Citation
U.S. Army Medical Department journal

Material Information

Title:
U.S. Army Medical Department journal
Alternate title:
United States Army Medical Department journal
Alternate Title:
AMEDD journal
Running title:
Army Medical Department journal
Abbreviated Title:
U.S. Army Med. Dep. j.
Creator:
United States -- Army Medical Department (1968- )
Place of Publication:
Fort Sam Houston, TX
Publisher:
U.S. Army Medical Department
Publication Date:
Frequency:
Quarterly[<Oct.-Dec. 2001->]
Bimonthly[ FORMER Sept.-Oct. 1994-]
quarterly
regular
Language:
English
Physical Description:
volumes : illustrations ; 28 cm

Subjects

Subjects / Keywords:
Medicine, Military -- Periodicals -- United States ( lcsh )
Military Medicine ( mesh )
Medicine ( mesh )
Medicine, Military ( fast )
United States ( mesh )
United States ( fast )
United States
Genre:
Electronic journals.
Periodicals.
Periodicals. ( fast )
Fulltext.
Government Publications, Federal.
Internet Resources.
serial ( sobekcm )
federal government publication ( marcgt )
periodical ( marcgt )
Electronic journals ( lcsh )
Periodicals ( mesh )
Periodicals ( fast )
Fulltext
Government Publications, Federal
Periodicals
Internet Resources

Notes

Dates or Sequential Designation:
Sept.-Oct. 1994-
General Note:
Title from cover.

Record Information

Source Institution:
University of Florida
Holding Location:
University of Florida
Rights Management:
This item is a work of the U.S. federal government and not subject to copyright pursuant to 17 U.S.C. §105.
Resource Identifier:
32785416 ( OCLC )
98642403 ( LCCN )
1524-0436 ( ISSN )
ocm32785416
Classification:
RC970 .U53 ( lcc )
616.9/8023/05 ( ddc )
W1 JO96 ( nlm )

Related Items

Preceded by:
Journal of the US Army Medical Department.

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Digital Military Collection

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P U B L I C H E A L T H A N D P R E V E N T I V E M E D I C I N E AprilJune2007Perspective1MGRussellJ.CzerwArmyPublicHealthandPreventiveMedicine:ProactiveApproachestoReadiness3BGMichaelB.CatesSick,Dead,&Discharged:DiseaseandtheDefeat5oftheConfederateCampaignintoNewMexico,1862WayneAusterman,PhDIntegratedDiseaseManagement:AnOldIdeaReadyforOurTime13COL(Ret)DanielStrickman,MS,USAExpandingtheRoleofPreventiveMedicineintheUnitedStatesArmy:16IntegrationandCooperationLTCJamesSheehan,MC,USA;CPT(P)BrentGibson,MC,USA;MAJBryanSisk,AN,USAHowtoStopFightingOurselves:RemovingtheStigma20ofMentalHealthTreatmentforSoldiersKayShepard,MSWDemystifyingtheEnvironmentalHealthSiteAssessment25LTCTimothyBosetti,MS,USAWaterPurifiersfortheWarfighter31MAJWilliamBettin,MS,USAAGuidetoBrigade-LevelPreventiveMedicine:35StrykerBrigadeExperienceinOperationIraqiFreedomII&IIICPTStephenLewandowski,MS,USA;CPTJasonFaulkenberry,MS,USAMeasuringEffectivenessofDeployedMedicalDetachments41LTCSonyaSchleich,MS,USA;MAJMarkCarder,MS,USAChallengesofEffectiveVectorControl:OperationIraqiFreedom050746LTCJamieBlow,MS,USA,CPTDarrylForest,MS,USA;CPTLewisLong,MS,USA,etalPreventiveMedicineSupportinAfghanistanDuringOperationEnduringFreedomVI56MAJChristopherGellasch,MS,USA;CPTLeslyCalix,MS,USAPreventiveMedicineSupporttoOperationLifeline:Pakistan200565CPTOwenPrice,MS,USA;LTCDavidWest,MS,USA;MAJJamesMancuso,MC,USA

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MGGaleS.Pollock ActingTheSurgeonGeneral Commander,USArmyMedicalCommandMGRussellJ.CzerwCommandingGeneral USArmyMedicalDepartmentCenterandSchool AprilJune2007 TheArmyMedicalDepartmentCenter&School PB8-07-4/5/6 0707809 GEORGEW.CASEY,JR General,UnitedStatesArmy ChiefofStaff DISTRIBUTION:Special AdministrativeAssistanttothe SecretaryoftheArmy ByOrderoftheSecretaryoftheArmy: Official: JOYCEE.MORROW Onlineissuesofthe AMEDDJournal areavailableathttps://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1 AProfessionalPublication oftheAMEDDCommunity The ArmyMedicalDepartmentJournal [ISSN1524-0436]ispublishedquarterlyfor TheSurgeonGeneralbytheUSArmyMedicalDepartmentCenter&School,ATTN: MCCS-DT,2423FSH-HoodST,FortSamHouston,TX78234-5078. CORRESPONDENCE: Manuscripts,photographs,officialunitrequeststoreceive copies,andunitaddresschangesordeletionsshouldbesenttothe Journal atthe aboveaddress.Telephone:(210)221-6301,DSN471-6301 DISCLAIMER: The Journal presentsclinicalandnonclinicalprofessionalinformation toexpandknowledgeofdomestic&internationalmilitarymedicalissuesand technologicaladvances;promotecollaborativepartnershipsamongServices, components,Corps,andspecialties;conveyclinicalandhealthservicesupport information;andprovideapeer-reviewed,highquality,printmediumtoencourage dialogueconcerninghealthcareinitiatives. Viewsexpressedarethoseoftheauthor(s)anddonotnecessarilyreflectofficialUS ArmyorUSArmyMedicalDepartmentpositions,nordoesthecontentchangeor supersedeinformationinotherArmyPublications.The Journal reservestherighttoedit allmaterialsubmittedforpublication(seeinsidebackcover). CONTENT: Contentofthispublicationisnotcopyrightprotected.Materialmaybe reprintedifcreditisgiventotheauthor(s). OFFICIALDISTRIBUTION: ThispublicationistargetedtoUSArmyMedical Departmentunitsandorganizations,andothermembersofthemedicalcommunity worldwide.

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AprilJune20071Sincethebeginningofwarfare,themedicalchallengesofdeploymenthaveremainedunchanged.Soldiersstillrequireprotectionfromthenaturalelements;theystillneedsafefoodandwaterandmustdealwithdiseasesandinsects.Thescienceandpracticeofpreventivemedicineinthemilitaryhaslongbeenrecognizedasparamounttotheachievementofarelevantandreadyforceandthesustainmentofcombatpower.ThisfactiswellsupportedinFieldMarshalViscountSlimsDefeatIntoVictory.ThisgreataccountoffightinginthejunglesofBurmaduringWWIIprovidesasuperbtestimonyoftheapplicabilityofpreventivemedicinetowarfare,asFieldMarshalSlimassessesthedeplorablehealthconditionofhisforces,derivesaplantofixit,andthen,aseverygreatcommanderdoes,heenforcesit.Tothatend,weareindeedfortunatetohaveourownprofessionalpublication,theAMEDDJournal,inwhichtoshowcasethetopicalscopeandintellectualdepthrepresentedbythisandtheotherareasofArmymedicine.Thisissuefocusesonthatcriticallyimportantdiscipline,withanemphasisonthespecialconsiderationsdemandedbythecombatenvironment.Forthesecondyearinarow,COLMustaphaDebboun,ChiefofMedicalZoologyBranchattheAMEDDCenterandSchool,hasorganizedandcompiledanoutstandingcollectionofarticlesfrompreventivemedicineprofessionalsthroughouttheArmy.Thisissueisjustonemoreexampleofthelevelofskill,capability,anddedicationofmedicalprofessionalswhoselflesslychoosetoserveourcountrywithdistinctionandhonor.BGMichaelCates,theCommandingGeneraloftheUSArmyCenterforHealthPromotionandPreventiveMedicineandtheFunctionalProponentforArmyPreventiveMedicine,openswithasuperbintroductiontothebreadthofresponsibilitiesandconcernsaddressedbythoseinvolvedinpublichealthandpreventivemedicine.Hisobservationsaresobering,whileatthesametimechallengingandexciting.Throughouthistory,theoutcomesofwarsandmilitarycampaignshaveoftenbeendeterminedbynoncombatfactors,especiallydebilitatingdiseases,nonbattleinjuries,andunhealthypersonalhabits.Indeed,thefateoftheUnitedStatesasweknowitmayhavehingedononeambitious,albeitlittle-knowncampaignearlyintheCivilWar.DrWayneAustermantellsthestoryoftheConfederateattempttoseizethewesternterritories,fromTexastoCalifornia,earlyinthewar.Theeffortwashamperedfromthestartbypoorplanningandleadership,whichrenderedtheforceunabletocopewiththeinevitableonsetofdisease,injury,hunger,anddisability.Thesecircumstancesdoomedtheefforttoearlyfailure.DrAustermansarticleisveryinformative,illuminating,andinstructive.ThestoryofsuchfailureinplanningandexecutionunderscorestheimportanceoftheemphasisthemodernArmyplacesonpublichealthandpreventivemedicine.Amongthevariousdisciplinesinmedicalscience,preventivemedicineisonethatabsolutelycannotbepracticedinisolation.Thenext2articlesclearlyillustratethatfact.First,COL(Ret)DanielStrickmanrevivesandclarifiestheconceptofintegrateddiseasemanagement,whichtiesmultipleaspectsofpublichealthandpreventivemedicinetogetherinacoordinated,task-orientedfashiontoattackallfacetsofagivenpublichealththreat,bothclinicallyandineverydaylife.Next,LTCJamesSheehanandhiscoauthorsdetailanexerciseinwhichamajormilitaryfacilitycollaboratedwithstateandlocalpublichealth,safety,andsecurityagenciesinanintegratedreactiontoasimulatedbioterrorismthreat.Theexercisehighlightedthenumerouswaysinwhichthemilitaryandcivilianpublichealthexpertise,resources,andrequirementsareinterrelated.Theirexcellentarticleillustrateshowsuchcooperativeworkingrelationshipsareessentialfortheprotectionandimprovementofbothindividualhealthandunitreadiness.PerspectiveMajorGeneralRussellJ.Czerw

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2ArmyMedicalDepartmentJournalAlthoughthedebilitatingaffectofthecombatenvironmentonmentalhealthhasbeenlongrecognized,treatmentisstillproblematic.GreatprogresshasbeenmadeintrainingourleadersastothevalueofmentalhealthevaluationandtreatmentfortheirtroubledSoldiers.However,thesocietalstigmaofalmostanyconcernsrelatedtoanindividualsmentalhealthstillpersists.KayShepardaddressestheseproblemsdirectlyandeffectivelyinanimportantandverytimelyarticleaboutthiscriticalareaofpublichealthofourforces.Sheprovidesanexcellentoverviewoftheproblems,anddescribesthesuccessesoftheSchweinfurtmedicalcommunity,spearheadedbySocialWorkServices,inprovidingservicestotheSoldierswhowererotatingintoandoutofcombatoperationsintheIraqtheater.LTCTimothyBosetticontributesanimportant,informativearticleclarifyinganessentialpartofpreventivemedicineplanningandoperations,theEnvironmentalHealthSiteAssessment.Hepresentsawell-organizedexplanationoftherequirements,components,andapplicationsforthisdocumentation,withspecialemphasisonitsvaluetothosechargedwithprotectingthehealthofourdeployedSoldiers.Potablewaterisessentialtothecombateffectivenessofanymilitaryorganization.Dehydrationorwaterbornediseasehasresultedinthecollapseofmanymilitarycampaigns.MAJWilliamBettinsarticlelooksattheArmysefforttoprovideindividualSoldierswiththebestpossiblecapabilitytogeneratetheirownsafewaterforemergencysituations.HedescribestheArmysdetailed,deliberatetestingofvariousindividualwaterpurificationsystems,andtheresults.Animportantoffshootofthestudywasthedevelopmentofastandardizedtestprotocolforuseinevaluatingfutureproducts,thuseliminatingtheneedtoreinventthewheel,savingcriticaltimeandmoney.Thelast5articlesprovideinsightsandlessonslearnedfromrecentdeploymentsofpreventivemedicineSoldiersintocombattheaters.First,CPTStephenLewandowskiandCPTJasonFaulkenberrydetailtheexperiencesofthefirstoperationaldeploymentsofbrigadecombatteamswithorganicpreventivemedicineassets.Theycoverthegrowingpainsassociatedwithaneworganizationalstructure,aswellasthemostimportantaspectsofpredeploymentpreparationandoperationsinthedeploymentarea.Theinformationistimelyandimportant,astheArmyrapidlytransformsitsforcestructureintothebrigadecombatteammodel,andtherolesandresponsibilitiesofpreventivemedicineadaptaccordingly.Thosechargedwithoptimizingapplicationofresourcesmusthaveamethodofmeasuringtheeffectivenessofthoseassets.LTCSonyaSchleighandMAJMarkCarderdetailaspreadsheetbasedevaluationmatrixthatwastheresultofacollaborativeeffortbythe5medicaldetachmentsdeployedwiththe61stMultifunctionalMedicalBattaliontoIraq.Thearticledescribesthecareful,deliberativeprocessinvolvedindevelopingandimplementingatoolwhichprovidesrelevantinformationwhichisnotaffectedbythecharacterofthedetachmentortherespectivedeploymentenvironments.Foroveracentury,vectorcontrolhasbeenavitalelementofpreventivemedicineandpublichealthresponsibilities.LTCJamieBlowandherteamofcoauthorspresentadetailedaccountoftheproblemsandsolutionstovectorcontrolwhichareencounteredduringcurrentoperationaldeployments.Theirarticleprovidesvaluableinsightsintothemyriadsituationsfacedbypreventivemedicinespecialists,includinginsects,feralanimals,birds,andbats.Theydescribethevariousattemptsatcontrol,somemoresuccessfulthanothers.Also,toreemphasizethecriticalimportanceofpersonalprotectivemeasuresincontrolofvectorborneillness,theAMEDDCenterandSchoolMedicalZoologyBranchhasprovidedimportantinformationontheDoDInsectRepellentSystemasanaddendumtothearticle.OperationsinAfghanistanarenolesschallengingforourpreventivemedicinespecialists.MAJChristopherGellaschandCPTLeslyCalixrelatetheirexperiencesprovidingsupportacrossthewidelydispersedforcesinanareawithconsiderablylessinfrastructurethanIraq.Theirarticledescribesthechallengesencounteredinprovidingalllevelsofpreventivemedicineservices,especiallyinthesupportoftheforwardoperatingbaseswhicharelocatedintrulyremotelocations.Again,thisarticleisavaluableresourceforthosepreparingfordeploymentintothevitallyimportantoperationalenvironment.Humanitarianmissionsintroducetheirownsetsofconcernsandchallenges.CPTOwenPriceandhiscoauthorscontributeadetailed,extremelyinformativeaccountoftheirrapiddeploymentintoPakistan(fromAfghanistan)toprovidereliefafterthedevastatingearthquakeinOctober2005.Inadditiontotheexpectedpublichealthandpreventivemedicineresponsibilities,theirexperiencesaspartofamultinationalreliefteamareavaluableinsightintothecultural,political,andfunctionalcomplexitiesinvolvedinsuchnonmilitaryenvironments.Perspective

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AprilJune20073FrommyperspectiveastheFunctionalProponentofArmyPreventiveMedicine,militarypublichealthincludesessentialelementsthatcontributetotheoverallhealthandwell-beingofourSoldiers,civilianemployeesandFamilies.Successfulpreventionleadsdirectlytoenhancedreadinessthroughhealth.AllArmyleaders,Soldiers,civilianemployees,andFamilieshavearoleinprotectingtheirownhealth,andtheArmyMedicalDepartment(AMEDD)hasoutstandingmilitaryandcivilianexpertsreadyandabletoassistthem.Armypublichealthencompassesawidevarietyofexpertiseandcapabilities,withpersonnelinover50specialtiesfromeverycorpsintheAMEDD.Thisteamincludesdeployableindividualsandunitsembeddedinbrigadecombatteamsupthroughthecombatantcommandsheadquarters,preventivemedicinepersonnelassignedtoArmyheadquarters,militarytreatmentfacilitiesandinstallations,Armyveterinarypersonnel,andtheprofessionalsassignedtotheUSArmyCenterforHealthPromotionandPreventiveMedicine.Currentpublichealthchallengesinourmilitaryincludeinjuries,behavioralhealthissues,infectiousdiseases,chronicdiseasesandotherconditionsrelatedtolifestylechoices,environmentalexposures,occupationalhazards,andfoodandwatervulnerabilities.Allhavevariouscausesandeffects,andallrequireadiversesetofsolutions.Injuries,mostlynonbattleinjuries,placethelargestburdenonourmilitaryhealthcaresystem,ingarrisonandduringdeployments.Falls,sportsinjuries,physicaltraining,andprivatemotorvehicleaccidentsarethemajorcausesofnonbattleinjuriesinourmilitary,creatingsignificantproductivitylossacrosstheentireDepartmentofDefense.Behavioralhealthissuesareagrowingconcern,especiallyamongthosewhohavedeployed.ThereisawiderangeofdiagnosesinthisfieldcurrentlyaffectinganincreasingnumberofourSoldiers.Appropriateandtimelyidentificationofthosewhoneedmentalhealthcareisdifficultand,thus,akeypiecetowardsuccessfulresolution.Also,thestigmaassociatedwithanytypeofmentalhealthcarecreatesadisincentiveforSoldierstogetthecaretheyneed.Educationandtrainingeffortsareamongthemostimportant,proactivetoolshere,focusedonimprovingbehavioralhealththroughearlyidentificationandreducedstigma.Healththreatsfromemergingorreemergingdiseasesincludetuberculosis,malaria,drug-resistantAcinetobacterinfections,leishmaniasis,andzoonoticdiseasesassociatedwithindigenousanimals.Afullunderstandingoftheepidemiologyandpathogenesisofmanyoftheseisoftenlacking.So,surveillance,effectiveprophylaxis,earlydetectionandrapidmitigationarethebestapproachestodecreasetheimpactofsuchhealththreats.RecognizingthatmanyofthehealththreatsthatSoldiers,civilians,andFamilymembersfacearecausedbylifestylechoices,theArmypublichealthandpreventivemedicineprogramshaveembracedtheArmyPublicHealthandPreventiveMedicine:ProactiveApproachestoReadinessBrigadierGeneralMichaelB.Cates BGCatesistheCommandingGeneral,USArmyCenterforHealthPromotionandPreventiveMedicine;theFunctionalProponent,USArmyPreventiveMedicine;andChief,ArmyVeterinaryCorps.

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4ArmyMedicalDepartmentJournalconceptofeducatingindividualstopreventillnessandinjurythroughanaggressivehealthpromotionandwell-beingcampaign.ThreecontinuingproblemsinSoldierhealtharetobaccouse,weightcontrol,andalcoholabuse.Eachposestremendousshort-termandlong-termhealthrisks,andrecentsurveysdepictnegativetrendsamongourmilitarypersonnelandtheirFamiliesthatwemustcontinuetoaddress.Ourmilitaryhaspersonneldeployedtomorethan100countriesinanygivenweek.Theinfrastructuresofmanyofthosecountriesarepoor.Manytimes,wehaveverylittleknowledgeofthehistoryofthoseenvironmentsandtheirassociatedhealthrisks,andwhenwedo,theinformationwehavemayhavealreadychanged.Samplingmaybeslowordifficultasweattempttolearnmoreaboutthepotentialhealthriskstoourmilitarypersonneldeployedthere.Yet,environmentalsurveillancemonitoringair,water,andsoilforindigenousthreatstohealthisanabsolutelynecessarypieceofthepreventivemedicineprogram.Newweaponsandnewvehiclesemployedbythemilitaryarebetter,bigger,andbringnewhealthrisks,suchasacousticenergy,temperatureextremes,shockandvibration,andoxygendeficiency.Oftheseexamples,acoustictrauma,withresultinghearinglossorotherproblems,isthebiggestconcern.Inthefuture,foodandwaterhavegrowingpotentialforhealthrisks.TheUnitedStateshasthebestfoodandwatersafetyprogramintheworld,yettheCentersforDiseaseControlandPreventionestimatetheincidenceoffoodborneillnessat76millioncasesayear.Aswedeploypersonnelintomorethan100countrieswithpublichealthinfrastructuresnotasrobustasours,thehealthrisksfromfoodandwateraremuchhigher.Today,wemustalsobeconcernedaboutintentionalcontaminationoffoodandwater,orthedestructionofourwatersupplysystems.OurArmypublichealthandpreventivemedicineteam,relativelysmallinsize,butbroadanddeepinexpertise,iscurrentlyworkingtowardsolutionstothesecurrentchallengesaroundtheworld.TeammembersstrivetoprotectourSoldiers,civilianemployees,andFamilieslocallywhileremainingreadyandwillingtoprojectglobally.TheyareanamazinggroupthatrarelyreceivesthecredittheydeserveforensuringtrueForceHealthProtectionandReadiness.IamexcitedthatthiseditionoftheAMEDDJournalshowcases,forthesecondstraightyear,someoftheircapabilitiesandcontributions.Aswemoveforward,especiallyinatimeofwar,wemustcontinuetoimproveourmilitarypublichealthefforts.Forone,wemustplacegreateremphasis,fromalllevels,onpreventivehealth,toincludemoreofaninvestment,lookingforthelong-term,aswellastheshort-termbenefitsofsuchefforts.OursurveillancemustbemoresynchronizedwithintheDepartmentofDefenseandtherestoftheUSGovernment,witheasyinformationlinksbetweenhumanandanimalhealth,aswellaswiththeenvironment.Wemustprovidetimely,accurate,andactionabledatatoourcommandersinthefieldtoquicklyidentifyandmitigateanysignificanthealthrisks,andwemusthaveeffectivewaystochangeriskybehaviorsandreduceinjuries.Mostimportantly,partnershipsandcollaborativeeffortsshouldbeenhancedamongourmilitarypublichealthexpertsinalloftheuniformedservices,aswellaswithoutsideagencies.Preventivemedicineiscrucialinmaintainingthereadinessofourmostimportantresourceourpeople.Sustaining,andevenimproving,aSoldiershealthisamuchwiseruseofresourcesthanwaitinguntilthatSoldierbecomessickorinjuredbeforeattemptingtorestorehealth.Thebetterwepreventdiseases,conditionsandinjuries,themoreresourceswillbeavailabletoapplytothosethingswecannotprevent.Whilethereiscontinuingandgrowingemphasisonproactiveapproachestohealthintodayssocietyandmilitary,wemustallstrivetowardtranslatingthatintoreal,evengreaterlong-terminvestmentsinthefutureofourpersonnel.Preventionisthebestwaytohealth.ArmyPublicHealthandPreventiveMedicine:ProactiveApproachestoReadiness

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AprilJune20075OnMay31,1861,HenryHopkinsSibley,anarticulate,alcoholic,45-year-oldmajorinthe2ndUSDragoonswhosufferedfromchronicrenalcolic,resignedhiscommissionatFortUnion,NewMexico,andtraveledeastwardtoRichmond,Virginia,capitalofthenewlyformedConfederateStatesofAmerica.TherehegainedanaudiencewithPresidentJeffersonDavis,winningacommissionasabrigadiergeneralandofficialsanctionforhisaudaciousplantoseizemodern-dayNewMexicoandArizonafortheConfederacyasapreludetolaunchingoffensivesagainstthesilverminesofColoradoandgoldfieldsofUnionistCalifornia.ThedecisionmadeinDavisofficeduringthemeetingwithSibleysealedthefateofhundredsofyoungTexansdoomedtodieinthecourseofhisill-starredcampaignandcommittedthemanpowerandmateriel-poorConfederacytoaneffortwhosemodestdemandonresourcespromisedpotentiallydecisivestrategicresults.ThatwasbeforeSibleysalcohol-addledineptitudeasacommanderandhisforceslackofanadequatefieldmedicalsupportsystemallowedexposureanddiseasetosapitsstrengthanddictatedefeatinthearidhighlandsofNewMexico.1WhenSibleyarrivedinSanAntonio,Texas,onAugust12,1861,hefoundthatpartofhismissionhadalreadybeenaccomplishedforhim.LieutenantColonelJohnR.Baylorofthe2ndTexasMountedRifleshadtakenabattalionoftheregimentwestwardoverthe500milestoElPasoearlyinJuneandseizedtheabandonedpostofFortBlissearlyinJuly.OnJuly25,theaggressiveBaylortookhis350-oddtroopers40milesupthecourseoftheRioGrandeandfoughtapitchedbattleontheoutskirtsofMesilla,NewMexico,withthegarrisonofnearbyFortFillmore,subsequentlycompellingtheentire7thUSInfantryregimenttosurrender.AsaresultofBaylorszeal,thegatewaytoUnionistNewMexicolayopentoinvasionbyConfederateforces.ItremainedforSibleytorecruitandequiphisnewbrigadeintheSanAntonioareabeforemarchingwestwardtoresumeandexpandBaylorsoffensive.1(pp209-221),2,3SibleyhadbegunassemblingastaffbeforeheleftRichmondwithhisnewcommission.HeselectedDrEdwardN.Coveyashisbrigadesurgeon.AveterancontractsurgeonwhohadearlierservedwithSibleyinNewMexico,DrCoveyremainsanenigmaticfigureinthecampaignshistory.HemusthavebeenawareofSibleysdebilitatingproblemwithkidneydiseaseandhisadvancedalcoholism,yetheseemstohavejoinedtheenterprisewithlittlereservationandtohaveexertedlittlerestraintonSibleysappetiteforthebottle.1(p219),4,5BymidOctober,Sibleyhadmustered,organized,andequippedabrigadeof2,500menconsistingofthe4th,5th,and7thRegimentsofTexasMountedVolunteersalongwith2batteriesoffieldartillery.Becauseofananticipatedshortageofwaterandgrazingonthetrailtothewest,thebrigadewasbrokendownintoseveralmarchincrements,thefirstofwhichdepartedforElPasoonNovember9asthecoolerautumnweatherfinallysweptoverthestate.Contemporaryaccountsaredevoidofanydetailedinformationonthebrigadesmedicalestablishment.TherearenoreferencestoambulancesorenumerationofmedicalsuppliesintherecordofitsorganizationinSanAntonio.AccountsofsubsequentcombatactionsinNewMexicoaredevoidofanyreferencestothefieldmedicalsupportsystemanditsfunctionalorganization.ItisknownthatSibleytook10ambulancestoElPasowithhim,butnodocumentationsurvivestodetailhowtheywereorganizedforcasualtyevacuationoreveniftheywereassignedtothatmissionorusedsimplyasgeneralutilityvehicles.AnoviceregimentalquartermastersergeantgaveSibleyhighmarksasalogisticianwhentheunitleftSanAntonio,callingitthemostcompleteandperfectlyequippedbrigadesentoutbytheConfederacyduringSick,Dead,&Discharged:DiseaseandtheDefeatoftheConfederateCampaignintoNewMexico,1862WayneR.Austerman,PhD

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6ArmyMedicalDepartmentJournalthewar.WhenthecommanddepartedforElPaso,itssupplytrainconsistedofover300wagonsladenwithmateriel,whilethequartermaster,brigadeandregimentalheadquarters,andthemedicalcorpsalsohadwagons.Evenso,shortageswouldstalkthewardslongbeforethecampaignreacheditsdismalendbythefollowingspring.3(p96),6Thethreemountedregimentscountedatotalof10surgeonsservinginthatofficialcapacity,whilenumerousotherphysiciansfilledtherollsascompanycommandersandevencommonriflemen.Therewasnoshortageofmedicalmeninthebrigade,butlittlesignofanyunitedorganizationalframeworkcapableofexploitingtheirtalentsefficientlyabovetheregimentallevel.ThereweretobenoLettermansservingwithSibleyamidthemesquiteandchaparral.ThelongmarchinautumnweathertookitstollbeforethefirstcompanyreachedElPaso.Measleseruptedonthetrail,afflictinganentirecompanyofthe7thRegimentsobadlythattheunitwasleftinquarantineatapostalongthewayandmissedtheentirecampaign,losing15mentothediseaseduringone3-weekperiod.Youngmenfromruralbackgroundsassembledinlargegroupsforthefirsttimetypicallylackedanimmunitytosuchdiseasesandthusproveduniquelyvulnerable.Thecommandsmodernchroniclerrelated:DiseaseplaguedthecommandonitsmarchacrossTexasandfreshgravesmarkedthebrigadesroute.HospitalsalongthewaywerefilledwithpatientsfromSibleysbrigade.Smallpox,alreadypresentinArizona,posedathreat;regimentalsurgeonscounteredbyvaccinatingmostoftheirmen.Othervolunteersfellillonthemarch,farfromeventherelativecomfortsofthecrudemedicalfacilities.Routinecampdiseases,especiallydysentery,affectedsometroops.Pneumoniaalsoappearedinthecommand.Althoughfewofthetroopswerediagnosedashavingpneumoniaduringthemarch,manyhadacquiredanunsettling,rattlingcough.4(p220),6(pp124-125)ThevanguardofSibleysbrigadereachedElPasoinmid-December,butthebalanceoftheunitwasnotatFortBlissuntilJanuary19,1862.AbsorbingBaylorsbattalionandsundrylocalvolunteercompaniesintohiscommand,Sibleyconfrontedcontinuingattritionofhisforceduetodisease.OnetrooperremarkedattheendofDecemberhowourcompanyisinbadhealthnow.Thereisabouthalfofthecompanysick.Ithinkthereispoorprospectofourcompanygoingoutthiswinter,iftheboyskeepgettingsick.Theunitinquestion,CompanyAofthe2ndTexasMountedRifles,suffereda50%sicknessratethroughJanuary1862,andwasforcedtoremainintherearthroughouttherestofthecampaign,renderedfitonlyforlightoccupationduties.3(pp126-136),4(p304),7sick,dead&dischargedInearlyJanuary,SibleyresumedtheoffensiveinitiatedbyBaylor5monthsearlierbysendingunitsnorthwardtooccupyanewforwardbaseofoperationsattheabandonedprewarpostofFortThorn,sitedonthewestbankoftheRioGrandeapproximately40milesupriverfromFortFillmore.ThemovementandoccupationtookplacewithoutanyinterferencefromtheUnionforcesassembledfurtherupstreamatFortCraig,althoughApacheraidswereaconstantnuisance.ItwasatthispostthatSibleysfailingsasaplannerfirstbecamemanifesttohistroops.Thearrivalofthebrigadeaddedmorethan2thousandtemporaryresidentswhodescendedonthearealikeahumanavalanche,notedarecentchroniclerofthecampaign.Food,bothpurchasedandstolen,becamescarce,andpricesrose.Contractorsforthearmyincreasedtheirearningswhilepoorfarmersandtheirfamilieswenthungry.BaylorsTexanshadbeenacuriosity,Sibleysliberatorswereacalamity.AtFortThornthebrigadessupplydepotheldoveramonthsrations,andadditionalsupplieswereexpectedtobetakenfromtheenemy,butthearidcountrysideandsparsefarmingpopulationfoundeveninthegreen,cultivatedacreagealongtherivervalleymadeitclearthatNewMexicowouldofferpoorforagingtoanyarmyhopingtoliveofftheland.Sibleysantebellumserviceintheregionmusthavemadehimawareofthedirelogisticalproblemsconfrontinganysizeablemilitaryforceseekingtoconductextendedoperationsamidthemountain-hemmeddesertcountry.TheforcedsaleorconfiscationoffoodfromthelocalHispanicpopulationbegantheprocessofalienationfromtheinvaderswhichwouldcastmostofNewMexicosnativepopulationintotheUnionistcampasthecampaigncontinued.*Whilefoodwasnotyetapressingconcern,exposurewasalreadyaproblemamongtheTexans,mostofSick,Dead,&Discharged:DiseaseandtheDefeatoftheConfederateCampaignintoNewMexico,1862*References2(pp55-56),3(pp135-138),6(p18).

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AprilJune20077whomcamefromthewarmlatitudesoftheGulfcoastalplain.Unaccustomedtothewinterchillofthehighdesertcountry,theysufferedaccordinglyasupto4inchesofsnowblanketedtheirnewcamp.Lackingadequatetentage,thetroopssleptintheopenandsoonpneumoniawasrunningthroughthebrigade.ThewheezeandrattleravagedCompanyIofthe5thTexasinparticular,killing3menwithinthefirstweekofFebruary,leavingthemostofthemeninourcompanysick,dead&discharged,lamentedasoldier.Theharshweatheralsomadebathingandlaunderingofclothesdifficult.Theresultwasaplagueoflicewhichsoonhadtheentirebrigadescratchingandsearchingtheseamsofitsuniformsfordepositsofeggs.*Anyveterinarysurgeonsservingwiththebrigadealsohadtheirhandsfull,forpoordiet,hardusage,andexposurealsotookaheavytollamongthecommandshorsesandmules,andthemineral-impregnatedwateroftheUpperRioGrandehadgiventheanimalsanailmentcalledthescours.Evenmoretroublingwasthelackofproperfeedforthestock,whichledtoaprogressivephysicaldeteriorationoftheteams.Aforceof2,000troopstypicallyrequiredatrainof350supplywagonsinsupport.SibleyhadbarelyenoughwagonsandteamstosupporthisbrigadeatthestartofthecampaigninSanAntonio.BythetimehestrucknorthwardintoNewMexico,theshortageofteamsandscarcityofforageforthoseremainingdictatedthathiscommandwouldexistonasteadilyfrayinglogisticalshoestringunlessanduntillargequantitiesofsuppliescouldbecapturedfromtheenemyearlyinthecampaign.Thesteadyattritionoftheanimalsduetohungerandenemyactionwouldeventuallyleavemostoftheproudmountedvolunteersafootandreducethebrigadetrainstoafewscorewagons.2(pp49-50),3(pp141,149)OnFebruary7,Sibleyresumedhisadvanceupriverwiththe5thTexasinthevan.TheshortageofhealthymulesforcedthebrigadetoleavehalfitswagonsbehindatFortThorn,andpriorityofspaceintheremainingoneswasgiventofoodandammunition.Themenbeganthemarchonhalf-rations,andalthoughaherdofbeefcattleaccompaniedthecolumn,thesteersconditionwassopoorthattheycouldbarelystaggeralong,andthemenfoundtheirmeatbarelypalatable,butitwasalltobehadamidthatdesolatecountryofwant.3(p149)Bythistime,Sibleyskidneydiseaseandalcoholabusehadbeguntovisiblyaffecthisfitnesstocommand.Asurgeonofthe7thTexashadalready*References2(pp52,55),3(pp137-139,141-142,155), 6(pp16-20,25-28),8,9. TheConfederateArmycampaignintotheNewMexicoterritory,JanuarytoMay,1862.

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8ArmyMedicalDepartmentJournalobservedthattherewastoomuchdrunkennessamongthecommanderandhisstaff.Hiskidneydiseasehadplaguedhimforyears,andwhilewhiskeysoftenedthepainitalsoexacerbatedtheseverityofhiscondition.Unabletorideonhorseback,heledtheadvancefromanambulance.IbelievethatGeneralSibleywasabraveandgallantman,andatruepatriot,wroteoneofhisofficers.Hishealthwassuchthathewasnotfittocommand.Themindnaturallybecomesturnedwhendiseaseandpainracksthebody.(He)oughttohaveresigned.*AsSibleyscommandsloggednorthward,theenemyawaitedhisapproachbehindthenetworkoffieldfortificationsencirclingFortCraig.There,ColonelEdwardCanbycommandedaforceof3,800regularsandterritorialmilitia.Sibleyscommandingofficeratonepostingintheoldprewarservice,Canbywasacautiousandprudentcommander,whorealizedthattheentiresouthwesternregionofthenationwashistoloseinastrugglewiththerebels.Reasonablywellsuppliedandcommandinganadequateforcefordefense,hewouldchallengeSibleybutonceinthefield,thenleavehimwiththeoptionsofbatteringhisforcebloodyinfutileassaultsagainstFortCraigsheavygunsandfieldworks,orriskingstarvationinattemptingtocontinuehismarchnorthwardagainstSantaFeandtheothermajorbluecoatbastionatFortUnion,northeastoftheterritorialcapital.2(pp59-82)aspectaclethatwashorribleByFebruary15,Sibleys2,500menweredeployedforbattleroughly6milessouthofFortCraig.ThestillailingSibleyhadtemporarilyyieldedcommandofthebrigadetoColonelThomasJeffersonGreenofthe5thTexas.GreenattemptedtodrawCanbysforceoutintotheopenforabattle,buttheUniongarrisonremainedsafelybehinditsfieldworks,withheavycannonwhichheldtheTexansatarespectfuldistance.Greenfacedadilemmaasthebrigadesrationsdwindledtoa10-daysupply.HeelectedtocrosstotheeastbankoftheRioGrande,marchupstreamfor6miles,andthenrecrosstheriveratValverdeFord,hopingthatsuchamovemightprodCanbyintocomingouttofightforfearthattheTexansmightseverhislineofcommunicationsnorthward.CanbydivinedGreensintentions,however,andwhentheConfederatesreachedthefordonthemorningofFebruary21,theyfoundablockingforceoccupyingtheeastbankofthecrossingsite.AmajorbattleeruptedasSibleysatstuporouswithdrinkinanambulanceinthecompanyoftwowomenofuncertainvirtue.MusketryandartilleryfirelashedthefielduntilCanbysunsteadymilitiafledthesceneandtheTexansoverranabatteryofUnionguns,endingthebattleasthedefendersescapedacrossthefordandreturnedtothesanctuaryofFortCraig.UnionlossesatValverdeFordtotaled112deadand189woundedalongwith204missinginaction,ornearly18%oftheforceengaged.TheTexanscounted36dead,150woundedand1missing.Forty-threeoftheirwoundedsubsequentlydiedafterreachingthemakeshiftfieldhospitalerected2milesupstream.TheConfederateshadlost10%oftheirforceandCanbywasstillsecureinanimpregnableposition.AUnionofficerrecalledhowthefieldwascoveredwithblood,horses,tornanddismemberedlimbs,andheadsseparatedfromtheirbodiesaspectaclethatwashorrible.Eventhenorthernerswereshortoflittersandambulances,forsomeoftheircasualtieswerecarriedfromthesiteinbarrows.TheConfederatesborrowedlanternsandshovelsfromtheiropponentsasdarknessfellwhilebothsidescombedthebattlefieldforwoundedtoretrieveanddeadtobury.10(pp102,159)TheConfederateshadnotonlyfailedtowinanymeaningfulsortofvictory,theyhadsufferedaseverelogisticaldefeat.Unionartilleryandsmallarmshadwreakedhavocamongthesaddlehorsesanddraughtanimalsastheystoodtetheredintherear,killingnearlyathousandofthem.Thewholeseemedtobetheabodeofdeathitself,wroteonegrievingtrooperofthehumanandequinelossesalike.Manyofthetroopswerenowputafoot,whilemuchclothing,blanketsandotherequipmenthadtobeabandonedforlackoftransport.AsthebrigadebynecessitycontinueditsadvancenorthwardinsearchofsuppliesonFebruary23,6-mandetailscarriedsomeofthewoundedonlitters,whileothersoccupiedspacesintheremainingwagons.Onthe25th,theycapturedaUnionsupplydepotatSocorroandestablishedahospitalinachurchandprivatehomeinordertosheltertheir200Sick,Dead,&Discharged:DiseaseandtheDefeatoftheConfederateCampaignintoNewMexico,1862*References1(pp251-252),3(pp145,149),6(p42). References1(pp252-258),2(pp77-103),3(pp150-185), 9(118),10.

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AprilJune20079sickandwounded,whilemenweredetailedtoserveasnursesandstewards.ItwasthefirsttimeanyofthebrigadessickorwoundedhadbeenunderaroofsinceleavingFortThorn,overamonthpreviously.DrCoveyandDrSamuelB.Maney,aformerrifleman,usednewlycapturedmedicalsuppliestoeasethemenssuffering.3(pp180-184),10(pp102-103)SibleypausedinSocorrolongenoughtoreorganizethebrigadeandleavehiscasualtiesinthehospitalunderthecareofDrHenryJ.Hunterofthe7thTexas.HethenresumedthemarchtoAlbuquerque,whereuponarrivalonMarch2,thetroopsfoundamajorenemysupplydepotreducedtocharredruinsbythedepartingUniontroops.Itwasabitterblow,butsomeofthedisappointmentrecededsoonafterwardwhenDrFinisE.Kavenaugh,aformerUSArmycontractsurgeonandConfederatesympathizer,seizedanordnanceandquartermasterdepotthathadbeenestablishedinthehamletofCubero,65milestothewest.ThecoupnettedSibley25wagonloadsofprecioussuppliesandputtheinvadersonthebestlogisticalfootingtheyhadenjoyedsinceleavingFortThorn.Sibleyestimatedthathecouldsustainthebrigadeforanother3monthsonthebootyDrKavenaughseizedatCubero.Itwasthemostfatefulsingleactperformedbyaphysicianoneithersidethroughoutthecampaign.*ByMarch4,theUniongarrisonofSantaFehadtorchedthesupplydepotthereandabandonedthetown.NinedayslateraConfederateadvanceguardenteredthecapitaltosiftthroughtheashesofthecharredwarehouses.ThebulkofSibleysbrigaderemainedwelltothesouthnearAlbuquerquefor2weeksastheonsetofseverewinterweatherforcedittosuspendoperationsforatime.SibleyorderedlargeportionsoftheunittomoveeastwardintotheSandiaMountainsinordertoblocktheroadlinkingFortCraigwithSantaFeandFortUnion,whileutilizingthescantshelteraffordedbythescatteredsmallvillagesinthehighlands.ThehospitalestablishedinAlbuquerquewassoonfilledwithdozensofpneumoniacases.The5thTexashadmarkedanupsurgeinthediseaseafterleavingSocorro.Weburiedfourmen,adespondentsoldierwrote.Pneumonia,measles,small-pox,itchandbodylicearegettingintheirworkonus.Thedeploymenttothemountainsdestroyedthehealthofmany,forahospitalattendantrecordedhowagreatmanymorecomeinfromthemountainsandreportsnowallovereverything,blanketsandall.Thatfoolishmoveoutinthosemountainswillcausethedeathofmanyapoorfellow.3(pp184-201),8(p138),11unprotected,withnomedicineSibleycontinuedtoignoreCanbyashekepthiscommandmassedatFortCraig.HavingtakenSantaFewithatokenadvanceguard,hewaspoisedtorenewtheadvancenorthwardfromAlbuquerquewiththeobjectiveofclearingthepassesnortheastofthecapitaltoseizethemajorenemysupplydepotatFortUnion.Ifthatrichlodeofmaterielwastaken,Canbywouldbeforcedtoconcedehisisolationanddefeat,whileSibleywouldthenbepoisedtostrikenorthwardintoColoradoorconceivablyevenmountathreattoUnioncontrolofCaliforniaanditsPacificseaports.AtFortUnion,newlyarrivedColoradovolunteersjoinedtheregularsandmilitiaattheposttospearheadthedefendersripostetotheTexanadvance.ColonelJohnP.Sloughled1,342mensouthwardfromtheforttobartheenemyadvanceatGlorietaPass,a7-milelongnotchintheSangredeCristorange.Barelyaquarterofamilewideatitsmidpoint,thepasswaskeyterrainforanyforceseekingtostrikeateitherSantaFeorFortUnion.ElementsofSibleysmainforcewereeitherstillencampedoronthemarchfromAlbuquerquewhenSloughsColoradoanssentanadvanceguardintothepassfromtheeastonthe25thofMarch.Shortlybefore11oclockonthemorningofthe28th,ColonelWilliamR.ScurryledathousandmenofSibleysbrigadeintoactionagainsttheColoradoansnearthewesternendofthelongdefile.WhileScurryfoughtSloughtoanear-defeat,adetachmentofUniontroopsexecutedanarduousflankingmarchviaalittle-knownroutethroughthemountainsandthenmadeaprecipitousdescentfromamesatostrikeScurrysbaggagecamp,burning80supplywagonsandkillinghundredsofhorsesandmules.AregimentalchaplainwasalsoslainwhenheattemptedtohaltthesmallarmsfirethatrakedthenearbyConfederatefieldhospital.2(pp125-160),3(pp207-230),12Withthedestructionofhissupplytrain,Scurrywasforcedtoconcededefeatandbeginawithdrawal*References2(pp115-116,122-123),3(pp184-185,196), 6(pp79,87).

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10ArmyMedicalDepartmentJournalsouthwardtoSantaFe.Itwasthefirststeponthelong,punishingroadbacktoSanAntonio.SibleyhadbeenunabletobringthebulkofhiscommandtothebattlefieldatthedecisivetimeandplaceatGlorietaPass.LogisticalproblemsandthemountingsicknessratewhichsappedhismanpowerandimpededhismovementshadkeptmuchofhisforcefarsouthwardnearAlbuquerquewhilethecourseofthecampaignwasbeingdecidedinthewindsweptmawoftheSangredeCristos.Theturningpointofthecampaignhadcome,andeventsconspiredagainsttheConfederates,butScurrywasstillfacedwiththeissueofburyinghis42deadandevacuatinghis203woundedoverthe23mileswestwardtoSantaFe.Hisopponenthadhisown47deadand78woundedtoburyorbandage,andtheTexansfacednoimmediatethreatofpursuitasthecombatantsmutuallyagreeduponan18-hourtruce.Onceagain,thesouthernersborrowedpicksandshovelsfromtheirfoesinordertoburytheirdead.Withnowagonsorambulancesleftfortransport,norevenanimalsavailabletohaultravoisorslunglitters,theTexanwoundedfacedaslow,painfulpassagebacktoshelteratSantaFe.*WhenScurryscolumnarrivedinSantaFeonthemorningofMarch29,theyfoundthatnoneotherthanUnionColonelCanbyswifehadorganizedtheladiesofthetowninpreparationstoreceivecasualtiesfromthebattle.ConfrontedwiththeshortageofTexanambulances,shehitupontheexpedientofnailingtentcanvasacrosswagonbedsinordertomakehammocks,andorganizedaflowofsuppliesbacktoScurryscampatthepassinordertohelpthosewoundedtoobadlytobemoved.SoonregardedasaheroinebytheadmiringTexans,Mrs.Canbywasstillunabletostemtheravagesofpneumoniaamongthewound-weakenedmenunderhercare.InAlbuquerque,SibleyreceivednewsofthefightsnorthofSantaFeonMarch30,andheinitiallythoughtthatScurryhadwonamajorvictory.HeandhisstaffleftforSantaFesoonafterward,andonApril4theyreachedtownincompanywithColonelGreens4thTexas.Onceagain,theentirebrigadewasassembledinoneplace,itsnumbersshrunkentoapproximately1,700menbydeath,wounds,anddisease,whichhadsteadilyattritedtheforcefromElPasoandFortThornthroughAlbuquerquetoGlorietaPass,reducingittoperhapstwo-thirdsofitspeakstrengthduringthecampaigntodate.2(pp163-166)SibleywasponderinghisnextmovewhenwordarrivedthatCanbyhaddepartedFortCraigandmarchedeastwardtocombineforceswithunitsfromFortUnion.TheTexanshadnochoicebuttostagearetreat.Thebrigadehurriedlycountermarchedsouthward,reachingAlbuquerqueonApril10.Sibleyleft250sickandwoundedmenbehindinSantaFe,trustingthemtotheenemysmercy.Relievedofthatburden,thebrigadecommencedwhatprovedtobeaharrowingretreatsouthwarddownthecorridoroftheRioGranderivervalley.2(pp167-185),3(pp235-245)Lashedbywindandrainstorms,theConfederatesfoughtaminorskirmishwithUniontroopsatthevillageofPeraltaonApril16and17,sufferingonly4killedand6wounded.However,therapidlydeterioratingphysicalconditionoftheirwagonsteamsforcedthemtoleaveadditionalsickandwoundedbehindinthetinyvillage,withoutattendantsormedicinesandalmostwithoutfood.Theretreatcontinuedtoapoint70milesnorthofFortCraig,whereSibley,fearingbeingcaughtbetweenasortiebythefortsgarrisonandCanbyspursuingforcebehind,proposedleavingthewestbankoftheriverandtakingatorturousroutewestwardthroughthemountainstoregaintheriverroadbelowtheUnionbastion.Whatfollowedwasanightmaremarchof5daysand80milesastheTexansspikedmostoftheirartillery,burnedmostoftheirwagons,loadedsuppliesonpackmules,andbeganatorturouspassagedownthewesternslopesoftheMagdalenaandSanMateoranges.AlloftheremainingsickandwoundedwhocouldnotrideorwalkwereabandonedpriortothemarchonApril17,huddledaroundafirebeneathayellowhospitalflag.AUnionpatrolfoundthemafewdayslater,unprotectedwithnomedicine,nophysicianandbutfewattendants.2(pp186-191),3(pp246-251)howgeneralisthedebilityTheruggedcountryandfailingteamssoonforcedSibleytoabandontherestofhisartillery,burnanother22wagonsandcarriagesandall10ambulances,leavingonly7wagonstocarrytheremainingsick.Sibley,muchofthetime,unknowntotherankandSick,Dead,&Discharged:DiseaseandtheDefeatoftheConfederateCampaignintoNewMexico,1862*References2(pp162-163),13(pp101-109),13. References2(pp163-165),3(pp231-234),6(pp99-100),14.

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AprilJune200711file,wasdrunk.ThecasualtiesheabandonedfellintoUnionhands,asdidtheonesleftinthehospitalatSocorroduringhisearliermarchnorthward.Canbysubsequentlyreportedthatatthecampaignsendhehadparoledapproximately240enemyprisonersofwar,whileanother240remainedonhishands,ofwhomabouttwo-thirdsconsistedofsick,wounded,andhospitalattendants.Canbywiselydecidedtoforegoanotherbattleandsimplyletthestarvingenemydepartinpeace,forhehadnodesiretoassumetheburdenoffeedinghundredsofadditionalprisonersorcaringfortheirsickandwoundedfollowingafinalneedlessclash.Astherestoftheragged,famishedbrigadestumbledsouthwardforMesillaandElPaso,mutedcriticismofSibleybecameopencontemptamongofficersandmenalike.*UponarrivalatFortBliss,thebrigadereassembledforthefirsttimesinceleavingtheriverroadaboveFortCraigandtookstockofitsremainingstrengthandcondition.Theexperienceofthe4thTexasMountedVolunteerswasperhapstypical.TheunithadleftSanAntoniowith927officersandmen.Bycampaignsenditmustered552presentandfitforduty.Ithadlost7deadand10medicallydischargedenroutetoElPaso.Forty-sevenmenwerekilledinactionordiedofwounds.Another28diedofdiseaseduringthecampaign,while194werecaptured,ofwhom51werewounded,3ofwhomsubsequentlydied.AtthecloseofthecampaignatFortBlissandenroutebacktoSanAntonioanother20mensuccumbedtoillness.Onesurgeonand2leftbehindsickatFortBlissweretakenprisoner.BythetimeofthebrigadesFortBlissmuster,lessthan1,800menremainedofthe2,515whohadmarchednorthwardwithSibleybarely3monthspreviously.Allthemenaremoreorlessunwell,anditisdistressingtonoticehowgeneralisthedebilityincamp,recordedasoldier.Measles,smallpox,andpneumoniacontinuedtoclaimmen.Bleedinggumsandtoothacheswerepervasivesymptomsofscurvyandvitamindeficiency.OneofficerlamentedthatIhavescarcelytenmeninmycompanyfitfordutyandsevenofmybestmenaredead.Wehavemanysicktherearemanycomplainingandsomejustgettingovermeasles,beingquiteweak.TheremnantsofthebrigademadethelongmarchbacktoSanAntonioinJuneandJuly1862.Reconstituted,theunitgavegallantserviceinTexasandLouisianathroughtherestofthewar,butSibleyhadlosttheirtrust.Hespenttheautumnof1862defendinghimselfagainstthechargesofdrunkenmisconductbroughtagainsthimbyhisownofficers.Escapingconviction,heretainedcommandofhisdisgruntledbrigade,buthisdrunkenincompetenceduringanApril1863actioninLouisianaledtohisreliefandasecondcourt-martial.Escapingconvictionyetasecondtime,hewasleftwithoutacommandandneverledConfederatetroopsagain.AfterthewarhesecuredageneralsrankinthearmyoftheKhediveofEgypt,buthisalcoholismledtohislossofthatpositionaswell.HediedinpovertyinFredericksburg,Virginiain1886,besotted,diapered,andincontinent.1(pp301-369),2(pp203-206)TheConfederateoffensiveintoNewMexicohadbeendoomedfromthestartduetoSibleysdeludedbeliefthathisforcecouldliveoffthelanduntilitcapturedsufficientenemysuppliestosustainitsdriveallthewaynorthwardtoseizeFortUnion.HislogisticalplanningfailurewasparticularlyinexcusableinlightofhisextensiveprewarserviceinthedesertSouthwest.HisopponentsbiographercitedseveralmajorfactorsforthedefeatoftheConfederateoffensive.ThefirstlayinthemixedapathyandhostilityofthenativeHispanicpopulation,whofoundnoreasontoallythemselvesortheirresourceswiththeinvaderscause.Moreimportantweretherelatedelementsoftimeandsupply.TheTexansfitfulrateofmovementnorthfromMesillagaveCanbytimetoorganizethedefensesofUnionistNewMexicoandsummonreinforcementsfromColorado.Thedemolition,byanumberofthosetroops,oftheConfederatesupplytrainatLaGlorietaPasswastheimmediatecauseofthefailureoftheSouthernventure.Inaddition,thedroughtwhichhadafflictedtheregionduringthepast2yearsresultedinashortageoflocalfoodstuffsandrangeforagefortheTexanshorsesandmules,furthercomplicatingtheproblemofsupply.14(pp180-181)OptimisticzealandpersonalambitionmayhavecoloredSibleysjudgmenttoadegree,butthesuspicionlingersthatJohnBarleycornoccupiedaslargearoleinSibleysplanningprocessesasdidthemaximsofNapoleon,Jomini,orClausewitz.Alcoholismwasbynomeansuncommonamong*References2(pp199-203),3(pp235,252-260). References3(pp262,264),4(pp37,54),9(132).

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12ArmyMedicalDepartmentJournalseniorofficersoneithersideinthatconflict,butseldomdidtheliquor-fueledfailingsofonemanhaveamoreprofoundeffectuponthecourseofanentirecampaign.Thelogisticalfailureensuredthathistroopslackedadequatetentage,winterclothing,medicalsupplies,andtransportforwhatsuppliestheydidpossess.Notedaveteranofthecampaign:Whilewehadgood,kindandablesurgeons,whowerealwayswillingandanxioustodoallintheirpowertohealthewounded,curethesickandalleviatetheirsufferings,yettheywereutterlywithoutthemedicinesandhospitalstorestodoso.Andtosuchextremitieswerewereduced,thatmenwouldlingeranddieintheircompanies,ratherthangotothehospitals.6(pp128-129)Thebrigadeshighdiseaseratesandthefateofitssickandwounded,sooftenabandonedtotheenemy,musthavesappedtheTexansmoraleastheyfoughtboththeelementsandtheYankeesinthatbleakfieldofoperations.Intheend,Sibleycouldnotconcentrateadequatecombatpoweratthedecisivetimeandplacetodestroytheenemy.Measles,pneumonia,dysentery,andmalnutritionhadbeatenhiscommandlongbeforetheColoradoanstrekkedsouthfromFortUniontoGlorietaPass.SibleyspersonalhealthproblemsandhisfailuretosafeguardhismenfromtheravagesofmalnutritionandmicrobesalikedoomedoneofthemostaudaciousandpotentiallydecisiveoperationsinallofAmericanmilitaryhistory.ThestudentofthistragicepisodeisleftponderingtheenigmaticfigureofDrCovey,whogavesuchableservicetothebrigadessickandwoundedthroughoutthecampaign,andyetsilentlyacquiescedintheretentionofcommandbyanailingalcoholicwhowasunfittooverseearecruitingdepot,muchlessacampaignofpotentiallystrategicimportance.InDrCoveysreticencelaytheseedsofdisasterfortheConfederacysNewMexicoCampaign.REFERENCES 1.ThompsonJD.HenryHopkinsSibley:ConfederateGeneraloftheWest.Natchitoches,LA:NorthwesternStateUniversityPress;1987.2.HallMH.SibleysNewMexicoCampaign.Austin,TX:UniversityofTexasPress;1960:26-28.3.FrazierDS.BloodandTreasure:ConfederateEmpireintheSouthwest.CollegeStation:TX:A&MUniversityPress;1995:23-72.4.HallMH.TheConfederateArmyofNewMexico.Austin,TX:PresidialPress;1978:46-47.5.HeitmanFB.HistoricalRegisterandDictionaryoftheUnitedStatesArmyfromitsOrganization,September29,1789,toMarch2,1903.Vol2.Washington,DC:USGovernmentPrintingOffice;1903:330.6.ThompsonJD,ed.CivilWarintheSouthwest:RecollectionsoftheSibleyBrigade.CollegeStation,TX:TexasA&MUniversityPress;2001:7.7.HallMH,ed.TheTaylorletters:ConfederatecorrespondencefromFortBliss,1861.MilHistTexas&Southwest.Fall1980;15:59.8.FaulknerWA,ed.WithSibleyinNewMexico:thejournalofWilliamHenrySmith.In:WestTexasHistoricalAssociationYearbook.Vol27.Lubbock,TX:TexasTechUniversity;1951:127-133.9.AlbertsDE.RebelsontheRioGrande:TheCivilWarJournalofA.B.Peticolas.Albuquerque,NM:UniversityofNewMexicoPress;1984:33.10.TaylorJ.BloodyValverde.Albuquerque,NM:UniversityofNewMexicoPress;1995:17-44.11.ThompsonJD,ed.WestwardtheTexans:TheCivilWarJournalofPrivateWilliamRandolphHowell.ElPaso,TX:TexasWesternPress;1990:95.12.EdringtonTS,TaylorJ.TheBattleofGlorietaPass.Albuquerque,NM:UniversityofNewMexicoPress;1998:28-39,41-100.13.ScottR.Glorieta:TheGettysburgoftheWest.Boulder,CO:JohnsonBooks;1992:181-190.14.HeymanMLJr.PrudentSoldier:ABiographyofMajorGeneralE.R.S.Canby1817-1873.Glendale,CA:TheArthurH.ClarkCompany;1959:183.AUTHOR DrAustermanisCommandHistorian,USArmyMedicalDepartmentCenterandSchool,FortSamHouston,Texas.Sick,Dead,&Discharged:DiseaseandtheDefeatoftheConfederateCampaignintoNewMexico,1862

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AprilJune200713Wehumanbeingsaresurroundedbysystemswhereverwego.Thosesystemsmightbepositive,liketheonesthatproducecleanairthroughphotosynthesis,ortheymightbenegative,suchastheonesthatresultinviolentculturalopposition.Diseaseandhealtharealsotheresultofsystemsaroundus;onesthatweverymuchwanttomanipulateinordertofavorthelatterandnottheformer.Medicalentomologistsareusedtothinkingaboutthemanyenvironmentalfactorsthatleadtoexcessivepopulationsofwhateverinsectiscausingaproblem.Forexample,someofthemosquitoesthattransmitPlasmodium,andthereforecausemalaria,ineastAfricadevelopinweedy,sunlitpoolsasaquaticlarvae.Theadultsemergeandtakebloodmealsevery2or3days,preferringhumansashosts.Femalesmateafterthefirstbloodmealandlayeggsonthewaterofthosesunlitpoolsacoupleofdayslater.Femaleskeepfeedingonbloodandlayingeggsforatleast6weeksoruntiltheymeetwithanuntimelyend.Temperaturesneartheequatorinthatpartoftheworldhardlyvaryduringtheyear,buttherainfallisveryseasonal.Therhythmoftherainyseasonsistherhythmofthemosquitopopulations.Themosquitopopulationsmultiplywhenpoolsareabundant,producingmanyyoungfemales.Attheendoftherainyseason,thepopulationdeclinessothattheaverageageofbitingmosquitoesgetsolderandolder.Itisadangerousworldfortheadultmosquitoes,withapproximately20%ofthemdyingeachday.Peopleinthatpartoftheworldoftenliveinsimplehomesthatarealmostcompletelyopentomosquitoes,sothatgettingamealfromasleepingpersonisnoproblem.Theyarealsoverypoor,withsporadicaccesstohealthcareanddifficultybuyinghouseholditemsthatwemightthinkofasnecessities.Thecombinationofapathogenthatstaysinthebloodforweeks,amosquitothatbitesrepeatedlyandprefershumans,andahumanpopulationthatisfreelyavailableforbitesmakesfortheexplosivemalariasituationcommonlyobservedineastAfricaandelsewhere.Thechallengeforthosechargedwiththealleviationofinfectiousdiseasesistodeterminehowtoaffectadiseasesystematexactlythosepointsthatwillhavethebiggestnegativeimpactonthepathogenandpositiveimpactonthehumanpopulation.Priortothecommonavailabilityofantibioticsandvaccines,peoplehadtorelyonsanitationandavoidancetoescapedisease.Evenbeforethegermtheoryofdisease,manypeopleseemtohavevaluedcleanwater,cleanhabits,andwholesomefood,asdocumentedinthescriptureofwesternreligions,guidestohealth,andthewisdomofancientluminariessuchasAristotleandGalen.Oncethenatureofpathogenswasdiscoveredinthelate19thcentury,manyschemesemergedfordiseasepreventionbasedondetailedstudiesofthenaturalhistoryofthepathogens.Theworldsvariouspopulationsdesperately,andsometimessuccessfully,assembledthetoolsavailabletomitigatetheravagesofmalaria,plague,typhus,andotherscourgesofpublichealth.Withtheexceptionofafewvaccines,mostoftheseinterventionswereoutsidethehumanbodyuntiltherapiddiscoveriesofeffectivedrugsbeganinthelate1940s.Wearenowinapositiontocombinetheinterventionsoutsidethehumanbodywiththoseinsidethehumanbodytomakedramaticprogressagainstinfectiousdisease.Thereismuchroomforimprovement,buttherearewonderfulexamplesofapplyingexactlythatcombinationtodefeatdisease.Certainlytuberculosisandentericinfectionwouldbemuchworsewithoutthemultilayeredinterventionsofsanitation,detection,andtreatmentthatthepublichascometoexpect.Itispossiblethattheprofessionalcommunitiesthatdealwitharthropod-transmitted(vector-borne)pathogenshavebeenlessabletocommunicatewitheachotherthanwithcommunitiesinvolvedinotheraspectsofmedicine.Thereasonmaylieinthegreatbreadthofmedicine,anobviouslyall-consumingprofession,andappliedmedicalentomology,anequallycomplicatedendeavor.MedicineappliedintheclinicundertheauspicesofpublichealthhassomeIntegratedDiseaseManagement:AnOldIdeaReadyforOurTimeCOL(Ret)DanielStrickman,MS,USA

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14ArmyMedicalDepartmentJournaldifficultycommunicatingwithvectorcontrolthatoperatesinsewers,swamps,andbackyardsundertheauspicesofenvironmentalhealthandpublicworks.Themilitarymakesavigorousattempttofacilitatecommunication,butinpractice,theassessmentsofonesidearenotstudiedconsistentlybytheother,exceptwhenenergeticandwell-intentionedindividualsforcetheprocesstowork.Integrateddiseasemanagementisnotanewcatchphrase,butitiscertainlynotascommonlypracticedasitcouldbe.Entomologyhaspossiblydevelopedabetterframeworkforapplyingintegratedinterventionthroughitsowndevelopmentofintegratedpestmanagementinthe1950sthroughthe1970s.Integratedpestmanagementcanbedividedinto4components:1.Riskassessment(whatwefindoutremotelyfromexistinginformation)2.Surveillance(whatwefindoutbymeasurementsontheground)3.Control(thefullcomplexofvectorcontrolandpersonalprotection)4.Monitoring(thatwhichisdonetodetectaresurgenceoftheproblemandtostimulatemaintenanceoftheprogram)Integrateddiseasemanagementextendstherangeoftoolstoincludethoseofpublichealthandmedicine,withtheobjectiveoflimitingpathogentransmissionbycombiningallmeasuresthatareeffective.Riskassessmentincludesepidemiologyaswellasentomology.Surveillanceincludespassiveandactivehumansurveillance,aswellasvectorsurveillance.Controlincludesdrugprophylaxis,vaccination,medicaltreatmentofexistingdisease,andothermedicalinterventionsaswellasentomologicalinterventionssuchascommunityvectorcontrolandpersonalprotectivemeasures.Monitoringlooksatincidence,damagetohumanactivityandqualityoflife,andotherpotentialdamagefromadisease,aswellasdistributionofthepathogenandvectors.Thetermintegrationisoftenusedfreelywithoutagreatdealofexplanation.Whenthinkingaboutintegrateddiseasemanagement,itispossibletopicturethediseaseasasystem.Malariaanddenguehavehumansastheirprinciplereservoirs,greatlysimplifyingthesituationincomparisontodiseasessuchasWestNilevirusfeverorLymedisease,whichinvolveanimalreservoirs.Itisprobablyaccuratetoconsidermalariaordengueas3partsystemsconsistingofthepathogen,thehuman,andthevector.Interventionsthatreduceanyofthese3componentsarelikelytoreducetransmission.Experienceinoperationalmedicalentomologyandcommonsensesuggestthatusingmoredifferentmethodstoattackallthreeofthecomponentsofthesystemismorelikelytosucceedthanusingasinglemethod.Forexample,imperfectvectorcontrolandimperfectcasedetectionandtreatmentmightbecombinedtoachieveregionaleradicationofmalaria,asprobablyoccurredinThailand.Malariahasbeenvirtuallyeliminatedinmostofthecountrybythesystematicapplicationofhousesprayingformosquitoesandcasedetectionandtreatmentforhumans.Housesprayinghasbeendoneinresponsetofociofmalariadetectedthroughanetworkoffreeclinicsdedicatedsolelytomalaria.Thesimpleclinicswerecarefullyplacedinlocationsthatcouldbereachedbythemajorityofruralpopulationsandbecamethecommondestinationforanyonewithfever.Thailandcreatedaspecializedcorpsofmalariaworkerswhocoulddetectmalariawithcheapequipment,dispenseantimalarialdrugs,andfollow-upwithvisitstohouseholdswherenecessary.Thesuccessoftheprogramhasbeentheresultofthoughtfulapplicationofeconomicalmethodsinresponsetoactualrisk.1Theusualapproachtointegrationistocombinemethodsinhopesofachievingthesumoftheeffectofalltheactions.Itisunusualtotrulyintegratethemethodsintoasystemthatspecificallytargetsvulnerableaspectsofthediseasesystem.Forexample,thedistributionofrepellentsduringtheWestNilevirusoutbreakinNewYorkCitywasdoneinthehopethatenoughpeoplewouldusetherepellenttosupplementaerialspraying,anadditive,ratherthanintegrated,approach.Ontheotherhand,astrategyofvectorcontrolandpersonalprotectioninprimaryschoolsinareasofendemicdenguetransmissionmightlimittransmissionofthevirusinalocationwhereittravelsmosteasilyfromfamilytofamily.Thesystematicstudyofsusceptiblestagesofinstitutionalfoodpreparation,andtheconstructionofpracticalprocedurestoprotecteachsusceptiblestage,isanotherexampleoftrueintegrationofpreventiveeffort.IfwewereabletotakeintegrationastepfurtherandapplymedicalinterventionsincoordinationwithIntegratedDiseaseManagement:AnOldIdeaReadyforOurTime

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AprilJune200715environmentalinterventions,wewouldhavetrueintegrateddiseasemanagement.However,suchcoordinationisoftenmadedifficultbythelackofanoverallauthorityinapositiontodirectcooperationofthedisparateelementsthatmustworkinconcerttoachievesuccess.AnexampleofthesuccessfulemploymentofthisstructureisthemodernUSmilitary,wherehierarchicalsystemshaveachievedalargemeasureofthissortofintegrationbycreatingasmallgroupofempoweredexpertsatthehighestlevelofanoperationaltheater.Despitethefrustrationofrelativedistributionofresources,imperfectreporting,andlimitedtoolsforintervention,theUSmilitaryhassometimesbeenabletoachieveremarkablelevelsofhealthinadeployedtheater.OnecaseinpointisOperationEnduringFreedom,when,forafewmonthsin2001and2002,militarypersonnelscatteredfromUzbekistantoKenyaexperiencedoneofthelowestratesofdisease(inmilitaryterms,diseasenonbattleinjury)inmilitaryhistory.Asshownintheillustration,the3rdMedicalCommandsforcehealthprotectionexpertswerecolocatedwiththeoperationscell,allowingrapidevaluationofsituations.Theresultingdecisionswereaccomplishedinonelocation,thenquicklyimplementedintotheflowofoperations.Broaderapplicationofthecoordinationofenvironmentalhealthandclinicalmedicinecouldachieveintegrateddiseasemanagementinmoreareasandinresponsetomorechallenges.Inthecivilianenvironment,thestructuretodrivethenecessarycoordinationwouldlikelybetheprovinceoflocal,regional,andfederalgovernments,aswellasprivateandautonomousentitieslikehospitals,mosquitoabatementdistricts,andcontractors.Mostgovernmentsalreadyhavesomeresponsibilitiesinmanyofthedisciplinesinvolvedinbothenvironmentalandhealthinterventions.However,successfulintegrateddiseasemanagementwillrequiretact,skillfuldiplomacy,andahighlevelofmanagementskillstogaincooperationofvariousagenciesthatmayalreadycompeteamongthemselvesforresourcesandareasofoverlappingauthority.Inmostcasesitwillnotbesimpleorstraightforward,butoverthelongruntheimprovementscouldresultintheconquestofpersistentinfectiousdiseases,improvementsinpopulation-levelhealth,anddramaticallyreducedcostsforsociety.REFERENCE 1.MalikulS.Thecurrentsituationoftheanti-malariaprogrammeinThailand.SoutheastAsianJTropMedPublHealth.1988;19(3):355-359.AUTHOR COL(Ret)StrickmanistheNationalProgramLeader,Veterinary,Medical,andUrbanEntomologyattheUSDeptofAgriculture,AgriculturalResearchService,Beltsville,Maryland. Thegroupofprofessionalsinthe3rdMedicalCommandwhomanagedforcehealthprotectionduringOperationEnduringFreedomfromDecember2001throughMay2002.Workingundersuchconfinedconditions,asanitarian,physician,entomologist,veterinarian,anddentistwereabletocometodecisionsquicklywithconsiderationofallaspectsofhealth,aprocessthatapproximatedarealapplicationofintegrateddiseasemanagement.Themilitaryoperations(G-3)functionisinthebackground,itsproximityallowinghealthprotectiondecisionstobequicklytranslatedintooperationalpracticeundertheseconditions.

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16ArmyMedicalDepartmentJournalTheUSArmyhasalong-standingglobalpublichealthpresence,operatinganetworkofcommunityhospitalsandclinicsinruralandurbanareasaroundtheworld.ItisfromthesecommunitiesthattheArmydrawsthemajorityofitscivilianworkforce,anditisthesecommunitiesthatinturnbenefitfromwell-runpublichealthprograms.Insomeinstances,theArmymaybethemostaccessiblepublichealthpresenceintheseareas,providingservicestothepopulationsthathavesupportedandlivedinharmonywiththemilitaryfordecades.Inaddition,manymilitarymissionssupportuniquelyhazardousindustrialoperations,includingmunitionsmanufacturingandstorage;aswellasnuclear,chemical,andbiologicalmaterialstorage,research,anddestruction.Inadeployedorhumanitariansetting,theArmymaybetheonlyformalpublichealthpresence,andisuniquelysuitedtosupportinfrastructurerebuildingand/ormodernization.Militarypreventivemedicineassets,theArmyanalogofcivilianpublichealthdepartments,areuniquelysuitedtooperateinthisenvironment.SinceSeptember11,2001,thepublichealththreathasbecomemorecomplex,stimulatingarapidchangeinthepracticeofpublichealth.Militarypublichealthnurses,environmentalscientists,sanitaryengineers,physicians,veterinarians,physiciansassistants,medicalentomologists,healthphysicists,audiologists,medics,preventivemedicinespecialists,andmanyothersarefacedwiththemonumentaltaskofrespondingtothisever-changingenvironment.Themostefficientwaytofulfilltheobligationtoprotectthepublicshealthisformilitaryandnonmilitaryagenciestoworktogetherandshareresourceswhendealingwithcommonissues.Collaborativeeffortswithlocal,county,andstatehealthdepartments,aswellaswithschoolsofpublichealth,aremutuallybeneficialandnatural.PublichealthprofessionalsacrossalldisciplinesarenowundertrainingtobeexpertsinastandardsetofproficienciesusuallyreferredtoastheTenEssentialServicesofPublicHealth,showninthetable.Thesecommoncompetenciespromotepartnerships,standardizeprocesses,andstreamlinecommunication,thusprovidingamorerobustassessmentofacommunityshealth.Overall,partnershipsenhancetheabilitytoprotectourcommunitiesasthedemandsonpublichealthprofessionalsintensify.AnillustrativeexampleofthisrelationshipwasevidentduringacombinedtrainingexerciseheldinOklahomaduringthesummerof2005.Beginninginlate2004,theStateofOklahomabeganplanningastatewidemassprophylaxisexerciseinExpandingtheRoleofPreventiveMedicineintheUnitedStatesArmy:IntegrationandCooperationLTCJamesSheehan,MC,USACPT(P)BrentGibson,MC,USAMAJBryanSisk,AN,USA NationalPublicHealthPerformanceStandardsProgramTenEssentialServicesofPublicHealth1.Monitorhealthstatustoidentifyandsolvecommunityhealthproblems.2.Diagnoseandinvestigatehealthproblemsandhealthhazardsinthecommunity.3.Inform,educate,andempowerpeopleabouthealthissues.4.Mobilizecommunitypartnershipsandactiontoidentifyandsolvehealthproblems.5.Developpoliciesandplansthatsupportindividualandcommunityhealthefforts.6.Enforcelawsandregulationsthatprotecthealthandensuresafety.7.Linkpeopletoneededpersonalhealthservicesandassuretheprovisionofhealthcarewhenotherwiseunavailable.8.Assurecompetentpublicandpersonalhealthcareworkforce.9.Evaluateeffectiveness,accessibility,andqualityofpersonalandpopulation-basedhealthservices.10.Researchfornewinsightsandinnovativesolutionstohealthproblems.

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AprilJune200717ordertoupgradeitsStateDepartmentofHealthpreparednessstatusfromamberplustogreen.Theexercisewasdesignedtotestthestatesresponsetoabioterrorismattack,particularlyitsabilitytoworkwiththeStrategicNationalStockpile(SNS)andtoensurethesafe,secure,andtimelydistributionofSNSmedicationstothegeneralpopulation.ComancheCounty,Oklahoma,wasoneof3majorregionsparticipatingintheexercise.ThiscountyishometoLawton,thefourth-largestcityinOklahomaandthecommunitythatsupportstheUSArmyinstallationatFortSill.ThepopulationintheLawtonFortSillareais100,000,withapproximatelyhalfofthepopulationhavingtiestothemilitaryinstallationwhichincludesSoldiers,theirFamilies,andemployeesworkingontheinstallation.TheFortSillCommandingGeneralallowedthebasetoparticipateintheexercise,afirstforanyDepartmentofDefenseinstallation.TheFortSillplanningteamconsistedofthePublicHealthEmergencyOfficer(thepreventivemedicinephysician),anArmyPublicHealthNurse,theReynoldsArmyCommunityHospitalemergencyplanner,andthepreparednessplannerfromtheinstallation.TheteamworkedcloselywiththeComancheCountyHealthDepartmentandtheOklahomaStateDepartmentofHealthplannersto OklahomaStateDepartmentofHealthNewsStateDepartmentofHealthBioterrorismExerciseScheduledJuly12-14PublicEncouragedtoParticipateAspartofalarge-scaleefforttotestemergencyresponsesystemsinapublichealthcatastrophicevent,theOklahomaStateDepartmentofHealthannouncedtodaythatabioterrorismexercisesimulatingaterroristreleaseofplaguewillbeheldinthreeOklahomacountiesnextmonth.Theexercise,calledOperationFireworkFanfare,isoneofthemostambitiousandcomplexexercisesofitskindeverheldinOklahoma.Theexercise,scheduledJuly12-14,willbearealisticsimulationdesignedtochallengethestatesresponsetoacatastrophichealthemergency.Thissimulatedeventwouldresultinpneumonicplague,adiseasethatcanbetransmittedpersontoperson,inadditiontothoseoriginallyexposed.Suchanattackwouldrequireamassivecoordinatedresponsetodeliverantibioticstoaffectedpersonsinthethreecountiesparticipatingintheexercise:Comanche,Oklahoma,andTulsa.AkeycomponentoftheexercisewillbedemonstratingtheOklahomaStateDepartmentofHealthsabilitytorequest,receiveanddistributeemergencysuppliesfromtheStrategicNationalStockpile.TheStrategicNationalStockpilecandelivermedicine,vaccine,andantidoteswithin12hoursandismaintainedbythefederalCentersforDiseaseControlandPreventioninaconstantstateofreadinesstorespondtoapublichealthemergency.OnJuly12and13,theexercisewillfocusontheidentificationofthebiologicagentandemergencyproceduresnecessarytorequest,receiveanddistributesuppliesfromthestockpiletoappropriateareaswithinthestate.OnJuly14,Oklahoma,Tulsa,andComanchecountieswilloperatecountywidemedicationdispensingsitestosimulatedispensingantibioticsfromthestockpiletomasspopulationswhomightbeatriskofacquiringpneumonicplague.OperationFireworkFanfarewilldemonstratewhatwehaveaccomplishedinpreparingtorespondtoaseriouspublichealththreataswellasidentifyingareasforfutureimprovement,saidStateHealthCommissionerDrMikeCrutcher.Inaddition,theexercisewilldemonstratethecloseworkingrelationshipbetweenbranchesoffederal,stateandlocalgovernmentsandlocalfirstrespondersinpreparingforabioterroristattack.Tohelpmaketheexercisemorerealistic,statehealthofficialsareaskingOklahomanstovolunteerJuly14asmockpatientsfortheexercisebysimulatingthetypesofcrowdsatmedicationdispensingsitesthatmightoccurinarealpublichealthemergency.PeopleinterestedinparticipatingareencouragedtocontactthelocalhealthdepartmentsinComanche,Oklahoma,andTulsacounties.StatepartnersintheexerciseincludetheOklahomaDepartmentofEmergencyManagement,OklahomaOfficeofHomelandSecurity,OklahomaDepartmentofPublicSafety,andtheOklahomaDepartmentofTransportation.CountyhealthdepartmentsparticipatingincludetheComancheCountyHealthDepartment,theOklahomaCity-CountyHealthDepartment,andtheTulsaCity-CountyHealthDepartment.

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18ArmyMedicalDepartmentJournalensurethattheinstallationandthepopulationitsupportedwereaccountedforinthefinalSNSdistributionplan.Onemisconception,identifiedearly,wasthebeliefthatthemilitaryhasitsownversionoftheSNS,when,infact,militaryinstallationsarecountedaspartofthelocalcommunitybytheUSCentersforDiseaseControlandPrevention.Theestablishmentoflinesofcommunicationwiththesurroundingcountysofficialsclarifiedthisissueandensuredthattheinstallationreceiveditsallotmentofmedicationsandsupplies.Ultimately,theinstallationwasincorporatedintothecountydistributionplan.Duringtheexercise,theinstallationestablishedapointofdispensing(POD)sitewhichexpectedtodispense50,000dosestoindividuals.TwoadditionalPODs,establishedbythecounty,woulddispensetotheremaininglocalpopulation,aswellastoresidentsfromruralareasandsmallertownsinthecounty.Theexpectedhourlythrough-putateachPODsitewas750individualsperhour.ThecommunitybenefitedgreatlyfromtheestablishmentofthethirdPODbythemilitary,asthecountywasabletopositionitsdispensingsitesfurtherfromthecenteroftown.Thethird,morecentrallylocated,militaryvenuemadeiteasierforthoselivingoutsideofLawtontoreceivetheirmedicationsfromtheother2PODs.Individualsbenefitedfromdecreasedtraveltimetoandfromthesites,aswellasfromdilutionofthecrowdsateachsite(lesswaittime,saferenvironment,andlesschanceforexposurefromproximitytopotentialcarriers).Themilitarybenefitedfromthisarrangementaswell.SoldiersandtheirFamiliesdidnothavetodrivethroughthecitytoreceivetheirprophylacticdoses;theyonlyhadtotraveltothePODclosesttotheirhome.Despitethesebenefits,therewereseveralchallengesthatposedsignificantbarrierstomissionsuccess.Forexample,therewasanotablelackofinteroperabilitybetweencommunicationssystems.Militaryradioscouldnotcommunicatewithcivilianradiosand,eveninthecommunity,fireservicescouldnotdirectlycommunicatewithpoliceagencies.Thiswasnotanovelfindinginemergencyresponse,butitpromptedtheinstallationandcommunitytoworkonacquiringasinglecommunicationsystemthatwouldallowallagenciestotalkdirectlytoeachother.Thissystem,onceoperational,willimprovetheflowofinformation,bothinacrisissituationandduringroutineoperations.Forceprotectionstatusoftheinstallationwasanotherimportantconsideration.Theimmediatereactionbyinstallationleaderswastosignificantlyrestrictaccesstotheinstallationtoonlythosepersonnelonactivedutyandtheirfamilies.Inmanyemergencies,thismaynotbenecessary.Infact,bythetimetheinstallationwaseffectivelysealedoffinthisscenario,thediseaseprocesswasalreadyestablishedwithinthebase,andthelevelofsecuritywouldundoubtedlydelayaccesstotreatmentorprophylaxis,andpotentiallycostmorelives.ExpandingtheRoleofPreventiveMedicineintheUSArmy:IntegrationandCooperation Atthemilitarypointsofdispensing,gates,tables,andhighvisibilitymarkingsweresetuptosupportlogicalpatientflowanddecreasetheneedforverbalinstruction.Thisisanimportantconsiderationinfast-paced,tense,noisyenvironments. Soldiersqueueatdesignatedstationstobescreenedforallergiestomedication.Local,state,andfederalofficialsobservedas750Soldiersperhourpassedthroughthepointofdispensingsite.

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AprilJune200719Anotherareaofconcernthatemergedinvolvestherespectivelinesofauthority.WhiletheArmyhasawell-establishedcommandstructurethatmirrorstheIncidentCommandSystemusedbythecivilians,thereissomeambiguitysurroundingtheinterplayoffederalandstateauthoritiesduringadomesticemergency.Inmostscenarios,thegovernoristheultimateauthoritywithinastateandmilitaryparticipationrequiresthattheinstallationrespondtotheinstructionsanddirectivesissuedbystateofficials.Thisisinadditiontofollowingdirectionandguidanceissuedbythemilitarychain-of-command,andthepotentialthereforeexistsforconflictbetweenopposingdirectives.Onefinal,yetkey,elementwasthatcontrolofthePODmissionwasdeferredtothemilitarymedicaltreatmentfacility(MTF).However,inthisscenario,theMTFwasoverrunwithpatients.Consequently,physicians,nurses,andmedicswerenotavailabletostaffthePODsite.Anotherperspective,providedbypopulation-orientedpreventivemedicineexperts,wasthatmedicationdistributionwouldbejustaseffectivelymanagedbyanynumberofpersonnelundertheguidanceofpublichealthphysiciansandnurses.Thisapproachpreservesremainingclinicalprovidersforthoseroleswhicharelesseasilydelegated,suchasdiagnosisandtreatmentofaffectedpatients.TheOklahomaStateDepartmentofHealthexerciseisonlyoneexampleofmilitary-civilianpublichealthcooperation.Lookingbeyondthisexample,therearemanyothermilitarycommunitieswherefacilities,supplies,andtrainingofcivilianpersonnelarejointlyexercised.Thesynergyoflocalhealthcare,publichealthassets,andtheirmilitaryequivalentsisessentialforsuccessfulaccomplishmentoftheoverallmissionofprotectingthepublicshealth.ExtendingevenbeyondtheboundariesoftheUnitedStates,thesesameprinciplesandskillsetsareessentialtotheaccomplishmentofmilitarymissionsabroad.Theassessmentofestablishedpublichealthinfrastructureandcooperationwithlocalofficialscreatesasystemthatultimatelyimpactsthehealthofthehostnationinapositivemanner.Militarypreventivemedicineassetsareuniquelytrainedtoworkwithlocalgovernmentsindomestic,deployed,andhumanitariansettings.Theyprovidetrainingandassistancewithassessmentofcommunities,settinggoals,andestablishmentandevaluationofinterventionsinsupportofthelocalgovernmentsobjectives.Theseeffortsnotonlycontributetothehostcommunities,butalsobuildgoodwill,permitourforcestogainvitalinsightintoendemicdiseases,andprioritizeinterventionsthatprotectthehealthofthelocalpopulationandUSforces.Effectiveoversightofsuchcooperativeeffortsdependsheavilyonpreventivemedicineandpublichealthspopulation-basedperspectiveonhealthcare.Thesecomponentsareabsolutelyessentialinassuringseamlessmutualpublichealthsupport.AUTHORS LTCSheehanisChief,CommunityHealthPracticesBranch,ArmyMedicalDepartment(AMEDD)CenterandSchool,FortSamHouston,Texas.CPT(P)GibsonistheOccupationalMedicineInstructor/WriterfortheCommunityHealthPracticesBranch,AMEDDCenterandSchool,FortSamHouston,Texas.MAJSiskistheDeputyChief,CommunityHealthPracticesBranch,AMEDDCenterandSchool,FortSamHouston,Texas. FortSill,Oklahoma

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20ArmyMedicalDepartmentJournalHowtoStopFightingOurselves:RemovingtheStigmaofMentalHealthTreatmentforSoldiersKayShepard,MSWABSTRACTSoldiersfearofstigmatizationbypeersandsuperiorsistheprimarybarrierthattheUSArmymustovercomeasaprerequisitetoprovidingsuccessfulmentalhealthtreatmenttoSoldierswhohavebeenexposedtothecombatenvironment.Untreatedmentalhealthconditionscanleadtoincreasedseverityofsymptomsandadverselyaffectmissionreadiness.CommandleadershipmustbecomeawareoftheeffectsofcombatexposureupontheirSoldiers,andreferSoldierstobehavioralhealthfacilitieswhennecessary,sothattheirSoldiersarepeakperformersandmissionready.INTRODUCTIONSoldiersfearofstigmatizationistheprimarybarrierthattheUSArmymustovercomeasaprerequisitetoprovidingsuccessfulmentalhealthtreatmentforcombatstress.SoldiersdeploytoOperationEnduringFreedomandOperationIraqiFreedom(OIF)onarotationbasisandarerepeatedlyexposedtothecombatenvironment.Soldiersarereturningfromthecombatenvironmentwithmajordepression,generalizedanxiety,andPostTraumaticStressDisorder(PTSD).ThereisaclearcorrelationbetweencombatexposureandPTSD,withgreaterlevelsofexposureleadingtogreaterprevalence.1IndividualsneedtreatmentforthesementalhealthconditionsinordertobeagoodspouseandparentinthefamilyenvironmentandaSoldierwhoismissionready.Soldiersexpressseveralconcernswithseekingmentalhealthtreatment.Adominantconcernisthattheybelieveitwillaffecttheircareers.In2002,theEpidemiologicalConsultationteamexaminedthecircumstancessurrounding5murdersand2relatedsuicidesatFortBragg.TheyfoundthatSoldiersresistedseekingmentalhealthservicesfrommilitaryresourcesforfearofjeopardizingtheircareers.2PERCEIVEDBARRIERSTOSOLDIERSSEEKINGMENTALHEALTHTREATMENTSoldiersconcernaboutconfidentialityinmattersinvolvingmentalhealthisunderstandableiftheyarereceivinginformationonlyfrompeerswhoareinvoluntarilysenttotreatmentbytheircommander.SoldiershearrumorsoftheseparationofSoldiersfromtheArmyaftervisitingCommunityMentalHealth,andaboutthechainofcommandsinvolvementwithaSoldiersattendancefortreatmentatSocialWorkServices(SWS).Thefirstsituationcouldoccurifthecommanderdeemsanindividualinneedofadutyfitnessevaluation.ThesecondsituationcouldoccurifaSoldierisdirectedtotheSWSFamilyAdvocacyProgrambecauseofadomesticviolenceincidentinthehome.SoldierswhovoluntarilyreferthemselvestoeitherSWSorCommunityMentalHealthreceiveahigherlevelofconfidentiality.TheseSoldierstypicallywillnotvolunteerinformationtotheirpeersorchainofcommandthattheyareparticipatinginmentalhealthtreatment.BoththeHealthInsurancePortabilityandAccountabilityActof19963andMilitaryRulesofEvidence4precludethestaffatthebehavioralhealthfacilityfromevenacknowledgingtheindividualsattendanceattreatment,unlesstheindividualhadpreviouslysignedareleaseformpermittingthedisclosureofsuchlegallyprivilegedinformation.Furthermore,licensedprovidersworkingatSWSareboundtoupholdclientconfidentialitybythecodesofethicsofboththeNationalAssociationofSocialWorkers5andtheAmericanAssociationforMarriageandFamilyTherapy.6Clientconfidentialityisnotabsolute.Itbecomeslimitedwhensomeonetellsatherapistthattheyaregoingtoharmthemselves,oranotherperson.Insucha

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AprilJune200721case,thetherapistisrequiredtoreportthisdangertoauthorities.AreviewofthestatusofthepsychologicalhealthofSoldierswhoareineitherthepersonnelreliabilityornuclearsuretyprograms,orhaveaTopSecretclearance,mayberequiredatanytime.Theinformationisdisclosedonaneed-to-knowbasis.AccordingtoHoge,7Soldierswhoaremostinneedoftreatmentarethesameoneswhoaremostresistanttoseekinghelp.Therespondentsinthisstudythoughttheywouldbeseenasweak(65%)orbetreateddifferentlybyunitleaders(63%).SoldierswhovisitSchweinfurtSWSrepeatedlymentionthedifficultytheyexperienceinobtainingtimeofffromtheirdutiestoattendtheirappointments.Onrareoccasions,SoldiersreportbeinghumiliatedbytheirsuperiorsaftermentioningapersonalappointmentatSWS.Soldiersdonotwanttoappearweak.Thisfearwasthenumberonebarriertoseekingmentalhealthtreatment,accordingtoHogesstudy.ItisimportantthattheSoldierbeabletoreceivetreatmentwithoutpressurefromhispeersorsuperiors.AtLedwardBarracksinSchweinfurt,Germany,allreturningunitsconducteda90-daypostdeploymentscreening.Duringthisscreening,oneSoldierwasobservedbyhispeersintheareasittinginthehallwaycompletingtheform.TheSoldieradministeringthescreeningsummarizedtheentireformfortheSoldierwithwordstotheeffect:Areyouhittingpeople?Youreokay.Justmarktheformthatyoureokay.Thepostdeploymentscreeningwaspoorlyadministeredbecauseitfailedtoprovideconfidentiality,permittedtheinfluenceofpeerpressure,andpotentiallyfailedtoreachSoldiersthatmayhaveneededmentalhealthservices.PartofbeingaleaderintheArmyistobearolemodel.Positiveleadershipadoptsaholisticviewofindividuals,andacknowledgesthementalandemotionalforcesactingupontheSoldiersandtheleadersthemselves.Onlyrarelydoleaderspubliclyparticipateinmentalhealthactivities.OnecaptainfromSchweinfurtboldlydidthisbyattendingandparticipatinginaCriticalIncidentStressManagementDebriefingthathehadrequestedforhisSoldiersuponreturnfromOIF.IttakescourageforanySoldierinaleadershippositiontobearolemodelinthefieldofmentalhealthtreatment.AccordingtoCOLThomasBurke,DirectorofMentalHealthPolicyfortheDepartmentofDefense,thechainofcommandmayelecttoremoveaSoldierwhoisreceivingtreatmentforamentalhealthconditionfromaleadershipposition.8WhilesomeSoldiersgetmedalsafterreceivingphysicalinjuriesinthelineofduty,aSoldierwhosementalconditionisinjuredandisinneedoftreatmentbecauseofcombatexposurereceivesnomedals.Rather,thatSoldiermaysufferfurtherwithdiminishedpromotionopportunitiesiftheperceptionofinstabilityremains.EFFECTSOFUNTREATEDMENTALHEALTHCONDITIONSUntreatedcombatstressorothermentalhealthconditionscanleadtoincreasedsymptoms,oranescalationoftheseverityoftheirdiagnosis.ExamplesofthisareevidentwhenuntreatedcombatstressdeterioratesintoPTSD,orwhensubstanceabuseandmaritaldifficultiesleadtoirreversiblebehaviorssuchassuicidesandthemurdersatFortBragg.Untreatedmentalhealthconditionsaffectmissionreadiness.FollowingtheVietnamWar,PTSDaffected25%to30%ofthereturningveterans.Currently,15%ofthoseveteransstillsufferfromthisdisorder.WorldWarIIveteransweretested45yearsafterreturninghome.Ofthatgroup,Soldierswhohadservedincombatareashada13.3%greaterriskofhavingPTSDsymptomsthantheSoldierswhohadnotbeeninareasinvolvingdirectcombat.9Anotherconsequenceofuntreatedmentalhealthissuesistheprevalenceofself-medication.Inresponsetothestresscreatedbytheseunresolvedissues,manySoldiersincreasetheirconsumptionofalcohol.Inreplytothepredeploymentsurveyquestion,Haveyoufeltyouwantedorneededtocutdownonyourdrinking?12.5%oftheSoldiersansweredyes.AfterreturningfromtheirdeploymenttoIraq,responsetothesamequestionincreasedtoa20.6%responseofyes.7GerryWarner,ClinicalDirectoroftheSchweinfurtAlcoholandSubstanceAbuseProgram,providesanecdotalfiguresrelatingtothetreatmentofindividualsreferred90daysafterreturningfromOIF.MsWarnerstatedthatabout50%ofourreferralshadbeentocombatandscoredonthemoderatetohighrangeonthePTSDquestionnaireand50%ofthecaseswerenewSoldiersjustgettingtoGermanyontheirfirstenlistment.Captainsreportthattheyandtheirfriendsareusingalcoholtohelpthemsleepatnight(G.Warner,e-mail,22February2006).ASoldierwithmentalhealthconcernsthatusesalcoholasasleepaidisnotmissionready.Even

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22ArmyMedicalDepartmentJournalworse,thistypeofmissionimpedimentdoesnotshowupontheradaroftheirchainofcommandandisnotfactoredintostrategicreadinessplanning.Thisblindzoneforthechainofcommandcouldeasilyleadtooverestimationofforcecapabilitiesandfatalresultswhenthoseunreadyindividualsarerelieduponincombat.TREATMENTOFMENTALHEALTHAlthoughknownbyavarietyofnames,PTSDhasexistedaslongaswaritself.InWorldWarI,theeffectswerecalledshellshock.InWorldWarIIandKorea,itwascalledcombatfatigueorbattlefatigue.InVietnam,itcametobeknownasPostTraumaticStressDisorder.4In1980,theAmericanPsychiatricAssociationaddedPTSDtoitspublication,DiagnosticandStatisticalManualofMentalDisorders.10InWorldWarI,manySoldiersweresentawayfromthecombatareaifitwasdeterminedthattheyweresufferingfromshellshock.ThisresultedinashortageofSoldiers.Toremedythis,theArmychangedproceduresandrelocatedtreatmentprovidersnearthefrontlinestotreatSoldiersandgetthembackintocombat.Thelong-termeffectsofshellshockappearedtobeminimalforthoseSoldierstreatedusingthismethodwhoreturnedtothebattlelines.1Today,theArmyhasCombatOperationalStressReaction(COSR)teamsthatgototheunits.Todate,theeffectivenessofthesebehavioralhealthteamsisinconclusive.During2004,SWSconductedmentalhealthscreeningsofSchweinfurtSoldiersreturningfromIraq.TheseSoldiersconfirmedthattheyweredirectedtomeetwiththeCOSRteamafterincidentswheretheyhadseenpeoplekilledorinjured.However,theSoldiersalsostatedthattheygenerallydidnotreportanydisturbancetotheCOSRteambecausetheydidnotwanttobeseenasweak.Theyalsoquestionedhowhelpfulitwouldbetoreportanymentalhealthconcerns.Duringhisinterview,COLBurkediscussedcombatstresscontrolunitsandtheSoldierswhosescreeningsidentifiedsymptomsrequiringtreatmentperformedneartheareaoftheirunitbutawayfromthecombat.Inabout95%ofthecases,theirsymptomswereaddressedandtheywerereturnedtotheirunits.AccordingtoCOLBurke,70%oftheSoldierssenttoahospitalinIraqreturnedtoduty,50%ofthoseevacuatedtoKuwaitreturned,10%ofthoseevacuatedtoGermanyreturned,andnoneofthosesenttotheUnitedStatesreturnedtothetheater.8TheprovisionoftreatmentintheSoldiersownenvironmentwheretheyknowtheywillreturntoduty,andwheretheyareassuredthattheirfeelingsareanormalresponsetoanabnormalcircumstance,allowsSoldierstoavoidthefeelingofbeingadverselylabeledwithamentalhealthdiagnosis.ThisleveloftreatmentintroducesSoldierstotheconceptofcaringaboutmentalandemotionalhealth,inadditiontotheirphysicalhealth.ThismethodoftreatmentmayalsohavetheunexpectedbenefitofweakeningthestructureofthebarrierstoSoldiersseekingmentalhealthtreatment.MentalhealthservicesofferedtotheSoldierreturningfromdeploymentmayvaryfromposttopost.InSchweinfurt,SoldierscanreceiveservicesfromateamofbehavioralhealthprofessionalsincludingSocialWorkServices,CommunityMentalHealth,andDivisionMentalHealth.RecenthistoryfromtheSchweinfurtbehavioralhealthteamandcollaboratingagenciesillustratesthepositiveeffectsofmentalhealthcareforSoldiersandFamilymembers.PriortotheredeploymentofSoldiers,SWS,ArmyCommunityService,andtheFamilyLifeCenterchaplainmetwitheveryfamilyreadinessgroupandconductedbriefings.SocialWorkServices(SWS)briefingscoveredtopicssuchas:combatstress,possibleeffectsofcombatexposure,effectsuponthefamily,andservicesofferedbySWS.DuringreintegrationinFebruary2005,over18%ofapproximately4,900returningSoldierswereindividuallyscreenedorassessedbyaprofessionaloftheSchweinfurtbehavioralhealthteam.TheseSoldiersresponsestothemedicalquestionnaireindicatedsymptomsrelatedtoacombatenvironmentcombatstress,depression,anxiety,orPTSD.SWSalsoconductedcombatstressgroupbriefingswitheveryreturningSoldierandwithsomespouseswhojoinedtheirhusbandsduringthereintegrationprocess.Ongoingbriefingstobattalions,commands,andunitsoncombatstressandCriticalIncidentStressManagementDebriefingscontinuetobeconductedbySWSuponrequest.SchweinfurtSWSsawanincreaseinSoldiersself-referringfortreatmentrelatedtothecombatenvironment.Itistypicallydifficulttolinkpreventionworkwithresultsbecauseitrequiresacomparisonofthenumberofeventsthatdidoccurwiththenumberofeventsthatwouldhaveoccurredintheabsenceofpreventivemeasures.Thesecondcomponentofthisequationisalwaysanunknownfactor.However,reliableestimatescanbeobtainedbycomparingthelocalrateofdomesticRemovingtheStigmaofMentalHealthTreatmentforSoldiers

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AprilJune200723violenceincidentsafterdeploymenttoOIFtothoseofothermilitarycommunitieswithdemographicallysimilarpopulations.Incomparisonwithlocationswithsimilarlycombatexposedpopulationsbutlesspreventivecommunityoutreach,Schweinfurtsawonlyasmallspikeduringthefirst45daysaftertroopsreturnedfromIraq.OneyearaftertheirreturnfromOIFasSoldiersagainpreparefordeployment,reportsofdomesticviolenceremainatalltimelows.Schweinfurtreportszeroincidentsamongits6,000troopsduringJanuaryandFebruaryof2006.MoreSchweinfurtSoldiersaremissionreadyfortheupcomingdeploymentbecausetheyhavetakencareofthemselvesmentallyandemotionally.ThemanySoldierswhoparticipatedintheCombatOperationalStressGrouphavedonethesmartthingbyproactivelydealingwithemotionalissueswhileinthesafetyofthegarrisonenvironment,ratherthanwaitingandbeingdistractedbythoseconcernsinlifeordeathsituationsonthebattlefield.TheyvoluntarilyattendedtheCombatOperationalStressGroupswheretheytalkedabouttheirthoughtsandfeelingsaboutwhattheysaw,withotherSoldierswhohadthesameexperiences.TheSoldiersandtheirspousesparticipatedinmaritaltherapy,addressingissuesthatcameupbothduringthelastdeploymentandwhiletheSoldierwashome.Duringaninterview,SteveRobinson,theExecutiveDirectoroftheNationalGulfWarResourceCenterstated,Theresenoughevidencetoshowthatifpeoplegethelpearlyandoften,theycanrecoverandcontinuetofight.11RECOMMENDATIONSTODESTROYTHEBARRIERSThemilitaryshouldincludeoutreach,education,andadditionaleasyaccesstomentalhealthcaretoaddressthebarriers.7Armyleadersatalllevelsshouldspeakoutclearly,decisively,andfrequentlyontheimportanceofmentalhealthasacoequalfactorwithphysicalhealthasadeterminantofdutyfitness.LeadersmustdiscouragedisparagingcommentsaboutSoldierswhoseekmentalhealthtreatmentwiththesameemphasisthattheywoulddiscouragedisparagingsexualorracialremarksaboutfellowSoldiers,andmustrecognizethesecommentsassimilarlyharmfulverbalself-attacksuponourownSoldiers.Informationdisseminationisakeyfactorinbulldozingthebarriers.Outreachprogramsofthemedicalcommandsbehavioralhealthteamsshouldensurethatbriefingsreachentireunits.BriefingsattendedbyeveryonefromtheunitcommandertothemostjuniorSoldierpromotedevelopmentofacohesiveunitattitudeofsolidaritytowardsovercomingmentalhealthissues.Additionally,sincepublicbriefingsabouttreatmentprogramsdonotopenlydiscussanyindividualsconfidentialinformation,officerattendancecanvisuallydemonstrateleadershipsupportofmentalhealthprogramstotheenlistedSoldierswithoutraisingconcernsofdiminishedperceptionsofthoseofficers.Thus,notsurprisingly,thefirststepinremovingthebarriersbeginswithArmyleaderparticipationinbehavioralhealthbriefings,leadingtheirSoldiersbyexampleandparticipatingthemselves.AnexampleofthepowerfulnatureofthisinfluencecanbeseenfromtheeventsfollowinganSWSbriefingin2005.Attherequestofaninfantrybattalion,SchweinfurtSWSconductedabriefingoncombatstressanditseffectsontheSoldierandFamily.Thewholebattalion,includingthecommander,attendedthebriefing.Thefollowingday,SchweinfurtSWSbeganreceivingcallsfromthoseinfantrySoldiersrequestingservices.Thestreamofphonecallscontinuedforseveralweeksfollowingthebriefing.ProactiveoutreachservicessuchasCriticalIncidentStressManagement(CISM)Debriefingscanforewarnunitpersonneloftheeffectsofcombatexposureonanindividualsmentalandemotionalstates,andleadtoearlyrecognitionandtreatmentofthesesymptoms.CISMdebriefingscanbeflexiblyscheduled,bothintimeandlocation,formaximumconvenienceofeachunit.TheprovisionofreadyaccesstoCISMdebriefingsfrombehavioralhealthproviderscanbeacriticalfactorinloweringthebarriersconfrontingSoldierswhoaredecidingwhethertoseektreatmentorignoretheirsymptoms.Theincreaseofself-referralsfortreatmentanddecreasedlevelsofdomesticviolencefollowingtheimplementationofSchweinfurtSWSoutreachprogramsillustratethetangiblebenefitstotheArmy.FewerSoldierswereembroiledinlegalproceedingsfollowingdomesticviolence,andSoldiersweremissionreadysoonerbecausetheywereproactive,ratherthanreactive,indealingwiththeirsymptoms.NoweaponintheArmysarsenalisaccurateorsophisticatedenoughtorecognizeandoverrideflaweddecisionsofanoverstressedSoldier.Therefore,our

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24ArmyMedicalDepartmentJournalmostsophisticatedandadvancedtechnologyhashumanemotionasitsweakestlink.Reasonwouldthendictatethatproductiveutilizationoftechnologicalresourceswillbemaximizedbyreductionofcounterproductiveinfluencesresultingfromemotionaldistress.Toreachthisobjective,behavioralhealthprofessionalsmustrecognizethatbarrierswhichpreventSoldiersfromreachingouttothemcurrentlyexist,andcompensatewithinitiativestoreachouttotheSoldiersinstead.ThisdirectconnectionwithSoldiersisonlypossiblewhenunitlevelArmyleadersunderstandtheimportanceofthisissue,andtakethefinalstepofusingtheavailablebehavioralhealthresources.CONCLUSIONTotreatcombatstresseffectively,theprimarybarrierthattheUSArmymustovercomeisthefearofstigmatizationthatSoldiersassociatewithmentalhealthtreatment.TheGlobalWaronTerrorismhasbroughttotheforefrontmentalhealthissuesrelatedtocombatexposure.Soldiersarereturningfromcombatzonesinneedoftreatmentforcombatstress,depression,anxiety,andPTSD.Soldierswillcontinuetoavoidvoluntarytreatmentunlesstheybelievethattheycanavailthemselvesofmentalhealthserviceswithoutitaffectingtheircareerorcausingthemtobeviewedasweakbytheirpeersandsuperiors.ArmyleadersmustplaceincreasedemphasisonreducingthebarrierofthatstigmaSoldiersfearwhenseekingmentalhealthtreatment.CommandleadershipmustBecomeawareoftheeffectsofcombatexposureontheirSoldiers.BeableandwillingtoreferSoldierstobehavioralhealthfacilities.InvestthedutytimenecessarytoensuretreatmentisaccomplishedsothattheirSoldiersarepeakperformersandmissionready.REFERENCES 1.CozzaSJ.CombatexposureandPTSD.PTSDResQ.2005;16(1):1-8.2.MientkaM.FortBraggkillingsinvestigated.USMed.December2002.Availableat:http://www.usmedicine.com/article.cfm?articleID=561&issueID=45.Accessed4February2006.3.PublicLaw104-191HealthInsurancePortabilityAndAccountabilityActOf1996.August21,1996:Availableat:http://aspe.hhs.gov/admnsimp/pl104191.htm.4.JointServiceCommitteeonMilitaryJustice.ManualforCourtsMartialUnitedStates(2005Edition).WashingtonDC:USDeptofDefense;2005:PartIII,SectionV,Rule513.5.CodeofEthicsoftheNationalAssociationofSocialWorkers.WashingtonDC:NASWPress;2006.6.AAMFTCodeofEthics.Alexandria,VA:AmericanAssociationforMarriageandFamilyTherapy;2001.7.HogeCW,CastroCA,MesserSC,etal.CombatdutyinIraqandAfghanistan,mentalhealthproblems,andbarrierstocare.NEnglJMed.2004;351(1):13-22.Availableat:http://content.nejm.org/cgi/content/full/351/1/13.Accessed17January2006.8.TheSoldiersHeartInterview,ThomasBurke[transcript].Frontline.PBStelevision.March01,2005.Availableat:http://www.pbs.org/wgbh/pages/frontline/shows/heart/interviews/burke.html.Accessed04February2006.9.SpiroSA,AldwinCM.Combat-relatedposttraumaticstressdisordersymptomsinoldermen.PsycholAging.1994;9:17-26.10.DiagnosticandStatisticalManualofMentalDisorders,ThirdEdition.Arlington,VA:AmericanPsychiatricPublishing,Inc;1980.11.TheSoldiersHeartInterview.SteveRobinson[transcript].Frontline.PBStelevision.March05,2005.Availableat:http://www.pbs.org/wgbh/pages/frontline/shows/heart/interviews/robinson.html.Accessed19February2006.AUTHOR MsShepardisChief,SocialWorkServicesattheUSArmyHealthClinicsinKatterbachandIllesheim,Germany.Atthetimethisarticlewaswritten,shewasChief,SocialWorkServices,USArmyHealthClinic,Schweinfurt,LedwardBarracks,Schweinfurt,Germany.RemovingtheStigmaofMentalHealthTreatmentforSoldiers

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AprilJune200725WHATISANENVIRONMENTALHEALTHSITEASSESSMENT?WhatisanEHSAandwhywoulditberelevantinanexpeditionaryArmy?Thesearequestionsmanyhaveasked.Unfortunately,fewcanprovideasoundanswertothesequestions.Theanswerisnotcomplicatedanddoesnotrequireyearsofexperienceandtraining.Simply,theEHSAisdesignedtoprotectourdeployedforceanddocumentpotentialexposuresresultingfromtheirdeployment.TheEHSAsarelivingdocumentsthatdescribeenvironmentalandhealthconditionsatdeployedlocations.Theyidentify,describe,anddocumentpotentiallycompleteandcompletedexposurepathways.ThisarticleprovidesanoverviewoftheEHSAprocess,thesiteassessment,andthefinalreportinordertodemystifytheEHSAprocessanditsusefulnesstopreventivemedicinepersonnel.TheobjectiveoftheEHSAistoidentifycompleteandpotentiallycompleteexposurepathwaysatdeploymentsitesthatmayaffectthehealthofdeployedpersonnel.DatageneratedfromtheEHSAisusedtoconductoperational(composite)healthriskestimates.TheEHSAprocessconsistsof5components:predeploymentactivities,sitereconnaissance,conceptualsitemodels,environmentalsampling,andareporttodocumentfindings.TheneedforastandardmethodologyfordocumentingenvironmentalconditionsatdeployedlocationsfirstbecameevidentafterOperationsDesertShield/Storm.However,itwasnotuntiltheUSinvolvementintheBalkansthattheneedforamethodologytodocumentenvironmentalconditionsthatmayaffecthealthwererequired.ThisdocumentationhadtobeseparatefromtheexistingenvironmentalbaselinesurveyconductedbytheArmyCorpsofEngineers.TheJointEnvironmentalSurveillanceWorkingGroup(JESWG)recognizedtheneedforastandardpracticeamongthemilitaryservicesandthemethodologytodocumentenvironmentalhealthconditionsatdeploymentlocations.Althoughsomedeploymentenvironmentalsurveillancewasconducted,itwasnotnecessarilyasystematic,scientificallybasedmethodologythatwasrecognizedbyallservices.In2003,theAmericanSocietyofTestingandMaterials(ASTM)InternationalpublishedtheStandardGuideforEnvironmentalHealthSiteAssessmentsforMilitaryDeployments.1ThiswastheresultofajointeffortchampionedbytheJESWG.ThepublicationofthismethodologythroughtheASTMprovidedapeer-reviewed,third-partyacceptedstandardthatisscientificallydefensible.DoDI6490.032providesimplementationguidanceforEnvironmentalHealthSiteAssessments.Althoughthe1997versionmentionedtheneedtodocumentbaselineDemystifyingtheEnvironmentalHealthSiteAssessmentLTCTimothyG.Bosetti,MS,USA ABSTRACTAttherequestoftheMultinationalCorps-Iraq(MNC-I),theUSArmyCenterforHealthPromotionandPreventiveMedicinedeployedaSpecialAugmentationResponseTeam-PreventiveMedicinetosupportMNC-IandpreventivemedicineassetsinIraqinordertocompleteenvironmentalhealthsiteassessments(EHSAs)formajorforwardoperatingbases.Priortothemission,therewasalotofconcernfromthefieldonwhatconstitutedanEHSAandhowtoconductone.TheEHSAisalivingdocumentthatdescribesenvironmentalandhealthconditionsonaforwardoperatingbase.Itidentifies,describes,anddocumentspotentiallycompleteandcompletedexposurepathways.The90-daymissioninvolvedconducting2iterationsofEHSAtrainingtopreventivemedicinedetachmentsandbrigadecombatteamEnvironmentalScienceandEngineeringOfficers,conductingsiteassessmentsofmajorforwardoperatingbasesinIraq,andcompletingover25EHSAreports.ThisarticleprovidesanoverviewoftheEHSAprocess,thesiteassessment,andthefinalreportinordertodemystifytheEHSAprocessanditsusefulnesstopreventivemedicinepersonnel.

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26ArmyMedicalDepartmentJournalconditionsandconductenvironmentalbaselinestudies,specificguidanceontheEHSAwasnotavailable.Asaresult,policyguidancefromtheJointStaffdidnotspecifytheneedtoconductanEHSA.TheJointStaffmemorandumhasbeenupdatedtoincorporatespecificlanguagethatrequiresEHSAs.AsbasecampsbegantoappearalloverIraq,theneedtodocumentexistingenvironmentalconditionsaroseagain.AlthoughsomeEHSAswereconducted,itwasnotastandardpractice.In2005,theUSCentralCommand(CENTCOM)SurgeonsstaffexertedpressuretohaveEHSAsconductedatalltrooplocationswithintheCENTCOMareaofresponsibility.Thishigh-levelpush,quotingnebulousthird-partyagenciesandDepartmentofDefense-levelrequirements,resultedinthebeliefthatEHSAswerebeyondthecapabilitiesofpreventivemedicineassetsintheater.Fromthere,themysterysurroundingtheEHSAgrew.ConcernswerethattheEHSAwasaburdentotheaterpreventivemedicineassetsaboulderintheiralreadyfullrucksack.However,inreality,theEHSAisnothingmorethanpackagingwhatisalreadydonebyfieldpreventivemedicinepersonnelatalllevelsofsupport.InNovember2005,theUSArmyCenterforHealthPromotionandPreventiveMedicine(USACHPPM)receivedamissionrequestfromtheMNC-ItoconductEHSAsforthemajorforwardoperatingbases(FOB)inIraqandtotrainpreventivemedicinepersonnelontheEHSAprocess.TheUSACHPPMSpecialAugmentationResponseTeam-PreventiveMedicine(SMART-PM)consistedofpersonnelfrombothUSACHPPPMHeadquartersandEuropewithspecialtiesinenvironmentalengineering,industrialhygiene,publichealth,and2preventivemedicinetechnicians.InJanuary2006,theteamdeployedtoIraqtobeginitsmission.TwotrainingclasseswereheldatCampAnaconda,Balad,Iraq.Over40preventivemedicinepersonnelfromtheArmyandAirForceweretrained.Uponcompletionoftraining,theteammovedaroundthetheater,visitingthemajorFOBs,providingadditionalEHSAtraining,andcompletingtheEHSAsforeachmajorFOB.Within60days,theUSACHPPMSMART-PMhadcompleted25EHSAs,whichincludednotonlythemajorFOBsbutseveralsatellitecampsandcampsdesignatedforclosure.Whileexitingthetheater,theteamstoppedinKuwaitandprovidedEHSAtrainingtopreventivemedicinepersonnelinKuwait.PREDEPLOYMENTACTIVITIESPredeploymentactivitiesforanEHSAarethesameasthoseforpreparingfordeploymentormission.Inpreparationfordeployment,preventivemedicinepersonnelidentifythemedicalthreatstodeployedforces.Thethreatscanbeintheformofenvironmentalstressors,endemicdiseases,vector-bornediseases,environmentalandindustrialcontamination.ThepredeploymentactivitiesrelatedtotheEHSAarenotdifferentfromthosealreadyperformedbypreventivemedicinepersonnel.WHEREDOESTHEINFORMATIONCOMEFROM?Therearemanysourcesofinformation.AmongthecommonlyknownaretheArmedForcesMedicalIntelligenceCenter,theCentralIntelligenceAgencyWorldFactBook,3andtheWorldHealthOrganization.Thesearetypicallyusedtodevelopmedicalthreatbriefingsandpreventivemedicineestimatesofthesituationforadeployment.MostareawarethattheUSACHPPMDeploymentEnvironmentalSurveillanceProgramisagreatresourceforgatheringhealthinformationpapersandproducts,andmedicalthreatbriefings.However,theUSACHPPMalsohasaresourcethatcanbeusedtodevelopthepreventivemedicineoperationalpictureforthedeploymentlocation.ThiscapabilityiscalledtheGlobalThreatAssessmentProgram(GTAP).TheGTAPcanprovideaPhaseIDeploymentDemystifyingtheEnvironmentalHealthSiteAssessment EHSAProcess ORM EHSA Preliminary Hazard Analysis Risk evaluation Riskanalysis andother ORM components Report CSM1 CSM2 CSM3 CSM4PreDeployment Activities SiteRecon and InterviewsSa mpling EHSAProcess1 PredeploymentActivities

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AprilJune200727OccupationalandEnvironmentalHealthRiskSummarythatincludesanoverviewofthesiteandgeographiclocation,samplescollected,potentialhazardsinthearea,surroundingindustries,andpotentialmedicalthreats.Thereareseveralsourcesofinformationforpreventivemedicinepersonnelfromwhichtogatherdataconcerningthedeploymentsite.Alloftheseinformationsourcesshouldbeusedtodevelopthepreventivemedicineestimateofthesituationtoidentifythepotentialmedicalandhealththreats.Thatestimatecanthenbeusedtodevelopthemedicalthreatbrief,andserveasthebackgroundresearchforyourEHSAandthefoundationforthedevelopmentoftheconceptualsitemodels.CONCEPTUALSITEMODELSTheconceptualsitemodel(CSM)isagraphicalrepresentationofanexposurepathwayforacontaminantofconcern.Itdescribeshowacontaminantofconcernmovesthroughtheenvironment(air,soil,andwater),identifiestheactivitiesthatcouldresultinpotentialexposures,andidentifiesthepotentialroutesofexposure.Althoughthatprocesssoundscomplicated,itisactuallyquitesimple.Firstistheidentificationofthecontaminantsofconcern.Thiscomesfromthepredeploymentactivitiesandthemedicalandhealththreatsthatwereidentified.Secondisthedeterminationofhowthecontaminantexistsintheenvironment.Thisisnothingmorethanidentificationofthephysicalpropertiesofthecontaminantofconcernandhowitexistsintheenvironment:liquid,solid,orgas.Thephysicalpropertiesdeterminehowthecontaminantofconcernbehavesandmovesthroughtheenvironment,andhowitentersthehumanbody:dermalcontact,ingestion,orinhalation.Thirdisthedeterminationofwhat,ifany,activitywillresultinanexposuretothecontaminantofconcern.Thisiscritical,ifthereisnorouteofexposure,thereisnoexposure.Rememberthattime,distance,andshieldingdeterminetheamountofexposure.Aftertherouteofexposurehasbeenidentified,weneedtoassessthepotentialroutesofexposure:dermalcontact,ingestion,orinhalation.Finally,intheconceptualsitemodel,wemakeanassumptionastowhetherthatexposurepathwayendswithahumanreceptor.Thismodel,orconceptualexposurepathway,remainsuntilwecanvalidate,throughsampling,whetheritexistsasacompleteexposurepathway,apotentiallycompleteexposurepathway,oranincompleteexposurepathway,ie,noexposure.Theconceptualsitemodelassistsinansweringthefollowingquestions:Whatarethecontaminantsofconcernandwhatisthesourceofcontamination?Howdoesthecontaminantexistintheenvironment?Howaredeployedforcesexposed?Whatistheactivitythatcausestheirexposure?Whatistheexposureroute:dermal,ingestion,orinhalation?Isthereacompletedexposurepathway?Thatlastquestioniskeyisthereacompletedexposurepathway?Thatiswhatweaspreventive ExposurePathways Water Inhalation Deposition Ingestion Soil Ingestion/ DermalAbsorption DermalContact Air Deposition SourcePathway Receptor Deposition PotentialExposureSourcesHazardousmaterial/wastestorageareasMotorpoolsExistingcontamination&spillsIndustryFuelstorageareasWastedisposalareas

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28ArmyMedicalDepartmentJournalmedicineprofessionalsareattemptingtodetermine,andanswer.WeanswerthatbyusingtheCSMdevelopedforacontaminantofconcernanddevelopingasamplingprogramtodeterminewhetherthatexposurepathwayiscompletedandifthereisahumanexposure.TheCSMshouldbeusedtodevelopthesamplingandanalysisplan(SAP)forthedeployedsite.TheSAPshouldbediscussedintheEHSAreport(typicallyinparagraph5),oritcanbedetailedasanappendixtotheEHSA.Eitherway,theSAPshouldprovideadescriptionoftheobjectivesforthesamplingandtherationaleforconductingthesampling.ThepurposeofthesamplingistodocumentenvironmentalconditionstovalidatetheCSMandcharacterizepotentialexposurepathways.Butwhatdoesthatreallymean?Anysamplingdoneatthesiteshouldhaveapurpose,andthatpurposeshouldrelatebacktotheCSM.TheCSMshowshowacontaminantmovesthroughtheenvironment(air,soil,andwater)andtoahumanreceptorthroughanexposurepathway(ingestion,dermalcontact,orinhalation).Thesamplingtobeconductedshouldfocusonthoseexposurepathwaystodeterminewhethertheyarepotentiallycompleteorcompleteexposurepathways.Thegoalistoanswerthequestion:doesthatcontaminantexistataconcentrationwhichcanposeahealththreattodeployedforces?Themoredetailedthesamplingplan,thelessopportunityforoversightormisunderstandingduringthesampling,analysis,anddatamanagement.TheconfidenceinwhichyoucananswerthatquestionisrelatedtothedetailintheCSMandSAP.SITERECONNAISSANCEANDINTERVIEWSInformationfromsitereconnaissanceandinterviewsisimportanttoverifyinformationcollectedduringthepredeploymentactivities,answerquestionsaboutthesite,andidentifyinformationthatwasnotpreviouslyknown.Inmostcases,thegroundtruthcanbeverydifferentfromwhatwasthoughtfromathousandmilesaway.Therefore,itisimportanttostayobjectiveandmakealistofquestionsthatmustbeaddressedonceyouareontheground.Therearemanychecklistsavailablefromdoctrinalmanuals,technicalguides,andreferences.Anyofthesecanbeused.However,thebestmeansofbothgatheringinformationonthesiteandconductingthesitereconnaissanceisthroughtheperformanceofnormal,routinepreventivemedicineinspections.Aspreventivemedicineprofessionals,thereareavarietyofroutineinspectionsandsurveysthatweconductthat,whenevaluatedholistically,developthesitepicturebetterthananychecklist.Individually,theseroutineinspectionsmaynotseemsignificant,however,whencombinedandcomparedtootherinspections,surveys,andreports,theresultingdatacanbeusedtoidentifycommonalitiesbetweenpotentialexposures.LookingattheseinspectionsacrossthecontinuumofpreventivemedicinesupportmayalsohelpidentifywhatshouldbeaccomplishedforDeploymentOccupationalandEnvironmentalHealthSurveillance(DOEHS)sampling.DemystifyingtheEnvironmentalHealthSiteAssessment CONCEPTUALSITEMODELLEADINDUSTRIESINMITROVICA,KOSOVOExampleofaconceptualsitemodeldevelopedforapriordeploymentintoapotentiallycontaminatedareaofoperations. LeadIndustriesSmeltingBatteriesMining Air Soil Water ParticulateemissionsVolatilization(smelting) DiggingAgriculturalactivities Localwellsandsurfacewater Wind-blowndust Leaching/runoffInhalationYesDermalContactNoIngestionNo InhalationNoDermalContactNoIngestionYes InhalationNoDermalContactYesIngestionYes POINTOFEXPOSUREROUTEOFEXPOSUREHUMANRECEPTORENVIRONMENTALMEDIASOURCE

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AprilJune200729DEPLOYMENTOCCUPATIONALANDENVIRONMENTALHEALTHSURVEILLANCESAMPLINGThereisalinkbetweentheconceptualsitemodelandthesamplingandanalysisplan.Thesamplingplanshouldbebasedupontheconceptualsitemodelandshouldsupportyourconclusion.Intheconceptualsitemodel,wemakeanassumptionastowhetherthatexposurepathwayendswithahumanreceptor.Thismodel,orconceptualexposurepathway,remainsuntilwecanvalidate,throughsampling,whetheritexistsasacompleteexposurepathway,apotentiallycompleteexposurepathway,oranincompleteexposurepathwaynoexposure.ManyofthebaselinerequirementsforDOEHSsamplingareidentifiedinpolicyguidancedocuments.Theminimumrequirementsforenvironmentalsamplingshouldidentifytheexistingsitecharacteristicsandpotentialareasofcontamination.Itshouldbeevaluatedfrequentlytoensurethatthecorrectdataiscollectedandadjustedtocoverareasthatneedmoreattention.Thebaselinerequirementsshouldremaincenteredontheconceptualsitemodelsandpotentialexposures.Archivingdatacollectedisimportant,however,mostpeopleonlyfocusonthesignificantfindingsorresearchthedataifthereisaproblem.Althoughtheseareimportant,themostimportantpieceofdataandinspectionreportistheoneofnegativefindings.Weoftenoverlookthesereportsbecausetherewasnothingofnote,however,thesecompletethepictureofdeploymentexposures.Theyarethemissingdatalink.Wecanidentifywhenthereisaproblem,butwhatabouttheother99%ofthetime?Werethereanyissues?Withoutthecompletepicturewewillneverknow.Thisiswhyitisimportanttodocumentyourfindings,bothpositiveandnegative.TheEHSAprovidesastandardformatfordocumentingconditionsatadeploymentsite.DOCUMENTATION:THEEHSAREPORTTheASTMstandard1providesabasicformatfortheEHSA.Thisisasuggestedformat.Theconditionsonthegroundorthenatureoftheoperationmayrequiremodificationstothesuggestedformat.Changingtheformatisacceptable.Theemphasisandgoalisondocumentationofthedata;notensuringthatyoufollowedtheformat.Themajorcomponentsdonotnecessarilychange,however,thedetailswillvarydependingonthedeployedsite.TheEHSAisandmustbealivingdocument.Justaswedonotconductaninitialinspectionandneverreturntoensurethingsarestillmeetingthestandard,weshouldnevercompleteaninitialEHSAandfilethedocumentaway.Itshouldberevisitedfrequentlytoensurethattherearenochangesandtoupdatefindingsbaseduponnewlydiscoveredinformation.Thesameappliestotheconceptualsitemodelsandexposurepathways.Aretheystillvalid?Aretherechangestothemissionorsituationthatpotentiallyaffecttheassumptionsorrouteofexposure?Onlythroughroutinereviewcansuchissuesbeaddressed.ArchivingtheEHSAcanalsoprovidealaterrollupofthepreventivemedicineactivitiesconductedatadeployedlocation.Itcanserveasanhistoricalreportandatransitionbookfortheupcomingrotation.CONCLUSIONTheDOEHSsamplingshouldbeconductedatallmajorFOBsandothertrooplocations.DocumentationofbaselineconditionsandroutinesurveillanceshouldcontinueinaccordancewithcurrentDoDguidelinesandpolicies(eg,DoDI6490.032).TheEHSAprovidesthemeansandanapprovedstandardforthedocumentationofbaselineconditionsandpotentialexposurestodeployedforces.Itcanalsoserveasa EHSAReportFormat1IntroductionSiteDescriptionInformationSourcesInformationfromSiteReconnaissanceEnvironmentalSamplingDataConceptualSiteModelsConclusionFindingsandRecommendationsTechnicalAssistanceAppendicesReferencesPhotographsSiteMapsSampleLocationsAnalyticalData

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30ArmyMedicalDepartmentJournaltoolforpreventivemedicineunitsandpersonnelduringtheirtransferofauthoritybyprovidingdocumentationofenvironmentalconditionsandpotentialissuesateachbaseorsupportarea.TheEHSAisnotacomplicatedormysticalprocessthatrequiresanadvanceddegree.Itisdesignedtobeatoolforallpreventivemedicinepersonnel,andprovideastandard,logicalprocessforourprofessiontodocumentwhatwealreadydotoprotectthehealthofdeployedSoldiers,Sailors,Airmen,andMarines.REFERENCES 1.AmericanSocietyforTestingandMaterialsInternational.ASTME2318-03:EnvironmentalHealthSiteAssessmentProcessforMilitaryDeployments.WestConshohocken,PA:AmericanNationalStandardsInstitute;2003.2.DepartmentofDefenseInstruction6490.03:DeploymentHealth.Washington,DC:USDeptofDefense;August11,2006.3.TheCentralIntelligenceAgency.TheWorldFactbook.Availableat:https://www.cia.gov/cia/publications/factbook/index.html.AUTHORLTCBosettiisChief,EnvironmentalEngineeringDivision,USArmyCenterforHealthPromotionandPreventiveMedicine-Europe,Landstuhl,Germany. DemystifyingtheEnvironmentalHealthSiteAssessment ArchivingDataandReportsSUBMITDIRECTLYTODOEHRSDATAPORTALhttp://doehrswww.apgea.army.mil/doehrs-oehs/Anyuserwithamilitary(.mil)domainemailaddressDOEHSDATASUBMITTEDVIAEMAILDatamaybesubmittedtothefollowingaddressUnsecured:oehs@apg.amedd.army.milorSecure:oehs@usachppm.army.smil.milDOEHSDATASUBMITTEDVIAMAILDeploymentDataArchivingandPolicyIntegrationProgramUSACHPPMATTN:MCHB-TS-RDD5158BlackhawkRoadBuildingE-1675ArlingtonProvingGrounds,MD21010-5403FAX:(C)410-436-2407DSN312-584-2407

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AprilJune200731Warfightersneedamplesuppliesofsafe,drinkablewatertofightandwinonthebattlefield.Incaseswheretheydonothaveaccesstodrinkingwaterprovidedbymilitarysources,theymustrelyonemergencyindividualwaterpurifiers(IWP)tomeettheirdrinkingwaterneeds.Currentmilitary-issuedemergencywaterpurifiersworkslowly,andmayproducemicrobiologicallyunsafewater.Commercialvendorshavemarketedalternatepurifierstothemilitary,butnonehavebeensystematicallytestedbymilitaryagencies.ToremedytheseshortcomingsandtobetterprotectWarfighterhealth,theUSArmyCenterforHealthPromotionandPreventiveMedicines(USACHPPM)WaterSupplyManagementProgramrecentlyperformedanin-depthperformanceandhealthriskassessmentofcommercialoff-the-shelfindividualwaterpurifiersinordertodevelopsimple,directrecommendationsfortheWarfighter.TheUSACHPPMhaspresentedtheresultsofthisstudy,andcreatedaninternetaccessibledatabaseofcommerciallyavailableIWPs.*PROBLEMBACKGROUNDWatersupplyobviouslyremainsacriticalrequirementforforcesustainmentonthebattlefieldWarfightersneedamplesuppliesofsafe,drinkablewatertofightandwin.EmergencyIWPsareanimportantcomponentofwatersupply.CurrentlyfieldedindividualwaterpurificationoptionsfortheWarfighterincludeiodinetabletsandchlor-floctablets.NeithermethodfullymeetstheneedsofmodernWarfightersintermsofeaseofuse,volumeofwaterproduced,orconfidencethatthefinalproductismicrobiologicallysafe.Manysmall,hand-operatedwaterpurifiers,includingbothfiltrationanddisinfection-baseddevices,havebeencommerciallydevelopedinrecentyearsforcampersandhikers.Althoughmilitaryunitshaveusedunitfundstopurchasecommercialpurifiersfordeployments(insomecasesindividualWarfightershaveevenpurchasedtheirownpurifiers),theirselectionshavebeenprimarilybasedonpackagingandmarketing,ratherthanascience-based,systematicassessmentofdeviceperformanceinamilitaryenvironment.LackofsuchanassessmenthasplacedtheWarfighteratriskofcontractingwaterbornediseasesthroughtheingestionofwaterbornepathogens.TheUSACHPPMrecognizedthisriskthroughthemanyrequestsfromdeployedunitsandindividualsforrecommendations.ItsresultingassessmentwassponsoredbytheofficeoftheDeputyAssistantSecretaryoftheArmyforEnvironment,SafetyandOccupationalHealth,andthenfundedbytheArmyStudyProgram.RESULTSNomatterthemethodologyemployed,ultimatelytheIWPmustprovidesafedrinkingwater.InevaluatingthesafetyofIWP-produceddrinkingwater,theUSACHPPMstudymadeexposureassumptionsregardingpopulationandduration.ThestudyteamWaterPurifiersfortheWarfighterMAJWilliamJ.Bettin,MS,USA *http://usachppm.apgea.army.mil/WPD/

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32ArmyMedicalDepartmentJournalassumedthatonlythedeployablemilitarypopulationwouldusetheIWPs,andthatthispopulationwouldonlyusetheminfrequentlyandforshortperiodsoftime.Basedonthese2assumptions,themostsignificantrisktoWarfighterhealthinusinganIWPistheriskfromingestingwater-bornemicrobialpathogens.ThusweevaluatedanIWPsabilitytoprovidesafedrinkingwaterintermsofitsabilitytoreducethenumberofactivepathogensinwatertoasafe(noninfectious)level.Forourteststandardsweusedthetestprotocolmetricwidelyacceptedindrinkingwaterscienceandinthedrinkingwaterindustry:asafelevelofpathogenremovalequatesto6-log(99.9999%)removalofbacteria,4-log(99.99%)removalofviruses,and3-log(99.9%)removalofparasiticcysts.ThusabestIWPshouldmeetthispathogenremovalmetric.ThestudyfoundthatfewcommerciallyavailableIWPscouldmeetthismetric.MostcommercialIWPsreducepathogensbasedononeoftwoprimarymechanisms,eitherfiltrationordisinfection.Eachhasinherenttechnologylimitationstomeetingthebestpathogenreductionmetric.Filter-basedIWPsreducepathogensinwaterthroughsizeexclusion.Theygenerallydowellatreducingthelargerpathogens,bacteriaandcysts,fromwater,butdonotreducethesmallerviralpathogenstosafelevels.Manyfilter-basedIWPsevaluatedinthisstudycouldsuccessfullyremovebacteriaandcysts.Asmallnumberalsoshowedpromiseofviralreductionthroughadsorptiononaproprietaryfiltermedium,butrequirefurtherindependenttestingtoverifythecapability.Onefilter-basedIWPwascommerciallypackagedwithdisinfectantdropsasasecondpurificationstep,andsuccessfullymetthebestpurifierpathogenreductionmetric.Disinfectant-basedIWPskillorinactivatemicrobialpathogensinwater,thusrenderingthemnoninfectious.Chemicaldisinfectantsgenerallyreducebacteriaandviruseswell,butstruggletoreducethetougher,morechemicallyresistantparasiticcyststosafelevels.Evenathighchemicaldoseandlongtreatmenttime,IWPsbasedonchlorineoriodinecouldnotsafelyreducecryptosporidium,thetoughestofthepathogens.However,atproperdoseandtreatmenttime,thechlorinedioxide-basedIWPscouldkillcryptosporidiumandmeetthebestIWPmetricforpathogenreduction.Beyondreducingpathogens,abestIWPalsohadtobesmallandlightweight,purifyquickly,purifyturbid(cloudy)waters,notmakethewatersmellortastebad,besimpletouse,andbedurableunderfieldconditions.ThestudyfoundthatchoosingabestIWPinvolvesinherenttradeoffsbetweenthesecharacteristicsbecausenosingleIWPreceivedthehighestratingforeach.Therequiredtradeoffisusuallybasedontheprimarypathogen-reducingtechnologyoftheIWP,eitherfilterordisinfectant.Forexample,disinfectantsareinherentlysmall,lightweight,andsimpletouse,butpurifyslowlyandleavewaterwithanunpleasantchemicalsmellandtaste.Filterspurifyquicklyandcanreducebadtastes,odorsandturbidity,butarebigger,heavier,andmorecomplextousethandisinfectants.Overall,thestudyteamassessed68IWPsproducedby27differentmanufacturers.Ofthese,53usedfiltrationastheprimarymeansofpathogenreductionwhile15useddisinfection.TheresultswerepackagedbyUSACHPPMandmadeavailableasaweb-basedIWPdecisiontool*tohelpWarfightersmakeIWPchoicesthatbetterprotecttheirhealth.Thisdecisiontoolcontainsacomparative,searchable,relationaldatabaseofthetechnicalspecifications,operatingcharacteristics,andthepathogenremovalcapabilitiesofavailablecommercialIWPsasevaluatedbyUSACHPPM.DATACOLLECTIONANDEVALUATIONToidentifyandcollectIWPdata,theUSACHPPMstudyteamconductedanextensivemarketsurveyofcommerciallyavailableIWPsthatcouldbepurchasedbyunitsorindividualWarfighters.Aspartofthissurvey,theteamattemptedtocontactallidentifiedIWPmanufacturerstorequestdetailedtechnicalinformationandperformancetestdata.Manufacturerswereinformedofthenatureofassessmentasthebasisfortherequest.OnlypubliclyavailableproductinformationwascollectedfortheIWPsofthosemanufacturersthatdidnotrespond.TheevaluationofIWPpathogenreductioncapabilitybyUSACHPPMwasakeypartinthedevelopmentofdatabaseinformation.Laboratorytestingresultswerecriticaltoahigh-confidenceevaluationofthiscapability.ThestudyteammadedeliberateandWaterPurifiersfortheWarfighter *http://usachppm.apgea.army.mil/wpd/comparedevices.aspx

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AprilJune200733exhaustiveeffortstolocateandreviewallavailablelaboratorytestresultsshowingdeviceefficacyatpathogenreduction.Theteamevaluatedthequalityoftestdatabasedonthesecharacteristics:1.Howcloselythetestingfollowedanapplicabletestprotocol2.Thedegreeofindependent,third-partystatusofthetestingorganization3.Thedegreetowhichtestingwasconductedinaccordancewithmanufacturer-specifieddeviceoperatingconditions4.Thedegreetowhichtestingwasdevice-specific,versusbasedontechnologyorproductfamilysimilaritiesEXPERTPANELSUPPORTANDMULTIATTRIBUTEANALYSISAspartofthisstudy,USACHPPMalsodevelopedspecificscenario-dependentrecommendationsforbestIWPs.Thestudyteamdevelopedtheserecommendationsthroughanoperationalanalysis,followedbyamultiattributedecisionmodelanalysisperformedby2multiservice,interdisciplinary,intradepartmentalexpertpanels.Tofacilitatethedecisionanalysis,USACHPPMalsoaddeddecisionanalysisexpertstothestudyteam.ToverifyUSACHPPMsoperationalanalysisandtodevelopthedecisionmodel,thestudyteamfirstconvenedapanelofmultiservicecombatdevelopers,materialdevelopers,andlogisticiansasuser-representativeexperts.ThepanelincludedrepresentativesfromtheUSArmyInfantryCenter,DirectorateofCombatDevelopments;theMarineCorpsCombatDevelopmentCommand;theArmyG4;andtheProductManager,PetroleumandWaterSystems.Thisexpertpaneldevelopedadecisionmodel,shownintheFigure,thatidentified,defined,andweightedthe12mostimportantIWPcharacteristicsrequiredforthebestIWP.Next,thestudyteamconvenedapanelofmultiservicewaterscientists,engineers,andpreventivemedicinepersonnelastechnicalexpertstoevaluateIWPsagainstthedecisionmodel.InadditiontotheUSACHPPMin-houseexperts,thispanelincludedrepresentativesfromtheUSArmyTankandAutomotiveResearch,Development,andEngineeringCenter;theUSArmyNatickSoldierResearch,Development,andEngineeringCenter;NavalSeaSystemsCommand;NavalFacilitiesEngineeringCommand;andtheAirForceInstituteforOperationalHealth.TheydevelopedconsensuscharacteristicscoresforeachIWP.BecausetherewereincompletedataforsomeIWPs,theexpertpanelsknowledge,experience,andprofessionalopinionwerecriticallyimportantintechnicalevaluationtogenerateIWPcharacteristicscores.Overallscoreswerethencalculatedusingalinearadditiveapproach,inwhichtheconvertedscoreforeachcharacteristicwasmultipliedbyitsweight,andthensummedforallmodelcharacteristics.TESTPROTOCOLDEVELOPMENTAspartofthisstudy,USACHPPMalsodevelopedanIWPtestprotocol.Thestudyteamfoundthattherewasnosingle,acceptedperformancemeasurebywhichtoassessandcompareIWPpathogenremovalperformanceinmilitaryoperations.Incorporatinglessonslearnedfromitstechnicalexpertpanelandbuildingonrelatedtestprotocols,thestudyteamdevelopedamilitary-orientedIWPtestprotocoltobethatsingle,comparablemeasureofIWPperformance.Thesignificantanduniquemilitary-specificcomponentsdevelopedforthisprotocolincluded:1.Alistofdesirablecharacteristicsandoperationalcapabilitiesthatimpactdevicesuitabilityforuseinvariousemergencymilitaryfieldscenarios. TheUSACHPPMdecisionmodelusedtoidentify,define,andweightthe12mostimportantcharacteristicsrequiredforthebestindividualwaterpurifier. BESTINDIVIDUALWATERPURIFIER RemoveTaste/Odor ReduceTurbidity ReducePathogens PurifyQuickly Small ResistClogging FunctionIndicator Lightweight EasytoUse Durable SimpleStorage LongShelfLife Performance Operational LogisticsDECISIONMODEL

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34ArmyMedicalDepartmentJournal2.ThespecificationthattheIWPmanufacturerorvendor,togetherwiththeequipmenttestingorganization,produceawritten,device-specifictestplanandforwarditforreviewtothegovernmentreviewagencybeforetesting.3.Anupdateddiscussionandspecificationoftheselectionofmicroorganismsforperformancetesting.ThestudyteamthenengagedNSFInternational(AnnArbor,Michigan48113,734-769-8010),arecognized,reputable,third-partyentityspecializinginstandardsdevelopment,productcertification,education,andrisk-managementforpublichealthandsafety,topublishtheprotocolasNSFProtocolP248EmergencyMilitaryOperationsMicrobiologicalWaterPurifiers(Availableat:http://www.nsf.org/business/newsroom/nsfremarks/reMarks-spring06.pdf,page2).CONCLUSIONTheUSACHPPMhassuccessfullyperformedanin-depthperformanceandhealthriskassessmentofcommercialoff-the-shelfindividualwaterpurifiersinordertodevelopsimple,directrecommendationsfortheWarfighter.Inmeetingthisprojectsobjectives,USACHPPMcontinuestosupporttheGlobalWaronTerror,sustainingacampaign-capableexpeditionaryArmythroughprovidingthemeanstoassessandidentifysafe,effectivecommercialwaterpurifiersforemergencyindividualuse.IthasalsosupportedArmyTransformationbyidentifyingsustainmentenablersfortheFutureForceconceptofextendedautonomousoperations.WaterPurifiersfortheWarfighter AUTHOR MAJBettinisChiefoftheFieldWaterSection,WaterSupplyManagementProgram,attheUSACHPPM,AberdeenProvingGround-EdgewoodArea,Maryland.

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AprilJune200735AGuidetoBrigade-LevelPreventiveMedicine:StrykerBrigadeExperienceinOperationIraqiFreedomII&IIICPTStephenA.Lewandowski,MS,USACPTJasonB.Faulkenberry,MS,USAINTRODUCTIONThetransformationoftraditionalArmybrigadesintomodularbrigadecombatteams(BCT)bringsanenvironmentalscienceandengineeringofficer(ESEO)andpreventivemedicinespecialist(militaryoccupationalspecialty(MOS)68S)tothebrigadelevel.Priorto2004,doctrineprovidedorganicpreventivemedicinecapabilitiesatdivisionlevelorhigher.TheformationofStrykerbrigadecombatteams(SBCT)firsttestedthischange,designedtoimproveforcehealthprotectionandmaketheunitsmoreself-sustainable.The3rdBrigade,2ndInfantryDivision(3/2)SBCTandthe1stBrigade,25thInfantryDivision(1/25)SBCTwerethefirstStrykerbrigadestodeploy,servingfromfall2003tofall2005,primarilyinNinevehprovinceinnorthernIraq.Duetothisrestructuring,theinexperienceofmanyjuniorESEOsandMOS68Spersonnelfillingtheseauthorizations,thewidescopeofdefinedresponsibilities,andlimitedtrainingtimepriortodeployment,apotentialexistsforunderutilizationormisuseoftheBCTpreventivemedicinesection.Thisarticleprovidesageneraloverviewandfocustonewpreventivemedicinepersonnelandinformscommandersandmedicalplannersoftheirexpectedrolesandvaluetotheorganization.BACKGROUNDTheBCTpreventivemedicinesectionisauthorized2entry-levelpersonnel,oneeachofMOS72Danda68S10.ItisfrequentlyafirstassignmentfortheMedicalServiceCorpsofficerwhomaybedirectcommissionedwithlittleexperienceintheArmy.Theofficerwillhaveadegreeinascience-basedfieldandmayhaveattendeda9-weekspecialtytrainingcourse,PrinciplesofMilitaryPreventiveMedicine,followingOfficerBasicLeadershipCourse.BoththeESEOandthechainofcommandmusthaveasolidunderstandingoftheexpectedrolesandresponsibilitiesfortheposition.FieldManual3-90.6,1whichdescribestactics,techniques,andproceduresforthetacticalemploymentoftheBCT,statessimplythatthepreventivemedicinesectionassistsunitcommandersthroughsanitaryinspectionsoffoodservice,latrines,andshowerpoints;medicalsurveillanceoffieldwatersupplies;andsamplecollectionforpotentialtoxicindustrialmaterials.DAPamphlet40-11,2usedwithArmyRegulation40-5,3statesthatthesectionprovideslevelIIsupportbymeansofbasicfieldsanitation,unitfieldsanitationteamtraining,fieldscreeningandpresumptiveanalysisofwatersupplies,basicpestmanagementandsurveillance,focalapplicationofpesticide,andlimitedmedicalsurveillance.FieldManual4-02.174listsasimilarscopeofservices(discussedasdivisionpreventivemedicinesincetheregulationwaswrittenpriortothedevelopmentofbrigadecombatteams).Althoughthelistedresponsibilitiesaloneaccountforafullworkloadforpreventivemedicinewhenappliedacrossthebrigadeoperationalenvironment,theyarenotall-inclusive.Mostsignificantly,thepreventivemedicineteammustconsidertheirroleinconductingoccupationalandenvironmentalhealthsurveillancetocharacterizelong-termhealththreats.Withconsiderationofthiswiderangeofpreventivemedicineobjectivesandtheimportanceofimplementation,coordinationandcommunicationbecomecritical.COORDINATIONCoordinatingthebrigadepreventivemedicinemissioncanbeacomplicatedtaskfortheESEO.TheESEOhastoworkthroughpropercommandandtechnicalchainsofmultiplelevelsofsupport.TheSBCTpreventivemedicinesectionfallsunderthebrigadesupportmedicalcompany(BSMC)aspartofthe

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36ArmyMedicalDepartmentJournalbrigadesupportbattalion(BSB).TheBSMCcommanderisresponsibleforoperatingalevelIImedicaltreatmentfacilityandprovidinghealthservicesupporttoallunitsinthebrigade,whiletheBSBcommanderprovidesthecoreofsustainmentforthebrigade.Theseleadershavemanyotherpressingissuesandmayhavetobeconvincedofthemagnitudeofpreventivemedicinepriorities.ThelevelofsupportofthechainofcommandhasagreatimpactontheESEOsabilitytoexecutethemission,especiallywhenitcomestoavoidingoverstrainofadditionalduties.TheextraassignmentswillalwaysbepresentintheBSB,withmanycompany-gradeofficersalreadypushedouttocombatrepairteamsandaconstantneedforbodiesintheguardtowersandthemotorpool.Onthetechnicalside,theESEOsrelationshipwiththebrigadesurgeonisvital.Thebrigadesurgeonservesastheprimaryadvisortothebrigadecommanderonthehealthofthebrigade.TheBCTsurgeonsection(BSS)integratesthehealthservicesupportplanwiththebrigademaneuverplan.Anotherimportantcontactformissionplanningisthesupportoperationsofficemedicaloperationsofficer,alsopartoftheBSB.Thesupportoperationsofficemanagessupportoperationsandisakeyinterfacewithsupportedunits.COMMUNICATIONThedifficultyofcommunicationiscompoundedwhilesupportingthebrigadeinanoncontiguousareaofoperations.Withtheadvancedin-theatermobilityoftheSBCT,theESEOmayhaveSoldierstosupportatadozenlocationsormoreatdistancesofover250kmaway.Furthermore,contactwithkeyleadersmaybelimitedbytheseparationofforwardoperatingbases(FOBs).InOperationsIraqiFreedomII&III,theSBCTBSBandbrigadeheadquarterswerebasedonoppositesidesofthecityofMosul.ThisseparationmadecommunicationwiththeBSSmoredifficultandwasahindrancetoinvolvementwithmedicalplanningforfutureoperationsandinfluenceonthecommand.However,alocationinproximityoftheBSBprovidedtheadvantageofavailabletransportationthroughlogisticspackagesandagreaterabilitytomonitorthedistributionofpreventivemedicinesuppliesthroughoutthebrigade.TheBSBalsocontainsfieldfeedingteamsandwaterpurificationunitsthatworkcloselywithpreventivemedicinepersonnel.CommunicationsabovetheBCTlevelarenecessaryforsituationalawarenessandsupportagreements.Fortechnicalpreventivemedicinesupport,thisincludedcommunicationswithpreventivemedicinedetachmentsassignedintheregion,preventivemedicineofficersassignedtoMultinationalCorps-Iraq,andtheUSArmyCenterforHealthPromotionandPreventiveMedicine(USACHPPM).Assetsfromthe224thand793rdMedicalDetachments,althoughwidelydispersedandlimited,conductedvaluablebase-campassessmentsinoursectoraspartoftheirmission.AnAreaMedicalLaboratorymayalsobeavailableforsupport.ThenexthigherheadquartersforourSBCTsinMosulwereTaskForcesOlympiaandFreedom,consecutively.Inoursituation,neitherTaskForceSurgeonhadanassignedpreventivemedicinestaff,andconsequentlyworkeddirectlywithusonpreventivemedicineissues.Themethodofcommunicationwithinthebrigadecanalsohaveabigimpactonhowthepreventivemedicinemissionisreceived.Itispreferabletotransmitnecessarypreventivemedicinemeasuresaspartofanoperationsorfragmentaryorderthantosendmemorandaofrecommendations.Companycommandersandfirstsergeantswillmaketheefforttocomplywiththeorder,whereasamemowithsuggestionsfromalieutenantinthemedicalcompanyismorelikelytobelosttohigherpriorities.ItisintheESEOsbestinteresttokeepboththecommandandtechnicalchainswellinformedofactivitiesandtoprovidecourtesycopiesofreportsatmultiplelevels.Itisnoteasytorespondtosomanyparties,but,ontheotherhand,thesecontactscanprovidesupplies,transportation,andauthority.Thelevelofinteractionwiththedifferentsections(eg,thesupportoperationsofficeorBSS)willvarywitheachESEOandBCTdependingonindividualspersonalities,backgrounds,abilities,andemphasisonpreventivemedicine.Theserelationshipsareimportantsincetheydeterminehowthepreventivemedicineperspectiveisaccepted,aswellasthedegreeofindependencegiventotheESEOtosetpriorities.WhiletheBCTESEOsmissionistoprovidedirectsupporttothebrigadeasthefirstlineofdefenseagainstdiseaseandnonbattleinjuries,heorshemayalsobecalledupontoprovideservicestounitsoutsideoftheBCTtaskorganization.Inourcase,weconductedroutineinspectionsatalogisticssupportareawithaCorpsSupportCommandCombatSupportHospital,andotherjointandcombinedforcesadjacenttoourprimaryFOB.SBCTSoldierswouldrefuelandeatatthislocation,sotherewasstillapayoff.ThisAGuidetoBrigade-LevelPreventiveMedicine:StrykerBrigadeExperienceinOperationIraqiFreedomII&III

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AprilJune200737coveragefreedthepreventivemedicinedetachmenttocoverotherbasesandminimizerisksoftravel.Wealsoinspecteddetentionfacilities,aMultinationalSecurityTransitionCommand-Iraqtrainingpost,andarestandrecuperationpasssite.SuchadjustmentsareinlinewiththeguidanceofDAPam40-11:Inthetheaterofoperations,preventivemedicinesupportistailoredandphasedtoenhancemissionrequirements,counterthemedicalthreat,andprovidepreventivemedicinesupportasfarforwardasthetacticalsituationwillpermit.PreventivemedicineresourcesprovidinglevelII,III,andIVpreventivemedicinesupportwillbeemployedonanareabasistoprovidetheutmostbenefittothemaximumnumberofpersonnelintheareaofoperations.2However,itisadvisabletoensurethechainofcommandiswellawareoftherequirementsandthereasoningbehindthedecisionbeforeengaginginamissionoutsideofthedirectscopeoftheBCT.PREDEPLOYMENTPreventivemedicineeffortspriortodeploymentsubstantiallyreducedependenceoncedeployedandprovideforamoresustainableandhealthierforce.Withpreparationandtraining,theESEOwillhaveamoreattainablemission,allowingfocusonareasotherthanbasicsanitation.Givenahighoperationstempoandfulltrainingcalendar,itisnecessarytotakeadvantageofeveryopportunity.Thepreventivemedicinesectionshould:Trainfieldsanitationteam(FST)members.Evaluatecompaniesfortheirpreventivemedicinereadiness.Inspecttheconditionofthebrigadeswatertrailers,waterpurificationanddistributionequipment,andfieldfeedingequipment.Incorporatepreventivemedicineintofieldtrainingexercisesasmuchaspossible.Obtainandmaintainpreventivemedicinemedicalequipmentsets.TraintomaintaintechnicalproficiencyonmissionessentialtasksandthesustainmentofSoldierreadinessandsurvivability.Oncedeploymentordersarereceived,preventivemedicinecanassistplannersinthemedicalintelligencepreparationofthebattlefield,conductinformationbriefstokeyleadersandSoldiersonpreventivemedicinemeasurestocountertheanticipatedmedicalthreat,andensurespecificmeasuressuchasuniformpermetherintreatmentarefullyaccomplished.TheESEOhasaccesstoawealthofmedicallysignificantinformationthroughtheUSACHPPMDeploymentEnvironmentalSurveillanceProgramandGlobalThreatAssessmentProgramaswellastheArmedForcesMedicalIntelligenceCentertoaidintheriskmanagementprocess.FIELDSANITATIONBasicfieldsanitationconstitutesthemostimmediaterequirementforBCTpreventivemedicinetopreventacuteoutbreaksofdisease.Soldiersatalllevelsareresponsibleforimplementingpreventivemedicinemeasuresandeachcompanyissupplementedbyafieldsanitationteam.Onpaper,the2-memberFSTiscertifiedandequippedtosupervisetheconstructionofpreventivemedicinedevices,monitorhand-washing,testtheunitwatersupply,ensurefoodisstoredproperly,controlarthropodsandrodents,ensuretheproperdisposaloftrash,andrequestpreventivemedicinesupportforproblemsbeyondtheircapabilities.TheauthorsobservedvariableFSTeffectivenessthroughoutthebrigades.AdequatenumbersofSoldiersreceiveda40-hourfieldsanitationteamtrainingcoursesponsoredbythemultiplepreventivemedicineunitsonFortLewispriortodeployment.Forthemostpart,however,thesetrainedSoldierswerenotfullyutilizedforpreventivemedicineoversight.In Deeppitlatrine,EuphratesRiverValley

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38ArmyMedicalDepartmentJournalsomecases,whenquestionedinthefield,companieswereunabletoidentifytheirFSTmembers.Additionally,FSTmemberswerenotalwaysavailablewhenneededduetoinjuries,leaverotations,orcompanyoperationsfrommultiplelocations.InplaceofactiveFSTs,medicsfromthebattalionaidstationsoftentookinitiativeandservedaspointsofcontactforfieldsanitation.AnotherchallengewasmaintainingaccessibilityofunitFSTsupplieswhichwouldbestoredsomewhereinaluminumchests.Accordingly,thepreventivemedicinesectionreceivedfrequentrequestsforbasicsuppliessuchasflystripsandmousetraps.FSTsuppliesareClassIIorClassIXitems,andunitsshouldbedirectedtoobtainthemthroughcompanysupplychains.TheESEOcanprovideassistance,butshouldnotbeexpectedtoactasasupplyofficerforFSTs.ThelifesupportservicesprovidedbycontractorsonthemajorFOBscontributedtoasenseofcomplacencyregardingsanitationduties.However,eveninsucharelativelycomfortableFOBenvironment,FSTswereneededtoinspectwatertanks,controlmiceandflies,andensureSoldierswereusingthestandardmilitarytopicalclothinginsectrepellent,amongotherduties.ThetruevalueoftheFSTbecameapparenttounitsmovedtoexpedientoutposts,whetherintheopendesertorurbanslums.Withthelossofallexternalsupport,essentialtasksnowincludedtheconstructionandmaintenanceoffieldwastedisposaldevicesandclosemonitoringpersonnelhygiene.MostSoldiershadminimalhands-onfamiliaritywiththeoperationofsuchdevicesduetorestrictionsagainstdiggingandburningintrainingareas.Commonmistakesincludedlackofmaintenanceorfailuretocoverwastewithdirt,airgapsinlatrinesthatallowedfilthfliestobreed,lackofhand-washingdevicesateachsite,andthelocationofgarbageburnpitsincloseproximitytoorupwindoflivingareas.OCCUPATIONALANDENVIRONMENTALHEALTHSURVEILLANCELevelIIIpreventivemedicinedetachmentsmaytaketheleadingroleincollectingoccupationalandenvironmentalhealthsurveillance(OEHS)samples,butbrigadepreventivemedicineshouldassumethatresponsibilitywhenoperatinginremotelocationsorwhenresourcesarelimited.Thesewater,soil,andairsamplesareneededtofulfilldirectedrequirementstodocumentenvironmentalhazardswhereverSoldiersmaybeexposed.Thesamplesalsoprovidedatafordetailedlong-termhealthassessmentstothecommand,althoughresultswillnotbeimmediatelyavailable.TheBCTpreventivemedicinemustcontendwiththedifficultiesofbalancingtimetodevelopandimplementcomprehensivesamplingplanswithimmediatesanitationconcerns,andfindingwaystoshipsamplestoGermanyortheUSinatimelymanner.WhereasstandardfieldsanitationandhygienearetaskscommontoallSoldiersforwhichthepreventivemedicinesectionprovidesoversightandrecommendations,theOEHSmissionrequiresspecifictechnicalskillstoleveragethesophisticatedlaboratoriesavailableforvaliddatacollectionandanalysis.BASECAMPASSESSMENTSThepreventivemedicinesectionservesastheeyesoftheBCTsurgeonandchainofcommandfordiseaseandnonbattleinjuryissuesacrosstheareaofoperations.TheESEOfunctionsasamedicalscoutinthesensethatheorsheistheforwardpreventivemedicineassetandcananticipate,recognize,andprioritizehealthhazardsfrommultiplelocationsandbattlepositions.Thebasecampassessmentisthereportingmechanismforsummarizingfindingsfrompreventivemedicineinspections.Theexactformatsvaried,somewereuptoadozenpageslong,butthechecklistsensuredallareasofconcernwereevaluated.Thekeyareasoffocusalwaysincludedfood,water,andpestcontrol.AGuidetoBrigade-LevelPreventiveMedicine:StrykerBrigadeExperienceinOperationIraqiFreedomII&III ThecollectionofOEHSwatersamplesatFOBMarez

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AprilJune200739Foodservicefacilitiesrangedfromlarge,contractedkitchenstomobilekitchentrailers.ThecontractedfacilitiesgenerallymaintainedgoodpracticesoncetrainedtotheArmystandard,aslongastheywereregularlyinspected.Communicationcouldbedifficultwithstaffscomprisedofthird-countrynationals,butthegeneralmanagersspokeEnglish.OneofthebiggestproblemsencounteredwastheabundanceofforeignvendorssellingproductsfromnonapprovedfoodsourcestoSoldiersontheFOBs.Throughinsistencebypreventivemedicineandveterinarypersonnel,FOBleaderseventuallyplacedthesesitesoff-limitstoSoldiers.Thischangetookconsiderableeffortsincethevendorshadwell-establishedrelationshipsonthebasesandenjoyedpopularityamongSoldiersseekingachangefromthemesshallandlackinganyfamiliarfastfoodsourcesintheregion.Inadditiontoviolatingtheatermedicalpolicyforunapprovedfoodsources,thecooksatthesefoodstandsandrestaurantswereunaccustomedtoourfoodhandlingrequirementsandrequiredconsiderableoversight.TheseestablishmentsincreasedthevulnerabilityofourSoldiersduetolackofcontroloverthefoodsupplychainandplacedalargedemandonpreventivemedicine.Bottledwaterwasusedfordrinking,withbulktreatedwaterusedforsuchpurposesascookingandhygiene.Themajorityofthetreatedwatercamefromcontractedreverseosmosiswaterpurificationunits(ROWPUs),however,ArmyROWPUswereusedonasmallscale.Theinitialsetupofthecontractedunitsrequiredheavypreventivemedicineoversight.Assignedoperatorslackedexperience,theItalian-designedunitswerenotconfiguredforpostchlorination,andwatertestingsupplieswerelacking.Inadditiontoroutinewaterqualitychecks,preventivemedicineshouldmonitorhowthewaterisdistributedtoensureuntreatedwaterisnotplacedincontainersmarkedpotable,andensurethatwatertrucksaresecuredandonlyusedtotransportwater.Whetherforwaterorfood,theESEOshouldmaintaincontactwiththegovernmentcontractingofficerrepresentativetoreportanyfailuresofcontractorstomeetArmystandardsortorecognizepositiveefforts.InsectsandrodentsareubiquitousinnorthernIraq.Differentnuisancepestsseemedtoemergewitheachchangeofseason.Filthflies,sandflies,mosquitoes,rats,andferaldogsandcatswereallcauseforhealthconcernsandrequiredpestcontrolmeasures.Thediseasevectorpotentialofthesecommonpestsincreasedduetoconditionsofpoorsanitationandimproperwastedisposal.Pestcontrolwasexceedinglydifficultatbaseswithinoronthefringeofurbanareasduetonearbyopensewage,trashpiles,andstandingwater(seerelatedarticle,page46).However,thefilthfliesevensurfacedascampfollowersatpreviouslyuninhabitedareaswithlessthanperfectsanitation.Cutaneousleishmaniasisbecamethemostsignificantinsect-bornediseasewefacedintermsofprevalenceandpotentialeffectonthemission.Whereinfectionrateswerehigh,suchastheareaaroundTalAfar,preventivemedicineimplementedmeasurestoeducateSoldiersonavoidingsandflybites,reducetheanimalreservoirs(intensiverodentdestruction),andcontrolthesandflypopulationincoordinationwithcontractedpestcontrolwhereavailable.CONCLUSIONPreventivemedicinepersonnelintheBCTcarryauniqueskillsetandhavemanyvariedresponsibilitieswhichmaynotbewidelyunderstood.Whenproperlyemployed,thepreventivemedicinesectioncanhaveasignificantimpactonthehealthandreadinessoftheforce,helpingtoensurethatSoldiersareavailablewhenandwheretheyareneededmost.CommandemphasisenablestheESEOtobeeffective,givingthepreventivemedicinesectionthetimeitneedstocompleteitssurveysandidentifyproblemsbeforetheyimpacttheSoldier.Thehealthhazardsandprioritiesinthecombatenvironmentcontinuetochange,requiringapreventivemedicinesectionthatisagileandadaptiveliketheSoldiersitsupports.InadditiontounitfieldsanitationandOEHSduties,demandisgrowingforpreventivemedicinesupportofcivilaffairsandsecurityforcetrainingmissions.AllofthesefactorsdictatethattheESEOmustcommunicateextensivelywithtechnicalandcommandchainstoensureprovisionofthebestservicetosafeguardthehealthofallSoldiersincontingencyoperations.REFERENCES 1.FieldManual3-90.6:TheBrigadeCombatTeam.Washington,DC:USDeptoftheArmy;August2006.2.DAPamphlet40-11:MedicalServices:PreventiveMedicine.Washington,DC:USDeptoftheArmy;July22,2005.

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40ArmyMedicalDepartmentJournalAGuidetoBrigade-LevelPreventiveMedicine:StrykerBrigadeExperienceinOperationIraqiFreedomII&III3.ArmyRegulation40-5:MedicalServices:PreventiveMedicine.Washington,DC:USDeptoftheArmy;July22,2005.4.FieldManual4-02.17:PreventiveMedicineServices.Washington,DC:USDeptoftheArmy;28August2000.AUTHORS CPTLewandowskiisChief,EnvironmentalHealth,DewittHealthCareNetwork,FortBelvoir,Virginia.PreviouslyhewasBrigadeEnvironmentalScienceOfficer,1/25SBCT,FortLewis,Washington.CPTFaulkenberryisChief,FieldPreventiveMedicineDivision,USACHPPM-West,FortLewis,Washington.PreviouslyhewasOfficerinChargeofPreventiveMedicineforthe3/2SBCTduringitsinauguraldeploymenttoIraq.

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AprilJune200741INTRODUCTIONCurrently,3typesofmedicaldetachment(preventivemedicine)TablesofOrganizationandEquipmentexistinthecombathealthservicesupportforcestructure.Twotypes,sanitationandentomology,weredevelopedinsupportofMedicalForce2000(MF2K)andconsistof10personnelandequipment.ThethirdwillreplacethoseMF2Ktypesandconsistsof13personnelandequipmentundertheMedicalReengineeringInitiativedesignedtosupportcombathealthservicesupporttotheForceXXIArmy.2AsdelineatedbytheUSArmyCenterforHealthPromotionandPreventiveMedicine(USACHPPM)TechnicalGuide2483anddiscussedbySamesetal,4theunitresponsibilitiesandscopeofessentialservicesrequiredofapreventivemedicinemedicaldetachmenttomaintainandsustainahealthyforceincludethefollowing:Provideassistanceinthecontrolofarthropod-androdent-bornediseases,includingtechnicalconsultation,entomologicalsurveysand/orinvestigations,andreinforcementoftheunitsorganicpestmanagementcapabilities.Provideassistanceinthecontrolofwaterbornediseasesbymonitoringwaterquality.Provideassistanceinthecontroloffoodbornediseasesbymonitoringfoodserviceoperationsandprovideguidancetocommanders.(Theactualfunctionofsafetyandqualityassurancefoodinspectionisaveterinaryresponsibility.)Providepolicyguidanceandmonitoringcomplianceforimmunization,chemoprophylaxis,antidotes,andpretreatmentactivitiesandbarriercreamuse.MeasuringEffectivenessofDeployedMedicalDetachmentsLTCSonyaS.Schleich,MS,USAMAJMarkC.Carder,MS,USA ABSTRACTTheArmyMedicalDepartments(AMEDD)effortstoprovideon-targetcombathealthandcombathealthservicesupporttotheWarfightercontinuetoevolve.Withintheframeworkofmodularizingtheforce,TheAMEDDintegratedthemedicalbattalion(areasupport),medicalbattalion(evacuation),andmedicallogisticsbattalionintoasinglemultifunctionalmedicalbattalion(MMB),approvedbyHeadquarters,DepartmentoftheArmy,tosupporttheforcecommanderontheground.1In2005,the61stMMB(Provisional),thefirstofitstype,deployedinsupportofOperationIraqiFreedom(OIF)05-07toprovidelevelsIandIIareamedicalsupport,groundevacuation,dental,optometry,combatandoperationalstresscontrol,veterinaryservices,andpreventivemedicine.WhiledeployedduringOIF05-07,the61stMMBcommanderemployed5preventivemedicinemedicaldetachmentsacrosstheentireIraqiTheaterofOperations:the898thMedicalDetachment,485thMedicalDetachment,255thMedicalDetachment,223rdMedicalDetachment,and903rdMedicalDetachment.ThenumberofmedicaldetachmentsassignedtoanMMBissituationalandbasedupontheoperationalrequirementsofthecombatantcommanderontheground.The61stMMBcommanderfacedauniquechallengeinevaluatingmissionsuccessfortheindividualmedicaldetachments,aseachpossessedslightlydifferentcapabilitiesaswellasnumberanddiversityofinspectionscoveredwithintheirrespectiveareaofresponsibility.Thisarticledescribesanextensivematrix,developedbythemedicaldetachmentcommanders,tomeasuremissionsuccessandprovideausefultoolfortheMMBcommander.

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42ArmyMedicalDepartmentJournalProvideassistanceandsubjectmatterexpertiseinthecontrolofexcessiveoccupationalandenvironmentalhealth(OEH)exposurestosuchhazardsasnoise,toxicindustrialmaterials,andclimaticextremes.ProvideassistancetocommandsurgeonsintheevaluationofElementsofthemedicalthreat,Risktotheforceassociatedwithidentifiedelementsofthemedicalthreat,andIntegrationofthemedicalthreatintoplanningforandexecutingforcehealthprotectionoperations.EstablishamedicalandOEHsurveillancesystemwhichencompassespredeploymentmedicalscreening(developamedicalbaseline),deploymentandsurveillancewhileintheoperationalarea,medicalscreeningpriortoredeployment,andfollow-upmedicalassessmentsuponreturntohomestation.Educatetroopsindiseaseandnonbattleinjurypreventionmeasures,includingthosemeasuresusedtoreducerisksfromchemical,biological,radiological,andnuclearagents/weapons.Trainunitfieldsanitationteams.Providetechnicalconsultationonselectionanddevelopmentofbivouacsites,cantonmentareas,refugeecamps,andenemyprisonerofwar/detaineecompounds.Conductfieldwatervulnerabilityassessments.Provideprofessionalandtechnicaladvicetocommandersatalllevelsonmeasurestoreducenoneffectivenessfromdiseaseandnonbattleinjury.Reportdeploymenthealthsurveillanceandreadinessstatisticsandenvironmentalhealthdata,asrequired.Surveyoperationalenvironmentstodetectandidentifyhealthhazardsandformulatemeansforminimizingtheireffects.Investigatediseaseoutbreaksandrecommendcontrolmeasures.Provideassistanceinreducingnoisehazardsinrestandrecuperationareastononstressfullevels.Thebroadscopeofresponsibilitiespresentedachallengeforeachindividualmedicaldetachmenttomeasuremissionsuccessandpromptedthedevelopmentofthemedicaldetachmentpreventivemedicinematrix.DEVELOPMENTThe5commandersofthe61stMMBpreventivemedicinemedicaldetachmentsreviewedseveraldraftmatrices.Thedraftsincludedlistsofallperformedinspectionsandconsultationsandtheassignmentofweightedvaluestospecifictasks.Theassignmentofweightedvaluesandtotalcompletedinspectionswerequicklyrecognizedasinaccuratemetricsbecauseoffluctuationsinmissionset,numberofinspectionsbasedonthenumberoffacilities,consultations,etc,withineachdetachmentsareaofresponsibility.Ahypotheticalexample:DetachmentAhas20Army/AirForceExchangeServicefoodserviceestablishmentstoinspectwithinitsareaofresponsibilitypermonth,whileDetachmentBhas10.AmeasurementofDetachmentAagainstDetachmentBbasedonthenumberofinspectionsperformedisnotinformative.Therefore,theinitialpreventivemedicineweeklyreportdevelopedbythe30thMedicalBrigadeSanitaryEngineerwasmodifiedandexpandedsignificantlytofullycaptureandmeasureweeklymissionsuccessandtimelinessofcompletion.ThepreventivemedicinematrixwasdevelopedinaspreadsheetformatusingMicrosoftExcel.Thefirsttableinthepreventivemedicinematrixworkbookisasummationspreadsheetthatprovidesanoverviewspecifictothereportingpreventivemedicinedetachment.Thefirstpageofthepreventivemedicinematrixworkbookcontainsunitinformation:personnelstatus;logisticstatusrelativetomissionessentialequipment;alistofsupportedbasecamps,forwardoperatingbases,andcontingencyoperatingbases;thedatelastinspected;thenumberofroutinepreventivemedicineinspections;andoccupationalandenvironmentalhealthsurveillance(OEHS)anddeployedenvironmentalsurveillanceprogram(DESP)inspections.Theoverallpreventivemedicineriskassessmentisbasedon6derivativetypeinspectionswhichareincludedwithintheroutinepreventivemedicineinspections.TheoverallOEHSriskassessmentisbasedon2derivativetypeinspectionswhichfallundertheOEHSandDESPMeasuringEffectivenessofDeployedMedicalDetachments

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AprilJune200743inspections.Theoverallriskassessmentsarerankedbasedonthenumberandfrequencyofsatisfactoryandunsatisfactoryinspections.Theresultantactionlevelsaredepictedbythecolorsgreen,amber,andred,asillustratedinFigure1.Thecolorgreenreflectsallsatisfactoryratings,amberrepresentsminordeficiencies,andredisusedforanywatersamplepositiveforbacteriological/chemicalcontaminants,anyhealth/environmentalissuethatposesanimmediateornear-termimminenthealththreattopersonnel,orafaileddiningfacilityatthatparticularbasecamporforwardoperatingbase.Theremainderofthesummationsheetincludesinformationregardingdiseaseoutbreakinvestigations,trainingprovided,andfutureoperations.ThesubsequentspreadsheetswithinthepreventivemedicinematrixworkbookallowtheMMB Figure2.ExamplefromPreventiveMedicineMatrixWorkbooksectionfortheWasteManagementcategorytoillustratederivativeinspectionsthatcomprisethenumberreportedonthesummationsheet.*MultinationalForceWest.Thereportsheetisforinspectionsatcampsandfacilitieswithinthatareaofresponsibility.The485thMedicalDetachmentwasresponsibleforinspectionswithinMNF-W.PreventiveMaintenanceChecksandServices. H a z a r d o u s M a t e r i a l H a z a r d o u s W a s t e R e g u l a t e d M e d i c a l W a s t e W a s t e W a t e r E m a i l C o n s u l t s T e l e p h o n e C o n s u l t s W a l k i n C o n s u l t s E q u i p m e n t P M C S T o t a l W a s t e I n s p e c t i o n s T o t a l C o n s u l t s & P M C S G r a n d F O B o r C a m p T o t a l s ForwardOperatingBaseorCampAsNeededAsNeededAsNeededAsNeededAsNeededAsNeededAsNeededAsNeededMonthlyMonthlyMonthly MNF-W* Camp111202 Camp2000 Camp3111213 MNF-W*Camp16/7/06BCT-1555/27/06000020 000 Camp26/15/06MAW2/27/06000000 000 Camp36/15/06MAW000030 000 F o o d S a n i t a t i o n G e n e r a l S a n i t a t i o n F i e l d W a t e r T e s t s B o t t l e d W a t e r T e s t s W a s t e D i s p o s a l P e s t M a n a g e m e n t S u r v e i l l a n c e & C o n t r o l O v e r a l l P M R i s k A s s e s s m e n t O c c u p a t i o n a l H e a l t h S t u d i e s E n v i r o n m e n t a l o r W o r k p l a c e N o i s e D E S P O v e r a l l O E H S R i s k A s s e s s m e n tOEHSIncidentResponse&DESPRoutinePVNTMEDInspectionsBaseCamporForwardOperatingBaseStatus(AnyAmberorRedReadinessCategoriesRequireComments)BaseCamporFOB D a t e o f l a s t F O B v i s i t b y r e p o r t i n g u n i t E c h e l o n I I S u p p o r t U n i t D a t e o f l a s t k n o w n F O B v i s i t b y E c h e l o n I I u n i t Figure1.ExampleofsectionfromPreventiveMedicineMatrixWorkbooksummationsheetshowingcategoriesofpreventivemedicineinspectionsandriskassessments.*MultinationalForceWest.Thesummationsheetisforinspectionsatcampswithinthatareaofresponsibility.The485thMedicalDetachmentwasresponsibleforinspectionswithinMNF-W.BrigadeCombatTeam155MarineAircraftWing.

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44ArmyMedicalDepartmentJournalcommandertoexaminethespecificdatafromthederivativeinspectionswhicharepresentedinthesummationspreadsheet.Eachofthederivativeinspectiontypesarefurtherbrokendownintoseveralcategories,eachofwhichhasacolumnonthespreadsheet.Theinspectiontypesandnumberofcategories(inparentheses)includeFood(10),General(12),Water(13),WasteManagement(8),Vector(21),Epidemiology(8),IndustrialHygiene(8),DESP(10),Consultations(3),Training(10),andMovement(3).Figure2isanexampleofthederivativeinspectionsheetforwastemanagement.CAPABILITIESThemedicaldetachmentpreventivemedicinematrixisatoolformeasuringmissionsuccessofanindividualunitandprovidestheMMBcommanderwithasnapshotofeachunitsworkloadandaccomplishment.Inaddition,thedatacontainedineachunitsmatrixissubmittedtothenexthigherechelonofthepreventivemedicinesupportstaffwithinthemedicalchainofcommand,oftentimesamedicalbrigadewhichwillultimatelyprovidedatatotheUSArmyCenterforHealthPromotionandPreventiveMedicine.Membersofthebrigadepreventivemedicinestaffusetheinformationtoidentifytrends,providerecommendations,andprovideinformationtothetheatersurgeonaswarranted.Thebenefitsofthisreportingmatrixinclude:Consolidationofreporteddata.Immediateaccessibilitytodetailedinformation,anumericalpresentationoftheoverallpreventivemedicinemissionset.AnalysistoolfortheMMBcommanderwhichcanbeusedonamonthly,quarterly,biannual,ordeployedbasistotrackworkloadtrends.MissionsuccessandachievedperformanceismeasuredagainsttheindividualunititselfwithrespecttopreventivemedicinecoverageandAOR.Futureimprovementstoenhancethismatrixmayincluderecordingtheamountofhours/manpowerassociatedwitheachmissioninadditiontodesigningappropriateweightedvaluesthatreflecttheimpactontheatriskpopulation.Somemayarguethatthisassessmentmatrixissimilartothefoxguardingthehenhouse,butdiseaseandnonbattleinjuriesareasureindicatorofthesuccess,orlackthereof,aunitachievesinitspreventivemedicinemission.CONCLUSIONSThepreventivemedicinematrixprovedtobeanexcellenttool,notonlyforthe61stMMBcommandertomeasuremissionsuccess,butalsoforusebyeachindividualmedicaldetachmentcommanderinsupportofOIF05-07.Withappropriatemodifications,thematrixcanbetailoredtootherdeployments,contingencies,andgarrisonenvironmentstoreflectthemissionsetofanindividualunit.ThepreventivemedicinereportingmatrixisunderevaluationforinclusionintheArmysnewMMBFieldManual.ACKNOWLEDGEMENT Wethankthefollowingdedicatedprofessionalsfortheirassistanceinthepreparationofthisarticle:LTCScottWrightforprovidingtheinitialbaselinepreventivemedicinereportingformat.LTCWilliamB.Grimes,Commander,61stMMBforcriticalreviewandeditorialcomment.ForassistancewiththeinitialmatrixformatduringtheOIF05-07rotation:MAJJamesT.Flanagan,Jr,Commander,223rdMedicalDetachmentCPTDarrylA.Forest,Commander,255thMedicalDetachmentCPTCharlesB.Raymond,Commander,903rdMedicalDetachmentMAJJamesJ.Meckel,Commander,898thMedicalDetachmentCPTLewisLong,ExecutiveOfficer,223rdMedicalDetachmentMeasuringEffectivenessofDeployedMedicalDetachments

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AprilJune200745REFERENCES1.AcademyofHealthSciencesUpdate,VolumeFY06,Issue2,February2006.Availableat:http://www.cs.amedd.army.mil.2.FieldManual4-02.17:PreventiveMedicineServices.Washington,DC:USDeptoftheArmy;28August2000.3.TechnicalGuide248,GuideforDeployedPreventiveMedicinePersonnelonHealthRiskAssessment.AberdeenProvingGround,MD:USArmyCenterforHealthPromotionandPreventiveMedicine.2001.Availableat:http://chppm-www.apgea.army.mil/documents/tg/techguid/ttg248.pdf.4.SamesWJ,DelkTC,LyonsPJ.Fieldpreventivemedicine:challengesforthefuture.ArmyMedDeptJ.AprilJune2006:40-45.AUTHORS LTCSchleichistheExecutiveOfficerandChief,EntomologicalSciencesDivision,USACHPPM-West,FortLewis,Washington.Previously,shewastheCommanderofthe898thMedicalDetachment,Baghdad,Iraq.MAJCarderistheCommanderofthe485thMedicalDetachment,FortPolk,Louisiana.Previously,MAJCardersimultaneouslyservedasboththe485thMedicalDetachmentCommanderandwastheEnvironmentalScienceOfficerforthe61stMMB,Balad,Iraq. Crestofthe61stMultifunctionalMedicalBattalion

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46ArmyMedicalDepartmentJournalTheprimaryfocusofvectorcontroloperationsinsupportofOperationIraqiFreedomisprotectionoftheWarfighterandgovernmentrealpropertyandmateriel.Vectorcontrolresponsibilitiesfocusonthesearchforandsuppressionofarthropodandrodentbornediseasevectors,entomologicalsurveysandinvestigations,andpesticideapplicationusingmilitaryandcontractorpestmanagementcapabilities.TounderstandthecomplexityofvectorcontroloperationsinIraq,onemustunderstandthelevelsofArmypreventivemedicinesupport.Thefirstlevelisthecompany-sizedunitsfieldsanitationteam,composedof2Soldiersthathaveattendeda40-hourteamtrainingcourseonallaspectsofbasicfieldsanitation.Thissmallteamhasverylimitedsurveillanceandcontrolcapabilities,andonlyprovidessupportwithinacompanysimmediatearea.Thesecondlevelisthebrigadeanddivisionsorganicpreventivemedicinepersonnelandequipment.Brigadecombatteams(BCT)arestaffedwithanEnvironmentalScienceandEngineeringOfficer(ESEO)andafewPreventiveMedicineSpecialists.ThissmallteamsupportsthebasecampsoccupiedbytheBCTssubordinatecompanies.Theyhavelimitedvectorsurveillanceandcontrolcapabilities,butareabletoidentifyproblemsandrequestassistancewhennecessary.DivisionlevelpreventivemedicinehasaseniorESEOwhoprovidesassistancetotheBCTESEOsandcoordinateswithothernondivisionpreventivemedicineassetsintheater.Thethirdlevelisthemedicaldetachmentsthatprovideareasupportwithinaspecifiedarea(eg,northernIraq)andreporttothemedicaltaskforce.Themedicaldetachmentshaveamilitaryentomologistandmorevectorsurveillanceandcontrolcapabilities.Theentomologistprovidesadviceandrecommendationsonallaspectsofpestsurveillanceandcontrolmeasureswithintheirareaofresponsibility.Inaddition,thereisaseniorentomologistlocatedatthemedicaltaskforceheadquarterswhoprovidesguidanceonvectorsurveillanceandcontrolwithinthetheater,andcoordinateseffortswhenneeded.Addingtothecomplexityofthesituationistherealitythatvectorcontrolisonlyoneaspectoftheoverallpreventivemedicinemission.Preventivemedicinepersonnelatalllevelsarealsoresponsiblefortheinspectionoffoodservicefacilities,includingAAFESfoodconcessions,monitoringwatersupplies,testingbottledwater,vectorsurveillance,noisesurveillance,sanitationinspections,investigationsoffoodorwaterborneillnessoutbreak,andtheprovisionofotherindustrialhygiene,occupational,orenvironmentalhealthsurveillanceactivitiesasrequired.Initially,preventivemedicinepersonnelweretheonlyonesconductingbothpestsurveillanceandcontrolmeasures.Apestcontrolcontractorwashiredasthetheatermatured.Pestcontrolactivitiesarenowperformedatmostcampsbyeitherafullorpart-timeDoDorstatecertifiedvectorcontrolcontractoremployee.Thecontractorprovidesallthepesticides,applicationequipment,andcertifiedpersonnelinaccordancewiththerequirementsspecifiedinthecontract.Theirpestcontrollersworkinclosecoordinationwiththeirlocalpreventivemedicinepersonneltoidentifyproblems,conductsurveillance,lookforintegratedpestmanagementoptions,andimplementappropriatecontrolmeasures.Ascampshavegrown,sohavevectorsurveillanceandcontrolefforts.Inmostcamps,personnelarenowsleeping,eating,andworkinginclimatecontrolledbuildings,therebyreducingthenumberofarthropodbites.Controleffortshaveexpandedtomeetthenewdemandsofthemorepermanentfacilityenvironment,ChallengesofEffectiveVectorControl:OperationIraqiFreedom0507LTCJamieA.Blow,MS,USACPTDarrylA.Forest,MS,USACPTLewisS.Long,MS,USAMAJJamesJ.Meckel,MS,USACPTCharlesB.Raymond,MS,USAMAJMarkC.Carder,MS,USA

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AprilJune200747andtheexpectationsofthedeployedpersonnel.Flyandrodentcontrolandnuisancepestissues(ants,spiders,etc)havebecomelargerissuesasthecampshavebecomesemipermanentandpersonnelarelesstolerantofpests.Surveillanceformosquitoesandsandfliescontinuestobeanimportantmissionduetothethreatofmalariaandleishmaniasistransmission.Theuseofultralowvolume(ULV)applicationsofpesticidescontinuestobeaprimarycontrolmethodformosquitoesandsandflies,althoughmosquitolarvacidesandapplicationofresidualpesticidestorestingsitesarealsoused.Also,theefficacyofonetypeofcommercialinsecttrapwasevaluatedinsomelocations.Feralanimalsareaconstantprobleminourcamps,andcontrol,includingbirdcontrol,continuestobeanongoingissue.Asweuseexistingstructures,thebirdsresidentinthemarecausingconcernsaboutpersonnelhealth.MOSQUITOANDSANDFLYSURVEILLANCEATVICTORYBASECOMPLEXVictoryBaseComplex(VBC)iscomposedofseveralbasecampslocatedaroundtheperimeteroftheBaghdadInternationalAirport.The898thMedicalDetachmentwasresponsiblefordevisingandsustainingoneofthelargestandmostcomprehensivesurveillanceinitiativestodateduringadeploymentoperation.Undertheguidanceoftheircommander,theSoldiersoftheunitdiligentlyset,maintained,andretrieved30CentersforDiseaseControlandPreventionlighttrapswithintheperimeteroftheVBC.Over10,700specimenswerecollected,identified,andprocessedfrom1Aprilthrough30September2006.Alltrapcatchesweresorted,andmosquitoesandsandfliesidentifiedtogenera.TheresultingdistributionbygenusisillustratedinFigure1.Eachtrapcatchforasinglenightwashandledasadiscretesetthroughoutthecollection,processing,shipment,andpathogendetectionprocess.Eachtrapcatchwassortedintomalemosquitoes,femalemosquitoes,andsandflies.Sandflies,bothmaleandfemale,fromasingletrapcatchweresortedintopoolsofnogreaterthan100,eachofwhichwasthenplacedinavialwithapproximately1mlof100%ethylalcohol.Femalemosquitoesfromasingletrapcatchweresortedtogenus(ie,Anopheles,Culex,Aedes)andplacedin2mlvialswithnopreservative(nomorethan10specimenspervial).AllsampleswerelabeledandprocessedforpathogentestinginaccordancewiththeUSArmyCenterforHealthPromotionandPreventiveMedicine(USACHPPM)-NorthandMultinationalCoalition-Iraqestablishedprotocols,thenshippedtotheUSACHPPM-Northformalaria,leishmaniasis,andWestNileviruspathogendetection.Remarkably,ofthe10,700specimenstested,therewerenopositiveidentifications.The898thMedicalDetachmentfosteredacloseworkingrelationshipwiththeVBCvectorcontrolpersonnelwhileconductingentomologicaloperations.Theinitialactionthresholdwasdeterminedtobe25mosquitoesand/or15sandfliesinasinglelighttrapin Other(4%)Sergentomyia(6%)Phlebotomus(23%) *Aedes(29%)*Culex(38%)Figure1.Breakdownofthe10,700+mosquitoesandsandfliescaughtinlighttrapsatVictoryBaseComplex,Iraqbetween1Apriland30September2006.*mosquitoessandfliesmosquitoes:Uranotaenia(4),Culiseta(194),Anopheles(17) Lighttrapswereemplacedinthelateafternoonwithsensorssettoactivateatduskforroutinesurveillance.

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48ArmyMedicalDepartmentJournalasinglenight.Thisinitialactionthresholdwasbasedonlimitedhistoricalinformationandpersonalknowledgeofboththeentomologistandvectorcontrolpersonnel.Thethresholdcouldbesubsequentlyadjustedhigherorlowerbasedontrapcollectionnumbers,collectionofsandfliesormosquitoesthattestedpositiveformalaria,leishmaniasis,orWestNilevirus,andcustomercomplaints.Whentheactionthresholdestablishedforatrapsitewasreached,aplanwasdevisedincoordinationwithvectorcontrolsupervisorsinvolvedresidualpesticideapplicationtopotentialrestingsitesandULVapplicationtotheareaofthetrapsitethatrequiredtreatment.Typically,afteralatenightULVapplication,thetrapnumberswerenoticeablylowerforthenextweek.Astheseasonprogressed,temperaturesincreasedandraintaperedoff,withresultingdecreasesinmosquitotrapnumbersandincreasesinsandflypopulations,asanticipated.Figure2depictsthetotalnumbersofmosquitoesandsandflies,percollection,fromtrapslocatedaroundVBCfromthestartofthemosquitoseasoninearlyApriluntiltheendoftheseasontheendofOctober.ThegreatestchallengeofoperatingacomprehensivesurveillancesystemonVBCwasbalancingthemanpowerrequirementsofthedailymissionofsanitation,environmentalandvectorsurveillancewiththeneedtorespondpromptlytoemergingsituations.Thepreventivemedicinespecialistsalwaysmanagedtobalanceallthemissionswhileprovidingthebestsupportpossibletopersonnel.Thesurveillancedataiscurrentlybeinganalyzedbyindividuallighttraplocation.ThedataamongthelighttraplocationswillbecomparedinanattempttodetermineifthereareindicatorsforspecificareaswithintheVBCwhichmaybepronetoharborarthropodsofmilitaryimportance.MOSQUITOMAGNETSBaladAirbase,alsocalledLogisticSupportArea(LSA)Anaconda,issurroundedbyanirrigationcanalfedbytheTigrisRiver.Althoughthecanalisasteadilyflowingbodyofwater,ithasmanyareasofstagnatedand/orstillpoolswheremanyaquaticplantscangrowupto8feet.Thistalldensevegetationalongtheshoresofthecanalmakeanidealbreedingsiteformanyblood-feedingfliesandislocatedinverycloseproximitytothousandsofdeployedpersonnel.The255thMedicalDetachmenthadthemonumentaltaskofprotectingthebasepersonnelfromthisthreatandworkedcloselywiththesupervisorofthecontractorvectorcontroloperationsonLSAAnaconda.Duetotheextensivebreedinggroundsjustoutsidethebase,theuseofULVpesticideshadbeensubstantialinpreviousyears.InanefforttoreduceULVpesticideapplication,thecontractorpurchasedapproximately50MosquitoMagnets*in2003touseasacontrolmeasure.TheMosquitoMagnetworksbyproducingtheverysamecharacteristics(CO2,heat,moisture)thatamammalianhostwouldemit.Inordertoreproduce,femalemosquitoesmustfindasuitablehosttoobtainabloodmeal.TheyhavefinelytunedsensorsthataidChallengesofEffectiveVectorControl:OperationIraqiFreedom0507 020040060080010001200 M osquitoes SandFlies 25April4May17May6June24July31August28September1May11May25May26June6August15September15October 2April-18April N u m b e r C o l l e c t e dFigure2.ChronologicaldepictionofthenumbersofmosquitoesandsandfliesgatheredfromtrapslocatedaroundtheVictoryBaseComplex,fromthestartofthemosquitoseasoninearlyApriluntiltheendoftheseasoninlateOctober.(2006data) *AmericanBiophysicsCorp,140FrenchtownRoad,NorthKingstown,RhodeIsland02852

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AprilJune200749theminfindingahostbydetectingcarbondioxide,warmth,certainplantchemicals,andsometimesevensweat(moisture)chemicals.1Usingthesesensors,mosquitoesfoundanabundanceofprimebloodsourcesamongallthepersonnellocatedatBaladAirbase.TheMosquitoMagnetproducesCO2byburningpropanegas,whichcontainscarbonandhydrogen,producingcarbondioxideandwatervapor.However,thenewermodelsoftheMosquitoMagnetincorporateaninterestingtwistontheburningprocess.Insteadofaflame,thepropaneisburnedcatalytically,usingthesameideaasthatusedinthecatalyticconverteronacar.Thepropaneflowstothecatalystasetofceramicbeadsoraceramicgridcoatedwithplatinum.Thecatalystconvertsthepropanedirectlytoheat,carbondioxide,andmoisturewithoutactuallyneedingaflame.Theadvantageofthissystemisthatyoucancatalyzeverysmallquantitiesofpropaneoveralongperiodoftimewithouthavingtoworryabouttheflameevergoingout.Inaddition,therearenoworriesaboutothergases,likecarbonmonoxideornitrogenoxides,beingproducedbytheflame.Thelackofaflamealsoreducestheriskoffire.Byitself,theCO2wasfoundtobeinadequate,soacartridgethatcontainseitheroctenol(agenericmoleculethatsimulatesplantchemicals)orLurex*(aproprietarymixturethatsimulatessweatchemicals)wasadded.Thesechemicalsactasstrongattractantsfordifferenttypesofmosquitoes.Lurex-typechemicalsworkbestontheAsiantigermosquitoes,whileoctenolworksbestonmosquitoeswhicharenativetotheUnitedStates.Bymixingthechemicalattractantwiththecarbondioxideandmoisture,thenemittingthewarmmixtureintothesurroundingair,thetrapcreatesaplumeofgasthatmosquitoesfindirresistible.Theywillflyupwindtofollowtheplumetoitssource.Whenthemosquitoesgettothemosquitomagnet,theyencounteravacuumcreatedbyafanandaresuckedintoanetbag,wheretheydehydrateanddie.ThecontractorhadstartedtheMosquitoMagnetcontrolprogramin2004withmixedresults.However,in2005,theyincreasedthenumberofdevicesandimprovedtheplacementbasedon2004data.Thenumberswereincredible;over1.3millionmosquitoesand600,000sandflieswerecaughtbetweenAprilNov2005.In2006,thecontractorandthe255thMedicalDetachmentcontinuedthemosquito/sandflycontrolprogram.First,theyinitiatedanaggressivelarvalcontrolprogramontheinteriorofLSAAnaconda.ThiswasdonebyusingbothAltosidbriquets,Altosidliquid,andmethoprenemosquitodunksinstormdrains,unusedsewerlines,andareasofstandingwater.Additionally,thenumberofMosquitoMagnetswasincreasedinsidethefencelinealongtheperimeterofLSAAnacondaandtheirspacingwasmodifiedsotheywereapproximatelyoneacreapart.Thiswasdoneinanattempttooverlapthemagnetsattractingrangetoensuremaximumcoverage.The2006resultswereoutstanding,approximately1.5millionmosquitoesand800,000sandflieswereWellmark,International,1501E.WoodfieldRoad, Schaumburg,Illinois60173*AmericanBiophysicsCorp,140FrenchtownRoad,North Kingstown,RhodeIsland02852 SomeoftheinsectscapturedbytheMosquitoMagnettrapsemplacedaroundLSAAnaconda. TheMosquitoMagnetusespropanetoproduceCO2andheattoattractinsectvectorswhicharecaughtinthevacuumanddepositedinthecollectionbag.

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50ArmyMedicalDepartmentJournaltrapped,andcomplaintswerealmostnonexistent.Anecdotalevidence*indicatedthatthestrategicallyplacedMosquitoMagnets,inconjunctionwithanaggressivelarvacideprogram,appearedtosignificantlyreducethenumberofblood-feedingdipteraonLSAAnaconda.ULVOPERATIONSTheULVsprayeristheprimaryweaponutilizedtosuppressadultsandflyandmosquitopopulationsinIraq.However,withouttheinsecticide,theULVwouldbeuseless.Pesticidesarehazardousmaterials(HAZMAT)andshippingthemhalfwayaroundtheworldisnotaneasyendeavor.Thefirstmajorcomplicationisthatspecialtrainingandcertificationarerequiredinordertocontainerize,load,andshipthepesticides.TherearespecificrequirementsfordocumentingtheHAZMATbeingshippedwhichincludematerialsafetydatasheets,declarationdocumentation,spillresponseandcontingencyplans,safetyrequirements,andloadplans.Thedocumentationiscomplicatedandthevolumeisstaggering.UnitsarerequiredtohaveHAZMAThandlersandcertifiedpersonnelinordertoexpeditethematerialtransportprocess.However,theprocessisworththeeffortoncetheinsecticidearrivesandvectorsuppressionoperationsbegin.Thesecondmajorcomplicationisthesheervolumeofpesticidesrequiredandthedifferentrestrictionsofshippingclasses.Asabasicplanningfactor,preventivemedicinepersonnelshouldplanfor8weeksofsustainedoperationsbeforeresupply.Thisisthefactorrecommendedifthetheaterofoperationsisnotdevelopedlogistically.Obviously,lessmayberequiredbasedupontheintelligencegatheringfromthebattlespacepriortodeployment.Itshouldalsobenotedthatcertainclassesofinsecticidescannotbeshippedinthesamecontainerduetoreactivity.Anotherfactortoconsideristhatclothing,tools,andfieldgearshouldnotbeshippedwithinsecticides.Thesefactorswillincreasecontainerrequirements,aswellastrackingconsiderationsforthosecontainers.AthirdcomplicatingfactoristhattheleadacidbatteriesrequiredtoruntheULVsprayermostcommonlyusedinIraqbyUSforces,theBeecomist15MPareconsideredHAZMAT.Onceintheater,ULVsprayermaintenanceisrequiredonregularintervalsandwillrequiremorevigilanceandextensiveattentiontodetail.Twoareasofparticularconcernarestaticbuildupandbatterycharging.Inhotdryclimateswhereelectricaldevicesareused,staticelectricitycanbecomeanissueifequipmentisnotproperlygrounded.ThisisespeciallytrueforULVsprayersmountedintrailerswhicharesubsequentlytowedbyHMMWVsduringpestcontroloperations.Attentionmustalsobegiventobatterymaintenanceandcharging.Regularuseofavoltmetertocheckthevehiclealternatoroutputisrecommendedtoensurethevehiclebatteriesarebeingadequatelycharged.AcheckoftheonboardULVsprayerbatterypriortoandafteroperationisalsorecommendedtoensureitisnotdepleted.Finally,environmentalconditionsmustbetakenintoconsideration.Dusty,hot,andwindyoperatingenvironmentsrequirethattheULVsprayersbedustedand/orrinsedaftereachmissiontoensuremaximumequipmentoperatinglife.Althoughthetopicsdiscussedherearenottheresultofanepiphanyandseempainfullyobvious,iftheyarenotfollowed,themissionwillnotbeaccomplished.ThesecommentsarebasedontheexperiencesofseveralpreventivemedicinedetachmentcommanderssincethebeginningofoperationsinIraqin2003.ANIMALCONTROLNotonlydoferalandwildanimalsposethedangerofanimalbitesandpotentialdisease(rabies)transmission,butperhapsmoreimportantlyforSoldiersindeployedenvironments,theycanactasreservoirsforvariousvector-bornediseases(eg,leishmaniasis).Therefore,animalcontrolshouldbepartofanycomprehensivepreventivemedicineplanintendedtoprotectUStroopsandpreservecombatpower.ThecontractordoesthevastmajorityofanimaltrappingoncampsthroughouttheIraqitheaterofoperation,butisprohibited,bycontract,fromeuthanizingcapturedanimals.Whenavailable,USChallengesofEffectiveVectorControl:OperationIraqiFreedom0507 ClarkeMosquitoControl,110E.IrvingParkRoad,Roselle,Illinois60712Highmobilitymultipurposewheeledvehicles *ThevectorcontrolsupervisoratLSAAnacondarelatedthatcomplaintsandrequestsformosquitoand/orsandflycontrolwereaveraging16to18amonthpriortotheMosquitoMagnetcontrolprogram.Oncetheprogramwasinplaceandfullyoperational,thenumberofcomplaintsfellconsiderablyto3or4amonth,andthosewereprimarilyfromtemporaryhousingareasforpersonnelawaitingredeploymentorassignmenttopermanentquarters.

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AprilJune200751militaryveterinarypersonnelperformtherequiredeuthanasia,however,theyarenotpresentonallcampsandthe903rdMedicalDetachmentpersonnelassumedtheeuthanasiamission.Severalformsofeuthanasiawereauthorizedintheaterbasedonguidancefromthetheaterveterinarian.Thepreferredmethodofcontrolwasthroughtheuseofeuthanasiadrugs.Nonveterinarypersonnelreceivedtrainingineuthanasiaproceduresandhandlingandaccountabilityofeuthanasiadrugs.Oncetrainedandapprovedbyaveterinarian,theywereprovidedwithasupplyofketamineandsodiumpentobarbital(whichweretreatedascontrolledsubstances).Intheabsenceofpersonneltrainedinadministeringeuthanasiadrugs,theuseofkineticmeanswasalsoauthorizedandcontinuedtobeusedforlarge,potentiallydangerousanimals,asthatmethodwasjudgedsaferthanattemptingtoholdandclosewiththelargerstrongeranimals.Thesamepersonnelhandledalleuthanasiadutiesduringthedeployment,andwereresponsibleforthehumaneeliminationofnearly200animalsatCampEchoalone.Notallanimalscapturedbythecontractorrequiredeuthanasia.Wildanimals,ifhealthy,weregenerallyreleasedoutsidethecompound.Afterthepresumablyunpleasantexperienceofspendingthenightinacage,andtheappearanceofhumansthefollowingmorning,wildanimalswereseldomrecaptured.Theseincludednativefoxes,sandcats,Africanpygmyhedgehogs,andoccasionallylargebirdssuchasblackfrancolins.Healthyferaldogsandcats,uponfirstcapture,weremarkedbyaspotoforangepaintontheflankortail,andreleasedoutsidethecamp.Ifmarkedanimalswererecapturedasecondorthirdtime,theyweredeemedinveteratepestsand,forthesafetyofcamppersonnel,humanelyeuthanized.Toreducethepotentialspreadofillnessand/orparasitestoeithercamppersonnelornativeanimals,illorunhealthyanimalswereeuthanizeduponinitialcapture.Completecontrolisnotalwaysdesirableforsomespecies.Forexample,intensivecontroleffortsbythecontractorandthe903rdMedicalDetachmentvirtuallyeliminatedtheferalfelinepopulationatCampEcho.Anincreaseinrodentandtheninsnakepopulationsoverthefollowingmonthswasindicatedbycustomercomplaintsandvisualsurveys.Thoughanecdotal,thesituationillustratesthesometimesconfoundingrelationshipsbetweentargetedpestspecies.Presumably,theeliminationofakeypredatorallowedrodentandreptilepopulationstoquicklyincreaseandthelargerrodentpopulationspossiblyattracted(andmaintained)additionalsnakesinthecampperimeter.Consequently,controlmeasuresrelativetothecatpopulationwererelaxed,andthenumberofcatsallowedtoincreasetoaleveldeemedadequatefornaturalrodentcontrol,andsubsequentcontroleffortswereaimedatmaintainingthepopulationatthatarbitrarylevel.BatsdiscoveredinbunkersatCampEchopresentedaspecialproblem.First,althoughthepresenceofbatsinstructuresisgenerallyundesirable,likeferalcats,theseflyingmammalsperformavaluableandbeneficialfunction.Manyspeciesofbatsareinsectivorousandhuntatduskandduringtheeveninghours,whenmost Nativewildanimalsthatwereoccasionallycapturedincludedsmall-to-medium-sizedpredatorssuchasthisfox. Asandcatcommunicatesdispleasureatitstemporarycaptivity.Mostcapturednativewildanimals,includingthiscat,werereleasedoutsideoftheperimeter.

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52ArmyMedicalDepartmentJournalflyingblood-feedinginsectsareactive.Asinglebatcanconsume400to1,200mosquitoesandotherinsectsinanhour.Fewnaturalpredatorsaremoreeffectiveatreducingnight-flyinginsectpopulations.2Also,atleast5speciesarelistedontheIraqRedListasprotectedorthreatenedinIraq:theGreaterHorseshoeBat(Rhinolophusferrumequinum),theMediterraneanHorseshoeBat(R.Euryale),MehelysHorseshoeBat(R.mehelyi),theLong-fingeredBat(Myotiscapaccinii),andtheSindBat(Eptesicusnasutus).Therefore,toconservevaluablepredatorsandavoidthedifficultiesinherentinattemptsbynonexpertstodifferentiatebetweenprotectedandunprotectedspecies,nonlethalcontrolofbatpopulationswaspursued.Themostpractical,andhumane,approachwastoblockavailableopeningsinvacatedbuildingsandbunkersafterthebatsleftfortheirnightlyfeedingforaystopreventtheirreturn.Iftheopeningswereblockedwhilebatswereinside,theywouldstarve,producingenvironmentalhazardsintheformsofcarcassesthataredifficulttorecover.Parasiteswouldthenleaverecently-deceasedbatsandseekthenearestwarm-bodiedhost.Inaddition,thecontractorconstructedbatboxeswhichwereinstalledatsuitablelocationsaroundthecamptoprovidealternativeroostingsites,andpossiblyattractadditionalbats.Whilethereislittlehealthhazardassociatedwithfree-livinghealthybats,manypersonnelexpressedadistinctfearordistasteofbats,particularlyifencounteredinsidelivingandworkingareas.Inaddition,batsarecommonlyassociatedwithrabiesbythegeneralpublic,eventhoughthebestavailableevidenceindicatesthatlessthan1%ofallbatsareinfectedwiththevirus.3Bat-transmittedrabiesisveryrare,lessthanonecaseperyearintheUnitedStates.Publiceducationeffortscanalleviatesomeoftheseconcerns.Animalcontrolisanintegralpartoftheoverallpreventivemedicineresponsibility.Flexibility,adaptability,andthewillingnesstoseethebiggerpicturearekeycomponentsofferalandwildanimalcontrolindeployedsituations.Theoperatingenvironmentmaybeconsiderablydifferentfromwhatpreventivemedicineunitsareaccustomedto(evenfromdeploymenttodeployment),andunexpectedmissionsmaybeincurred.Euthanizationofferalandsometimeswildanimalsisanecessaryifoftenunpalatablemission,and,ifveterinaryunitsarenotavailable,itisamissionthatlogicallyfallsonthepreventivemedicinepersonnel.Thepersonnelthatperformtheeuthanasiashouldbevolunteers(manyfindthistaskabhorrent,objectionable,and/orstressful),andreceivetrainingfromveterinarypersonnelinproperproceduresforhumaneeuthanasia.Therearestrictguidelinesforstorage,accountingforusage,andmonthlyinventoryofanyeuthanizingdrugsmaintainedbypreventivemedicinepersonnel.Ifafirearmisused,additionalammunitionmayberequiredaswellasproperaccountingforexpendedrounds.Finally,itisimportanttokeepinperspectivethefactthatanimalcontrolisnotsynonymouswitheuthanasia.Healthywildanimalsshouldgenerallybereleased(ifpractical),andpreventivemedicinepersonnelshouldeducatethemselvesonanyprotectedwildspeciesintheirareaofoperations.Itmaybepreferabletopermitsomespeciesofferalanimalstoremainatsome(arbitrary)populationlevelinordertohelpcontrolevenlessdesirablepests,aswasthecasewithcatsandbats.BIRDCONTROLAnoftenoverlookedaspectofanimalcontroleffortsduringdeploymentsisbirdcontrol.Birdsposelittleproblemwhententsaretheprimaryformofhousingorworkareasbecauseofthelackofestablishedroosting/feedinghabitats.Birdcontrolproblemsinthesesituationsarenormallylimitedtobirdsfeedingontrash.Asatheatermatures,existinghardstandbuildingsareutilized,bringingwiththemattendantbirdproblems.PigeonsaretheprimarybirdpestinIraq,althoughsparrowsandotherbirdsalsocontributetotheproblem.Pigeonsroostonbuildingledgesandroofs,coatingtheexteriorswithfeces.Duetopoorconstruction,birdscanreadilygainaccesstobuildingattics.Mostrooftopsareflat,providingexcellentroostingsitesforbirds.ForwardOperatingBase(FOB)Spiecherhadoneofthemostsignificantbirdproblemsintheaterduetothelargenumberofdamagedbuildings.Openairwarehouses,hangars,andabandoned/damagedbuildingsprovidedampleroostingsites.Personnelandequipmentstoredinthesebuildingswereoftencontaminatedbyfecesandbotheredbynoisefromthelargepopulations.Exclusionofthebirdsfromthebuildingswasimpossibleduetothenumerousopenings.BuildingrenovationswereoftenlimitedtoChallengesofEffectiveVectorControl:OperationIraqiFreedom0507

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AprilJune200753repairingroomsandceilingstomakethemusable,buttheexteriorstructureswerenotsealedandbirdscontinuedtousethebuildings.The223rdMedicalDetachmentprovidedsupporttocampslocatedinnorthernIraq,anddealtwiththebirdcontrolproblematFOBSpeicherbypersistentlyremovingsuitablehabitat.Thisresultedinthedeclineofthepopulationtosmaller,moremanageablepopulations.Razingofotherroostingsitesresultedinfurtherdispersionofthepopulation,mainlytothehangars.BirdexclusionmeasuresthatwewouldoftenuseelsewherewerenotfeasibleinIraq,duetothecostandlackofmaterials.Birdspikesonledges,windowsills,andotherroostingsiteswerecostlyandrequiredsignificantmanpowertoinstall.Birdnettingwasnotpracticalbecauseofthelargeareasthatrequiredcoveragetoreduceaccess.Further,thebirdswerenotreadilystartledbyloudnoisesbecauseofthealmostconstantnoisearoundthebase.Avicideswereauthorizedforuse,butonlyonalimitedbasisduetolimitedefficacyandcomplaintsaboutdeadanddyingbirdsonbase.Anyreportofadeadordyingbirdimmediatelycausedconcernaboutavianinfluenza.Theuseoflivetrapswasconsidered,however,suchmeasureswouldintroducetheproblemofdispositionofthecapturedbirds.Removalfromthebuildingandreleasewouldonlymeantheywouldreturnimmediatelyifthebuildingwasnotsealed.Contractorpersonnelwherenotauthorizedtokillthecapturedbirds,so,aswithotherferalanimals,itwouldhavebeenincumbentonpreventivemedicinepersonneltoeuthanizethem.WelackedaCO2chamberandtheremovalofindividualbirdsfromthetrapstoinjectthemwasnotconsideredaviableoption.Afewpelletgunswereusedtoshootpigeonstoscarethemaway,butwithonlylimitedresults.Aswiththeothermethods,shootingpigeonswouldscarethemawayforatime,buttheyreturnedinforce.Thismethodalsorequiredextensivecoordinationandwasoftennotfeasibleinareaswherepersonnellivedandworked.Pigeonsaredifficulttocontrolevenonthebestofdays,butpigeoncontrolinIraqisaconstantproblemcompoundedbythethreatofavianinfluenza.VectorcontrolinIraqpresentedmanyuniqueanddifficultchallenges.Themilitarypreventivemedicineteamworkedcloselywiththecontractorvectorcontrolpersonneltodoanoutstandingjobofsearchingforandidentifyingnewandinnovativeapproachestoproblems.Throughtheirefforts,Warfightersareprotectedfromvectorbornediseasesandenvironmentalhazardsthataresodetrimentaltotheperformanceoftheirprimarymission.REFERENCES 1.SutherlandDJ,CransWJ.MosquitoesinYourLife.RutgersUniversity.TheNewJerseyAgricultureExperimentStationPublicationSA220-5M-86.Availableat:http://www-rci.rutgers.edu/~insects/moslife.htm.2.StateofMichigan.Emergingdiseaseissues:biologicalmosquitocontrol.Availableat:http://www.michigan.gov/emergingdiseases/0,1607,7-186-25805_25824-75797--,00.html.Accessed2April2007.3.OrganizationforBatConservation,CranbrookInstituteofScience.Batsandrabies.Availableat:http://www.batconservation.org/content/Batsrabies.html.Accessed2April2007.AUTHORS LTCBlowistheBrigadeEntomologist,30thMedicalBrigade,Heidelberg,Germany.Previously,shewasthePestManagementConsultant,MultinationalCoalition-Iraq,withtheTF-30MedicalBrigadeinBaghdad,Iraq. OneofthenumerousdamagedbuildingsatForwardOperatingBaseSpiecherthatwasinfestedwithbirds.Portionsoftheinteriorofthisbuildingwerebeingrenovatedforuse.Numerousopeningsmadeexclusionofbirdsimpossible.

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54ArmyMedicalDepartmentJournalChallengesofEffectiveVectorControl:OperationIraqiFreedom0507CPTForestisanEntomologyProjectOfficer,USACHPPM,AberdeenProvingGround,Maryland.PreviouslyhewastheCommander,255thMedicalDetachment,Grafenwoer,Germany,andtwicedeployedtoIraq.CPTLewisistheExecutiveOfficer,223rdMedicalDetachment,Ft.Carson,Colorado.MAJMeckelisanEntomologicalProjectOfficer,USACHPPM-West,FortLewisWashington.Previously,hewastheCommander,898thMedicalDetachment,FortLawton,Washington,duringthedetachmentsdeploymenttoOIF05-07.CPTRaymondistheCommander,903rdMedicalDetachment,Beloit,Wisconsin.HewastheCommanderduringtheunitsdeploymentinsupportofOIF0507.MAJCarderistheCommander,485thMedicalDetachment,FortPolk,Louisiana.Previously,hewastheEnvironmentalScienceOfficer,61stMultifunctionalMedicalBrigade,Balad,Iraq. UsingDoDInsectRepellentSystemasaPersonalProtectiveMeasureAgainstDiseaseVectorsThroughoutthecourseofmilitaryhistory,morecasualtieshaveresultedfromdiseaseandnonbattleinjuriesthanfromwoundsinflictedbytheenemy.Thebitesofinsectsandtickstransmitmanyofthedisease-causinggermsthatgiveourmilitarythemosttrouble.Dontletyourselfbepesteredbyarthropods,orworse,becomeavictimofanarthropod-bornedisease.Thesediseasescantakeyououtoftheaction,makeyoumiserablysick,orevenkillyou.Thediseasesandthecreaturesthattransmitthemareasmuchofathreatduringroutinetrainingexercisesorhumanitarian/disasterassistanceoperationsasduringactualcombat.TheDoDInsectRepellentSystemisavailableforusebyallpersonneltopreventarthropod-bornediseases,suchasmalaria,leishmaniasis,scrubtyphus,WestNilevirus,andLymedisease.Whenusedproperly,theDoDInsectRepellentSystemwillpreventdisease,pain,andtheannoyancecausedbybitesofinsectssuchasmosquitoes,sandflies,andotherarthropodssuchasticksandchiggers.Thefollowingproceduresfortherepellentsystemwillensuremaximumprotectionforyouwhileperformingroutinetrainingexercisesoractualmissionsinareaswherevector(insect)-bornediseasesarecommon:1.Permethrinonclothing.Thiscanbeaccomplishedinanyoneoffourways.YoucanusethePermethrinimpregnationkitknownastheIndividualDynamicAbsorption(IDA)Kit(NSN6840-01-345-0237).Onekittreatsoneentireuniform,andthetreatmentlastsforapproximately52washes(generallyconsideredthecombatlifeoftheuniform).IftheIDAkitisnotavailable,usetheaerosolspraycan(NSN6840-01-278-1336).Oneapplicationofapproximately-canlasts4to6washes.Youcanalsousea2-gallon,pumpsprayerforpermethrinapplicationtomanyuniformsatthesametime.Thismethodmustbeappliedbyproperlytrainedpersonnelwhoprotectthemselvesfromthespraywitharespirator.Youwillnotbeexposedtoasmuchpermethrinbecausethechemicalbindswiththeclothafteritdries.Anotherrecentlyapprovedmethodistohaveuniforms(BDU,DCU,orACU)factorytreated.ThefactorytreatmentmethodresultsinthesamechemicalconcentrationasboththeIDAkitandthe2-galsprayermethod.Factorytreatmentisabigadvantagebecauseitismoreconvenientfortheindividualandtheunit,aswellasprovidingauniformthatretainsitsrepellencyforthelifeoftheuniform.Ifaunitcontractstohavetheiruniformstreated,theuniformswillbereturnedwithalabelindicatingthattheyweretreatedwithpermethrin.ThenewACUsaremadeofthesamefabricastheoldBDUsandDCUs,sotheACUtreatmentisthesame.DONOT drycleanapermethrintreateduniform,asdry-cleaningsolventscompletelyremovethepermethrin,renderingthetreatmentineffective.However,adry-cleaneduniformcanberetreated.2.Deetonexposedskin.Applyathincoatofthecurrentstandardmilitaryskinrepellent.Thisproductwascarefullydevelopedtominimizetheamountofactiveingredient(35%)andmaximizethedurationofprotectionbyincorporatingtheactiveingredientintoasustained-release,polymerformulationknownastheextendeddurationtopicalinsectandarthropodrepellent(EDTIAR)(NSN6840-01-284-3982).Applyittoallexposedskinexceptareasclosetotheeyesandmouth.Besuretofollowlabeldirectionswhenapplyingthisoranyotherrepellent.Oneapplicationlastsupto12hours,dependingontheclimate.

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AprilJune2007553.Properlyweartheuniform.Wearthesleevesrolleddownandcloseallopeningsonyourclothingthatmightprovideaccesstoinsects.Tuckpantsintoyourbootsandundershirtintoyourpants.Theuniformshouldbelooseandnottightfittingsothatinsects,particularlymosquitoes,cannotbitethroughtheclothintoyourskin.Checkyourclothingroutinelyforinsectsandticks,andusethebuddysystemtoinspectareasoftheuniformthatyoucanteasilysee.4.Treatbednet.Someinsectssuchassandfliesaresmallerandcanfitthroughthemeshofthenet.Treatyourbednetwithpermethrininawell-ventilatedareabeforeyoubeddown.Aself-supportingpopupbednetisnowavailable(NSN3740-01-516-4415[olivedrab]andNSN3740-01-518-7310[coyotebrown]).Thenewpopupbednetsarefactorytreatedwithpermethrinanddonotrequirepolesoraseparateframe.5.Malariapills.Therearedrugs,knownaschemoprophylaxis,whichcanbetakentopreventmalaria.Someofthesedrugscanmakeapersonfeelill,especiallywhentheyarefirstused.Besuretouseonlythedrugsthatareprescribedbecauseaneffectivedruginonepartoftheworldisuselessinanother.Ifyouthinkyouarehavingbadsideeffects(upsetstomach,disturbedsleep,rashes,visionimpairment,etc)fromchemoprophylaxis,tellaphysicianassoonaspossible.TheDODInsectRepellentSystemiscriticaltotheArmysMedicalRegimentmottotoConservetheFightingStrength.ItisamissionessentialtasklocatedinSTP-21-1-SMCT;SoldiersManualofCommonTaskTesting,SkillLevel1dated11Oct2005.ThesystemisaDoDPolicythateverySoldier,Airman,Marine,andCorpsmanneedtostrictlyfollow.AdditionalinformationonpersonalprotectivemeasurescanbefoundintheArmedForcesPestManagementBoardsTechnicalGuide36,PersonalProtectiveMeasuresAgainstInsectsandOtherArthropodsofMilitarySignificance,whichcanbedownloadedfromhttp://www.afpmb.org/pubs/tims/tims.htm;intheUSArmyCenterforHealthPromotionandPreventiveMedicinefactsheetontheDoDInsectRepellentSystem(http://chppm-www.apgea.army.mil/documents/DODInsectRepellentSys.pdf);andintheArmyMedicalDepartmentCenterandSchooldeploymenttrainingportalathttp://www.cs.amedd.army.mil/deployment2.aspx#.Forfurtherinformation,contact:COLDebboun(mustapha.debboun@amedd.army.mil[210-221-7649])andSSG(P) Vincent(andrea.vincent@amedd.army.mil[210-221-6801]),MedicalZoologyBranch,DeptofPreventiveHealthServices,AcademyofHealthSciences,AMEDDCenterandSchool,FortSamHouston,Texas. 1 2 3 ItsDoDPolicy Itsabasictrainingtask ItscriticalforyourhealthCourtesyoftheEntomologicalSciencesProgram,USArmyCenterforHealthPromotionandPreventiveMedicine,AberdeenProvingGround,Maryland

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56ArmyMedicalDepartmentJournalINTRODUCTIONAlthoughUSmilitaryoperationsinAfghanistanhavebeenconductedformorethan5yearsaspartofOperationEnduringFreedom(OEF),thechallengesinprovidingpreventivemedicinesupportarenotwidelyrecognizedbythemajorityofUSmilitarymedicalpersonnel.Thenatureoftheclimate,terrain,infrastructure,andmissiondictatedthatprovisionofpreventivemedicinesupportwasnotalwaysaccordingtodoctrine.TerrainandClimateAfghanistan,locatedinsouthcentralAsia,is647,500km2(250,000sqmiles)inarea,whichisslightlysmallerthanTexas.1ThislandlockedcountryisdominatedbytheruggedHinduKushMountains,withplainsinthenorthandsouthwesternportionsandelevationsrangingfrom258m(846ft)to7,458m(24,469ft).AlthoughsomeUSforwardoperatingbases(FOBs)arelocatedatanelevationof500m(1,640ft)abovesealevel,mostaresituatedaboveanelevationof1,500m(4,921ft),withsomeFOBsatelevationsapproaching2,750m(9,022ft).Higherelevationsgenerallyleadtocoldertemperaturesandanincreaseincoldweatherinjuries.Altitudesicknessisanotherconcernfortroopsdeployedtothesehighelevationareas.TheclimateinAfghanistanistypicallydrywithhotsummersandcoldwinters.AreasnearthePakistanborderareinfluencedbymonsoonalweatherpatternsthatbringsignificantamountsofraininshortperiodsoftime.TheareasofsoutheasternAfghanistansurroundingJalalabadandKhowstareclassifiedasaSubtropicalSteppeclimate.2SummertemperaturesinJalalabadreach46C(115F)withhighhumidity,andwintertemperaturesnormallyremainabovefreezing.WintertemperaturesbelowfreezingatKabulareduemainlytotheelevationof1,791m(5,876ft).ManyoftheFOBshaveaclimatesimilartoKabulbecauseoftheirhighelevations.TransportationTransportationinfrastructureislimitedthroughoutthecountry.Only8,231km(5,000mi)ofpavedroadsexistinAfghanistan1andmostofthosearelocatednearKabulandafewotherlargecities.ThelackofroadscombinedwiththeruggedterrainresultedinanalmosttotaldependenceonairtransportationformovementofmilitaryforcesbetweenFOBs.Somelocations,suchasBagramAirfield,KandaharAirfield,FOBSalernonearKhowst,andJalalabadAirfieldhaverunwayscapableofsupportingC-130aircraft.However,mostlocationsareonlyaccessiblebyrotarywingaircraft,primarilyCH-47ChinookandUH-60Blackhawkhelicopters.ThedemandforairtransportwashighandflightstooutlyingFOBswerelimitedtooneortwoperweek.Besidesthenumbersofpersonnelvyingfortransport,asignificantamountofspacewasallocatedtomail,equipment,andsupplies.Flightoperationsathigherelevationsalsoreducedtheamountofpersonnelandcargothatthehelicopterscouldcarry.PreventiveMedicineAssetsinTheaterThedispersedandisolatednatureofapproximately18,000USandCoalitionForcesmandatedalargerpreventivemedicinepresencethandoctrinallyspecified.The71stand480thMedicalDetachments(PreventiveMedicine)providedsupportintheaterandweretaskorganizedunderTaskForceStrength(comprisedmainlyofthe249thGeneralHospital).The71stMedicalDetachmentsupportedBagramAirfieldandtheRegionalCommand(RC)East,basedinFOBSalerno.The480thMedicalDetachmentsupportedRCSouth,basedatKandaharAirfield,andabaseatKarshi-Khanabad,Uzbekistan.TwoBrigadeCombatTeams(BCT)weretheprimaryelementsofeachRC:PreventiveMedicineSupportinAfghanistanDuringOperationEnduringFreedomVIMAJChristopherA.Gellasch,MS,USACPTLeslyC.Calix,MS,USA

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AprilJune200757the1stBrigade,82ndAirborneDivisioninRCEastandthe173rdAirborneBrigadeinRCSouth.EachBCThaditsownEnvironmentalScienceandEngineeringOfficerandoneortwoPreventiveMedicineSpecialists(68S).TheMedicalDetachmentandBCTpreventivemedicinepersonnelworkedtogethertoprovideareasupportwithineachRC.ThetechnicalreportingchainforallpreventivemedicineassetsintheaterwentthroughtheCombinedJointTaskForce-76(CJTF-76)SurgeonCellsForceHealthProtectionOfficer.NomedicalbrigadeorotherhigherechelonmedicalunitwaspresentinAfghanistan.ThehigherheadquarterstoCJTF-76,CombinedForcesCommand-AfghanistaninKabul,didnothaveaSurgeonCell.ReportingofpreventivemedicineissueswentfromCJTF-76totheCoalitionForcesLandComponentCommand.SUPPORTTOLARGERBASESThreebasesinAfghanistan(Figure1),BagramAirfield,KandaharAirfield,andFOBSalernoweremuchlargerthantheothersandhadpopulationsbetween1,500and10,000personnel.Thelargerbasesrequiredasignificantamountofman-hourstoconductallrequiredinspectionsandsurveysastheyweretransportation,logistics,andservicehubswithmanygarrison-typeoperations.Contractorswereresponsibleforoperatingdiningfacilities(DFACs),potablewaterproduction,wastedisposal,vectorcontrol,laundry,andotherbaseoperations.Sincetheselocationsweretransportationhubs,theywereideallocationsforpreventivemedicineunitstouseasbasesofoperations.BagramAirfieldissolargethatitwasdividedintoapproximately20smallerbasecamps,eachrequiringaseparatemonthlybasecampinspection.Thebasecampsincludedthehospitalcompound,engineertaskforcearea,contractorhousing,andmanyothers.FoodandWaterPersonnelatemostoftheirmealsattheDFACs,buttherewerealsoArmyandAirForceExchangeServicefoodconcessionairesoneachbase.ThelargestbasewasBagramAirfieldwith7DFACsand9foodconcessionaires.ThefoodconcessionairesconsistedmostlyoffastfoodchainsfamiliartoSoldiers(Subway,BurgerKing,DiaryQueen,etc)butwererunprimarilybythirdcountrynationalsnotaccustomedtoUSstandardsoffoodservicesanitation.Consequently,severalfacilitieswereclosedafterpreventivemedicineinspectionsfoundseriousdeficiencies(eg,poorsanitation,expiredfood)andmanyhadrepeatclosures.Thecontractor-operatedDFACs,severalofwhichweremanagedbyretiredUSmilitaryfoodservicepersonnel,hadrelativelyfewviolations.Contractorrunpotablewateroperationsusedgroundwaterfromlarge,deepwellsastheprimarysource.Waterqualitywasgoodandchlorineresidualsatthesourcewerekeptbetween3ppmand5ppm,andwasnormallyabove3ppmforwateratthepointofuse.Althoughtherewasalowhealthriskfromthiswater,bottledwaterwastheprimarysourceofdrinkingwater.Weeklytestingforchlorineresidual,pH,andcoliformbacteriawasconductedatsitesthroughoutthebases.Duetoalackofwaterdistributioninfrastructureatsomebases,potablewatertankertruckswereusedtotransportwatertoshowerpoints,latrines,DFACs,andothersites.ThetruckswereinspectedquarterlybypreventivemedicineSoldiers.SolidWasteandWastewaterAsignificantamountofsolidwasteandwastewaterwasgeneratedatthesebases.Contractor-operatedburnpitsweretheprimarymeansofsolidwastedisposal,buttheywereinefficientanddidnotcompletelyburnthewaste.TheFigure1.LocationsofArmypreventivemedicineresourcesatthebeginningofOEFVI. FOBSalerno71stMedicalDetachment(-)1stBDE82ndAirborneDiv BagramAirfield71stMedicalDetachment(-)CJTF-76Headquarters KandaharAirfield480thMedicalDetachment(-)173rdAirborneBrigade Karshi-Khanabad480thMedicalDetachment(-) FOBSalerno71stMedicalDetachment(-) Karshi-Khanabad480thMedicalDetachment(-) KandaharAirfield480thMedicalDetachment(-) BagramAirfield71stMedicalDetachment(-)

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58ArmyMedicalDepartmentJournalburningcreatedalargeplumeofsmokethatwasanirritantifinhaled.EffortsbytheCJTF-76Engineers(J7),Surgeon,andpreventivemedicinetohaveincineratorsinstalledforgeneraltrashdisposalwereunsuccessful.Norecyclingofmetal,glass,orpaperinthemunicipalwastestreamwasundertaken,althoughtheJ7EnvironmentalOfficerattemptedtofindacontractortoinitiatearecyclingprogram.Regulatedmedicalwastewastakentoacontractor-operatedincineratoratBagramAirfieldfordisposal.WastewaterdisposalatBagramAirfieldconsistedofdumpinguntreatedgraywaterfromshowers,laundry,andDFACsintoastreamthatflowedofftheinstallation.Theblackwaterfromlatrineswastakenoff-sitebyalocalcontractor,butuponinvestigation,noonecouldbefoundthatknewexactlywheretheblackwaterwasbeingdisposed.AtbothKandaharAirfieldandFOBSalerno,largesettlingbasinswereusedtotreatwastewater,buttheefficacyofthesestructureswasquestionableandtheyservedasbreedingsitesforCulexsppmosquitoes.VectorSurveillanceThevectorcontrolmission(includingspraying)hadbeenassumedbythecontractor,butthevectorsurveillancemissionwasstillperformedbypreventivemedicinepersonnel.CentersforDiseaseControlandPrevention(CDC)miniaturelighttrapswereusedtoconductmosquitoandsandflysurveillanceduringthedeployment.Trapsweresetup2or3timesaweek,dependingonavailablepersonnelandthreatlevel.Surveillancewasconductedduringthesummermonthswithvariationbetweenbasesduetoelevationandaveragedailytemperatures.ThecollectiondatafromFOBSalernoispresentedinFigure2.Themajorityofinsectswerecollectedfrommid-Junetomid-July,whentemperatureswerehighest.MalariaisendemicinAfghanistanandspeciesofAnophelesmosquitoes,avectorofmalaria,arepredominantintheeastandsouthregions.3ThemostcommoncauseofmalariaintheaterwasPlasmodiumvivaxwithasmallernumberofP.falciparumcases.CJTF-76policydirectedallSoldiersintheatertotakeachemoprophylaxis,typicallydoxycyclineormefloquine,duringdeployment.However,noncompliancewiththechemoprophylaxispolicywasfoundineveryinstanceofthemorethan40casesofmalariaduring2005.Sandfliesareavectorofleishmaniasis,however,therisklevelforthisdiseasewaslowinthesouthernandeasternportionsofthecountry.Rodentsandhouseflieswerethemostcommonpestsfoundthroughoutthetheater.SUPPORTTOFORWARDOPERATINGBASESIncontrasttothelargerbases,manyoftheFOBshadlittleornocontractorsupport,andmostDFACswerestaffedbymilitaryfoodservicespecialists.Insomecases,therewereseveralsmallercampspresentwithinPreventiveMedicineSupportinAfghanistanDuringOperationEnduringFreedomVI Lighttrapinstallationataforwardoperatingbase 020406080100120 23-27May 31May-Jun3 6-9Jun 13-18Jun 21-23Jun 28Jun-Jul1 6-9Jul 13-16Jul 19-22Jul 30-31Jul 1-6Aug 9-10Aug Culexspp. Sandflies Anophelesspp. N o o f i n s e c t s Figure2.InsectcollectiondatafromFOBSalerno,23Mayto10August2005. Culexspp. Sandflies Anophelesspp. N u m b e r o f I n s e c t s

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AprilJune200759theFOB(eg,SpecialForces,ProvincialReconstructionTeam,infantrycompany)withsomeduplicationofbaseoperationsineachcamp.ConceptofSupportandLimitationsDuringthepreviousrotation,onlythe172ndMedicalDetachment(PreventiveMedicine)wasintheaterandFOBswereonlyvisitedonceperquarter.With2detachments(the71standthe480th)presentforOEFVI,thedecisionwasmadetovisitFOBsevery4to6weeks,withagoalofmonthlyvisits.Toillustratehowthisprocessworked,theplanofsupporttoportionsofRCEastfromBagramAirfieldisdiscussedinthefollowingparagraphs.ThelimitingfactorsinprovidingsupporttoFOBswerepersonnel,transportation,andpreventivemedicineequipment.InordertokeepenoughpersonnelatBagramAirfieldtoconductmissionsontheinstallation,onlyonepreventivemedicinespecialistratherthanateamof2or3SoldierswasabletotraveltoeachFOB.ManyoftheSoldiersinthe71stMedicalDetachmentwererecentgraduatesofAdvancedIndividualTrainingwithlimitedexperience.ThesejuniorSoldierswererequiredtoflytoanFOB,conductallinspections,recommendcorrections,andprovideanyothersupportasneededwithoutanydirectsupervision.Withoverlapduetoflightavailability,atanygiventime,2SoldierswereatFOBswhile2SoldierswereatBagramAirfieldconductingmissions.ThetypicalFOBmissionrequired2or3daystocompletebutflightstosomeFOBsarrivedonlyonceevery8days.ThisresultedinjuniorSoldiersremainingatanFOBforseveraladditionaldayswithneitheramissionnornoncommissionedofficersupervision.SomeproactiveSoldiersspenttheextratimeapplyingpreventivemedicineprinciplesandlookingforadditionalwaystohelptheFOBmayorimprovelivingconditions.EquipmentpresentedanotherchallengeinthesupportofFOBs.ThenormalmedicalequipmentsetsusedbyateaminamedicaldetachmentarecontainedinmedicalchestsandfillanM1114HMMWV.*Duetospacerestrictionsonaircraft,thepreventivemedicinespecialistvisitinganFOBwaslimitedtoapersonalbag(rucksackorduffelbag)plusonefootlockerorsimilar-sizedcontainerforequipment.Thisrequiredsomecreativitytomaintaincapabilitywhilemeetingspacerequirements.Typically,preventivemedicinespecialistswouldcarrythefollowing:BinderwithformsWaterTestingHachDR/890ColorimeterMilliporeIncubatorColilertmediaandbottlesLaMotteKitorteststripsFoodSanitationCopyofTBMED5304FoodserviceCltestpaperFoodThermometersEntomologyOneCDCLightTrapRodentstickytrapsFlystripsMosquitolarvacidedunksInsteadofusingthestandardHachDREL2400waterqualityanalysislaboratory,aHachDR/890PortableColorimeterwassubstituted.Thissavedasubstantialamountofspacewhileretainingmostofthecapabilityrequiredtoconductonsitedrinkingwateranalysis.ThestandardgrayMilliporeFieldIncubatorusedtoincubatesamplesforthepresenceorabsenceofcoliformbacteriawasessentialonFOBmissions,butrequiredalmosthalfofthespaceallotted.Initially,afewoftheoldermodelincubatorswereusedsincetheyaremuchsmaller,buttheysoonstoppedfunctioningandcouldnotberepaired.Onlylimitedentomologyequipmentandnoindustrialhygieneequipmentwaspartofthestandardkit.Ifaneedforadditional *HighMobilityMultipurposeWheeledVehicleHachCompany,Loveland,Colorado80539,800-227-4224MilliporeInc.,Billerica,MA01821,978-715-4321 HachDREL2400CompleteWaterQualityLab

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60ArmyMedicalDepartmentJournalequipmentwasrecognizedduringavisit,thepreventivemedicinespecialistwouldbringitonthenextmonthsmission.FoodandWaterThequalityofsanitationatthemilitarydiningfacilitiesatFOBswasvariable.Ingeneral,largerFOBshadhigher-rankingsupervisionattheDFACandbettercompliancewithfoodservicesanitationstandards.CommondeficienciesatFOBDFACsincludedimproperfoodholdingtemperaturesandpoorsanitationpractices.4Poorlymaintainedormalfunctioningequipmentsuchassteamtablesorrefrigeratorscouldnotberepairedorreplacedquickly.MostfoodwastransportedtoFOBsvialocalnationaltrucksoverAfghanistansprimitiveroadsystem.ThefrozenandrefrigeratedfoodoftenarrivedattheFOBabovetheacceptabletemperaturesorwasclearlyallowedtothawandthenrefreeze.ThisresultedinanincreasedriskoffoodborneillnesstoUSandCoalitiontroops.Althoughbottledwaterwasusedfordrinking,wellwaterwasutilizedforpersonalhygiene,laundry,andwashingdishesattheDFAC.Ingeneral,wellswerenotproperlyconstructed,didnothaveasanitaryseal,andwerecontaminatedwithcoliformbacteria.Somewellsdidhavechlorineinjectorsbutmostdidnotfunction.Theonlylocationswithaconsistentchlorineresidualinthewatersupplywerethoseinwhichpersonnel(normallymedics)manuallyaddedcalciumhypochloritetostoragetanksandtestedchlorineresidualonadailybasis.DuringFOBvisits,preventivemedicinespecialistsprovidedassistancebyensuringthatwatertankchlorinationwasconductedbytrainedpersonnelandthatasupplyofcalciumhypochloriteandchlorineteststripswasonhand.SolidWasteSolidwastewasburnedatmostFOBs,althoughtheeffectivenessrangedfrommoderatetopoor.Atsomelocations,wastewasdumpedoutsidetheFOBperimeterandnotburnedimmediately.Groupsoflocalnationalswouldrummagethroughthewastelookingforusefulitemsandsubsequentlyspreadthetrashoveralargearea.Otherlocationswouldpourfuelontrashpilesandignitethemwithoutensuringpropercombustion.Althoughthetermburnpitwasnormallyused,highwatertablesinsomeareaspreventedexcavatingmorethanafewfeetbelowgroundlevelandburnedtrashwasnotalwayscoveredwithsoil.Mostsolidwastedisposalareasbecamemagnetsforrodents,houseflies,andstraydogs.VectorSurveillanceandControlVectorsurveillancedatawasvaluableforefficientcontrol.Contractorpersonnelappliedchemicalcontrolonlyfollowingarecommendationbyamilitaryentomologist.MosquitobreedingsiteswereidentifiedandlarvaecontrolledbyapplyingAltosidorBacillusthuringiensisbriquettes.5SandflyandAnophelesmosquitospecimensweresenttotheBiosystematicsUnitoftheWalterReedArmyInstituteofResearchandtheUSArmyCenterforHealthPromotionandPreventiveMedicine(USACHPPM)-North,respectively,tobetested.Houseflyinfestationswerewidelyproblematic,particularlyaroundtheDFACs.SanitationpracticeswereinstitutedandthensupplementedwithflybaitandflystripssuchasQuikstrike.*Integratedpestmanagementpracticesusedthroughouttheyearofdeploymentsignificantlyreducedtheuseofpesticides.UniformTreatmentTheproperchemicaltreatmentofuniforms,asmandatedbyDepartmentofDefensedirectives,isimperativeforthepreventionofvectorbornediseases.Soldiersneedgreaterawarenessandtraininginuniformtreatmentproceduresbeforedeploying.Theimminentthreatofdiseasessuchasleishmaniasisandmalariamadethetreatmentofuniformsintheaterapriorityformanyunitsthatwerenotabletodosopriortodeploying.PreventivemedicinepersonneltreateduniformsatmanyFOBswheretroopsdidnothavesprayequipmentorpermethrin.5EnvironmentalSamplingSoilandwatersampleswerecollectedperiodicallyinsupportoftheArmyDeploymentOccupationalandEnvironmentalHealthRiskManagementProgram.SincewateratFOBswasnottreated(withtheexceptionofsomechlorination),rawwatersamplingwasrequiredateachwell.TwoorthreewellswereinPreventiveMedicineSupportinAfghanistanDuringOperationEnduringFreedomVI HachDR/890PortableColorimeter *Do-It-YourselfPestControl,Inc.,Atlanta,Georgia30341

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AprilJune200761useatmanyFOBs,whichrequiredalargecoolerforeachsample.Normally,anEnvironmentalScienceandEngineeringOfficer(ESEO)accompaniedapreventivemedicinespecialisttoanFOBduringanormallyscheduledvisitinordertocollectthesesamples.Asmentionedearlier,thelogisticsofbringingextraequipmenttoanFOBwasproblematic.Inaddition,aftertherawwatersampleswerecollectedtheyhadtobemaintainedat4C,andduringthesummermonthsicepacksonlykeptsampleschilledforalimitedtime.SomeanalyteshaveshortholdingtimesandtherewerechallengesgettingwatersamplesfromaFOBtoamainbase,suchasBagramAirfield,andthentoUSACHPPMforlaboratoryanalysis.ItwasdifficulttomovesamplesfromremotelocationstoaUSACHPPMlaboratorywithina14-dayholdingtime.OTHERPREVENTIVEMEDICINEMISSIONSClosureofKarshi-KhanabadTheairbaseatKarshi-Khanabad(K2),Uzbekistan,wasusedprimarilyasalogisticshubforequipmentandsuppliesflowingintoAfghanistan.ThepreventivemedicineteamatK2consistedofanESEO,and2preventivemedicinespecialistsfromthe480thMedicalDetachment.TheroutinemissiontoprovidepreventivemedicinesupportchangedinJuly2005whentheGovernmentofUzbekistanorderedUSforcestovacateK2within6months.Therapiddrawdownandclosureoftheairbasepresentedsomechallengesthatwerehandledbypreventivemedicinepersonnel,includingthediscoveryofa20-footlongshippingcontainerthathadbeenaccumulatingregulatedmedicalwaste(RMW)formorethan3years.NoinventoryexistedandtheLevelIIclinicpersonnelhadbeenaddingredbagsofRMWtothecontaineronaregularbasis.TheESEOhadtoquicklydeterminetheproperwaytocategorizeanddisposeofalloftheRMW.Alocalcontractorwasfoundthatcouldproperlyhandleandincineratethecontentsoftheshippingcontainer.ThissavedtheUSgovernmentthecostofshippingthecontainerofRMWtoGermanyfordisposal.Anothermajorissuerelatedtoclosureactivitiesinvolvedproperdisposalofalargeamountofhazardouswasteandhazardousmaterials.AnArmyReserveOfficerthatworksfortheStateofMissouridealingwithhazardouswasteissuesinhiscivilianjobwastheESEOatK2.HiscivilianexperiencemadehimaninvaluableassettotheK2mayorcellandpreventedapotentiallyseriousissuewithdisposalofhazardouswasteandmaterials.EarthquakeSupportinPakistanOn8October,2005,a7.6magnitudeearthquakestrucknorthernPakistan,killingmorethan86,000people,leavingmorethan4millionpeoplehomeless,andcausingmassivedestruction.6AtaskforcecomprisedmostlyofaviationunitsfromCJTF-76rapidlydeployedfromAfghanistantoQasimAirfieldnearIslamabad,Pakistan,toprovidehumanitarianrelief.NopreventivemedicinepersonnelwereauthorizedtoaccompanytheinitialgroupintoPakistan.Oneweeklater,theCJTF-76headquartersreceivednumerousreportsthatUSSoldiersinPakistansufferedfromfoodborneillness,poorsanitaryconditions,andalargenumberofmosquitobites.Atthatpoint,theCommanderofthe71stMedical ApreventivemedicinespecialisttreatsuniformswiththeclothingrepellentPermethrin Preparingtoconductrawwatersamplingataforwardoperatingbase

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62ArmyMedicalDepartmentJournalDetachmentwasdispatchedtoPakistantodirecteffortstoimprovethesituation.Althoughthemissionwasinitiallyfocusedoncorrectingexistingproblems,preventivemedicinemeasureswerealsoquicklyimplementedtoreducethediseaseandnonbattleinjuryrate.Workingwiththetaskforceengineer,asemipermanentbasecampforusebytheaviationtaskforcewasdesignedandafoodservicecontractorwasselected.Afteroneweek,aNavyForwardDeployablePreventiveMedicineUnitarrivedandassumedthemissionatQasim.MalariaandLeishmaniasisInvestigationsInSeptember2005,aSoldiercontractedP.falciparummalariainPaktikaprovince,Afghanistan.Falciparummalariaisthemostseriousmalarialinfectionandmaycausecoagulationdefects,shock,renalandliverfailure,pulmonaryandcerebraledema,coma,anddeath.TheSoldierwasevacuatedbyairtothelevelIIItreatmentfacilityatBagramAirfield,thentotheLandstuhlRegionalMedicalCenter,Germany,andeventuallytotheWalterReedArmyMedicalCenter.TheSoldiersurvived,butsufferedpermanentliverdamage.AnArmyRegulation15-6investigation7conductedbytheExecutiveOfficerofthe71stMedicalDetachmentrevealedthattheSoldiercontractedmalariaindividuallyastheresultofacombinationoffactors.Hedidnottakehismalariaprophylacticoruseanyotherpersonalprotectivemeasurestoreducetheriskofcontractingmalaria.Personalprotectivemeasuresincludechemoprophylaxis,permethrintreateduniforms,properwearingofuniforms,useofmilitaryDEETskincreamandmosquitobednets.Acombinationofallofthesepreventivemeasurescouldhaveprotectedhimfrommalaria.Thechainofcommandfailedtoensurethatmalariamedicationwaspartoftheprecombatinspectionsandchecks.LESSONSLEARNEDDecentralizedPreventiveMedicineOperationsWiththeinitialsplit-basedoperationsusedbypreventivemedicineintheearlypartofthedeployment,mostofthelargerFOBsreceivedamonthlyassistancevisit.However,someofthesmallerFOBsandfirebasescouldonlybereachedbyirregularflightsorgroundconvoysfromalargerFOB.AttemptstocoordinatevisitstothesesmallerFOBsregularlyfailedduetochangingconvoyschedulesortheinabilitytocoordinateflightswithconvoys.ThealternativewastohaveaSoldieronthegroundfor16daystoaccomplish4daysworthofwork.ThesolutioninRCEastwasthereorganizationofpreventivemedicinepersonnelthe82ndAirborneDivisionorganicpreventivemedicineassetscoveredFOBSalernoandteamsof2Soldiersfromthe71stMedicalDetachmentandtheirequipmentwereforwardpositionedatthebattalion-levelFOBs.ThisallowedgreaterintegrationwiththemaneuverunitsandallowedonepreventivemedicinespecialisttobeavailabletoaccompanyaconvoyorflighttothesmalleroutlyingFOBs.Althoughhavingaforwardpresenceresultedinmanybenefits,alackofequipmentresultedinlimitedcapabilityand/orportabilityforsometeams.Teamsusuallyconsistedof2juniorenlistedSoldiersthathadminimalsupervisionbyapreventivemedicinenoncommissionedofficer(NCO)formonthsatatime.ItalsoloweredmoraleforSoldiersthatcoveredonlytheBagramAirfieldmissionandnolongerhadtheopportunitytotraveltoFOBs.AplanwasdevelopedtorotateSoldiersatBagramAirfieldandtheFOBsevery3to4monthstomitigatetheseissues.FieldSanitationTeamsBasedonunitreportsandobservationsinthefield,mostcompany-sizedunitsintheaterdidnothavefunctioningFieldSanitationTeams.ArmyRegulation40-5requiresthatCompany-sizedunitswillestablishandemploymanned,trained,andequippedunitfieldsanitationteams(FSTs).8WhenquestionedaboutthestatusoftheirFSTs,manyunitsrepliedthattheyhadorderedtherequiredequipmentbeforedeployment,butitneverarrived.IfSoldiersintheFSThadreceivedthe40-hourFSTtrainingcourse,theydidnotusethatknowledgeinthefield.Oneexample:duringthePakistanearthquakesupportmission,aSergeantintheaviationtaskforcementionedthatheattendedanFSTclasstaughtbythe71stMedicalDetachmentafewmonthspriortotheearthquake.ThisNCOhadtheknowledgetocorrectmanyofthesanitationproblemsnegativelyimpactingthemissionathislocation.Hechosenottotakeactionorinformhischainofcommandofthecorrectiveactionsthatwereneeded.Asaresult,anESEOwasrequiredtodeploytoPakistanandcorrecttheseproblems.PreventiveMedicineSupportinAfghanistanDuringOperationEnduringFreedomVI

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AprilJune200763TheimportanceoftheFSTmustbestressedtounitsduringpredeploymenttrainingandfieldsanitationshouldbeincorporatedintotrainingscenarios.The71stMedicalDetachmenthasworkedwithobserver/controllersattheJointMultinationalTrainingCenter(JMTC)(formerlytheCombatManeuverTrainingCenter)inHohenfels,Germany,tohaveunitsconstructlatrines,determinethewetbulbglobetemperature,andperformotherFSTfunctionsduringtrainingandpredeploymentrotationsattheJMTC.ClinicalPreventiveMedicineDuringOEFVItherewereadequatenumbersofESEOs,medicalentomologists,preventivemedicinespecialists,andNCOstohandlemostproblemsrequiringtheirskillssets.However,noclinicalpreventivemedicineexpertisewaspresentatanyofthelevelIIorlevelIIImedicaltreatmentfacilities.Issuessuchastuberculosisandhepatitispoliciesforlocalnationalandthirdcountrynationalworkersonbase,pandemicinfluenza,sexuallytransmitteddiseases,andtrackingofreportablemedicaleventsbelonginthepurviewofpreventivemedicinephysiciansandArmyPublicHealthNurses(APHN).AccordingtoHollandsworthetal,9theroleoftheAPHN(formerlyArmyCommunityHealthNurse)isexpandingtocoverthesetopicsindeployedsettings.TherearenowauthorizationsforAPHNsinthecombatsupporthospitals,butnoneweredeployedinOEFVIorthefollowingrotation.TheseclinicalpreventivemedicinespecialistsmustbepresentindeployedsettingstoensurethepropermixofskillsetsisavailabletomaximizeForceHealthProtection.WaterWellConstructionInthesummerof2005,whileconductinganassessmentofwatersuppliesusedbyUSandCoalitionForces,severalorganizationswerecontactedtodeterminethenumberandlocationofwellsateachFOB.NoonewithinCJTF-76hadacomprehensivecensusofwellsateachlocation,andplanningforrawwatersamplingwasdifficult.Further,ateachFOBnoinformationrelatedtotheconstruction,depth,orgeologyofthewellsitesexisted.WellsweretypicallyconstructedbylocalcontractorsattherequestoftheFOBmayor,andhigherheadquarterswasnotinformed.MostwellswerenotconstructedtoUSstandardsandfrequentlybecamecontaminatedwithcoliformbacteria.Tocorrectthissituation,preventivemedicinepersonnelworkedwiththeJ7EnvironmentalOfficerinanattempttobringinUSmilitarywelldrillingteamstoconstructnewwellsatFOBs.AlthoughwaterwelldrillingunitsexistintheArmy,Navy,andAirForce,10nonewereavailablefordeploymenttoAfghanistan.AllArmywelldrillingunitshavebeenmovedtotheReservecomponentsandtheirequipmentisagingandinneedofreplacement.InordertoensureUStroopsarereceivingwaterfromproperlyconstructedwellsthatminimizetheriskofcontamination,militarywelldrillingunitsshouldbedeployedtoconstructwellsatFOBs.11InanefforttoconstructwellstoUSstandards,awellspecificationguidetemplatewasdevelopedbypreventivemedicinepersonnelworkinginconjunctionwiththeArmyCorpsofEngineers.TheguidecanbeusedbyFOBmayorswhenhiringlocalcontractorsforwellconstruction.EnvironmentalSampleAnalysisSoil,water,andparticulateairsamplescomprisedthebulkofmediacollectedandsentoutoftheaterforanalysis.Thelogisticsofcollectingandshippingsamplesposedmultipleproblems.Somesamplesshippedbycommercialcarrierswereleftsittingatthepointofdeparturefordays,anditcouldtakeweeksforsamplestoarriveatthelaboratory.ThemostreliablemethodofshippingsampleswastheUSAirForcemedicalevacuationflightsfromBagramAirfieldtoRamsteinAirbase,Germany.ApatientescortwouldmaintainaccountabilityforthesamplesduringtheflighttoRamsteinandsubsequenttriptothenearbyLandstuhlRegionalMedicalCenter(LRMC).OnceatLRMC,thepatientescortwouldcallthecontactnumbersprovidedfortheUSACHPPM-Europetoarrangepickup.Thelimitationtothisprocedurewasthatevacuationflightswerenotregularlyscheduled,andnotallflightswentdirectlyfromBagramAirfieldtoGermany.Insomecases,aweekwouldelapsebetweenflights.AsolutiontotheproblemofhavingsamplesquicklyanalyzedwouldbethedeploymentofanAreaMedicalLaboratory(AML)totheUSCentralCommandAreaofResponsibility.Neitherofthe2AMLshasdeployedsincetheirformationin2004,eventhoughtheyhavethecapabilitytoperformmost,ifnotall,analysesrequiredbytheArmyDeploymentOccupationalandEnvironmentalHealthRiskManagementProgram.12Ataminimum,oneAMLshouldbedeployedtoKuwaittosupportunitsdeployedinbothAfghanistanandIraq.

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64ArmyMedicalDepartmentJournalPreventiveMedicineSupportinAfghanistanDuringOperationEnduringFreedomVICONCLUSIONTheclimateandterrainofAfghanistancombinedwithtransportationlimitationscomplicatedthepreventivemedicinemissionduringOEFVI.Thekeystosuccesswereprovidingthemaximumamountofsupportgiventhelimitations,andalwaysremainingflexible.Awiderangeofpreventivemedicinesupportwasrequired,andknowledgeofwhichin-theaterpersonnelhadexpertiseinindustrialhygiene,drinkingwater,hazardouswaste,andotherareaswascriticaltoensuringtheproperpersonwasconsultedforaparticularmission.Onseveraloccasions,missionsoccurredthatwereoutsidethenormalareasofresponsibilityforapreventivemedicineunit.Flexibilityandtheabilitytothinkoutsidetheboxwereimportanttosuccess.Whendeterminingthepropermixofmedicalsupportrequiredforanylargescaledeployment,itisveryimportanttoincludeclinicalpreventivemedicinepersonnel.REFERENCES 1.TheCIAWorldFactbook:Afghanistan.December19,2006.Availableathttps://www.cia.gov/cia/publications/factbook/geos/af.html.2.PalkaEJ,ed.Afghanistan:ARegionalGeography.WestPoint,NY:UnitedStatesMilitaryAcademy;2001.3.RowlandM,MohammedN,RehmanH,etal.AnophelinevectorsandmalariatransmissionineasternAfghanistan.TransRSocTropMedHyg.2002;96:620-626.4.TBMED530,TechnicalBulletinOccupationalandEnvironmentalHealthFoodSanitation.WashingtonDC:USDeptoftheArmy;October30,2002.5.ArmedForcesPestManagementBoard.ContingencyPesticideList.Availableathttp://www.afpmb.org/pubs.6.USGeologicalSurveyEarthquakeHazardsProgramWebsite.Availableathttp://earthquake.usgs.gov/eqcenter/eqinthenews/2005/usdyae.7.ArmyRegulation15-6:ProceduresforInvestigatingOfficersandBoardsofOfficers.Washington,DC:USDeptoftheArmy;October2,2006.8.ArmyRegulation40-5:PreventiveMedicine.WashingtonDC:USDeptoftheArmy;July22,2005:para1-7.9.HollandsworthJE,HallTI,HartCM.CommunityhealthnursingintheArmy:pastpresent,andfuture.ArmyMedDeptJ.JulySeptember2005:21-24.10.ScarbroughT,LangP.Militarywater-welldrilling.Engineer;July-September2001:4-9.11.GellaschCA.Groundwater:past,present,andfutureusesinmilitaryoperations.In:CaldwellDR,EhlenJ,HarmonRS,eds.StudiesinMilitaryGeologyandGeography.Dordrecht,TheNetherlands:KluwerAcademicPublishers;2004:307-319.12.TaylorPW,GordonSW,HallTL,KimmGL,TynerSD,VanHornGT.Forcehealthprotectionthroughlaboratoryanalysisandhealthriskassessment.ArmyMedDeptJ.AprilJune2006:66-72.AUTHORS MAJGellaschistheChief,EnvironmentalHealthEngineeringDivision,USArmyCenterforHealthPromotionandPreventiveMedicine-West,FortLewis,Washington.From2003to2006,hewastheCommander,71stMedicalDetachmentwhichdeployedtoAfghanistanfromApril2005toApril2006.CPTCalixistheExecutiveOfficer,71stMedicalDetachment,Grafenwoehr,Germany.ShewasalsotheDetachmentExecutiveOfficerduringtheunitsdeploymenttoAfghanistanfromApril2005toApril2006.

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AprilJune200765INTRODUCTIONOnOctober8,2005,amagnitude7.6earthquakestruckthePakistani-controlledregionofKashmir.ThequakewascenterednearthecityofMuzaffarabad,butthedamagewaswidespread.Theaffectedpopulationwasspreadoveranareaof30,000km2,mostofwhichwasinaccessible.Thefinaldeathtollwasestimatedtobe86,000people,buttheexactfiguremayneverbeknown.Populationdataformanylocationswereincompleteorinaccuratebeforethequake,anditisthusimpossibletoknowwhoperishedorwhosimplymovedaway.Similarly,thefigureof3.5millionpeoplelefthomelesswillremainanestimate.Initialdamageestimatesconductedfromtheairwerealsolow,anditwasnotuntilresponderswalkedthegroundthatthetruemagnitudeofthedestructionwasrealized.Structurescollapsedinternally,leavingtherooflargelyintactbutcrushingallinhabitants.Consequently,thestructuresappearedintactfromtheair,butthegroundtruthwasquitedifferent.ThemultinationalresponsetoassistthepeopleofKashmirwastremendous.TheUnitedNations(UN),theWorldHealthOrganization,militaryforcesfromseveralnations(includingAustriaandAustralia),theUSDepartmentofState,andnumerousnongovernmentalorganizationsconvergedontheaffectedareatoprovidevaryingtypesandlevelsofaid.RESPONSEBACKGROUNDTheUSmilitaryimmediatelyrespondedwithhelicoptersfromAfghanistan(relocatedintoPakistan)whichairliftedsuppliestoremotevillagesandbroughtoutthewounded.ThiswasfollowedbytheformationoftheDisasterAssistanceCenterPakistan(DACPAK)onOctober10.ThisNavy-ledtaskforce(TF)washeadquarteredinthecapitalcityofIslamabadandhadcommandandcontrolofallUSmilitaryassetsrespondingtothedisaster.UnderDACPAKwasthe212thMobileArmySurgicalHospital(MASH),thecommandelementofMedicalTF212,operatingoutofMuzaffarabad.ThemainbodyoftheMASHarrivedatMuzaffarabadonOctober25.ThepreventivemedicinesectionofMedicalTF212consistedofpersonnelfromtheUSArmyCenterforHealthPromotionandPreventiveMedicineEurope(USACHPPMEUR),the133rdMedicalDetachment,the100thMedicalDetachmentVeterinaryServices,andtheNavyEnvironmentalandPreventiveMedicineUnit7.Thespecialtiesrepresentedbytheteamincludedentomology,environmentalscience,epidemiology,foodinspection,infectiousdiseases,preventivemedicine,andpublichealth.Thepreventivemedicineteamultimatelyincluded12personnel,butduetopersonnelshifts,nomorethan10personnelwereassignedtotheteamatanytime.Therewereonly7personnelontheteamduring75%ofthedeployment.PREDEPLOYMENTSUPPORTPriortodeployment,thepreventivemedicineteamprovidedmedicalthreatconsultationtothetaskforceleadership.ItwasinitiallyunclearintowhichareaofKashmirtheMASHwoulddeploy,andthreatsimposedbyavarietyofenvironmentshadtobeevaluated.Deployingpersonnelwerebriefedonhighaltitudeoperations,coldweatheroperations,rabies,communicablediseasesendemicinthearea,hygieneandsanitation,malariapreventionandprophylaxis,pre-andpostdeploymentmedicalrequirements(eg,vaccination),andotherstandardpredeploymenttopics.SincehealththreatdataindicatedaveryhighriskofrabiesinPakistan,weelectedtofollowaselectivevaccinationstrategy,vaccinatingonlythoseathighestriskforexposureonandoffbasethepreventivemedicineteam.Theteamalsoevaluatedthemalariathreatbasedupongeographical,climatic,andhistoricalPreventiveMedicineSupporttoOperationLifeline:Pakistan2005CPTE.OwenPrice,MS,USALTCDavidF.West,MS,USAMAJJamesD.Mancuso,MC,USA

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66ArmyMedicalDepartmentJournaldataandsuggestedthatthelowriskofmalariadidnotmakechemoprophylaxisnecessary.However,theMASHcommandelectedtoremainconsistentwithUSCentralCommand(USCENTCOM)policyandrequiredchemoprophylaxisthroughoutthedurationofthedeployment.BASECAMPSUPPORTFollowingdeployment,thepreventivemedicineteamwasinitiallytaskedwithabasesupportroleandwasresponsiblefortheinitialsetupofthetaskforcebasecamp,aswellassupporttotheaircraftrefuelingpointlocatedattheMuzaffarabadairport.Thisincludedtheproperplacementoflatrines,drainageforshowersandlaundryfacilities,trashdisposalsites,anddesignofthehospitalsmedicalwastedisposalsystem.TheMASHdeployedwithwoodenlatrineboxesthatwereintendedtobeusedwithmetalbarrelsforcollectionandburningofwaste.Thebarrelsdidnotarrivewiththeboxes,however,andreplacementbarrelshadtobepurchasedfromthelocaleconomy.Burningofwastewasnotalongtermsolution,asPakistaniguardsexpressedadislikeforthesmokeandMASHpersonnelexpressedadislikeforburningwaste.TheboxesweremodifiedforuseasdeeppitlatrinesandpitsweredugbytheNavalMobileConstructionBattalion74,colocatedwiththeMASHonthebasecamp.Properdisposalofregulatedmedicalwastewasaproblemforotherhospitalsinthecity,andasafeandreliablesystemhadtobeinplacebeforetheMASHbeganreceivingpatients.Thetaskfelltothepreventivemedicinesection,andaburnandburyplanwasdeveloped.Small,forklift-movablecontainerswereinstallednearthehospital,andalargepitwasconstructedseparatefromtheregularwastepit.Completeincinerationwasassuredforeachloadofwaste.ThesystemworkedefficientlyandavisitinghealthteamfromtheUNstatedthatitwasthemodelforotherfacilitiesstrugglingtocopewiththegrowingquantitiesofmedicalwaste.Asthecampsbecamebetterestablished,thepreventivemedicineteamtookonamaintenancerole.Basecampassessmentswereconductedonaweeklybasiswithrecommendationsprovidedtothecompanylevelcommanderforaction.Areasoffocusincludeddrainage,noiselevels,properwastedisposal,livingspacewithinsleeptents,conditionoflatrines,qualityofwaterproducedbythecampsreverseosmosiswaterpurificationunit,andanyotherareasofconcernPreventiveMedicineSupporttoOperationLifeline:Pakistan2005 PreventiveMedicineSupportMajorEvents Earthquake, 8Oct2005 Oct05 Oct05 Feb06Feb06Jan06Jan06 Dec05 Dec05 Nov05Nov05 USACHPPMEUR NotifiedforPossible Deployment(9Oct) Deployment(22Oct) Arrivedin Muzaffarabad (24Oct) ArrivalofNEPMU7 Personnel(22Nov) Departureof NEPMU 7Personnel (18Dec) FinalOutreach Mission(11Feb) FirstOutreach Mission(12Nov) Departed Muzaffarabad (16Feb) Arrivedin Ramstein Germany(21Feb) U SNavyConstruction BattalionArrivedinMuzaffarabad(27Oct) Openingof ContractedDining Hall,SpikeinDNBI (24NOV) USNavyConstructionBattalionRedeploys(13Feb) TIMELINEPREVENTIVEMEDICINESUPPORTOFOPERATIONLIFELINE Theteamwasreadyfordeploymentwithin24hours. Thedelaybetweennotificationanddeploymentwas duetolimitedavailabilityofairliftassets.

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AprilJune200767identifiedduringtheinspection.Thecampassessmentsalsoincludedwatertestingandaninspectionofthediningfacility.Responsibilityforcorrectingmanyoftheissuesfelltothetaskforcesfieldsanitationteam,whichwastrainedandsupervisedbythepreventivemedicinesection.Vectorcontroloperationswerelimitedtofilthflycontrolinvolvingresidualtreatmentsoflatrineboxesandplacementofbaitstations.Foodservicesanitationinspectionsbecameacriticalmissionasthetaskforcemovedawayfrommeals-ready-to-eattocontractedmealservice.Theteamsfoodinspectorbecameavaluableasset.Failuretouseapprovedfoodsourcesandlowholdingtemperatureswerethemostcommoninfractions,buttherewasageneraldeficitinsanitaryfoodservicetechniques.Thepreventivemedicinesectionprovidedafoodservicecoursetothecontracteddiningfacilityworkersandmanagers,andtheinstancesofminorviolationsdroppedconsiderably.Thepreventivemedicineteamalsoconductedbaselineenvironmentalsampling.Concernswereraisedabouttheever-presentcloudofdustoverthecity,andsamplingwasconductedtoassesstherisksposedbyparticulatematterlessthan10mindiameter.Surfacesoilsamplingwasconducteduponarrivalandjustpriortoredeployment,bothattheMASHbasecampandattheaviationrefuelingpoint(locatedattheMuzaffarabadairport),sothatanyenvironmentalchangescausedbytheUSpresencecouldbeevaluated.Adeploymentscreeningkitwasusedtoevaluatewaterusedforcookingandhygiene.InadditiontosupportingtheMASHandtherefuelingpoint,thepreventivemedicineteamprovidedsupporttopersonnelbasedatthemilitaryairbaseinIslamabad,andtopersonneltemporarilyassignedtotheUSEmbassyinIslamabad.Foodservicesanitationinspectionswereconductedattheembassy,at3houseswherecateredfoodwasprovidedtoUSpersonnel,andatthediningfacilityatthemilitaryairbaseatQasim.Gastrointestinalillnessinvestigationswerealsoconductedwhenthenumberofcasesincreasedbeyondbaselinerates,whichhappenedtwiceatthemilitaryairbase.TheseinvestigationswereconductedincollaborationwiththeAustralianArmedForces,astheyalsosufferedgastrointestinalillnessabovethebaselinerates.PATIENTTRACKINGAkeycomponentofthebasesupportmission,andonethatcontinuedthroughoutthedeployment,wasthetrackingofdiseaseandnonbattleinjury(DNBI)forbothUSandPakistanipatientsseenattheMASH.Withinadeployedmedicalfacility,theCompositeHealthCareSystemIITheater(CHCSII-T)isusedtotrackpatientdata.AlthoughUSCENTCOMpolicymandatestheuseofCHCSII-Tindeployedlocations,thesystemwasnotavailabletotheMASHatthetimeofdeployment.Consequently,theMASHusedtheJointPatientTrackingApplication(JPTA).Thereareseveraldifferencesbetweenthesystems,twoofwhichdirectlyimpactedDNBItrackingduringthemission.InCHCSII-T,thephysicianenterspatientdataintothesystematthetimeoftheconsultation.Dataarethusrecordedimmediatelywithlittlechanceforerror.InJPTA,however,dataareinputbypatientadministrationtechniciansatalatertimewithpapermedicalrecordsasareference.Thisresultedindataofvaryingqualityandfrequentcodingerrors.Forexample,apatientwouldidentifykneepainasachiefcomplaint,andthephysicianwouldrecordthevisitasamusculoskeletaloroveruseinjury.Thetechniciancodingthevisit,however,wouldcodethevisitbythechiefcomplaintasTBoftheknee,whichisadiagnosisofTuberculosisoftheknee.Theseerrorsincodingmayhavebeencausedbytechnicianunfamiliarityanddifficultiesinadaptingtothesystem.Additionally,somepatientvisitswerenotrecordedatall,eitherthroughunfamiliaritywiththeJPTAtoolorthroughlostpaperwork.Documentswereoftenlostinpaperworkpilesorwithinthepaperworkgiventothepatientsthemselves.ThesedifficultieshighlighttherapidlychangingnatureofDNBIsurveillancetools,aswellastheneedforconstantvigilanceandcareful

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68ArmyMedicalDepartmentJournalmonitoringofthedatatoensuredatacompletenessandquality.Anotherdifferencebetweenthe2systemsisthelinktotheJointMedicalWorkstation(JMEWS),theclassifiedsystemusedtocompilepatientdataamongthevariousmilitaryservices.ThereisalinkbetweenCHCSII-TandJMEWSwhichupdatesautomatically,butthisisnottrueofJPTA.DatafromJPTAmustbemanuallyenteredintoJMEWS,aprocessinvolvingaccesstoasecretlevelcomputerterminalandenoughtimetomaketheentries.Thebottomlineisthatanallencompassingsystemforpatientdataentryandtrackingdoesnotexist.Eachsystemhaspositivesandnegatives,andtheprocessofcapturingsurveillancedataisstillevolving.PatientdatatrackingallowedtheteamtoobservetrendsamongTFpersonnel,andthisviewadequatelycomplementedinformationcollectedduringcampinspections.Thismultifrontapproachallowedtheteamtofocusitseffortsonareasofconcernandresolvemanyissuesbeforetheybecameproblems.TheaverageDNBIrateamongUSmilitaryatCampResolutewas6.4%(range:<2%to>10%).AsshowninFigure1,gastrointestinalillnessrepresentedthegreatestnumberofsickcallvisits.WhenanincreaseingastrointestinalillnesswasnotedamongMASHpersonnel,theteamsepidemiologistwasabletoconductathoroughinvestigationwhichincludedpatientinterviews.Possiblesourcesofinfectionwereeliminatedthroughincreaseddiningfacilityinspectionsandwatermonitoring,aswellastheidentificationofcommonalitiesamongpatients.Allcaseswerenonbloodyandnontoxic,andseveralstoolsamplesweresubmittedtolocallaboratoriesforculturetoconfirmtheabsenceofbacterialpathogens.Allresultswerenegative,andthepresenceofaNorwalk-likeviruswasconsideredlikely.Occurrencesofsuchvirusesarenotatypicalofsuchdeployments.1AnalysisofPakistanipatientdatapresentsaninterestingviewofhowPreventiveMedicineSupporttoOperationLifeline:Pakistan2005 PakistaniDNBI--TaskForce212020040060080010001200140016001800 23-Oct-05 6-Nov-05 20-Nov-05 4-Dec-05 18-Dec-05 1-Jan-06 15-Jan-06 29-Jan-06 Weekof N u m b e r o f v i s i t s ( # ) Dermatologic--All GI-Infectious Heat/ColdInjuries Injury,Other Respiratory-All Fever,Unexplained TotalDNBI Figure2.NatureofPakistanicivilianDNBIcomplaintspresentingattheMASHduringOperationLifeline. PakistaniDNBITaskForce212 Weekof Figure2.NatureofPakistanicivilianDNBIcomplaintspresentingattheMASHduringOperationLifeline. USPersonnelDNBITaskForce2120.00%2.00%4.00%6.00%8.00%10.00%12.00% 23-Oct-05 6-Nov-05 20-Nov-05 4-Dec-05 18-Dec-05 1-Jan-06 15-Jan-06 29-Jan-06 Weekof(SundaytoSaturday) R a t e o f v i s i t s Resp Injury AcuteGI Heat/cold Psych Total Figure1.NatureofUSmilitarypersonnelDNBIcomplaintspresentingatCampResoluteduringOperationLifeline. USPersonnelDNBITaskForce212 Weekof(SundaytoSaturday) Figure1.NatureofUSmilitarypersonnelDNBIcomplaintspresentingatCampResoluteduringOperationLifeline.

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AprilJune200769patientcarechangedfromtheonsetofthereliefeffortthroughthecourseoftheMASHsoperationsinPakistan.ItwasexpectedthattheMASHwouldseeprimarilytraumaticinjuries,butthiswastrueonlyatthebeginning.TheDNBIdata,showninFigure2,reflectsatransitionfromtraumaticprimaryeffectsintosecondaryandtertiaryeffects,andthenatransitiontowardscareofroutineandchronicillnessesnotnecessarilyassociatedwiththeearthquake.COMMUNICABLEDISEASESRelatedtotrackinghostnationpatientdatawastheinvestigationofcommunicablediseaseoutbreaks.Thesediseases,rareintheUnitedStates,includedoutbreaksofmeasles,tetanus,diphtheria,meningococcus,andscabies.Thereweremanychallengesassociatedwithtrackingdowntheseoutbreaks,someduetothechaosfollowingtheearthquake,othersinherentinthewaypopulationdataandvitalstatisticswerekepthistorically.Theearthquakeitselfisolatedmanyremotevillages,makingthemaccessibleonlybyairorbylonghikesoverdifficultterrain.Evenifvillagescouldbereached,patienthomeofrecordinformationwasofteninaccurateorvillagerswerenotfamiliarwitheveryoneintheirownvillage.Inoneinstance,thepreventivemedicineteamtraveledbyairtothevillageofSarliSatcheltovaccinatecontactsofadiphtheriapatient,onlytobetoldthepatientdidnotliveinthatvillage.Theteamhikedtoasecondvillagetobetoldthatthepatientdid,infact,liveinthefirstvillage.Otherproblemsincludedalackofcommunicationbetweenthevariousreliefagencies.Oftenateamwouldtraceanoutbreaktoavillagebutarrivetofindoneormorereliefagenciesalreadyworkingthere.Thisunnecessaryexpenditureoftimeandresourcescouldhavebeenpreventedifgoodcommunicationschannelshadbeenestablishedfromtheonset.Itisdifficulttoknowwhethertheseoutbreakswereoccurringingreaterfrequencyduetotheearthquakeandthecrowdedconditionscommonincampsforinternallydisplacedpersons(IDP).Theaccuracyofhistoricaldataisquestionableatbest,butitindicatesmanyofthesediseasesmeasles,diphtheria,hepatitis,tetanus,andmanyotherswereoccurringatthesamelevelsasexperiencedpriortothequake.AspatientsarrivedattheMASHsufferingfromthesecommunicablediseases,theneedforisolationfacilitiesgrew,asdidthenumberofquestionsthepreventivemedicineteamreceivedconcerninginfectioncontrol.Noidealsetupfortheisolationofpatientswithcontagiousrespiratoryillnessesexisted,butamakeshiftisolationcellwasbuiltusingplasticsheets.ThelackofisolationfacilitieswithintheMASHhighlightscommonalitieswithcombatsupporthospitalsinIraqandAfghanistanandtheneedtobetteraddressinfectioncontrolissuesindeployedtheaters.2ThisisparticularlytrueinlightoftheAcinetobacterissuesseeninboththeaters.3Intestinalparasiteswerealsocommon,andthepreventivemedicineteamansweredquestionsaboutthelikelihoodofparasitesbeingspreadtootherpatientsortoproviders.Similarly,providerssoughtadviceonprotectionfromscabiesastheconditionbecameessentiallyubiquitousamongearthquakevictims.Basicconcerns,suchaslatrineusagebypatientsandfamilymembers,becameaninfectionconcernwhenitwasdiscoveredthatthetraditionalstyleoflatrineutilizedbyUSforceswasunfamiliartomostPakistanis.TheMASHdeployedwithseveralbox-stylelatrinesequippedwithseats,butasquat-stylelatrinewasfarmorecommoninPakistan,andmanypatientsandfamilymembersweresimplyunabletousethelatrines.Someweresounwillingtousethemthattheyurinatedinhospitalhallwaysanddefecatednearthelatrineboxes.Thesituationwasremediedbythepurchaseofseveralsquat-stylelatrineplatesandtheNavysmodificationoftheboxlatrinestoaccommodatetheplates.OUTREACHPROGRAMOncethebasecampwasstabilized,thepreventivemedicineteambeganlookingformoreopportunitiestoleavethecampandworkwithinthecityofMuzaffarabadandbeyond.TheseopportunitiescamefirstintheformofsupporttoIDPcampsastheteamsinvolvementwiththeUnitedNationsChildrensFund(UNICEF)waterandsanitationcluster.Theteamdidnothavethecapabilitytodiglatrinesorsupplywater,butitcouldprovidetechnicalsupportthroughsanitaryinspectionsandthetestingofdrinkingwater.InspectionsweredocumentedonastandardizedUNICEFform,andfeedbackwasprovideddirectlytoUNICEF.Resourcesandmaterialscouldthenbedirectedtowheretheyweremostneeded.Theteam

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70ArmyMedicalDepartmentJournalhadverylimitedabilitytodirectlyenactchangewithinthecampsandcouldoftenonlymakerecommendationstoUNICEForcampmanagers.Therecommendationswerenotalwaysimplemented.ThelargestcomponentofthepreventivemedicinemissionwasonethatstartedoutonasmallscaleandgrewtobeoneoftheMASHshighest-visibilitymissions.WhenavaccinationinitiativewasundertakenbythelocalgovernmentandUNICEF,thepreventivemedicineteamofferedtoassistinreachingtheprogramsgoalofvaccinating800,000childrenagainstmeaslesovera2-weekperiod.Numerousnongovernmentorganizations(NGOs)alsosupportedthiseffort.Whentheinitialdriveended,thepreventivemedicineteamcontinuedprovidingvaccinationswithinandbeyondMuzaffarabad.ThecontinuationoftheprogramwaspossibleinpartbecauseitwasaverysmalllogisticalburdenfortheMASH.AllvaccinesandsupplieswereprovidedbyUNICEFtothePakistaniMinistryofHealth(MOH),aswellasNGOsandotherrelieforganizations,includingtheUSmilitary.Inadditiontomeasles,theteamprovidedvaccinationsagainstdiphtheria,tetanus,andpolio,andVitaminAtoreducetheeffectofmeasles.Personnelchallengesincludedatrainingdeficitastraditionallynonclinicaloccupationalspecialties(entomologists,preventivemedicinetechnicians,andfoodinspectors)requiredtrainingbeforevaccinescouldbegiven.Thehightempoofthemissionandlargegeographicalareacoveredalsomeanttheteamwascontinuallyonthego,butmedicalandnursingpersonnelassetsfromwithintheMASHwereusedtoaugmentthepreventivemedicineteam.ThevaccinationprogrambecametheMASHsMedicalOutreachProgramasitincorporatednutritionandwellbeingsurveysandthewaterandsanitationinspections.Bythetimetheoutreachprogramended,theteamhadgiven16,205vaccinationsto6,050peopleinmorethan50villages,schools,andIDPcampsintheMuzaffarabadarea.Thepopulationwell-beingprogram(11campsvisited,316patientcontacts)resultedinanaccurateandtimelydescriptionofthehealthstatusoftheIDPpopulationinMuzaffarabad.TheMOHfortheMuzaffarabadDistrictincorporatedthewaterandsanitationassessmentstodevelopadistrict-wideneedsassessmentthatwasbriefedtothemilitarychiefofthemedicaleffortintheregion.Inadditiontomedicaltasks,theteamalsodistributedapproximately200boxesofclothing,blankets,andtoysdonatedbytheAmericanpeople,andraisedfundstopurchasebooksforalocalschool.Theoutreachprogrammayhavehadthebiggestlong-termhealthbenefittothepeoplelivingintheaffectedareaofanyoftheUS-ledreliefprograms.Thehealthbenefitsofthevaccinationswillbefeltfordecades,andtheteamsfrequentpersonalcontactswithPakistanisgavetheUSapersonalface,whichresultedinastrongpositiveimpactonPakistani-USrelations.LIAISONEFFORTSTheoutreachprogramwasnotastandaloneeffort,however,andthepreventivemedicineteamworkedcloselywithseveralorganizationsthroughthecourseofthemission.Theclosestandmostimportantrelationshipwaswiththehostnationsmilitary.Pakistanimilitaryandpoliceforcesprovidedallsecurityfortheoutreachprogramanditsteammembers.Theywerealsoveryfamiliarwithregionalroads,andmanyprovidedvaluabletranslationassistance.CollaborationwiththePakistaniArmyMedicalDepartmentwasessential,andthemedicalpersonnelprovidedinformationonremotelocationsthatwerenotreceivingaid.Theycoordinatedhelicoptertransportationtomanyareas,andtheypossessedawealthofknowledgeontheprevalenceofcommunicablediseasesandvaccinationcoverage.Similarly,liaisoneffortswiththeWorldHealthOrganization(WHO)epidemiologycellkepttheteamabreastofdiseaseoutbreaksandprovidedanavenuethroughwhichdiagnosticsamplescouldberouted.Additionally,theWHOcollectedallpatientinformationfromareahospitalsandcloselytrackedemergingissues,providingdirectfeedbacktorelieforganizations.ThepreventivemedicineteamalsomaintainedacloserelationshipwithUNICEF,attendingboththehealthandwater/sanitationclustermeetingsonaregularbasis.TheclusterconceptwasintroducedbytheUNforearthquakereliefoperations,andreviewsweremixed.Theintentoftheconceptwastoappointaleadagencywithineachreliefsectorandtoimprovecoordinationbetweenreliefagencies.InPakistan,10clusterswereestablishedthatfocusedonhealth,emergencyshelter,waterandsanitation,logistics,campmanagement,protection,foodandnutrition,informationtechnologyandcommunications,education,andreconstruction.Theconceptwasstrong,asitallowedthefocusofresourcesandtechnicalPreventiveMedicineSupporttoOperationLifeline:Pakistan2005

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AprilJune200771specialties.Unfortunately,individualsappointedtoleadtheclustersoftenlackedtheexperience,technicalknowledge,orleadershipskillstoeffectivelyconductthemeetings.Asaresult,prioritieswereoftenincorrectlyset,andcommunicationsamongreliefagencieswerepoor.WorkingrelationshipswithothermilitariesandNGOsvariedbygroup.TheoutreachteammaintainedapartnershipwiththeAustrianarmedforceswhichmaintainedareverseosmosiswaterpurificationunitanddeliveredwatertomostoftheIDPcampswithinMuzaffarabad.TheoutreachteamworkedwithinthecampstoverifywatersanitationwhiletheAustriansworkedtopurifywaterandestablishadeliverysystemthatensuredasafeproductfrompurificationtodelivery.EncounterswithCubanhospitalsweretense,andseveralNGOschosetodistancethemselvesfromanymilitaryactivities.Forexample,ateammembertookaphotographofhimselfnearaMedecinsSansFrontieres(MSF)sign,andanorganizationmemberbecameveryupset.HeproclaimedthatMSFisonlysuccessfulbecauseithasnoaffiliationswithgovernmentsandmilitaries,andtohaveaphotowithanMSFsignandaUSmilitarymembercouldbedetrimentaltotheircredibility.Othergroupswelcomedthesanitaryinspections,technicaladvice,andwatertestingcapabilitiestheoutreachteambrought,astheyeitherlackedthosecapabilitiesorappreciatedtheopportunitytofocusonotherareas.Thepreventivemedicineteam,USStateDepartment,andtheUSAgencyforInternationalDevelopment(USAID)workedwelltogetherinthemajorityofcases,buttherelationshipscouldhavebeenimproved.ThepreventivemedicineteamwaslimitedinitsabilitytoleavetheMASHbasecampearlyinreliefoperations,whichmayhaveinfluencedUSAIDsviewoftheteamasausefulresource.Additionally,thehighturnoverrateamongUSAIDpersonnel(teamsrotatedapproximatelyeverymonth)madeitdifficulttoformcontactsandestablishgoodrelationships.Whateverthereason,thepreventivemedicineteamenjoyedahotandcoldrelationshipwiththeseagenciesthatcoulddefinitelybeimprovedduringfutureoperations.ItwouldbeofvaluetoestablishastrongrelationshipbetweenthemilitaryandUSAIDbeforethenextdisasteroccurs.Mostimportantly,asinglepointofcontactshouldbeestablishedwithineachorganizationthatcouldfacilitatebetterinteractionandcommunication.Pre-eventtrainingthatincorporatesbothDepartmentofDefenseandUSAIDpersonnelwouldallowbetterinteractionamongorganizationsduringthenextreliefoperation,andamorestructureduseofavailableresources.TheMASHsmedicaloutreachteamundoubtedlydemonstratedthatmilitarypreventivemedicinedoeshavearoletoplayindisasterresponse,withinwhichtheycanbeaveryeffectivetool.TheMASHalsoretainedacloserelationshipwiththemedia,andtheoutreachteamwasincludedinthecoverage.Somereportersprovedhostile,otherswerepreciselytheopposite.Overall,thecoveragewaspositive,andstoriesappearinginlocalpaperswerevaluableinimprovingtheimageoftheUSmilitarypresence.Mediapresencewasnotalwaysabenefit,however,asschedulematchingbetweenthemediaandvisitingdignitariessometimesledtothereschedulingofoutreachmissions.Achangeinplanwaseasyenoughfortheteam,butthelocalpeopleoftentraveledgreatdistancestohavetheirchildrenvaccinated.Achangeinthedatemeanteitherwaitingintheareaforthenextopportunityorreturningtotheirvillageswithoutvaccination.MISSIONCHALLENGESTheoutreachmissionhadtoovercomethechallengesofsecurityandtransportinordertobesuccessful.AllUSpersonnelwereentirelydependentuponthePunjabiRangersortheEliteNationalPoliceforsecurity,bothwithinthecompoundandwhileoutonmissions.Theoutreachteamreliedonthemtoprovideconvoysecurity,trafficcontrol,crowdcontrol,andeventranslationassistancewhenneeded.Aswithanyforce,somememberswereveryattentivewhileotherswerenot.Securitywasanonnegotiablerequirementintheeyesofthehostnation,butescortswerenotalwaysavailableorwerenotalwaysreadyontime.Thissometimesresultedinthecancellation,oratleastadelay,ofmissions.Asmentionedearlier,anysuchoccurrencewasalwaysahugedisappointmentforthelocalpopulation.Roadconditionsthroughouttheregionposedanobstacletotransport,aswellascreatingunpredictableandoftendangeroustravelingconditions.WhileroadswithinMuzaffarabadremainedlargelyintact,virtuallyallroadsoutsidethecitysuffereddamage.ThemainroadsintotheNeelumandJellumrivervalleyswere

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72ArmyMedicalDepartmentJournalimpassibleforthefirstmonthofreliefefforts,andlaterwereonlymarginallypassable.Forthefirst2months,theoutreachteamused3M998HMMWVs*tonegotiatetheroads,buttheyweresimplytoowideandtooheavytobesafeonthelooseandnarrowroadsthatservedastheonlyaccesstoremotevillages.Theoutreachteamschangedtotheuseofsportutilityvehicleswhichconsiderablyimprovedtheoverallsafetyofoutreachmissions.Whileairtravelwouldhavebeenabettermeansoftravelinsomecases,itwasnotalwaysavailable.Airassetswerelimitedlessbynumberandmorebypriority,withfoodandsupplyliftsandmedicalevacuationshavinghigherpriority.CONCLUSIONThereliefoperationwasanextremelyrewardingexperienceforallinvolved,aswellasagreatlearningopportunity.The212thMASHwasaproactiveorganizationthatutilizedpreventivemedicineassetsfromtheoutset,allowingtheteamtopracticepreventiveratherthanreactivemedicine,andencouragingoutreachprogramsthatpositivelyaffectedUSreliefoperations.TheeffortsoftheUStaskforcenotonlyreducedtheongoingandfuturesufferingofthoseaffectedbytheearthquake,butalsomadeconsiderableprogressinreversingthenegativeimageofAmericansheldbymanyKashmiris.Thepreventivemedicineteamdemonstratedthatmilitarypreventivemedicineandpublichealthhasaclearmissionindisasterreliefandhumanitarianoperations,andthatitcanperformthismissionwell.RelationshipswithotherUSagencies,suchasUSAID,shouldbeimproved,andcollaborationbetweenagencieswouldimprovefuturereliefmissions.Theestablishmentofpointsofcontactandconductingofdual-agencytrainingeventspriortothenextdisasterwouldsetthestageforastreamlinedUSresponse.ACKNOWLEDGEMENT Thesuccessofthepreventivemedicinemissionwouldnothavebeenpossiblewithoutthediligenteffortsofeachteammember.LTCWest,TeamLeaderMAJMancuso,EpidemiologistLCDRJobanputra,USN,InfectiousDiseasePhysicianLTLyons,USN,EnvironmentalHealthOfficerCPTPrice,EntomologistSFCGarcia,TeamNCOICSGTRussell,PreventiveMedicineNCOSGTRivera,FoodInspectorHM1Pallesco,USN,PreventiveMedicineNCOSPCFinucane,PreventiveMedicineSpecialistSPCChoate,PreventiveMedicineSpecialistREFERENCES 1.CentersforDiseaseControl.OutbreakofacutegastroenteritisassociatedwithNorwalk-likevirusesamongBritishmilitarypersonnelAfghanistan,May2002.MMWR.2002;51(22):477-479.2.SchofieldCM,MurrayCK,HorvathEE,CancioLC,KimSH,WolfSE,HospenthalDR.BacteriarecoveredfrompatientsadmittedtoadeployedUSmilitaryhospitalinBaghdad,Iraq.MilMed.2006;171(9):821.3.CentersforDiseaseControl.AcinetobacterbaumanniiinfectionsamongpatientsatmilitarymedicalfacilitiestreatinginjuredUSservicemembers,2002-2004.MMWR.2004;53(45):1063-1066.PreventiveMedicineSupporttoOperationLifeline:Pakistan2005 *HighmobilitymultipurposewheeledvehicleAUTHORS CPTPriceisamedicalentomologistintheEntomologicalSciencesDivision,USACHPPMEUR,Landstuhl,Germany.LTCWestisChiefoftheEntomologicalSciencesDivision,USACHPPMEUR,Landstuhl,Germany.MAJMancusoisanepidemiologyfellowattheUniformedServicesUniversityofHealthSciences,Bethesda,Maryland.

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SUBMISSION OF MANUSCRIPTS TO THE ARMY MEDICAL DEPARTMENT JOURNAL The United States Army Medical Department Journal is published quarterly to expand knowledge of domestic and international military medical issues and technological advances; promote collaborative partnerships among the Services, components, Corps, and specialties; convey clinical and health service support information; and provide a professional, high quality, peer reviewe d print medium to encourage dialogue concerni ng health care issues and initiatives. REVIEW POLICY All manuscripts will be reviewed by the AMEDD Journal s Editorial Review Board and, if re quired, forwarded to the appropriate subject matter expert for further review and assessment. IDENTIFICATION OF POTENTIAL CONFLICTS OF INTEREST 1. Related to individual authors commitments: Each author is responsible for the full disclosure of all financial and personal relationships that might bias the work or information presented in the manuscript. 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