD’s capacity to provide medical support for CB

warfare casualties.

We recommend that the Secretary of Defense address the gap between the

stated CB threat and the current level of medical readiness by clarifying

DOD’s expectations regarding medical preparation for CB contingencies

and, as appropriate, directing the Joint Staff to integrate biological medical

readiness in Defense Planning Guidance.

To the extent that DOD views chemical warfare or biological warfare as a

serious threat in its areas of operations and expects its medical forces to

prepare for these contingencies, we recommend that the Secretary of

Defense direct that

1. The services and Joint Staff support completion of the Common User

Database by concluding an agreement regarding which personnel are

qualified to provide specific treatments. Without such an agreement,

the services’ medical models use different assumptions about which

personnel are qualified to administer treatments, and the results are

neither comparable nor readily defensible. This database should

eventually be validated by proficiency testing of the identified

personnel to help further refine training and specialty mix

requirements.

2. In furtherance of a triservice approach to medical planning, the

services and joint staff use these enhanced modeling capabilities to

develop defensible and transparent risk assessments associated with

various evacuation rates. The services and joint staff develop and

approve joint models and tools to support more timely, flexible, and

integrated planning for these threats and enable effective updating of

both long-term specialty mix evaluations and short-term combat

medical requirements.

3. The services develop CB medical training requirements and assess the

effectiveness of the training with rigorous proficiency metrics and

standards.

4. DOD develop and maintain information management systems to

monitor completion of required CB training and track the proficiency
Page 38 GAO-02-38 Chemical and Biological Medical Readiness

of medical personnel, at least for medical first responders and

personnel in high-risk areas of operation.

5. The joint staff, CINCs, and services increase the realistic exercise of

medical support to a level commensurate with current CB threat

assessments. To the extent that there is a threat of mass casualties,

exercises should explore the limits of medical capabilities and the full

consequences of scenarios that overwhelm them.

DOD provided written comments on a draft of this report on September

10, 2001. These comments are reproduced in appendix IV. In view of the

September 11 attack, we reconfirmed with DOD that the report was still

unclassified and cleared as amended. DOD concurred with all our

recommendations and provided additional technical comments which we

have incorporated as appropriate. DOD indicated that it plans to take a

number of specific steps but did not make clear that they will collectively

redress the lack of clarity regarding expectations for CB medical

readiness.

In responding to our recommendation that the Secretary of Defense

address the gap between the threat as stated and the current level of

medical readiness, DOD stated that the Joint Staff will be asked to

reexamine CB training issues and to propose adjustments to enhance

medical readiness. It is not clear, however, that referring the matter to the

Joint Staff for further study will be sufficient to address the gap, clarify

expectations, or integrate medical readiness for biological warfare in

Defense Planning Guidance.

To the extent that DOD views CB warfare as a serious threat and expects

the nation’s military medical forces to prepare for its contingencies, we

offered several additional recommendations. In response to our

recommendation that DOD complete the Common User Database and

validate it with proficiency testing, DOD stated that the Joint Staff will be

requested to coordinate the completion of the Common User Database and

to consider service-specific environments. However, it remains unclear

whether DOD intends to identify specific types of personnel qualified to

treat specific problems and to validate their qualifications with proficiency

testing.

DOD had several comments regarding our recommendation that it use

enhanced modeling capabilities to develop risk assessments for various

evacuation rates. Regarding modeling capabilities, it stated that the MAT

Agency Comments

and Our Evaluation
Page 39 GAO-02-38 Chemical and Biological Medical Readiness

can now provide requirements once casualty rates have been determined.

We note that this process still cannot generate defensible specialty mix

requirements until the Common User Database identifies the specific types

of personnel qualified to address specific patient conditions. DOD also

stated that the many variables and the absence of historical casualty data

have so far precluded arriving at any one set of conclusions that would be

more logically defensible than any other set. We do not wish to minimize

the difficulties associated with modeling and estimating medical

requirements for CB attacks, and for this reason have suggested modeling

a range of assumptions to assess risks.

Regarding evacuation capabilities, DOD specifically concurred with the

need to better assess the percentage of casualties needing evacuation but

not the actual calculation of medical requirements based on delay

estimations and evacuation capacity. However, we were told that

evacuation rates have a tremendous impact on the size of the medical

forces required on the ground and in the air. We found that Army and Air

Force officials strongly disagreed about actual evacuation capabilities.

Army officials told us that because of this dispute, the Army is out of

compliance with this part of the Joint Strategic Capabilities Plan.

Therefore, without interservice agreement on evacuation, there is

effectively no coherent process for estimating overall joint medical

requirements. DOD further acknowledged that the evacuation issue is

greatly complicated by the BW threat. This underscores the need to use

enhanced modeling capabilities to assess risks.

DOD responded to our recommendation to develop CB medical training

requirements by saying that it had formed a working group for NBC

medical training requirements and that the Joint Staff will be asked to

establish an NBC oversight group. However, DOD was silent about

assessing the effectiveness of these requirements with rigorous

proficiency metrics and standards.

DOD concurred with our recommendation to improve information

management systems, and it suggested that we broaden this to

recommend a joint system to track the monitoring of training and the

proficiency of all personnel identified for functioning in a CB environment.

We concur and have changed the recommendation. While having servicetracking systems would be an improvement, a joint system would be best.

Similarly, although the scope of this report was limited to CB readiness,

we agree that it would be logical and appropriate to include medical

readiness for nuclear events in such as system.
Page 40 GAO-02-38 Chemical and Biological Medical Readiness

DOD concurred with our recommendation to increase the realistic

exercise of medical support. It stated that the Assistant Secretary of

Defense for Health Affairs will request heightened medical participation in

all relevant exercises. However, we note that the Assistant Secretary’s

concurrence is a necessary but insufficient condition for fully

implementing this recommendation. Most exercises are controlled not by

the medical staff but by those responsible for warfighting operations.

Concurrence of the military operations staff will be essential if medical

participation is to be included in combat exercises and not the first thing

cut when it gets in the way of other goals or becomes “too hard.” DOD was

also silent about the realistic exercise of mass casualties—exercises that

explore the limits of medical capabilities and the full consequences of

scenarios that overwhelm them.

As we agreed with your office, unless you publicly announce the contents

of this report earlier, we plan no further distribution of it until 30 days

from its issue date. We will then send copies of this report to the Secretary

of Defense, the Ranking Minority Member of your Subcommittee, and

other interested congressional committees and members. We will also

provide copies to others on request. If you have any questions or would

like additional information, please call me at (202) 512-2700. Other key

contacts and contributors are listed in appendix V.

Sincerely yours,

Nancy R. Kingsbury, Managing Director

Applied Research and Methods
Appendix I: Specific Signs, Symptoms,

Diagnoses, and Treatment for Some Common

Chemical and Biological Agents

Page 41 GAO-02-38 Chemical and Biological Medical Readiness

Agent Signs, symptoms, and diagnosis Treatment

Pulmonary: Phosgene Eye and airway irritation, shortness of breath,

chest tightness, and delayed pulmonary edema

Termination of exposure, resuscitation, enforced bed

rest and observation, oxygen with or without positive

airway pressure for signs of respiratory distress, and

other supportive therapy as needed

Nerve:GA, GB, GD, GF, VX Vapor:

Small exposure—miosis, rhinorrhea, mild

difficulty breathing

Large exposure—sudden loss of

consciousness, convulsions, apnea, flaccid

paralysis, copious secretions, miosis

Liquid on skin:

Small to moderate exposure—localized

sweating, nausea, vomiting, feeling of

weakness

Large exposure—sudden loss of

consciousness, convulsions, apnea, flaccid

paralysis, copious secretions

Administration of MARK I Kits (atropine and

pralidoxime chloride); diazepam in addition if casualty

is severe; ventilation and suction of airways for

respiratory distress

Management of a casualty with nerve agent

intoxication consists of decontamination, ventilation,

administration of the antidotes, and supportive

therapy. The condition of the patient dictates the need

for each of these and their order.

Vesicants:Mustard, Lewisite Asymptomatic latent period (hours):

Erythema and blisters on the skin; irritation,

conjunctivitis, corneal opacity, and damage in

the eyes; mild upper respiratory signs to marked

airway damage; gastrointestinal (GI) effects;

bone marrow stem cell suppression

Decontamination immediately after exposure is the

only way to prevent damage. There is no specific

supportive therapy. The eyes are the organs most

sensitive to mustard vapor injury.

The management of a patient exposed to mustard

may be simple, as in providing symptomatic care for a

sunburn-like erythema, or extremely complex, as in

providing total management for a severely ill patient

with burns, immunosuppression, and multisystem

involvement.

Anthrax Inhalation: Incubation period of 1-6 days:

Fever, malaise, fatigue, cough, and mild chest

discomfort followed by severe respiratory

distress with dyspnea, diaphoresis, stridor, and

cyanosis

Within 24–36 hours after onset of severe

symptoms: Shock and death

Physical findings are nonspecific.

Although effectiveness may be limited after symptoms

are present, high-dose antibiotic treatment with

penicillin, ciprofloxacin, or doxycycline should be

undertaken. Supportive therapy may be necessary.

Plague Pneumonic plague (incubates 2–3 days): High

fever, chills, headache, hemoptysis, and

toxemia, progressing rapidly to dyspnea, stridor,

and cyanosis; death from respiratory failure,

circulatory collapse, and a bleeding diathesis

Bubonic plague (incubates 2–10 days):

Malaise, high fever, and tender lymph nodes;

may progress spontaneously to the septicemic

form, with spread to the central nervous system

and lungs

Early administration of antibiotics is very effective.

Supportive therapy is required.

Appendix I: Specific Signs, Symptoms,

Diagnoses, and Treatment for Some Common

Chemical and Biological Agents
Appendix I: Specific Signs, Symptoms,

Diagnoses, and Treatment for Some Common

Chemical and Biological Agents

Page 42 GAO-02-38 Chemical and Biological Medical Readiness

Agent Signs, symptoms, and diagnosis Treatment

Viral hemorrhagic fevers VHFs are febrile illnesses that can be

complicated by easy bleeding, petechiae,

hypotension, and even shock, flushing of the

face and chest, and edema. Constitutional

symptoms such as malaise, myalgias,

headache, vomiting, and diarrhea may occur.

Intensive supportive care may be required. Antiviral

therapy with ribavirin may be useful in several of

these infections. Convalescent plasma may be

effective in Argentine hemorrhagic fever.

Botulinum toxins Ptosis, generalized weakness, dizziness, dry

mouth and throat, blurred vision and diplopia,

dysarthria, dysphonia, and dysphagia followed

by symmetrical descending flaccid paralysis and

respiratory failure. Symptoms begin as early as

24–36 hours but may take several days after

inhalation of toxin.

The botulinum toxins as a group are among the

most toxic compounds known to humans. No

routine laboratory findings. Biowarfare attack

should be suspected if multiple casualties

simultaneously present with progressive

descending bulbar, muscular, and respiratory

weakness.

Intubation and ventilatory assistance for respiratory

failure. Tracheostomy may be required. Administration

of heptavalent botulinum antitoxin (IND product) may

prevent or decrease progression to respiratory

failure and may hasten recovery.

Source: Field Management of Chemical Casualties Handbook, 2nd ed. (Aberdeen Proving Ground,

Md.: USAMRICD, July 2000), and Medical Management of Biological Casualties Handbook, 2nd ed.

(Fort Detrick, Md.: USAMRIID, August 1996).
Appendix II: General Distinguishing Features

of Chemical and Biological Terrorism

Page 43 GAO-02-38 Chemical and Biological Medical Readiness

Feature Chemical Biological

Time from attack to illness Rapid: minutes to hours Delayed: days to weeks

Distribution of victims Downwind from point of release Widely spread through the battlefield and

beyond

First personnel to respond Soldiers, medics, corpsmen Sick call physicians and nurses, infectious

disease physicians, epidemiologists, public

health officials, laboratory personnel

Release site Swiftly discovered; area of attack can be

cordoned off

Difficult to identify; area of attack cannot be

cordoned off

Decontamination of patients and

environment

Acutely important in most cases Not needed in most cases

Medical treatment Antidotes Vaccines, antibiotics

Patient isolation Not needed after decontamination Crucial if communicable disease is involved;

advance hospital planning for isolating many

patients is critical

Source: D. A. Henderson, “The Looming Threat of Bioterrorism,” Science, 283:5406 (Feb. 26, 1999);

and DOD

Appendix II: General Distinguishing Features

of Chemical and Biological Terrorism
Appendix III: U.S. Military CB Warfare

Medical Training Summary Tables, Fiscal

Years 1997–2000

Page 44 GAO-02-38 Chemical and Biological Medical Readiness

Table 3: Officers and Enlisted Personnel Trained in MCBC Courses, Fiscal Years

1997–2000

Course

Days in

course Army Navy Air Force

All

services

Total in-house 7 929 330 116 1,375

Medical Corps Officers:

physicians, physician assistants,

nurses

872 290 96 1,258

Enlisted: medics, corpsmen 57 40 20 117

Total off-site 3 4,201 394 1,288 5,883

Medical Corps Officers:

physicians, physician assistants,

nurses

3,108 173 947 4,228

Enlisted: medics, corpsmen 1,093 221 341 1,655

Total trained 5,130 724 1,404 7,258

Annual average 1,283 181 351 1,815

Table 4: Officers and Enlisted Personnel Trained in FCBC Since Fiscal Year 1999

Course

Days in

course Army Navy Air Force

All

services

In-house 5 724 71 13 808

Off-site 3 668 1 17 686

Total 1,392 72 30 1,494

Table 5: USAMRIID Biological Warfare Satellite Broadcasts, Fiscal Years 1997–2000

Year Army

Navy and

Marines Air Force All services

1997 942 856 1,558 3,356

1998 2,422 992 7,978 11,392

1999 1,869 939 2,431 5,239

2000 1,630 390 650 2,670

Total 6,863 3,177 12,617 22,657

Appendix III: U.S. Military CB Warfare

Medical Training Summary Tables, Fiscal

Years 1997–2000
Appendix III: U.S. Military CB Warfare

Medical Training Summary Tables, Fiscal

Years 1997–2000

Page 45 GAO-02-38 Chemical and Biological Medical Readiness

Table 6: Military Health Service Total End Strength, Fiscal Year 1999

Duty status Army Navy

Air

Force Total

Active duty

Physician Medical Corps 4,332 4,086 3,951 12,369

Nurse Corps 3,300 3,146 4,333 10,779

Physician assistants 478 235 455 1,168

Total active physicians, physician

assistants, and nurses

8,110 7,467 8,739 24,316

Reserve and Guard

Physician Medical Corps 4,380 2,707 2,472 9,559

Nurse Corps 11,778 3,702 5,895 21,375

Physician assistants 493 85 150 728

Total Reserve and Guard 16,651 6,494 8,517 31,662

Total active, Reserve, and Guard

physicians, physician assistants, and

nurses

24,761 13,961 17,256 55,978

Enlisted

Enlisted active duty 29879 22,459 20,711 73,049

Enlisted Reserves 51,709 11,309 11,333 74,351

Total enlisted 81,588 33,768 32,044 147,400

Medical Health Service

Active duty Medical Health Service officers

and enlisted

37,989 29,926 29,450 97,365

Total Medical Health Service health care

providers

106,349 47,729 49,300 203,378
Appendix IV: Comments From the Department

of Defense

Page 46 GAO-02-38 Chemical and Biological Medical Readiness

Appendix IV: Comments From the

Department of Defense
Appendix IV: Comments From the Department

of Defense

Page 47 GAO-02-38 Chemical and Biological Medical Readiness
Appendix IV: Comments From the Department

of Defense

Page 48 GAO-02-38 Chemical and Biological Medical Readiness
Appendix V: GAO Contacts and Staff

Acknowledgments

Page 49 GAO-02-38 Chemical and Biological Medical Readiness

Betty Ward-Zukerman (202) 512-2732

Daniel Rodriguez (202) 512-3827

In addition to the persons named above, Penny Pickett, Jonathan Tumin,

and Teia Harper made key contributions to this report.

Appendix V: GAO Contacts and Staff

Acknowledgments

GAO Contacts

Staff

Acknowledgments
Related GAO Products

Page 50 GAO-02-38 Chemical and Biological Medical Readiness

Bioterrorism: Federal Research and Preparedness Activities (GAO-01-

915, September 28, 2001).

Chemical and Biological Defense: Improved Risk Assessment and

Inventory Management Are Needed (GAO-01-667, September 28, 2001).

Chemical Weapons: FEMA and Army Must Be Proactive in Preparing

States for Emergencies (GAO-01-850, August 13, 2001).

Coalition Warfare: Gulf War Allies Differed in Chemical and Biological

Threats Identified and in Use of Defensive Measures (GAO-01-13, April

24, 2001).

Chemical and Biological Defense: Units Better Equipped, but Training

and Readiness Reporting Problems Remain (GAO/NSIAD-01-27, Nov. 14,

2000).

West Nile Virus: Preliminary Information on Lessons Learned

(GAO/HEHS-00-142R, June 23, 2000).

Biological Weapons: Effort to Reduce Former Soviet Threat Offers

Benefits, Poses New Risks (NSIAD-00-138, April 28, 2000).

Medical Readiness: DOD Continues to Face Challenges in Implementing

Its Anthrax Vaccine Immunization Program (T-NSIAD-00-157, April 13,

2000).

Combating Terrorism: Chemical and Biological Medical Supplies Are

Poorly Managed (GAO/T-HEHS/AIMD-00-59, Mar. 8, 2000).

Defense Health Care: Tri-Service Strategy Needed to Justify Medical

Resources for Readiness and Peacetime Care (GAO/HEHS-00-10, Nov. 3,

1999).

Combating Terrorism: Observations on the Threat of Chemical and

Biological Terrorism (GAO/T-NSIAD-00-50, Oct. 20, 1999).

Military Readiness: Full Training Benefits From Army’s Combat

Training Centers Are Not Being Realized (GAO/NSIAD-99-210, Sept. 17,

1999).

Related GAO Products
Related GAO Products

Page 51 GAO-02-38 Chemical and Biological Medical Readiness

Combating Terrorism: Need for Comprehensive Threat and Risk

Assessments of Chemical and Biological Attacks (GAO/NSIAD-99-163,

Sept. 14, 1999).

Combating Terrorism: Analysis of Federal Counterterrorist Exercises

(GAO/NSIAD-99-157BR, June 25, 1999).

Combating Terrorism: Issues to Be Resolved to Improve

Counterterrorism Operations (GAO/NSIAD-99-135, May 13, 1999).

Combating Terrorism: Observations on Biological Terrorism and Public

Health Initiatives (GAO/T-NSIAD-99-112, Mar. 16, 1999).

Defense Infrastructure: Central Training Funding Projected to Remain

Stable During 1997–2003 (GAO/NSIAD-98-168, June 30, 1998).

Medical Readiness: Efforts Are Underway for DOD Training in Civilian

Trauma Centers (GAO/NSIAD-98-75, Apr. 1, 1998).

Military Readiness: Reports to Congress Provide Few Details on

Deficiencies and Solutions (GAO/NSIAD-98-68, Mar. 30, 1998).

Defense Health Care: Medical Surveillance Improved Since Gulf War, but

Mixed Results in Bosnia (GAO/NSIAD-97-136, May 13, 1997).

Wartime Medical Care: Personnel Requirements Still Not Resolved

(GAO/NSIAD-96-173, June 1996).

Chemical and Biological Defense: Emphasis Remains Insufficient to

Resolve Continuing Problems (GAO/NSIAD-96-103, Mar. 29, 1996).

(713054)

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