Citation
U.S. Army Medical Department journal

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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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FORCE HEALTH PROTECTION April – June 2009 Perspective 1 MG Russell J. Czerw Joint Environmental Site Assessments in Support of Global Basing 6 LTC Timothy G. Bosetti, MS, USA Evaluation of Exposure Incident at the Qarmat Ali Water Treatment Plant 10 Coleen Baird Weese, MD, MPH Cohort Case Studies on Acoustic Trauma in Operation Iraqi Freedom 14 MAJ D. Scott McIlwain, MS, USA; MAJ (Ret ) Bryan Sisk, AN, USA; Melinda Hill, AuD Provider Resilience: The Challenge for Behavioral Health Providers 24 Assigned to Brigade Combat Teams LTC (Ret) Larry Applewhite, MS, USA; LTC (P) Derrick Arincorayan, MS, USA The Unit Field Sanitation Team: A Square Peg in a Round Hole 31 LTC Timothy Bosetti, MS, USA; CPT Davin Bridges, MS, USA Prisoner of War Camps: Lack of a Revolution 34 LTC Jennifer Caci, MS, USA; LTC Joanne M. Cline, MS, USA The Reporting and Recording of Unspecified Malaria 42 in the Military, 1998–2007 LTC Joseph K. Llanos, MC, USA Improvement of Force Health Protection Through 46 Preventive Medicine Oversight of Contractor Support MAJ Scott A. Mower, MS, USA Health Sector Development in Afghanistan: The Way Forward 51 Maj Paul Brezinski, MSC, USAF; et al Army Transformation and Level II Preventive Medicine 58 within a Deployed Division Task Force MAJ Kenneth D. Spicer, MS, USA Control of Concealing Vegetatio n Along Rural Routes in Iraq 62 CPT Dennis M. Rufolo, MS, USA; MAJ Rebecca A. Zinnante, MS, USA; CPT Ryan Bible, MS, USA Fort Carson: An Army Hearing Program Success Story 67 CPT Leanne Cleveland, MS, USA Establishing a Base Camp Assessment Program for a Forward Operating Base 76 CPT Davin Bridges, MS, USA; LTC Timothy Bosetti, MS, USA Army Force Health Protection: Past, Present, and Future 81 E. Wayne Combs, PhD, RN

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LTGEricB.SchoomakerTheSurgeonGeneralCommander,USArmyMedicalCommandMGRussellJ.CzerwCommandingGeneralUSArmyMedicalDepartmentCenterandSchool AprilJune2009TheArmyMedicalDepartmentCenter&SchoolPB8-09-4/5/6 0911102GEORGEW.CASEY,JRGeneral,UnitedStatesArmyChiefofStaff DISTRIBUTION:SpecialAdministrativeAssistanttotheSecretaryoftheArmyByOrderoftheSecretaryoftheArmy:Official: JOYCEE.MORROWOnlineissuesoftheAMEDDJournalareavailableathttps://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1 AProfessionalPublicationoftheAMEDDCommunity TheArmyMedicalDepartmentJournal[ISSN1524-0436]ispublishedquarterlyforTheSurgeonGeneralbytheUSArmyMedicalDepartmentCenter&School,ATTN:MCCS-DT,2423FSH-HoodST,FortSamHouston,TX78234-5078.CORRESPONDENCE:Manuscripts,photographs,officialunitrequeststoreceivecopies,andunitaddresschangesordeletionsshouldbesenttotheJournalattheaboveaddress.Telephone:(210)221-6301,DSN471-6301DISCLAIMER:TheJournalpresentsclinicalandnonclinicalprofessionalinformationtoexpandknowledgeofdomestic&internationalmilitarymedicalissuesandtechnologicaladvances;promotecollaborativepartnershipsamongServices,components,Corps,andspecialties;conveyclinicalandhealthservicesupportinformation;andprovideapeer-reviewed,highquality,printmediumtoencouragedialogueconcerninghealthcareinitiatives.Viewsexpressedarethoseoftheauthor(s)anddonotnecessarilyreflectofficialUSArmyorUSArmyMedicalDepartmentpositions,nordoesthecontentchangeorsupersedeinformationinotherArmyPublications.TheJournalreservestherighttoeditallmaterialsubmittedforpublication(seeinsidebackcover).CONTENT:Contentofthispublicationisnotcopyrightprotected.Materialmaybereprintedifcreditisgiventotheauthor(s).OFFICIALDISTRIBUTION:ThispublicationistargetedtoUSArmyMedicalDepartmentunitsandorganizations,andothermembersofthemedicalcommunityworldwide.

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AprilJune20091Forcehealthprotectionisatermthat,onthefaceofit,appearstorepresentastraightforwardandeasilydefinableconcept.Indeed,ArmyFieldManual4-02characterizesitasfollows:Forcehealthprotectionencompassesthepillarsofahealthyandfitforce,casualtyprevention,andcasualtycareandmanagement.1(p1-1)However,theoldproverb,thedevilisinthedetailsisnowheremoreapplicablethanhere.Anexaminationofeachofthoseelementsrevealsthelevelsofresearch,commitment,planning,application,andresourcesthatarenecessarytoachievethedesiredresultahealthy,fitWarriorinasustainable,effectivefightingforce.Thesecondelement,casualtyprevention,isespeciallydeceptiveinitsseemingsimplicity.However,asFieldManual4-02expandscasualtypreventionintoitscomponents,thecomplexityandscopeinherentinthateffortbegintoemerge:Thesecondpillarconcernsboththeenemythreatandthemedicalthreat.Tocounterthemedicalthreat,comprehensivemedicalandOEH*surveillanceactiv-ities,preventivemedicinemeasuresandfieldhygieneandsanitationcombinedwithpersonalprotectivemeasures(suchasthecorrectwearoftheuniformandtheuseofinsectrepellent,sunscreen,andinsectnetting)mustbeinstitutedandreceivecommandemphasis.Theseactivitiesmustbeconductedcontin-uouslyduringmobilization,predeployment,deploy-ment,postdeployment,anddemobilization.1(p1-2)Ofcourse,thefactorscontainedintheabovedescriptionareacombinationoftheeasilyunderstoodandintuitivelyobvious,(ie,sunscreen)andthosethatrequirededicatedresources,specializedtraining,andoftenexternalsupport(ie,medicalandOEHsur-veillance,hygiene,andsanitation).Asourunderstand-ingoftheinteractions(includingcausesandeffects)ofhumansandournaturalandman-madeenvironmentsexpandsandevolves,wearestilllearningthetrueextentandimportanceofthoserelationships.Fortunately,researchandproactiveeffortsintheenvironmentalsciencesarerecognizedfortheirdirectcontributiontothemedicalsciences,andcollaborationbetweenthedisciplinesisresultinginhealthierpopulationswhereandwhentheknowledgehasbeenapplied.Thisisyetanotherareawherethesynergisticeffectofeffortsbybothmilitaryandcivilianresourcesproducesresultsbeneficialtobothgeneralpopulationsandmilitarymissionaccomplishment.ThearticleswithinthisissueoftheAMEDDJournalareexcellentexamplesoftheworkbyourmilitarymedicalprofessionalsinvariousaspectsofforcehealthprotection.ThesubjectmatterrunsthegamutfromfieldsanitationtothedevelopmentofafunctioningnationalhealthcarestructureinAfghanistan,witharticlespresentingresearchprojects,addressingpreventivemedicineprograms,andlookingattheabsolutelycriticalareaofthehealthandwell-beingofbehavioralhealthprovidersassignedtocombatantcommands.Thiscollectionofferstrueinsighttothediversityandcomplexityofpreventivemedicinescontributionstoforcehealthprotection,andisanothertestimonytothededicatedmenandwomenofmilitaryhealthcarewhoworktirelesslytosupportourWarriorswhomustgointoharmsway. PerspectiveMajorGeneralRussellJ.Czerw *Occupationalandenvironmentalhealth

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2https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1TheUSmilitaryhasalwaysbeenstructuredforforceprojection,takingourcombatcapabilitywhereverintheworlditisnecessarytoprovidearmedforcesforcombatoperations,combattraining,orhumanitarianassistance.Ofcoursethishasbeenourcapabilityformanyyears,andthepotentialfordiseaseindeploymentareashasbeenaddressedsincethelate1800s.However,onlyinthelastseveraldecadeshasthepotentiallydetrimentaleffectsofenvironmentalfactorsonSoldiershealthbecomeavitalconsid-erationintheplanningandexecutionofdeploymentsandoperations.LTCTimothyBosettiscarefullydetailedarticleexplainsthejointenvironmentalsiteassessmentprocessthathasbeendevelopedandimplementedtoprojectandminimizepotentialenvironmentalhazardstoourpersonnel.Theassess-mentalsoallowsplannerstotakemeasurestoprotecttheenvironmentitselffromharmresultingfromthedeployment.LTCBosettisarticlealsoaddressesaninteresting,related,andincreasinglyimportantpurposeofenvironmentalassessments;thedocumentationofexistingconditionsasabaselineforansweringthirdpartyclaimswithregardtoenvironmentaldamage.Unfortunately,eventhoughtheinitialenvironmentalassessmentwillbeaccurateandcomplete,futureenvironmentaldamageattendanttoheavycombatoperationsisusuallyunavoidable.DrColeenWeesereturnstotheAMEDDJournalwithanarticlechroniclingsuchasituationinvolvingpotentialhazardouschemicalexposuretobothciviliancontractorsandSoldiersinBasra,Iraq,in2003.ThearticledescribestheincidentandthecorrectresponseoftheonsiteArmypreventivemedicinepersonnelintheirinitialevaluationandrequestforaspecialmedicalaugmentationresponseteam-preventivemedicine(SMART-PM)fromtheArmyCenterforHealthPromotionandPreventiveMedicine.Theteamquicklyarrivedandmadedetailedassessmentsoftheincident,potentialhealtheffectstoindividuals,andtheprotectiveactionstakentomitigatethehazard.Thiscaseisofparticularinterestbecauseitwasthesubjectofcongressionalhearingsduetoalawsuit,andwasreferredtotheDefenseHealthBoardforreview.DrWeesesarticleisanexcellentillustrationofthestructureinplacetoaddressenvironmentalhazards,andthecapabilitiesoftheSMART-PMtoaugmentdeployedpreventivemedicineresourceswhenthosecapabilitiesareinsufficienttoensurethehealthandsafetyofinvolvedpersonnel.MAJScottMcIlwainandhiscoauthorshavecontributedawell-researched,carefullydevelopedarticledetailingaclinicalstudyofhearingtraumaamongSoldiersinvolvedinoperationsinIraqin2006.Thearticleexaminescurrentresearchonthephysiologyofhearingtraumaindetail,withparticularemphasisonthedamagingnoisesexperiencedduringdeployedmilitaryoperations,inbothcombatandnoncombatsituations.ThoseresearchfindingsareappliedtotheresultsofcohortcasestudiesofhearingtraumapatientsinIraq.Theresultingconclusionsindicatemuchprogresshasbeenmadeintheemphasisonhearingprotection,examination,andtreatmentbytroopleadersandheadquarters,andtherecom-mendationsarelogicalextensionsofthemethodsandtechniquesthathaveachievedsuchmeasurablesuccess.TheirstudyisyetanotherexampleoftheprogressandimprovementsmilitarymedicinecontinuestomakeinpreparingourWarriorsfortheentirespectrumofhazardsofthecombatenvironment.TheJuly-September2008issueoftheAMEDDJournalfocusedonbehavioralandmentalhealthcareofourSoldiersastheyfacethedemandsandstressesoftheGlobalWaronTerror.Inonearticle,Booneetal2describedproviderresiliencytraining,aprogramofinstructionimplementedbytheArmyMedicalDepart-menttopreparethosechargedwithsavinglivesintheworstofenvironmentsforthestressandpotentialpsychologicalpressurestheywillencounter.Intheirarticle,LTC(Ret)LarryApplewhiteandLTC(P)DerrickArincorayanzeroinontheparticularstressesandchallengesfacedbybehavioralhealthproviderswhoaccompanyArmybrigadecombatteamsintothecombattheater.Intheirexcellent,well-researchedarticle,theydescribethefactorsthataffectthoseproviders,oftensubtlyandwithoutdiscerniblesymptoms,astheyworktoalleviatethepsychologicalpainandsufferingoftheirSoldiers.Thearticledetailshowtheeffectivenessofthebehavioralhealth-careproviderscanbeadverselyaffected,whichisonlydetrimentaltothosewhomtheyaresupposedtohelp.Further,likethetraumatizedcombatSoldier,thoseeffectscanbelong-lasting,extendinglongafterthecombatzoneshouldbeadistantmemory.Theauthorsofferaseriesofwell-reasonedrecommendationsforthosewhocreatedoctrineanddesignthestructureofexpeditionaryforces,aswellasthosepractitionerswhoare,orwillbe,directlychargedwiththebehavioralhealthcareofourWarfighters.Perspective 2https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1

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AprilJune20093THEARMYMEDICALDEPARTMENTJOURNALAswithmostsophisticatedthings,preventivemedicinemustsometimesbeexaminedatthebasiclevelstoensurethatitcontinuestoadequatelyaddressthoseneeds.LTCTimothyBosettiandCPTDavinBridgesexaminetheArmysfrontlineofdefenseagainstdiseasefordeployedSoldiers,thefieldsanitationteam(FST).InitiallyinstitutedduringWorldWarII,theFSTareSoldiersspecificallytrainedinhygiene,sanitation,arthropodcontrol,andwaterandfoodsafety.However,theauthorspointoutthatthelongstandingconceptfortrainingandemploymentoftheFSTisnotsuitedfortheexpeditionary,noncon-tiguousbattlefieldenvironmentoftoday,andtheforeseeablefuture.TheyproposethatFSTcapabilitiesmustbedrivendowntothesmallestunitlevel,theplatoon,becausethosesizedunitsareoftenemployedasoutpostsontodaysbattlefield,existingwithoutthefullrangeofsupportfromthelarger,parentunit.ThisexcellentarticledetailstheconsiderationsinherentinrethinkingtheFSTconcept,andthevariousfactorsthatmustbeaddressedtomeettheneedsofthemodernexpeditionaryenvironment.ThepointsmadebyLTCBosettiandCPTBridgesshouldbecarefullyconsideredbythoseplanningthechangestoourforcestructureandtrainingtoaccommodatethelessons-learnedinourcurrentconflicts.LTCsJenniferCaciandJoanneClinehavecontrib-utedanarticlethatlooksatoneoftheunavoidableelementsofwarfare,prisonersofwar(POWs),fromapreventivemedicineperspective.TheyexamineAmericanexperiencewithPOWsthroughoutourhistory,bothasprisonersandcustodians.Theirin-depthresearchrevealsthatonerecurringelementofPOWhistory,forboththeUSandothercombatants,isthefailuretoadequatelyplanforthemanagementandcareoftheprisonersthatwillinevitablybecollectedduringarmedconflicts.Theauthorsrecounttheatrocioussanitation,hygiene,andhealthcaresituationsofPOWsfromtheRevolutionaryWarthroughWorldWarII,anddescribethecircumstancesthatcontributedtothedifficultiesand,insomecases,criminalitiesthatoccurredintheGlobalWaronTerror.LTCsCaciandClinefindthat,forthemostpart,USforceshaveadequatelyaddressedthepreventivemedicineaspectsofprisonerhealthcareoverthelastcentury,butincreasedattentionmustbegiventopreparingthosewhowillmanagetheprisonerpopulation,especiallyinthecurrentcounterinsurgencyenvironmentsofIraqandAfghanistan,andundoubtedlyconflictsofthefuture.Especiallycriticalisthepsychologicalfoundationthatmustbelaid,forboththeleadersandtheSoldierschargedwithmanagingthePOWs.ThisarticlecontainsimportantinformationforeveryonewhoisorwillbeinvolvedwithPOWs,bothinandoutofthemedicalcommunity.Despitethebesteffortsofenvironmentalandmedicalscience,malariacontinuestobeadeadlyscourgeofmanyareasoftheworld.Assuch,itisafactorthatmustbeconsideredintheplanning,execution,andfollow-upofalldeploymentsintoareaswhereitisendemic,andespeciallyintoareaswheredatamaybeinconclusive,buttheenvironmentisfavorabletothediseasevector,theAnophelesmosquitospecies.Symp-tomsofmalariamaymimicthoseoflessseriousconditions,andthereforeitmaybemisdiagnosed,orsuspectedbutnotconfirmed.Theseriousnatureofmalariamandatesthatallcasesarereportedtothemilitaryscentraldatarepositoryforusebyplanners,andforthepatientspermanentmedicalhistory.LTCJosephLlanosinvestigatedcasesofsuspectedmalaria,termedunspecified,amongUSmilitarypersonnelfrom1998through2007.Hegroupedthecasesintoanumberofdemographicandclinicalcategories,anddeterminedthosecharacteristicsmostfavorabletoaconfirmablediagnosisofmalaria.Hisdetailedexam-inationrevealssomeshortcomingsinseveralareasofdiagnosisanddocumentation,includingrecognitionofmalariaininitialandfollowupexaminations,somelaboratoryprocedures,andespeciallyinthedocumen-tationofthediagnosticresultsandfollowupcare.LTCLlanosfindingsandrecommendationsshouldbecarefullyconsideredbyallofusinvolvedinpatientcare,especiallythosepatientswhoare,orhavebeen,involvedindeployments.Along-termpresenceinamaturingtheaterofoperationsallowsthemilitarytoestablishfixedbasecampswhichrequiremoresophisticatedlifesupportservicesthanarepossibleinthefluid,dynamicenvironmentofheavycombatoperations.Large,concentratednumbersofpersonnelcreateheavydemandsforsewageandtrashdisposal,pestcontrol,availabilityoffoodandwater,andotherbasicsan-itationandhygienesupportservices.Thesefunctionsarelargelycontracted,eliminatingtheneedforSol-dierstobepulledfromtheirmilitarydutiestoperformthesemundanetasks.MAJScottMowerpointsoutthatthereareproblems,however,inthatcontractorsareoftenlackingintheknowledgeandunderstandingnecessarytoperformthelifesupportservicestothe

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4https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1Perspectivestandardsrequiredbyourstandards,andhavelittlebasistounderstand,orrespect,contractualrequire-ments.Further,thosechargedwithcontractoversightoftenhavelittlebackgroundinpreventivemedicineandtheenvironmentalsciences,soproblemsincon-tractspecifications,andtheperformanceofthecon-tractorsthemselves,arenotrecognizeduntilserioussituationsdevelop.Theremediesfortheseresultingproblemsareusuallyexpensive,andalwaystime-con-suming.MAJMowerpresentsaseriesof10well-reasoned,fullydevelopedrecommendationstocreateastructuretoensurethatpreventivemedicinepersonnelareinvolvedateverylevelofcontractingforlifesupportservices.Thisisanexcellentpresentationoffactsandrecommendationsthatdeservestheattentionofeveryoneworkinginlifesupportservicesfordeployedpersonnel.AirForceMajPaulBrezinskiandhisteamofcoauthorshavecontributedanimportantpaperlookingatthestateofthedomestichealthcaresituationinAfghanistanandthelargelyuncoordinatedeffortsbyvariousentitiestoaddressthelackofcareandservices.Asthefirstsentenceofthearticlestates:Healthsectordevelopmentisacriticalcomponentofnation-buildingandacornerstoneofanyexitstrategysoitisvitalforeveryoneinvolvedinthecountry,bothforeignandAfghani,toestablishafunctioningnationalhealthsectorasquicklyaspossible.ThelimitedcapabilityandorganizationthatdoesexistwithintheAfghanistangovernmentisexamined,butthearticleconcentratesonthemyriadofexternalresourcesthatarepresentinthecountry,includingmilitary,othergovernmentalagencies,andnongovernmentalorganizations.Thearticledescribestheuncoordinated,fragmented,andoftenisolatedeffortsofthesemultipleagencies,eachapproachingtheircontributiontohealthsectordevelopmentastheyseeandunderstandtheimmediateneed.However,astheauthorspointout,thoseindividual,isolatedcasesofprogressareunsustainableontheirown,asultimatelytheexternalresourcesmustleave.Eachtimeapocketofsuchprogresscollapses,thecredibilityoftheentirenationaleffortisundermined,andnationbuildingonceagainsuffersastepback.MajBrezinskietalhavecapturedthecurrentsituationsuccinctlyandwithclarity,andhavedevelopedaschemebywhichtheexisting,disjointedactivitiescanbebroughtintoastructurethatwillfocustheireffortstowardsthegoalofsomedaytransitioningtoafunctioning,self-sustain-ing,Afghannationalhealthsector.MAJKennethSpicerdescribeshisexperiencesasadivisionenvironmentalscienceandengineeringofficerwhoseunitunderwenttransformationanddeployedtoIraqinSeptember2007.Fromthatperspective,hisarticledescribestheimprovementinforcehealthprotectionthatresultedfromthetransition,andhemakesadditionalrecommendationsastohowtheresultingpreventivemedicineservicesdeliverycanbefurtherimproved.Inhiswell-organizedarticle,MAJSpicerrelatesthedetailsofvariousaspectsofpreventivemedicineacrossthetheater,andclearlydescribesthoseareasthatcouldbenefitfromfurtheradjustmentsindoctrine,especiallywithregardtosomepersonnelassignments.ThisarticleisaninformativeupdateonthecurrentsituationofforcehealthprotectionservicesinIraq.Intheirarticle,CPTDennisRufoloandhiscoauthorsdescribeanenvironmentalsituationwhichlendsitselftoexploitationbyinsurgents,oftenwithdeadlyconsequences.InmanyareasofIraq,densevegetation,inparticularatypeoflargereed,crowdtheedgesofruralroads.Thisvegetationprovidesexcellentconcealmenttoinsurgentswhoemplaceexplosivedevices,and,ofcourse,evenmoreeffectivelyhidethedevicesthemselves.TheauthorsdescribethevariousmethodsthatUSforceshaveemployedinattemptstoeliminatethethreat,butburning,cutting,andcombinationsofthosemethodshaveproventoprovidetemporaryreliefatbest.Moreimportantly,thosemethodsareactuallycounterproductiveifnotperformedduringthecorrecttimeofthereedsgrowingcycle,andaredangeroustothosewhomustdothework.Therefore,commandersfindthattheymustcommittheirSoldierstoafrustratinglyendlesscycleofrepetitive,dangerous,difficultwork.CPTRufoloetalhavecloselyexaminedthefeasibilityofusingherbicidesasamuchmoreeffective,longerlastingreedcontrolmeasure,whichisalsomuchsaferfortheSoldiersandcontractorswhowillperformtheapplications.TheyhaveidentifiedherbicidesapprovedbytheEnvironmentalProtectionAgencywhichareusedeffectivelyintheUnitedStatesforsimilarcontrolapplications.Theirarticledescribeshowtheapplicationequipmentcurrentlyincommonusecanbeeasilyadaptedformilitaryuse,andhowapplicationwouldbeperformedundersupervisionofcertifiedpersonnel.However,thissolutionisnotcurrentlyavailabletomilitarycommandersbecauseofapresidentialexecutiveorder(11850)issuedin1975asaresultofheightenedsensitivitytotheuseof 4https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1

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AprilJune20095THEARMYMEDICALDEPARTMENTJOURNALpotentiallyhazardouschemicalsduringmilitaryoperations.Sincetheexecutiveorderwasissued,greatstrideshavebeenmadeinbothregulatoryoversightandtheformulationofsafe,effectiveherbicidesforcivilianuse,buttheirusebythemilitaryisstillseverelyrestrictedtheorderallowsnoherbicideuse,period,beyondinstallationboundaries.CPTRufoloetalmakeaverystrongcaseforatop-levelreviewoftheexecutiveorderinviewofstate-of-the-artherbicidesandtheirlongrecordofsafeuseincivilianappli-cations.Theirproposalshouldbeseriouslyconsidered,because,unfortunately,IraqwillverylikelynotbethelastlocationwhereourSoldiersarefacedwiththedeadlyproblemofconcealingvegetation.Anarticle3intheApril-June2008issueoftheAMEDDJournaldescribedtheevolutionoftheArmyHearingProgram,establishedtoprovidehearinglosspreventionservicestoArmySoldiersandciviliansinallenvironments,especiallythoseoftrainingandoperationalactivities.Inthisissue,CPTLeanneClevelandsdetailed,well-developedarticledescribestheimplementationoftheprogramatFortCarson,demonstratinghowdedication,planning,commandsupport,andsheerhardworkcanhavesignificantpositiveresultsforallconcerned.TheFortCarsonHearingProgramisoneofthefirstfullimplementationsoftheArmyHearingProgramatalargefacilitywithanincreasingSoldierpopulation,mostofwhomareinvolvedinintensivecombattraininganddeploymentrotations.Theincorporationofeachofthe4elementsoftheprogramisexplainedindetail,withstatisticstoillustratethepositiveresultsforeacharea.ThetargetpopulationoftheprogramatFortCarsonisdynamic,aspreparationsfordeploymentandunitsreturningfromdeploymentoftencoincide.Thepopulationisalsogrowing,asnewunitsarriveorarecreatedatthepost.ThevalueoftheArmyHearingProgramisthusdemonstratedinthemostdemandingofstatesideenvironments,aswellasitsinvaluableroleasavitalenhancementofthehearingprotectioneffortsinplaceinthecombattheaters.CPTClevelandsexcellentarticlecanserveasaguideforaproven,workingmodelimplementationoftheArmyHearingProgram.CPTDavinBridgesandLTCTimothyBosettihavecontributedanimportantarticleaddressingtheabsolutenecessity,andcomplexity,ofpreventivemedicinesurveillanceandassessmentofalltrooplocationsinadeployedenvironment,eventhoughtheymaybegeographicallydispersedacrossanareaofoperations.Theirarticlepresentsalogicaldevel-opmentoftheapproachtothevitalinspectionsanddatamonitoringneededtoreducediseaseandnonbattleinjurycasualtiesthroughproactivemeasures.Forexample,datagatheringisonlytheinitialphaseofanassessment.Thatinformationmustbeanalyzedtoidentifythehazards,evaluatethepotentialriskstheyrepresent,determineriskcontrol,andcommunicatetheinformationtotheforcesforaction.Thisarticleisaclearlywrittentreatmentofthesubject,packedwithinformation,tips,andrecommendationsforourpreventivemedicineprofessionalsontheapplicationoftheexperienceandtheextensiveskillsandknowledgetheyalreadypossess.ThelimitedhealthrelatedinformationavailabletoinvestigatethehealthproblemsofWarriorsreturningfromthefirstPersianGulfconflictin1990and1991promptedcongresstomandatehealthevaluationsofmilitarypersonnelbeforeandafterdeployments,andmaintainthatinformation.However,asDrWayneCombsexplainsinhisinformative,well-documentedarticle,theserviceswereslowtocomplywiththerequirements,andpractitionerswereoftenunawareoftheirexistence.Eventually,thestandards,metrics,andreportingrequirementswereformalizedandmandatedbyaDoDinstruction,followedbytheattendantArmyregulations.Theimplementationofformal,structuredqualityassuranceprogramsatbothDoDandeachoftheservicesmedicalcommandshasstabilizedthecollectionandqualityofthehealthdataformilitarymembersthroughouttheircareers,andciviliansinvolvedinoperationsanddeployments.DrCombsarticleclearlycapturesthehistoryandcurrentsituationofthedatawemusthavetoensurethebestpossiblehealthcareandforcehealthprotectionforourWarriors.REFERENCES 1.FieldManual4-02:ForceHealthProtectioninaGlobalEnvironment.Washington,DC:USDeptoftheArmy;February13,2003.2.BooneRR,CamarilloC,LandryL,DeluciaJ.Armyproviderresiliencytraining:healingthewoundsontheinside.ArmyMedDeptJ.July-September2008:57-59.3.McIlwainDS,CaveK,GatesK,CiliaxD.EvolutionoftheArmyhearingprogram.ArmyMedDeptJ.April-June2008:62-66.

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6https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1THEOPERATIONALENVIRONMENTThecurrentoperationalenvironmentisonethatischaracterizedbyinstabilityandpersistentconflict.Tomeetthischallenge,theArmyistransformingtobecomeamoreexpeditionaryforcewithincreasedglobalreach.Theexpeditionarycapabilityistheabilitytopromptlydeploycombinedarmsforcesworldwideintoanyoperationalenvironmentandoperateeffectivelyuponarrival.Expeditionarycapabilitiesassurefriends,allies,andfoesthattheUnitedStatesisableandwillingtodeploytherightcombinationofArmyforcestotherightplaceattherighttime.Forwarddeployedunits,forwardpositionedcapabilities,peacetimemilitaryengagement,andforceprojectionfromanywhereintheworldallcontributetoexpeditionarycapabilities.Insupportoftheexpeditionarycapability,theArmyneedsforwardbasesandcooperativesecurityloca-tions.Thismassiveeffortofglobalrestationing,repo-sitioning,andrebasingregardlessofshort-orlong-termpositioningofforcesrequiresanenvironmentalassessmenttoensurethatweareprotectingthehealthofdeployedforces,protectingtheenvironment,andprotectingtheUSgovernmentfromthirdpartyclaims.Itiscriticaltoknowthestakeholdersandidentifyandbalancethesamplingrequirementstoproperlydocumentenvironmentalconditions.Partneringisthekeytomakethishappen.STAKEHOLDERSANDREQUIREMENTSEnvironmentalsamplingisdependentupontheperspective.Butwhoarethestakeholders?Experiencehasshownthattherearetypically3majorplayersorstakeholders:theengineers,themedics,andthelawyers,asillustratedinFigure1.Theengineersaretypicallyinvolvedintherealestateprocurement,siteselection,sitelayout,andconstruction.Theengineersarealsoresponsibleforconductingtheenvironmentalbaselinestudy.Preventivemedicinepersonnelareresponsibleforconductingtheenvironmentalhealthsiteassessment,andprovidinganassessmentofthesitefromaforcehealthprotectionstandpointtodetermineifthereisanythingatthesitethatcouldpotentiallyendangerSoldierhealth(acuteorchronic).TheUSArmyClaimsServiceisinvolvedtoprotecttheUSgovernmentfromthirdpartyenvironmentalclaims.Toaccomplishthis,theyalsoconductenvironmentalsurveystodocumentenvironmentalconditions.Threemajorplayers,3differentperspectives,3differentstudiesoneenvironmentalsample.Knowingthestakeholdersandunderstandingthateachhasadifferentperspectivemeansthatthesamplingplancanbecoordinatedtoensuretheneedsofall3partiesareaddressed.Thispartneringcanhavegreatbenefitsinthereductionofenvironmentalsamplingcosts,nottomentiontheintegratedsamplingapproachJointEnvironmentalSiteAssessmentsinSupportofGlobalBasingLTCTimothyG.Bosetti,MS,USA ABSTRACTAstheUSArmybecomesmoreexpeditionaryandestablishesforwardoperatingbasesinnewlocations,theneedtodocumentenvironmentalconditionsbecomesparamountintheprotectionofthehealthofdeployedservicemembersandtheUSgovernmentfrompotentialclaims.ThesameholdstrueforexerciseswheretheUSpresencemayonlybeforaweek,however,thepotentialimpactsonforcehealthprotectionandenvironmentalclaimslingerforyears.Balancingandsynchronizingthesemultipledemandsandrequirementscanbedaunting.Overthepast3years,theUSArmyCenterforHealthPromotionandPreventiveMedicineEuropehasbeenworkingcloselywiththeUSArmyEuropeDeputyChiefofStaff,Engineer,andtheUSArmyClaimsServiceEuropetoconductjointenvironmentalassessmentsinsupportofcommandexercisesandforwardbasinginitiatives.Thesynergyandpartnershipsforgedduringthisprocessensurethatenvironmentalassessmentsareconductedtodocumentenvironmentalconditions,protecthumanhealth,andprotecttheUSgovernmentagainstclaims.

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AprilJune20097thatdevelopstoensurethedifferentneedsaremet,resultinginamorethoroughassessmentofthesite.Therefore,itispossibletotakeonesamplethatmeets3differentneedsandperspectives.Attheactionofficerlevel,weallagree.However,sometimesitisthecommandthatdoesnotunderstandtheimportanceofenvironmentalsampling.Inconductingenvironmentalassessmentsorfollow-onstudies,thequestionisoftenasked:whatistherequirementfortesting?Forthemostpart,weagreethatweshoulddosometypeofbaselineenvironmentalstudy.However,theamountofdiscoveryandsamplingrequiredisusuallyquestioned.Duringanenvironmentalassessment,therecanappeartobeagrayarea,especiallywhenitseemstofallbetweencontingencyandinstallationoperations;itdoesnotappeartobecoveredbyeitherone.Tobridgethisgap,theDepartmentoftheArmyissuedapolicymemorandum.1ThespecificsoftheseenvironmentalassessmentscomefromseveraldifferentsourcesasillustratedinFigure2.Partneringcanaddressthesedifferentrequirementsandensurethattheenvironmentalsamplingplanisdesignedtomeetthedifferentperspectives.Thenextstepistobalancetheserequirementstogainefficiencyinthesamplingandmaximizethereturnonoursamplinginvestment.BALANCETHESAMPLINGThespectrumofsamplingmustbeconsideredwhendevelopingthestakeholderrequirementsforenviron-mentalsampling.However,thedifficultquestionishowmuchsamplingisrequired?Theotherimportantquestioniswhatarethecoursesofactionwhenyougetunfavorablesampleresults?Also,willadditionalsamplingberequired?Toooften,thesecondhalfofthequestionisomitted.Itisonlyafterwehavediscov-eredaproblemthatitbecomesanissue,andweaskthequestion.Buthowdowerespondtothequestion?Typically,wescramblearound,developamorede-tailedplan,andgobacktothecommandtorequestmoretimeandmoney.Thisisnotagoodwaytoapproachthisissue.Itisimportanttoknowthespectrumofenvironmentalsampling,illustratedinFigure3,anddeterminehowmuchsamplingwillberequiredtoachievetheobjectives.Thisrequiresbalancingthepotentialorperceivedthreatagainstthetimeandresourcesavailable.Theendsofthespectrumarerelativelyeasytoidentify.Ifthesiteisclean,westop.Ifthesiteisextremelycontaminated,westop.Butwhataboutthesitethatisinthemiddle?Partneringcanhelpconsolidaterequirementstoreduceduplicativesampling,butthatprobablywillnotbeenoughtobalancetheamountofsamplingrequiredtocharacterizetheenvironmentalthreatandtheresourcesavailable.Therefore,youneedtolookatalternativewaystocharacterizethesite.Onewaytoaccomplishthisisthroughphasingthe 7 AIRWATERSOILEnvironmentalSample EngineerMedicalClaimsSamesampleanddata;differentperspectiveanduseofthedataEnvironmentalImpactontheSoldierSoldierImpactontheEnvironmentEnvironmentalImpactontheCommunity/HostNationPartneringensuresthatallthreedifferentviewsareaddressedEnvironmentalHealthSiteAssessmentInSupportofGlobalBasingAMatterofPerspective Figure1.Theprimarystakeholdersandtheirperspectivesintheenvironmentalsamplingandassessmentprocess. StandardPracticeforConductingEnvironmentalBaselineSur-veys:ASTMD6008-962EnvironmentalHealthSiteAssessmentProcessforMilitaryDeployments:ASTME2318-033DepartmentofDefenseInstruction6490.03:DeploymentSur-veillance4JointChiefsofStaffMemorandumMCM008-207:ProceduresforDeploymentHealthSurveillance5ArmyRegulation11-35:DeploymentOccupationalandEnvi-ronmentalHealthRiskManagement6DepartmentoftheArmypoliciesUSArmyEuroperegulationsFigure2.Sourcesfortherequirementsandspecific guidelinesforenvironmentalassessments.

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8https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1sampling:lookatthesitefrom30,000feet(broadsamplingapproach),thennarrowthescopeandfocustohotspots(areasofcontamination)formoredetailedassessment.Thephasedapproachgivesusthatopportunityandallowsustotailorthelevelofsamplingefforttomeetthesiteconditions.Thisworksaslongaswecommunicatethosegoalsandobjectivesfromthestart.Therefore,alimitationoftheenvironmentalassessmentisthatadditionalsamplingmayberequiredtoensureforcehealthprotection,toproperlydocumentenvironmentalconditions,andprotectagainstclaims.KNOWINGYOURLIMITATIONSTheenvironmentalhealthsiteassessment(EHSA)isrequiredbyDepartmentofDefenseInstruction6490.034andJointChiefsofStaffmemorandumMCM0028-07.5ThekeyobjectivesoftheEHSAaretoidentifyexposurepathways,confirmwhethertheyarecompletedorpotentiallycompletedthroughsampling,andconductariskassessmentondatagatheredinordertodeterminetheimpactonthedeployedforce.Liketheenvironmentalbaselinestudy(EBS),theEHSAisalivingdocumentthatmustbeupdatedwhenconditionschange:thesitewillchange,theplanforthesitewillchange,theforcewillchange,themissionwillchange,andthetruthwillchange.Whatwethoughttobetrueintheearlystagesoftheenvironmentalassessmentmayturnouttobefalseorbadassumptions.Therefore,weneedtoknowthelimitationsoftheenvironmentalassessments.TheEHSAandtheEBShavelimitations,themostprominentofwhichareshowninFigure4.Thisisimportanttounderstandwithrespecttoglobalrestationingbecausethingsmovequickly,changerapidly,andofteninvolvemultipleentities.Thekeyistounderstandandcommunicateupfrontwhattheenvironmentalassessmentswillbeusedfor,andassesswhetherfurtherassessmentsarerequired.Planningandfundingforadditionalassessmentsmustbeprogrammed.Flexibilityiscritical,phasingtheassessmentsareatooltoaccomplishthis.However,youmuststayengagedintheprocessandbeattunedtochangesinyourbaseassumptions.AnexampleofthisoccurredduringanenvironmentalassessmentforaforwardoperatingsiteineasternEurope.Wehadall3partiesengagedandhadplannedaphaseIIassessmenttocharacterizethesite.InthephaseIassessment,wehadidentified2areasthatcontainedsurfaceandsubsurfacecontamination,andrecommendednoconstructionactivitiesoverthoseareas.ThephaseIIassessmentfocusingonpotentialgroundwatercontaminationwascompleted.Everythingwasgoinggreat,amodelofpartneringandefficiencyorsowethought.WithinafewmonthsafterthephaseIIassessment,welearnedthattroopbilletswereplannedovertheareaidentifiedinthephaseIascontaminated.Howdidthishappen?Theplansforthesitehadchanged,thingshadshiftedforotherreasons,andthesechangeswerenotcommunicatedpriortothephaseIIassessment.Thiswasnotaninsurmountabletasktocorrect,butitdidtaketime.ItJointEnvironmentalSiteAssessmentsinSupportofGlobalBasing Documentenvironmentalconditions: SiteselectionIdentifypreexistingcontaminationHistoricalinformationPurposeProtectHumanHealthDocumentenvironmentalconditionsProtectagainstclaimsHowmuchsamplingisrequired?EndsofthespectrumaremoreeasilyquantifiedSynergesticandcompetingrequirementsBalancethemiddleFigure3.Determinetheextentofsampling necessarytoobtainthedatarequiredtoachievetheobjectives. ChronicThreatsAcuteThreatsEnvironmentalSamplingHowmuchsamplingisrequired?EnvironmentalBaselineIdentificationofHotSpotsEnvironmentalClaimsHealthAssessment SnapshotintimeMaynotbeacompleteassessmentMayonlyidentifyhotspotsMaynotcontaininformationrelatedtositelayoutandplannedactivitiesInitialassessmentisNOTthefinalassessmentThetruthhasadatetimegroupFactsandassumptionschangeovertimeMustnotbeastagnantreport,butratheralivingdocumentNotaboxcheckonalistFigure4.Limitationsinherentintheenvironmentalhealthsiteassessment.

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AprilJune20099THEARMYMEDICALDEPARTMENTJOURNALillustratesthelimitationsoftheassessmentsandtheneedtocommunicate,andstressestheimportanceofpartneringtoachieveacommongoal.PARTNERINGTOACHIEVEACOMMONGOALBasedupontheinvolvementoftheUSArmyCenterforHealthPromotionandPreventiveMedicineEuropewithenvironmentalassessments,specificallytheEBS/EHSAprocess,wehaveidentifiedthefollowinglessonsobservedoverthepast3years:InitialassessmentsareNOTthefinalassessment.Thephasedapproachisbest,andmostflexible.Therearelimitationstotheenvironmentalassessmentthatmustbearticulated.Conductingjointsurveysanddatasharingisgood.Thetruthwillchange.Communicationisimportant,especiallytoarticulatethepurpose,goals,andobjectivesoftheenvironmentalsamplingandassessments.Partneringiscriticaltosuccess.Partneringonenvironmentalbaselinesurveysisaprudentmovetoensurethatenvironmentalissuesareaddressedfromallperspectives.Thissynergycanprovideaconsolidatedeffort,lowerlaboratorycosts,reducethirdpartyclaims,standardizesamplingprotocols,andbalanceenvironmentalsamplingrequirementstoensuretheprotectionofhealthandsafetythroughproperdocumentationofexistingenvironmentalconditions.PARTINGTHOUGHTEnvironmentalsamplingisexpensive,buttheresultsofproperdiscoveryanddocumentationofexistingenvironmentalconditionsaregoodinvestmentsintheprotectionoftheDepartmentofDefensefromenvironmentalclaims,andensuringthatourSoldiers,Marines,Sailors,andAirmenarelivingandtraininginplacesthatarenotgoingtocauseadverseshort-orlong-termhealtheffects.REFERENCES 1.AssistantSecretaryoftheArmyforInstallationsandEnvironment.Memorandum:PolicyforEnvironmentalBaselineSurveysinGlobalRepositioningandClosuresOverseas.Washington,DC:USDeptoftheArmy;June6,2008.2.AmericanSocietyforTestingandMaterialsInternational.ASTMD6008-96:StandardPracticeforConductingEnvironmentalBaselineSurveys.WestConshohocken,PA:AmericanNationalStandardsInstitute;2005.3.AmericanSocietyforTestingandMaterialsInternational.ASTME2318-03:EnvironmentalHealthSiteAssessmentProcessforMilitaryDeployments.WestConshohocken,PA:AmericanNationalStandardsInstitute;2006.4.DepartmentofDefenseInstruction6490.03:DeploymentHealth.Washington,DC:USDeptofDefense;August11,2006.5.OfficeoftheChairman,JointChiefsofStaff.MemorandumMCM0028-07,ProceduresforDeploymentHealthSurveillance.WashingtonDC:USDeptofDefense;November2,2007.Availableat:http://amsa.army.mil/Documents/JCS_PDFs/MCM-0028-07.pdf.6.ArmyRegulation11-35:DeploymentOccupationalandEnvironmentalHealthRisk.Washington,DC:USDeptoftheArmy;May16,2007.AUTHOR LTCBosettiisChief,DepartmentofEnvironmentalSciences,USArmyCenterforHealthPromotionandPreventiveMedicineEurope,Landstuhl,Germany.

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10https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1BACKGROUNDIn2008,employeesofKellogg,Brown,&Root,Inc,filedalawsuitallegingexposuretotoxicchemicalswhileworkingtorestoretheinfrastructureinIraqin2003.ThelawsuitpromptedCongresstoholdhearingsregardingtheincident,andwhentheylearnedthatsomeNationalGuardmembersservedasescortsfortheKBRemployees,theyinquiredastowhethertherewasapotentialforadversehealtheffectsamongSoldiersintheseunits.TheUnitedStatesArmyCenterforHealthPromotionandPreventiveMedicine(USACHPPM)providedinformationbasedonanassessmentconductedbyaspecialmedicalaugmentationresponseteam-preventivemedicine(SMART-PM)whichdeployedatthetimeoftheincident.Toalleviateanyquestionsregardingtheassessment,TheSurgeonGeneraloftheArmyrequestedthattheassessmentbereviewedbytheDefenseHealthBoard.*Thereviewwasrequestedtoassesstheincidentandtheinformationgathered,determinewhethertheinformationwassufficienttoassessthepotentialhealthrisk,anddecidewhetheradditionalactionsshouldbetaken.TheQarmatAliIndustrialWaterTreatmentPlantlocatedinBasra,Iraq,producedindustrialwaterforuseinoilproduction,anddidnotproducepotablewater.Thesitewasinanurbanarea,enclosedbyaperimeterfence,andconsistedofseveralstructureslackingsleepingorlivingquarters.IthadbeenransackedandwasnotfunctionalwhensecuredbyUSmilitaryforces.Thesitewasvisiblycontaminatedbysodiumdichromate,acorrosionsuppressionagentusedinthewatertreatmentprocess.Sodiumdichromateisaninorganiccompoundcontaininghexavalentchromiumknowntobetoxicandcarcinogenictohumansandanimals.FourgroupsworkedatQarmatAliduringthetimeofconcern:Kellogg,Brown,&Root(KBR),aUSbasedcompanycontractedtorestoretheplanttooperativestatus;theUSArmyNationalGuardunitsfromOregon,SouthCarolina,andIndiana,whoprovidedpersonalsecuritytoKBR;theBritishmilitarypreviouslypresentatthesitetosecurethearea;andIraqicivilianshiredbyKBRtoassistintherestorationeffort.In2003,ArmypersonnelwereassignedtoprovidesecurityfortheKBRworkersrestoringtheindustrial-gradewatertreatmentfacilityatQarmatAli,Basra,Iraq.Inthesummerofthatyear,contractworkcrewsandsafetypersonnelidentifiedsodiumdichromateasapotentialoccupationalhazardintheworkenvironment.SeveralUSArmySoldiersreportedtothesupportingmilitarymedicalfacilityandinquiredaboutthepotentialhealthrisksposedtothemintheirroleassecuritydetail.Concurrently,KBRinitiatedcontainmentofthecontaminatedsiteandconductedenvironmentalsampling.In-theatermilitaryoccupationalandenvironmentalhealthspecialistsaddressedthehealthconcernsofthemilitaryunitsatalocaltownhallmeetingandrequestedaSMART-PMconductanin-theatreassessment.Theteamconsistedofindustrialhygienists,occupationalmedicinephysicians,andenvironmentalscientists.Theteamconductedsamplingandmedicalevaluationsforallpersonnelpresentatthattime,includingtheIndianaArmyNationalGuardSoldiersandDepartmentoftheArmycivilians.THEOCCUPATIONALANDENVIRONMENTALINCIDENT,ANDTHEROLEOFTHESMART-PMDepartmentofDefenseInstruction6490.03imple-mentspoliciesandprescribesproceduresfordeploy-menthealthactivitiestocontrolorreduceOccupationalandEnvironmentalHealth(OEH)risks,todocumentandlinkOEHexposureswithdeployedpersonnel,andtorecorddailylocationsofdeployedpersonnel.1(p1)EvaluationofExposureIncidentattheQarmatAliWaterTreatmentPlantColeenBairdWeese,MD,MPH *TheDefenseHealthBoardisaFederalAdvisoryCommit-teetotheSecretaryofDefense.Itprovidesindependentscientificadvice/recommendationsonmattersrelatingtooperationalprograms,healthpolicydevelopment,healthresearchprograms,andrequirementsforthetreatmentandpreventionofdiseaseandinjury,promotionofhealthandthedeliveryofhealthcaretoDepartmentofDefensebeneficiaries.Informationavailableathttp://www.health.mil/dhb/default.cfm.

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AprilJune200911TheinstructionrequiresatrainedandequippedstafftoprovidesupporttoconductdiseaseoutbreakandOEHexposureincidentinvestigations1(p6)andtoensurereportsanddocumentationarearchived.TheinstructionfurthernotesthatAllexposuresshallbereportedthatareimmediatelyhazardoustolifeorhealthorthatmaysignificantlyincreaselong-termhealthrisks(egcancer)throughappropriatecommandchannels.1(p6)Likewise,JointChiefsofStaffMemorandumMCM0028-07requirespreliminaryhazardassessmentsbeconductedatsitestosummarizeandidentifyanticipatedOEHthreatsandhazards.Thismemorandumrequiresdocumentationintheindividualmedicalrecordofanysignificantoccupationalandenvironmentalexposures2(pA-3)SignificantoccupationalandenvironmentalexposuresaredefinedasExposurestoOEHhazardsthatwillplausiblyresultinsomeclinicallyrelevantadversehealthoutcometoexposedindividuals2(pA-A-4)Alternatively,routineorinvestigativesamplingmightyieldaresultthatexceedsguidelinesandwasconsideredsignificant.ApreliminaryorphaseIsiteassessmentmayhaveidentifiedthecontaminationiftherewassufficientevidencetoraisethesuspicion.Alternatively,duringanoccupationalandenvironmentalhealthassessment,pastpractices,visiblegroundcontamination,orotherfindingsmayhaveledtoamoredetailedandspecificassessment.Inthisinstance,visiblecontaminationataworksitepromptedanevaluationbythecontractor,andtheSoldierswhoescortedthemtothesitewereconcerned.Theirexpressedconcernspromptedtherequestforadditionalassessmentsupportthroughcommandchannels.TherequestforaspecialmedicalaugmentationresponseteamwasreceivedbyUSACHPPM,andaSMART-PMstaffedwithpersonnelappropriatetothesituationwasformed.Theteamdeployedtoconductsamplingtoassesstherisk,andtoprovidemedicalevaluationsandriskcommunication.SPECIALMEDICALAUGMENTATIONRESPONSETEAMACTIONSBetweenSeptember30andOctober24,2003,theSMART-PMsampledsurfaceswithinthewatertreatmentplant,theairwithinandoutsidetheplant,andthesoiloutsidetheplant.Bythetimetheteamarrived,thecontractorhadcontainedthecontaminationwithanasphaltcover,andthusairsamplingdidnotidentifyanysamplesabovetheMilitaryExposureGuidelines(MEGs)forair.ThesoilsamplingresultsexceededtheMEGsforsoilonlyoutsidethefencelineoftheplant.Priortoencapsulation,3of48samplesofairwerefoundtoexceedtheMEGsforhexavalentchromium.ThesevaluesdidnotexceedthePermissibleExposureLimits,setbytheOccupationalSafetyandHealthAdministration,whichdefinetheamounttowhichworkersmaybeexposedfor40hoursaweekforaworkinglifetime.However,theMEGs,designedforuseondeployments,recognizethatmilitarypersonnelcouldbeexposedtocontaminantsinair24hoursperday,forperiodsfromoneto15years,ifthesourceswerecontinuous.Assuch,theMEGsarelowerthancomparableworkplacestandards.Thismeansthattheyaremoreconservative,andtheyarealsosetnottobeaneffectlevelatwhichadverseoutcomesoccur,butarescreeningvaluesthatindicateaneedforfurtherassessment.AsthesamplingconductedbytheSMART-PMdidnotproduceresultsthatexceededanylimits,theconcernforhealtheffectswaslow.However,asstatedpreviously,theseresultswereobtainedfollowingencapsulation.Itwasknownthatsomesampleshadexceededthelong-termMEGsforchromium.Toaddressthepotentialthatexposurespriortoencapsulationwerehigher,andmaybeofconcern,itwasdecidedthatmedicalevaluationsofthoseonsiteshouldbeconducted.MedicalevaluationswereofferedtothemembersofbothsecurityforcesandDepartmentofDefensecivilians.WhileKBRemployeesperformedrepairstotheplantpriortodiscoveryandcontainmentofthesodiumdichromatepowder,securityforcesandciviliansspentmuchlesstimeatthesite.Theroutesofexposureofconcernweredeterminedtobeinhalationandskincontact.Theevaluationsincludedtheadministrationofexposureandsymptomquestionnaires,andmedicalexaminationstailoredtoassesschromiumexposure.Elementsintheexamsincludedamedicalhistory,ageneralphysicalexamination,andbloodandurinetesting(wholebloodchromiumlevels,completebloodcounts,serumchemistries,liverandrenalfunctiontests),routineurinalysis,chestx-rays,andspirometrytesting.Themedicalevaluationswereconductedwithin30daysofthelastpotentialexposureatthesite.Underoccupationalstandards,aphysicalexamination

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12https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1targetingtheskinandrespiratorysystemmustbeconductedwithin30daysofanoverexposure,focusingonthepresenceofcharacteristiclesions(chromeholes)associatedwithhexavalentchromiumexposure.TheselesionswerecommonlyseeninoccupationalgroupsintheUSwhichworkedwithhexavalentchromiumatlevelsabovethecurrentoccupationallimits.Thespecifictestingforchromium,orbiomonitoring,wasparticularlyusefulinthisinstance.Typically,ifindividualsareexposedtometals,orsolventsormanyothertypesofsubstances,theytypicallyclearthebodydirectlyoraremetabolizedwithinhourstodays.Forthisreason,manyofthebiomonitoringtestsareusefulonlyifperformedsoonafterexposure.Whenhexavalentchromiumentersthebody,itistakenintoredbloodcellswhereitremainsforthelifeoftheredbloodcell,whichis120days.Wholebloodtesting,whichincludesredbloodcells,providedanindicationofexposuresupto4monthspriortothetest,priortoencapsulation.Thistesting,availableattheArmedForcesInstituteofPathology,wasperformed.Lessthan30%ofexaminedindividualsreportedsymptoms,andthesymptomsreportedwerenonspecificirritation,witheyeandthroatirritationbeingthemostcommon.Noneoftheindividualsexhibitedclassicalsymptomsofoverexposuretochromium.Asmightbeexpectedwhennonspecifictestingisperformed,someindividualswereidentifiedwithminorabnormalitiesonurinalysis,liverfunctiontests,pulmonaryfunctiontests,etc,buttheseabnormalitieswereminimal,fewinnumber,andhadmultiplepotentialetiologies.Abnormalfindingswerenotcorrelatedwithtimeonsitebyhistory,anddidnotsupportasignificantexposuretohexavalentchromium.TheSMART-PMconcludedthatthereportedsymptomscouldberelatedtoexistingpersonalmedicalconditionsanddesertenvironment-relatedexposures,suchasheat,sand,dust,andwind.WholebloodtestingfortotalchromiumwasdoneattheArmedForcesInstituteofPathology.Mosttestedindividualshadlevelsoftotalchromiumbelowthedetectionlimit.Averagevalueswerenotelevatedwhencomparedwithnonoccupationallyexposedgeneralpopulationranges.INCIDENTEVALUATIONSExposureassessmentisthenextstepfollowingidentificationofapotentialhazard.Ideally,exposuremonitoringcanbeconductedandcomparedtorelevantstandards.Typically,ifadequatesamplingresultsinlevelsbelowstandards,nofurtheractionisneeded.Inthisinstance,theinitialmonitoringindicatedaneedforfurtherassessment,basedonexceedanceoftheMEGspriortoencapsulation.AstheMEGsareconservative,theycanbeusedasascreeningguidetodirectfurtheraction.Inthisinstance,thoseactionswereadditionalsampling,whichindicatedthatencapsulationhadbeenasuccessfulprotectiveaction.Thiswascomplementedbyphysicalexaminationandbiomonitoring,whichdidnotindicatethatsignificantexposurehadoccurred.Thefindingsarebaseduponexposureassessment,includingtheidentificationandquantificationofexposure,andassessmentofpotentialriskbaseduponpriorknowledgeofdoseresponserelationships.Analysisofthematerials/specimenscollectedisaffectedbytimebetweencollectionandanalyses(degradation),quantityofmaterials/speci-mensgathered,andmostimportantly,thelimitsofdetection.Theendproductoftheinterpretationoffindingsoftheaboveanalysesisascientifically-defensibleestimateofriskfortheexposedindividualsgiventhelimitationsofbothmeasuresofexposureandresponse.Theestimateofriskislikelytobequalita-tive,suchaslow,medium,orhigh,butshoulddictatespecificactions.Thesecouldbe1)nofurtheraction,2)retainrosterofthoseinvolvedandconsiderpassiveepidemiologicalsurveillance,3)retainarosterofpopulationatriskandconductactiveepidemiologicalsurveillance,and4)recommendcertainscreeningorotherexaminationsatsomesetinterval.Inthisinstance,estimationoftheriskdeterminednosignificantrisk,andnoanticipationoffuturehealthoutcomes.Assuch,thefindingswerecommunicatedtotheindividualsinvolved,informationwasplacedintheirpermanentmedicalrecords,andtheywereinstructedtonotetheincidentontheirpostdeploymenthealthassessmentform.WhentheDefenseHealthBoardevaluatedthisincident,theydeterminedthattheriskassessmentconductedwastimely,comprehensive,andappropriateforthepotentialriskposedtoservicemembers.3(p1)TheyacknowledgedthatUSACHPPMmetorexceededthestandardofpracticeforoccupationalmedicineinregardtotheexposureassessmentandmedicalevaluationconductedin2003forSoldierspotentiallyexposedtohexavalentchromium.3(p9)EvaluationofExposureIncidentattheQarmatAliWaterTreatmentPlant

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AprilJune200913THEARMYMEDICALDEPARTMENTJOURNALTheyconcludedthattherewasnoexpectationofanyfutureadversehealthoutcomes.Additionally,theyrecognizedthattheanticipation,recognition,evaluation,andinterventioninsuchsituationsoftenrequiresexpertisebeyondassetsontheground.TheactionstakentoaddressthesituationofthepotentialexposuretohazardousmaterialsattheQuarmatAliWaterTreatmentPlantareacasestudyofhowon-scenepreventivemedicineandmedicalpersonnelcorrectlycollaborateintherecognition,evaluation,andresponsetoenvironmentalrisksinadeployedenvironment.Resourcesareavailabletoassistinthesetypesofsituations.Aswasdoneinthiscase,deployedpreventivemedicinepersonnelandmedicalpersonnelarestronglyencouragedtoseekadditionalsupportthroughUSACHPPMiftheyarefacedwithanexposureincident.REFERENCES 1.DepartmentofDefenseInstruction6490.03:DeploymentHealth.Washington,DC:USDeptofDefense;August11,2006.2.OfficeoftheChairman,JointChiefsofStaff.MemorandumMCM0028-07,ProceduresforDeploymentHealthSurveillance.Washington,DC:USDeptofDefense;November2,2007.Availableat:http://amsa.army.mil/Docu-ments/JCS_PDFs/MCM-0028-07.pdf.3.DefenseHealthBoard.DefenseHealthBoardReviewoftheUSArmyCenterforHealthPromotionandPreventiveMedicineAssessmentofSodiumDichromateExposureatQarmatAliWaterTreatmentPlant.FallsChurch,VA:USDeptofDefense;2008.ReportDHB2008-06.AUTHOR DrWeeseisProgramManagerforEnvironmentalMedicine,USArmyCenterforHealthPromotionandPreventiveMedicine,AberdeenProvingGround,Maryland.

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14https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1BACKGROUNDHearingisacriticalsensorofSoldiersthatisvitaltoboththeirsurvivabilityandlethality.Whenhearinglossispresent,theabilitytoconductauditorytasksisgreatlydiminished.Goodhearingisrequiredtoperformsuchtasksaslocalizingsound,gaugingauditorydistance,identificationofasoundsource,andunderstandingverbalordersorradiocommunications.Thismultidimensionalsenseprovidesanindispensableamountofinformationonthebattlefieldandcanmeanthedifferencebetweenlifeanddeathincombat.Theabilitytodistinguishthesoundsofdifferentweapons,bothfriendlyandenemy,isacombat-criticalskill.PoorhearingjeopardizestheunitmissionandincreasesthelikelihoodofaseriousmishapduetoaSoldiersdecreasedsituationalunderstanding.VerbalcommunicationsandhandandarmsignalsbetweendismountedSoldiersremaintheprimarymeansofcommunicationonthebattlefield.Althoughtechno-logicaladvanceshaveimprovedbattlefieldcommu-nicationsystems,theseelectronicadvancescannotovercomethefactthathumanhearingisrequiredtocompletemostcommunication.SoundisoftenthefirstsourceofinformationaSoldierhasbeforedirectcontactwiththeenemy.Unlikevisualcues,informationcarriedbysoundcomestousfromalldirections,throughdarkness,andoverorthroughmanyobstacles.Aggressiveactionproducessoundtheenemycannothideorcamouflage.Theabilitytohearandrecognizecombat-relevantsoundsisavitalcomponenttosituationalunderstandingandprovidesatacticaladvantage.Noise-inducedhearinglossisatacticalriskandthreatensbothindividualandunitcombateffectiveness.Hearinglossduetonoiseexposureusuallyoccursinthehighfrequencies.Sincespeechsoundsthatgivemeaningtowords(forexample,consonantssuchasch,th,sh,f,andp)arehigh-frequencysoundsaswellasthesoundsthatprovidetheabilitytodeterminethesignatureofweaponsandvehicles,high-frequencyhearinglossisparticularlydevastatingtomilitaryoperations.Intheheatofbattle,manywordscanbemistakenevenmoresoifhearinglossispresent.Forexample;breachandbreak,attackandgetback,ceasefireandkeepfiring,staydownandgoaround,orrightcarandwhitecar.Figure1displaysaspectrographofthesentencegetthewhitecar.Eachspeechsoundfromthesentenceissuperimposedatthelocationcorrespondingtoitsoccurrence.ThehorizontalaxisrepresentstimeinsecondsandtheverticalaxisrepresentsthefrequencyofthesoundinHz.Thecolorsrepresentintensity.Thebrighterthecolor,thelouderthesoundisatthatfrequency.WhenthesamesentenceisfilteredtoH3hearingprofilelevels,*thedecreaseorabsenceinintensityinthehigherfrequencyregionatthetopofthespectrographisconsiderable.ThisisavisualizationofjusthowmuchspeechcuesarenotaudibleinaSoldierwithanH3profile.Outsideofcombat,theabilitytohearstillmattersforsafetyandperformancereasons.Infact,mostofthe150differentenlistedjobsintheArmydonotdirectlyinvolvecombat.Evenso,mostofthesejobsdorequirecombatdeploymentsandhaveoccupationalhazardssuchasnoiseandototoxins.Theseauditoryhazardsarecompoundedby12-to18-monthdeploymentsthathavelengthyworkdays,noweekends,andverylittlefreetimeawayfromwork.Thesymptomsofnoise-inducedhearinglosscanbedeceptivelysubtle,usuallywithnoobviousphysicalinjuryorwound,buttheeffectscanbepermanent,debilitating,oftenuntreat-able,and,mostimportantly,preventable.LITERATUREREVIEWDuringthefirstyearofthewarinIraq,therewasanaverageofonemedicalevacuationadayforhearingloss(withnootherconcurrentinjury).MedicalCohortCaseStudiesonAcousticTraumainOperationIraqiFreedomMAJD.ScottMcIlwain,MS,USAMAJ(Ret)BryanSisk,AN,USAMelindaHill,AuD *H3hearingprofileisdefinedbytheUSArmyStandardsofMedicalFitness1asspeechreceptionthresholdinbestearnotgreaterthan30dBHL,measuredwithorwithouthearingaid;oracuteorchroniceardisease.

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AprilJune200915evacuationsforhearinglossweresenttotheaudiologyclinicatLandstuhlRegionalMedicalCenterinGermany.McIlwainfoundthatoutofthe564patientsseenthereduringthistime,65%werefromblastinjuries.2Sensorineuralhearinglossfromfriendlyforcesweaponssystemsmadeupapproximately25%oftheinjuries.Theremaining10%werebalance-relatedorconductivetypehearinglossthatwaspredominantlyunrelatedtohazardousnoiseexposure.Asaresult,amilitaryaudiologistpositionwastemporarilyplacedinBaghdadin2004toevaluateacoustictraumapatients.ThisprovidedanefficientwaytodetermineaSoldiershearingabilitywithouttheneedforalengthyandexpensivemedicalevacuationforanonlife-threateninginjury.Often-times,Soldiersareexposedtoanexplosionsuchasanimprovisedexplosivedeviceoramortarroundandhavenoapparentinjuries,butcansensetheirhearinghasdecreasedandtinnitusispresent.Withnovisibleinjuries,theSoldiersreturntotheirduties.Thisiswheretheterminvisibleinjuryisderived.Theabilitytodistinguishthesoundsofdifferentweapons,bothfriendlyandenemy,isaskillthatistaughtintheArmy.Ifthesoundsofweaponsfirearecomingfromthenextblockofbuildings,knowingwhetheritisenemyorfriendly,smallarmsorautomaticweapons,smallcaliberorlargecaliber,orifitisarocketpropelledgrenadeoranantitankweaponcanbecriticalinformationthatdeterminesaSoldiersreaction.Katzeletalfoundthatthesignaturesoundsdistinguishingaweaponssystemareprimarilyabove4kHz.3Thefrequenciesabove4kHzarealsowherehazardousnoiseaffectsthecochleathemost,andwherethetell-talenoisenotchoccurs.4Con-sequently,identificationofnoisesignatures,commu-nication,gaugingauditorydistances,andlocalizationarenegativelyaffected.Studieshaveshownthattheabilitytoaccomplishaunitsmissionisdirectlyproportionaltoitsabilitytocommunicateeffectively.Ifeffectivecommunicationdropsby30%,theabilitytocontroltheunitinordertoaccomplishthetaskdropsby30%aswell.5WeinerandRossdescribetheresonantcharacteristicsoftheouterearasboostingthesoundpressurelevelofthefrequenciesbetween2500Hzand3500Hz.6DonahueandOhlindescribethemiddleearasfrequencyselectivebecausethetransferfunctionsofthemiddleearallowthemid-tohigh-frequencysounds(approximately1500Hzthrough4000Hz)topassthroughitwithconsiderablylessresistancethanthelow-frequencysounds.4Theresultisthatthelow-frequencysoundsreachthecochleaatalowerintensitythanwhenitenteredtheearcanal.Conversely,soundsatfrequenciesbetween1kHzand3kHzaretrans-ferredtothecochleawithsignificantlylessresistanceandgreaterintensitythanwhentheyenteredtheearcanal.RudmoseandWardindependentlydemonstratedthatwhenhighintensitypuretonesreachthecochleainthe1kHzto3kHzfrequencyrange,theresultingthresholdshiftoccursapproximatelyahalftoonewholeoctaveabovethepuretoneexposure.7,8Asthewaveformincreasesinamplitudeonthebasilarmembraneduetoanincreaseinsoundintensity,thevibrationbecomeslesslocalizedandmovestowardthebasalportionofthecochlea.4YlikoskiandYlikoskistatethatthismovementcausesdamagetolociofthecochleathataredifferentfromthestimulusfrequencies.9Forbroad-bandnoisewithequalenergyinallbandwidths,themaximumthresholdshiftoccursbetween3000Hzand6000Hz.8 Figure1.Comparativespectrographsofthesentence,getthewhitecar.

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16https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1Studiesofnoise-inducedhearinglossintheGlobalWaronTerrorhavebeenanalyzed.Cavefoundthatmorethan50%of258acoustictraumapatientsseenattheWalterReedArmyMedicalCenterfromApril2005throughAugust2005,hadsignificanthearingloss,andagecouldnotaccountforthechangeinhearingfrombeforetoafterdeployment.Inaddition,one-halfofthesepatientsreportedhavingtinnitus.10HelferdataminedhearinglossassociateddiagnosescodesofpostdeploymentandnondeployedSoldiersbetweenApril1,2003andMarch31,2004.Hefoundthat68%of806postdeploymentevaluationshadbeendiagnosedforatleastoneofthefollowing:acoustictrauma(5.6%),permanentthresholdshift(29.3%),tinnitus(30.8%),eardrumperforation(1.6%),ormoderatelyseverehearinglossorworse(15.8%).Thenondeployedgrouphad4%of141,050diagnosedwiththesamehearinglossrelatedcodes:acoustictrauma(0.1%),permanentthresholdshift(0.5%),tinnitus(1.5%),eardrumperforation(0.1%),ormoderatelyseverehearinglossorworse(2.2%).11In2007,theVeteransAdministrationRehabilitativeResearchandDevelopmentDepartmentreportedthat839,907veteranswereidentifiedashavingservice-connectedhearinglossthatrequiredcompensationfromtheVeteransBenefitAdministration.In2006,totalcompensationtoVeteranswasover$1.2billionforhearinglossandtinnitusdisabilities12(p3)andaccountedfor17%ofthetotaldisabilityclaims.12(p12)Thisisanincreaseof18%fromthepreviousyearanda56%increasesince2002.12(p12)ThesestudiescorroboratethatthesoundsofcombatcanbedevastatingtoaSoldiershearingreadiness.BohneandHardingfoundthatthecochleaundergoes2histopathologicstagesafteranacoustictrauma:degenerationoftheouterhaircellsandthecontinueddegenerationofsupportingcells,afferentnervefibers,andadditionalhaircells.Thesecondhistopathologicstagehasadelayedonsetwithrespecttoidentificationofthresholdshiftswithroutinemonitoring.13Simplyput,hearinglossisprogressiveafteranacousticassaultandthereforetheactualrateofhearinglossintheArmyisgreatlyunderestimated.MultipletoursofdutyinIraqandAfghanistanwillacceleratethisdelayedonsetduetolengthyworkdays,noweekends,andlargedosesofhazardousnoiseexposureonaregularbasis.Thenumberofservicemenandservicewomenondisabilitybecauseofhearingdamagewillincreasenolessthan15%ayearundercurrentcombatconditionsanddisabilitypolicies.14TheUSArmyCenterforHealthPromotionandPreventiveMedicinehasfollowedveteransdisabilityclaimssince1969.In2008,thedisabilitypaymentsfromtheVeteransAdministrationfortinnitusandhearinglossexceededonebilliondollars.Unfortunately,aGovern-mentAccountabilityOfficeinvestigationfoundthattheaveragependingandappealprocessofapplyingforaserviceconnecteddisabilityin2007was789days.15EvenifaSoldiershearingthresholdsarewithinanormaltolerance,thedamagemayhavebegun.FuturehazardousnoiseexposurewillappendtopreviousdamageandleadtofuturehearinglossthatisnotwithinacceptablelimitsforArmystandards.OnceaSoldiersSpeechreceptionthresholdinthebestearisgreaterthan30dBhearinglevel(measuredwithorwithouthearingaid),theirabilitymustbeevaluatedforfunctionalityandpersonalriskwithrespecttotheirjobs.Forinstance,ifahelicopterpilothasahearinglossandpoorspeechintelligibility;manylivesareatriskiftheradiocommunicationcannotbeheard.Also,thepilotrisksfurtherhearinglosstothehazardousnoiseofthehelicopter.Ifthefindingsofthereviewboardarenegative,theSoldierisofferedamedicaldischargeorachangetoajobthatdoesnotinvolvehazardousnoiseexposure.EvenifSoldierschoosetochangejobsratherthantakeamedicaldischarge,theorganizationalknowledgeandtechnicalexperiencegoeswiththem.VARYINGEXPOSURESThefollowingcohortcasestudieswereobservedusingairconductionhearingthresholddatacollectedduringevaluationsconductedin2006attheUSArmyAudiologyClinicinBaghdad,Iraq.The2cohortcasestudiespresentedherearetheeffectsofacoustictraumawhilewearinghearingprotectionandtheeffectsofacoustictraumawhilenotwearinghearingprotection.CohortCaseStudyNo.1Paireddataofpredeploymentandduringdeploymenthearingthresholdsof50USArmySoldiers(100individualears)wererandomlyobservedamongSoldiersthatwereexposedtoacoustictraumawhilewearinghearingprotection.Allsubjectswerenoise-freeforatleast14hoursbeforeevaluation.OnlythresholddatafromSoldierswithnormaltypeACohortCaseStudiesonAcousticTraumainOperationIraqiFreedom

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AprilJune200917THEARMYMEDICALDEPARTMENTJOURNALtympanogramswerecollected.Ofthissample,25oftheSoldiersreportedexposuretoexplosionsincombatwhilewearingsomeformofhearingprotectionand25thathadnotbeenexposedtoexplosions,butreceivedhearingscreeningsasapartofroutinephysicalexams.Duringeachevaluation,predeploymentaudiometricthresholdswerecomparedtothecurrentresults.OneSoldierinthehearingprotectedacoustictraumagrouphadoneearwithaperforatedtympanicmembrane,sothatearwasexcludedfromthedataset,reducingthenumberofearsto49.Sincedatawerepaired,noweightingforageorgenderwasused.Thedifferencesinthresholdspredeploymentandduringdeploymentattheindividualfrequenciesof500Hz,1kHz,2kHz,4kHz,and6kHzwerethencomparedbetweengroupswithaone-wayanalysisofvariance(ANOVA)usingStatisticalPackageforSocialSciences(SPSS),Version11.0(SPSSInc,Chicago,Illinois).Levenesstatisticwasusedtotestforhomogeneityofvarianceateachfrequencybetweengroups.Sincetherewereonly2groups,noposthoctestswerenecessary.Thenullhypothesis:thereisnosignificantdifferencebetweenpredeploymentandongoingdeploymentaudiometricthresholdlevelsattheindividualfrequenciesof500Hz,1kHz,2kHz,4kHz,and6kHzbetweenroutinephysicalexamgroupandhearingprotectedacoustictraumagroup.Thenullhypothesiswasrejectedfortheindividualfrequenciesof500Hz,1kHz,and2kHz.Therewasasignificantdifferenceinhearingthresholdlevelsatthesefrequencies.AllfrequenciespassedLevenestest,except4kHz.Figure2displaysthemeanthresholddifferencesanderrorbarsforeachgroupandfrequency.ThedescriptivestatisticsaredisplayedintheTable.Theanalysisofvarianceat500Hzrevealedahighlysignificantdifferencebetweengroups,F=9.463,p<0.05withamediumeffectsize(2)of0.09.Theanalysisofvarianceat1kHzrevealedahighlysignificantdifferencebetweengroups,F=6.076,p<0.05withamedium2of0.06.Theanalysisofvarianceat2kHzrevealedasignificantdifferencebetweengroups,F=9.657,p<0.05withamedium2of0.09.Theanalysisofvarianceat4kHzrevealednosignificantdifferencebetweengroups,F=2.707,p>0.05withasmall2of0.03.Homogeneityofvariancewasviolated,=0.045,p<0.05.Theanalysisofvarianceat6kHzrevealednosignificantdifferencebetweengroups,F=1.607,p>0.05withasmall2of0.02.Theincreaseinstandarddeviationwiththeincreaseinfrequencyisnotableinthepostdeploymentthresholds,butexpectedinindividualsexposedtohazardousnoise.AnanalysisofmenexposedtohazardousnoiseintheInternationalStandardsOrganization1999databasebyBovoetalshowedthatmaleworkersexposedtoanoiselevelof100dBAfor30yearsexhibitedahearinglossat4kHzwithavariationof60dB.15Thisisconsistentwiththefindingsofthehearingprotectedacoustictraumagroup.Further,severalstudiesattributethisvariationtomechanicalresonanceandsoundtransferfunctionoftheearcanal,theactionofstapedialreflexes,andgenetics.15-17Thesignificancelevelswereleastremarkableat4kHzand6kHzduetothelowpowerandtheviolationofhomogeneityofvarianceat4kHz.FergusonandTukanedescribetheone-wayANOVAasbeingrobustenoughtoovercomeviolationsofhomogeneityof Figure2.Graphicaldepictionofdifferencesinpredeploymentandduring-deploymentaudiometricthresholdsbetweenpairedcontrolandexposuregroups.GlossaryPEroutinephysicalexamgroupAThearingprotectedacoustictraumagroupNotes1.PEandATarefollowedbythecorrespondingfrequencyinHz2.Decibelsmeasurementsarelogarithmic.

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18https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1variance.18However,theresultsof4kHzand6kHzinterpretationshouldbebasedonthemeananderrorbarsinFigure2.Theincreaseofhearingthresholdsinthehearingprotectedacoustictraumagroupisleastremarkableat4kHzand6kHz.Theattenuationcharacteristicsofhearingprotectionmayexplainthegreaterprotectiveeffectofthe4kHzand6kHzoverthelowerfrequencies.Higherfrequencysoundenergyismoreeasilyobstructedthanlowerfrequencysoundenergyinpassivehearingprotection.Toalargeextent,thewavelengthofthesoundisresponsibleforthisgreaterattenuationinthehighfrequencies;thehigherthefrequency,theshorterthewavelengthandviceversa.Generallyspeaking,acousticenergyisattenuatedmoreiftheearplugisgreaterthanone-halfthewavelengthofthesound.SincetheSoldiersinthiscohortcasestudywerewearingavarietyofapprovedhearingprotection(polyvinylfoamearplugs,combatarmsearplugs,andtacticalcommunicationandprotectivesystems),aproperlysizedandfittedhearingprotectorofanygivensizeorstylewillthereforeattenuatehigherfrequencysoundwithashorterwavelengththanalowerfrequencysoundwithalongerwavelength.Thisisconsistentwiththeprotectiveeffectat4kHzand6kHzinthisstudy.Thestatisticalsignificanceat500Hz,1kHz,and2kHzmayalsobeattributabletotheearplugpreventingtheacousticreflexfromoccurringduringtheimpulsenoise.Fletcherfoundthattheacousticreflexwasmoreeffectiveatprotectinghearingfromgunfireinfrequenciesbelow1kHzthanthesingleflangedearplug.However,healsofoundthesingleflangedearplugtobemosteffectiveinfrequencies2kHzandgreater.17Thiscorrespondstotheobservedhearingthresholdsofthiscasestudy,butalsodoesnottakeintoaccountboneconductionofthesound.Bergerfoundthatat40dBinthefrequencyof2kHz,soundreachesthecochleaviaboneconductionevenwhenhearingprotectionisworn.19Ifwetakeintoaccountthehalfwavelengththeorymentionedinthepreviousparagraph,itisexpectedthathigherfrequenciesareattenuatedmorethroughthehumanbodyandthereforethelowerfrequencysoundsarelouderatthecochleaviaboneconduction.Thisalsomayaccountforsomeofthedifferencepatternsobserved.Further,Pricedescribesthemiddleearasalinearsystemupto120dBsoundpressurelevel,andthatthetransferfunctionsofthemiddleearareflatinthelowerfrequenciesanddecreaseatarateof6dBperoctaveatfrequenciesabove1kHz.20,21KobrakandvonBekesyfoundthatinhumancadaversearsthestapeschangeditsmodeofvibrationathighintensitiesinsuchawaythatlessenergywastransmittedtothecochlea.22,23Thesestudiessupporttheideathatthemiddleearcanpeakcliphighintensityimpulsenoise.Sincetheexplosionscouldnotbemeticulouslymeasured,itisnotplausibletoarguethatthehearingprotectedacoustictraumagroupbenefitedfromthismiddleearpeakclipping,butisworthmentioning.CohortCaseStudyNo.2Independentsamplesofduringdeploymenthearingthresholdsof81USArmySoldiers(161individualears)wererandomlyobservedintwogroups:routinephysicalexamsandacoustictraumawithouthearingprotection.Allsubjectswerenoise-freeforatleast14hoursbeforeevaluation.OnlythresholddatafromSoldierswithnormaltypeAtympanogramswerecollected.Ofthissample,34oftheSoldiersreportedacoustictraumaincombatand47hadnotbeenexposedtoacoustictrauma,butreceivedhearingscreeningsasapartofroutinephysicalexams.OneSoldierintheacoustictraumagrouphadoneearwithaperforatedtympanicmembrane,sothatearwasexcludedfromthedatasetreducingthenumberofearsCohortCaseStudiesonAcousticTraumainOperationIraqiFreedom Datafromcomparativetestsofpredeploymentandduring-deploymentaudiometricthresholdsbetweenpairedcontrolandexposuregroups.GlossaryPEroutinephysicalexamgroupAThearingprotectedacoustictraumagroupNote:PEandATarefollowedbythecorrespondingfrequencyinHz

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AprilJune200919THEARMYMEDICALDEPARTMENTJOURNALto67.Allsubjectswereunder25yearsofage,sonoweightingforageorgenderwasused.24Thethresholdsattheindividualfrequenciesof500Hz,1kHz,2kHz,4kHz,6kHz,8kHz,and12kHzwerethencomparedbetweengroupswithaone-wayANOVAusingSPSS,Version11.0.Levenesstatisticwasusedtotestforhomogeneityofvariance.Figures3and4displaythequartilesandoutliersateachfrequency.Sincetherewereonly2groups,noposthoctestswerenecessary.Thenullhypothesis:thereisnosignificantdifferencebetweenaudiometricthresholdlevelsattheindividualfrequenciesof500Hz,1kHz,2kHz,4kHz,6kHz,8kHz,and12kHzbetweentheroutinephysicalexamgroupandtheacoustictraumagroup.Thenullhypothesiswasrejectedfortheindividualfrequenciesof500Hz,1kHz,2kHz,4kHz,6kHz,8kHz,and12kHz.Therewasasignificantdifferenceinhearingthresholdlevelsatthesefrequencies.Theanalysisofvarianceat500Hzrevealedahighlysignificantdifferencebetweengroups,F=5.485,p<0.05withamedium2of0.03.Theanalysisofvarianceat1kHzrevealedahighlysignificantdifferencebetweengroups,F=6.371,p<0.05withamedium2of0.04.Homogeneityofvariancewasnotviolated,=0.67,p>0.05.Theanalysisofvarianceat2kHzrevealedasignificantdifferencebetweengroups,F=11.661,p<0.05withamedium2of0.07.Homogeneityofvariancewasviolated,=0.03,p<0.05.Theanalysisofvarianceat4kHzrevealednosignificantdifferencebetweengroups,F=25.017,p>0.05withasmall2of0.01.Homogeneityofvariancewasviolated,=0.00,p<0.05.Theanalysisofvarianceat6kHzrevealednosignificantdifferencebetweengroups,F=17.159,p>0.05withasmall2of0.01.Homogeneityofvariancewasviolated,=0.00,p<0.05.Theanalysisofvarianceat8kHzrevealednosignificantdifferencebetweengroups,F=27.589,p>0.05withalarge2of0.17.Homogeneityofvariancewasviolated,=0.00,p<0.05.Theanalysisofvarianceat12kHzrevealednosignificantdifferencebetweengroups,F=28.736, AT12000HzPE12000HzAT8000HzPE8000HzAT6000HzPE6000Hz D e c i b e l s120100806040200-20 Figure4.Medianandquartilesofthedatacomparingsubjectsofthephysicalexamgroupversusthoseoftheacoustictraumagroup.GlossaryPEroutinephysicalexamgroupAThearingprotectedacoustictraumagroupNote:PEandATarefollowedbythecorrespondingfrequencyinHz AT4000HzPE4000HzAT2000HzPE2000HzAT1000HzPE1000HzAT500HzPE500Hz D e c i b e l s806040200-20 Figure3.Medianandquartilesofthedatacomparingsubjectsofthephysicalexamgroupversusthoseoftheacoustictraumagroup.GlossaryPEroutinephysicalexamgroupAThearingprotectedacoustictraumagroupNote:PEandATarefollowedbythecorrespondingfrequencyinHz

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20https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1p>0.05withalarge2of0.15.Homogeneityofvari-ancewasviolated,=0.00,p<0.05.Thesignificancelevelswereremarkableatallfrequencies.Theincreaseinstandarddeviationwiththeincreaseinfrequencyisnotable,butexpectedinhazardouslynoiseexposedindividuals.Severalstudiesattributethisvariationtomechanicalresonanceandsoundtransferfunctionoftheearcanal,theactionofstapedialreflexes,andgenetics.15-17Balatsourasevaluatedextendedhighfrequencyhearing(greaterthan8kHz)inbasictraineesoftheGreekArmy.25Thepurposewastodetermineiftherewasvalueaddedtotheinclusionofextendedhighfrequencythresholdtestingwiththestandardaudiologybattery.Thesubjectshadbeenexposedtoacoustictraumabysmallarmsweaponsfire.Theconclusionwasthatextendedhighfrequencytemporarythresholdshiftsubsidedandtherewasnosignificantbenefitfromtheaddedtimeandeffortforconductingthisprocedure.Hamernikidentifiedimpulsenoise,specificallyblastwaveswithveryshortdurations(0.5millisecond)andhighpeakintensities,ascapableofproducingamechanicalimpulsewhichcanresultinextremelyhighshearstressesandprematurefailureofelasticstructures.26Hefurtherdescribedblastwaveexposureasproducing2fundamentallydifferentlesionpatterns:severemechanicaldamagetotheorganofCortiwherelargepiecesofsensoryandsupportingcellsweretornloosefromthebasilarmembrane,andlesionsthatweremorelimitedinextentandconsistedprimarilyofmissingordamagedsensorycellswiththestructuralelementsoftheorganofCortiremainingessentiallyintact.Thislatterpatternoflosswasfrequentlyassociatedwithdamagetothetympanicmembrane.Theacoustictraumasinthisstudywerefromimprovisedexplosivedevicesorcarbombsandtheresultsabove8kHzwerepermanentandquitelargethresholdshifts.Thisislikelyduetothespectralandintensitydifferencesinsmallarmsfireandimprovisedexplosivedeviceexposure.Improvisedexplosivedevices(IEDs),whichwereusedsparselyattheoutsetofOperationIraqiFreedominMarch2003,nowaccountfornearly70%ofallUScasualtiesfromhostileactioninIraq.27Understandably,theIEDwasthemostcommontypeofimpulseexposureinIraqin2006.DuringthisphaseofOperationIraqiFreedom,mostoftheIEDswereconstructedoutof105mmartilleryshells.Pricemeasuredtheimpulseandspectrumofthisexplosivedevice.At5.64meters,theimpulsehasaspectralpeakat~100HzwithanAdurationof0.3millisecond.ThesecondmostcommonimpulseexposurewasfromthestandardissueM16rifle.At4.24meters,ithasaspectralpeakof~600HzwithanAdurationof0.2millisecond.21Eitherofthese,whensituatedwherethereisareflectionoftheimpulse,willcreateasecondreflectedimpulseexposurethatcanbeasmuchas90%oftheinitialimpulsesenergywithsimilarspectralenergy.InanurbanterrainsuchasBaghdad,warfareoftentakesplaceincitystreetswherethereisagreatdealofreflectivesurfaces.Thespectralpeakofthe2mostcommoncombatexposuresisbelow1kHzandisanotherprobablevariableforthehearingprotectedacoustictraumagroupshearingpostexplosionthresholdconfiguration.DISCUSSIONArmyaudiologyplaysaveryimportantroleinpreventivemedicineandthestandard3levelsofpreventionareroutinelyused.Primarypreventivemeasuresincludeproperselectionanduseofhearingprotection,annualeducation,andtakingabaselineaudiogram.Secondarypreventivemeasuresinvolveidentificationoftheearlystagesofnoiseinducedhearinglossandtakingstepstopreventitsprogressionthroughintervention,follow-upmonitoring,andclinicalvalidationofresults.Ifprimaryandsecondarypreventionstrategiesdonotwork,tertiaryservicessuchashearingaidfitting,auralrehabilitation,andadministrativecontrolsareused.TheprimaryandsecondarypreventivemeasuresofhearingconservationhavehadatremendousimpactinthereductionofthenumberofSoldierswithhearinglossoverthepast4decades,butcurrentlargescalecombatoperationshavereducedthesuccessrateofconventionalhearingconservationintheArmy.HearingconservationisarobustprogramintheArmy.Unfortunately,hazardousnoiseanditseffectsonhearingcannotbeeradicatedwithaonetreatmentvaccination,itisanongoingprogramthatrequirescontinuouseffortsandleadershipsupport.ArmydeploymentsarefluidandtheenvironmentstowhichSoldiersareexposedareconstantlychanging.Forthepreventionofhearingloss,thishastraditionallyposedCohortCaseStudiesonAcousticTraumainOperationIraqiFreedom

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AprilJune200921THEARMYMEDICALDEPARTMENTJOURNALaproblembecausehearingconservationprogramswerenotdesignedwithcombatinmind.Withasymmetricwarfare(coalitionforcesobservingdifferentrulesofengagementthaninsurgents)andanonlinearbattlefield(nofrontlines),Soldiersareexpe-riencingmoreexposuretothesoundsofcombat.Thishasforcedaudiologiststorethinktheirapproachtopreventioninthesechallengingenvironments.Eventhoughthesecohortcasestudieswerenotabletocontrolforthemanyfactorsthataffecthearingincombat,theydoprovideafieldperspectiveonhearingprotectionbeingusedincombatandhowitcorrelateswithpreviousresearch.ThisarticleonlyaddresseshearingthresholdsofSoldierswhoreportedwearinghearingprotectionwhentheywereexposedtoanexplosion.ItisimportanttopointoutthatforthemanySoldierswerenotwearinghearingprotection,thehearinglosswassubstantialandtypicallyinvolvedconductiveandsensorineuralcomponents.Thereisalsosomeanecdotalevidencethatcentralhearinglosswasacomorbidcomponentoftraumaticbraininjury.TheprevalenceofthistypeofacoustictraumainOperationsIraqFreedomandEnduringFreedomarenotyetknown,butarebeingstudied.Thevestibularsystemmayalsobedamagedbyhazardousnoiseduetoitscloseproximityandsimilarityincellstructuretothecochlea.28Soldiersareexposedtoexplosions,suchasimprovisedexplosivedevices,mortars,orcarbombs.Theyarealsoexposedtomanysteady-statenoisessuchasaircraft,trackvehicles,orlargeelectricalgenerators.Thesenoisesourcesmaycauseasymptomaticdamagetotheirvestibularsystem.Shupaketaldidfindthatsymmetricnoise-inducedhearinglossiscorrelatedwithsymmetricperipheralvestibularsystemdamage.29TheseresultswerecorroboratedbyM.HillandD.S.McIlwain(unpublisheddata,2006).Thereasonitispossibletobeunawareofavestibulardeficitinconjunctionwithacoustictraumaisbecauseofthecomplexrelationshipbetweenthecentralnervoussystem(CNS)ofthebrainandthe3primarysensorymodalitiescriticaltoequilibrium(vestibular,visual,andproprioceptivesystems).Ifaninsulttothevestibularsystemoccurs,theCNSreliesheavilyoninformationfromvisionandproprioceptiontomakeupforthelackofneuralfiringfromthebalancecentertocompensate.TheCNSadaptstothedifferentlevelsofneuralinputitreceives.Duringthisadaptationtime,theindividualoftenexperiencesaslightfeelingofimbalance,dizziness,orevenvertigo,especiallyintheabsenceofvision.Symptomaticfeelingsofimbalance,dizziness,andvertigotypicallysubside.Thevestibularsystem,combinedwiththevisualandproprioceptivesystems,contributestospatialorientation.Itisestimatedthat80%ofspatialorientationisbasedonvisualcues,butwhenvisualcuesarenolongeravailableorarediminished,thevestibularsystemsroleiscriticallyelevated.Situationswhileflyingaircraftordrivinganarmoredpersonnelcarrier,suchaswhite-outs(snow)orbrown-outs(sand),mayleadtogreatlyreducedvisualcues.Ifapilotordriversvestibularsystemisdamaged,thechanceofspatialdisorientationoccurringinlow-visionenvironmentsmayincrease,resultinginapotentiallycatastrophicaccident.Itisalsopossiblethatthisspatialdisori-entationcouldbeacauseofdangerforthegroundtroopsinsimilarlowvisibilitysituationswhileweigheddownwithabasiccombatload.CONCLUSIONThesolutionisonthebattlefield.EveniftheSoldiersarenotdirectlyinvolvedincombat,thecommondenominatorofthesmallbutsignificanthighfrequencythresholdshiftisacombatdeployment.GatesandFallonrecommendamoreaggressiveoperationalhearingprogramshouldbeimplementedwithmoreArmyaudiologistsdeployedtomeettherecommendedoneArmyaudiologistper10,000Soldiers.Currently,thereisonlyoneaudiologistforover160,000deployedSoldiersinIraq,andnoneinAfghanistan.30Increasedsensitivityforsecondaryinterventionisalsowarranted.ItisrecommendedthatSoldierswithasmallbutsignificanthighfrequencythresholdshift(averagepositive10dBthresholdshiftat4kHzand6kHzorapositivethresholdshiftof15dBineither4kHzor6kHz)postdeploymentshouldreceiveafol-low-upaudiogram.EmphasisshouldbeplacedonSoldiersavoidingnoiseofanykindforatleast14hourswithreeducationonwhatconstituteshazardousnoise.Ifasmallbutsignificanthighfrequencythresholdshiftisconfirmedonthefollow-upaudio-gram,theSoldiershouldreceiveatleastaverbalacknowledgementthattherehasbeenasmallchangeinhearing,interviewedonpossiblecauses,andamoredetailededucationonthelong-termpersonalandprofessionalconsequencesofhearingloss.Thesmall

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22https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1butsignificanthighfrequencythresholdshiftshouldbeviewedasanearlyindicatorofnoiseinducedhearinglossbecauseitplacesSoldiersathigherriskforclinicallysignificantnoise-inducedhearingloss.TheArmyspendsaconsiderableamountoftimeandmoneytraininganall-volunteerforce.Inaninstant,aSoldiercanbecomeariskforfurtherinjuryaswellasputothersatriskduetodecreasedjobperformance.Currently,thebestsolutiontotheage-oldproblemofhazardousnoiseintheArmyisthemilitaryaudiologist.Theseprofessionalsareindispensableindevelopingsolutionsforuniquesituationssuchasnoiseabatementandtheselectionanduseofcontem-poraryhearingprotectionincombatenvironments.REFERENCES 1.ArmyRegulation40-501:StandardsofMedicalFitness.Washington,DC:USDeptoftheArmy;December14,2007:80.2.McIlwainDS.CAOHCDeployed.CAOHCUpdate.2004;16(3):4.Availableat:http://www.caohc.org/updatearticles/fall04.pdf.AccessedApril7,2009.3.CombatRecognitionRequirements.HumanEngineeringReportSDC383-6-1.OfficeofNavalResearch.April15,1952:20-25.4.DonahueA,OhlinD.Noiseandtheimpairmentofhearing.Occupationalhealth:theSoldierandtheindustrialbase.Washington,DC:BordenInstitute.1993;207-252.5.GarintherGR,PetersLJ.Impactofcommunicationsonarmorcrewperformance.ArmyResDevAcquisBull.January-February1990:1-5.6.WeinerF,RossD.Thepressuredistributionintheauditorycanalinaprogressivesoundfield.JAcoustSocAm.1946;18:401-408.7.RudmoseW.Hearinglossresultingfromnoiseexposure.In:HarrisCM,ed.HandbookofNoiseControl.1sted.NewYork:McGraw-Hill;1975.8.WardW.Noise-inducedhearingdamage.Otolaryngol.1973;2:377-390.9.YlikoskiME,YlikoskiJS.HearinglossandhandicapofprofessionalSoldiersexposedtogunfirenoise.ScandJWorkEnvironHealth.1994;20(2):93-100.10.CaveK.Blastinjuryoftheear:clinicalupdatefromtheglobalwaronterror.MilMed.2007;172:726-730.11.HelferT,JordanN,LeeR.PostdeploymenthearinglossinUSArmySoldiersseenataudiologyclinicsfromApril1,2003throughMarch31,2004.AmJAudiol.2005;14:161-168.12.USDeptofVeteransAffairs.AnnualReport:NationalCenterforRehabilitativeAuditoryResearch,January1December31,2007.Portland,OR:2008.13.BohnB,HardingG.Degenerationinthecochleaafternoisedamage:primaryversussecondaryevents.AmJOtol.2000;21(4):505-509.14.DoleB.GAOFindingsandRecommendationsRegardingDoDandVADisabilitySystems.Washington,DC:GovernmentAccountabilityOffice;May25,2007.15.BovoR,CiorbaA,MartiniA.Geneticfactorsinnoiseinducedhearingloss.AudiologicalMedicine.2007;5:25-32.16.HolmesA,WidenS,ErlandssonS,CarverC,WhiteL.Perceivedhearingstatusandattitudestowardnoiseinyoungadults.AmJAudiol.2007;16(suppl):S182-S189.17.FletcherJ.Comparativeattenuationcharacteristicsoftheacoustic.JAcoustSocAm.1960;32:1524.18.FergusonGA,TakaneY.StatisticalAnalysisinPsychologyandEducation.6thed.Montral,Quebec:McGraw-HillRyersonLimited;2005.19.BergerE,KieperR,GaugerD.Hearingprotection:surpassingthelimitstoattenuationimposedbytheboneconductionpathways.JAcoustSocAm.2003;114:1955-1967.20.PriceR.Upperlimittostapesdisplacement:implicationsforhearingloss.JAcoustSocAm.1974;56:3.21.PriceR.Relativehazardofweaponsimpulse.JAcoustSocAm.1983;73:556-565.22.KobrakHG.TheMiddleEar.Chicago,Illinois:UniversityofChicagoPress;1959.23.VonBekesyG.ExperimentsinHearing.WeverEG,ed.NewYork:McGraw-Hill;1960.24.ISO7029:2000.Acoustics-StatisticalDistributionofHearingThresholdsasaFunctionofAge.InternationalOrganizationforStandardization:Geneva,Switzerland;2000.25.BalatsourasD,HousioglouE,DanielidousV.Extendedhighfrequencyaudiometryinpatientswithacoustictrauma.ClinOtolaryngol.2004;30:249-254.CohortCaseStudiesonAcousticTraumainOperationIraqiFreedom

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AprilJune200923THEARMYMEDICALDEPARTMENTJOURNAL26.HamernikR,TurrentineG,RobertoM,SalviR,Hen-dersonD.Anatomicalcorrelatesofimpulsenoise-inducedmechanicaldamageinthecochlea.HearRes.1984;13:229-247.27.DepenbrockP.TympanicmembraneperforationinIEDblasts.JSpecOperMed.2008;8,51-53.28.GolzA,WestermanS,WestermanL,etal.Theeffectsofnoiseonthevestibularsystem.AmJOtolaryngol.2001;22:190-196.29.ShupakA,Bar-ElE,PodoshinL,SpitzerO,GordonC,Ben-DavidJ.Vestibularfindingsassociatedwithchronicnoiseinducedhearingimpairment.ActaOtolaryngol.1994;114(6):579-585.30.GatesK,FallonE.HearingConservationProgram:Doctrine,Organization,Training,Materiel,Leader-shipandEducation,PersonnelandFacilities.Aber-deenProvingGrounds,MD:USArmyCenterforHealthPromotionandPreventiveMedicine;2007:7.AUTHORS MAJMcIlwainisaninstructorandcurriculumwriterattheUSArmyMedicalDepartmentCenterandSchool,FortSamHouston,Texas.MAJ(Ret)SiskistheCoordinatorofOutlyingClinicsattheVeteransAdministrationHospital,Temple,Texas.DrHillisaprincipleinvestigatorintheDepartmentofAcoustics,USArmyAeromedicalResearchLaboratory,FortRucker,Alabama.

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24https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1ProviderResilience:TheChallengeforBehavioralHealthProvidersAssignedtoBrigadeCombatTeamsLTC(Ret)LarryApplewhite,MS,USALTC(P)DerrickArincorayan,MS,USAINTRODUCTIONDeploymentrelatedmentalhealthproblemshavereceivedincreasedattentionsincetheGlobalWaronTerrorismbeganin2001.In2003,theOfficeofTheSurgeonGeneralsanctionedMentalHealthAdvisoryTeams(MHAT)toresearchmentalhealthissuesofdeployedWarriorsservinginIraqandAfghanistan.Themostrecentstudy,entitledMHATV,foundthatindividualswhowereontheirthirdorfourthdeploymentreportedexperiencingmorementalhealthsymptoms,stress-relatedworkproblemsandsuiciderateswereelevatedinboththeatersofoperations.1In2004,Hogeetal,inastudyofcombatdutyinIraqandAfghanistan,suggestedconservativelythatasmanyas17%ofcombatveteranscoulddevelopmentalhealthdisorderssuchasdepression,alcoholmisuse,andposttraumaticstressdisorder(PTSD)3to4monthsafterreturningfromdeployment.2ThecongressionallymandatedDepartmentofDefenseTaskForceonMentalHealthexaminedmentalhealthmattersinthearmedforcesandconcludedin2007thatThesystemofcareforpsychologicalhealththathasevolvedoverrecentdecadesisinsufficienttomeettheneedsoftodaysforcesandtheirbeneficiaries.3AccountsofthepersonalstrugglestoadjustingtolifeafterservinginOperationsIraqiFreedomand/orEnduringFreedomhaveprovidedinsightsintothechallengesconfrontedbymanyveterans.Ina2007article,CSMSamuelRhodes,whospentover30monthsdeployedtothemiddleeast,providedanespeciallypoignantdescriptionofhisexperienceswithPTSDandconcludedhisstorybyencouragingotherswithsimilarsymptomstogethelplikehedid.4Toaddressaseeminglygrowingproblem,behavioralhealthprofessionalsroutinelydeployasessentialcomponentsofcombatstresscontrol(CSC)detachmentsandcombatsupporthospitals.Lessonslearnedfromthesedeploymentshavebeenwelldocumented.RegerandMoore,psychologistswhodeployedwiththe98thand85thCSCDetachmentsrespectively,emphasizedtheneedtoretainflexibilityinallocatingassetsintheatertomaximizetheefficientandeffectivedeliveryofpreventiveandtreatmentservicesinacombatzone.5InastudyoftheeffectivenessofcriticaleventdebriefingsconductedinIraq,PischkeandHallman,veteransofthe785thMedicalCompany(CSC)inIraq,reinforcedtheneedforpsychologicaltreatmentandidentifiedthebenefitsofprovidingmentalhealthservicestoWarriorsonthefrontlines.6WhileCSCshaveperformedavaluableroleinsupportingdeployedunits,thosepsychologistsandsocialworkofficerswhoareassignedtobrigadecombatteamsrepresentthevanguardofbehavioralhealthresourcesintodaysexpeditionaryArmy.ThesepersonneldeploydirectlywiththosewhobearthegreatestburdenfightingthisasymmetricalwaronterrorismandconfrontmanyofthesamethreatsfacedbycombatarmsWarriors.Inordertoadequatelyprepareforthedemandsofdutyinacombatzone,behavioralhealthofficersassignedtoabrigadecombatteammustrecognizethechallengesthatawaitthemanddevelopanactionplantoenhancepersonalresiliency.Neglectingthiscriticalpredeploymenttaskcanresultinabehavioralhealthproviderwhobecomeslesseffectiveoverthecourseofalongdeployment,andjeopardizesthequalityofcareneededtosustainthepsychologicalfitnessofourWarriors.THESTRESSOFBRIGADEBEHAVIORALHEALTHOPERATIONSThedemandofsupporting2majorcombatoperationssimultaneouslyhasthepotentialtostretchourforcestothebreakingpoint.Multipledeployments,extendedtours,andstop-loss*policiesaresomeofthefactors *PresidentialauthorityunderTitle10USCode12305tosuspendlawsrelatingtoseparationofanymemberoftheArmedForcesdeterminedessentialtothenationalsecurityoftheUnitedStates.7

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AprilJune200925thathavecreatedanenvironmentthatcantaxthecopingabilitiesofevenwell-trained,highlymotivatedWarriors.Additionally,thereareaspectsofservingintodaysmilitarythatcompoundsanalreadystressfulsituation.Advancesintechnologyhavecreatedgreateraccesstoelectroniccommunications,enablingdeployedSoldierstostayintouchwithfamiliesbackhome.Whilemaintainingfamilyrelationshipsmayprovidemuchneededemotionalsupportparticularlyduringatimeofcrisisitalsomeansthattroopsmaybeexposedtothemundanestressesassociatedwiththehomefrontatatimewhentheycandolittletofixit.8Tohelpunderstandthepsychologicalstressinherentincontemporarymilitaryoperations,Bartoneetaldevelopedamodelthatclearlydelineatestheprimarysourcesofoperationalstress.9InitiallyappliedtoSoldiersconductingpeacekeepingoperationsintheformerYugoslavia,Bartonelaterexpandedthemodelandappliedittoothercontingencyoperations,includingOperationsIraqiFreedomandEnduringFreedom.10TheprimarydimensionsofstressidentifiedbyBartoneandhiscolleaguesareisolation,ambiguity,powerlessness,boredom,danger,andworkload.9,10WhilealloftheseelementsmayproducestresstosomeextentforalldeployedSoldiers,isolation,powerlessness,danger,andworkloadappeartobethosemostpertinenttobehavioralhealthoperationsinabrigadecombatteam.Isolation.Asenseofalonenesscanpermeatethetimespentservinginaforeignlandseparatedfromlovedones.ThenaturalfeelingofbeingalonecanbemagnifiedforproviderswhojoinaunitthroughtheProfessionalFillerSystem(PROFIS).*TheseindividualstypicallyarriveattheunitjustpriortodeploymentandfrequentlyhaveinsufficienttimetofullyintegrateintotheunitscultureortodevelopmeaningfulrelationshipswithfellowSoldiers.Havingatrustedconfidantorbattlebuddyhaslongbeenrecognizedasanimportantsourceofsupportforcopingwiththedemandsofalongcombatdeployment.Establishingarelationshipwithabattlebuddyismademoredifficultbythefactthatbehavioralhealthofficersareassignedoneperbrigade,thuseliminatingacoworkerasalogicalsourceofpeersupport.Furthermore,behavioralhealthprovidersmaybehesitanttoconfidepersonallyinothersastheyfeeltheburdenofresponsibilityoftheirpositioninwhichtheyareexpectedtobeasourceofsupportforothers.Thoseindividualswhoareofsimilarrank(commanders,chaplains,battalionsurgeons,othermedicalpersonnel)oftenreferSoldiersforbehavioralhealthassistance.Divulgingpersonalconcernsoradmittingtoexperiencingdeployment-relatedstressmaydamagetheprofessionalcredibilitythatisessentialtobeingviewedasadependablesupportsystemforSoldiers.Additionally,thesenseofbeingalonecanbeintensifiedduetotheconstraintsplacedonconversationswithfamilyandfriendsbackhome.Discussingthedetailsofworkinginawarzonewithspousesorothersviatelephone,webcam,oremailmaybeinappropriateandmostlikelyviolatesoperationalsecurity.Powerlessness.Inmanyways,brigadebehavioralhealthofficersoccupyapositionsimilartothatofamemberofthespecialstaff.Althoughtheypossessvaluableprofessionalexpertise,theircapacityforexercisingdirectpowerislimited.Itisawellknownaxiomthatstaffofficersmakerecommendations,commandersmakedecisions.Thus,itisnecessarytogetcommandsupportforrecommendationsthataffectaWarriorsdutystatus.Forexample,aSoldierseekingbehavioralhealthcareforacuteanxietyoracombat/operationalstressreactionmaybenefitfrombeingplacedonalternatedutythatdoesnotrequirehimorhertogooutsidethewire.RecommendingthattheSoldiertemporarilytakeakneewhilereceivingsupportivebehavioralhealthinterventioncouldmeetresistancefromthechainofcommandbecausetheunitprobablyneedsalloftheirpersonneltocompletemissionrequirements.Onesabilitytosucceedingettingsupportfortreatmentandpersonnelrecommendationsdependsinpartontheprofessional *PROFISpredesignatesqualifiedActiveDutyhealthprofessionalsservinginTableofDistributionandAllowanceunitstofillActiveDutyandearlydeployingandforwarddeployedunitsofForcesCommand,WesternCommand,andthemedicalcommandsoutsideofthecontinentalUnitedStatesuponmobilizationorupontheexecutionofacontingencyoperation.11Prescribestheorganizationalstructure,personnelandequipmentauthorizations,andrequirementsofamilitaryunittoperformaspecificmissionforwhichthereisnoappropriatetableoforganizationandequipment(thedocumentwhichdefinesthestructureandequipmentforamilitaryorganizationorunit).GenerallydefinedasthepersontowhomaSoldiercanturnintimeofneed,stress,andemotionalhighsandlowswhowillnotturntheSoldieraway,nomatterwhat.ThispersonknowsexactlywhattheSoldierisexperiencingbecauseofexperiencewithsimilarsituationsorconditions,eithercurrent,previous,orboth.

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26https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1credibilitythattheyhaveestablished,andnotnecessarilyfrompowerinherentintheposition.Thisisparticularlytrueforjuniorofficers.Ageneralsenseofpowerlessnessalsocangrowfromlimitationstoalleviateemotionaldistresscausedbypsychosocialcircumstances.Soldierswhoexperiencehomefrontproblemswiththepotentialforseriousconsequences,suchassuspectedmaritalinfidelity,threatsofdivorce,orchildcustodyissues,oftenbelievethatgoinghomeistheonlysolutiontothesituation:TheonlywayIcansavemymarriageistogethome!Whiletheseclaimsmaybelegitimateandelicitempathyandunderstandingfromtheprovider,rarelydotheirpsychologicalsymptomswarrantmedicalevacuationfromtheater.Clinicalstrategiescanbeemployedtoengagetheindividualinatherapeuticmanner,butthepersonmaynotbemotivatedtolearnmoreadaptivecopingtechniquesandremainsintentongoinghometoaddresstheproblem.ProfessionalswhoarededicatedtohelpingothersmaydespairoverworkinginanenvironmentthatlimitstheiroptionstoeffectchangeandmakeapositivedifferenceinthelivesofSoldiers.Asthedeploymentgrindson,anddisappoint-mentsmount,itispossibletoadoptahardened,dontcareattitudetohelpmanageexpectations.ThiscanpresentanobstacletodevelopingtherapeuticrelationshipswithSoldierswhoneedhelp.Danger.AccordingtotheDepartmentofDefense,asreportedintheArmyTimes[February2,2009],therehavebeenover4,200WarriorskilledduringOperationIraqiFreedomand636whohavediedsupportingOperationEnduringFreedom.12ThisisnottooverstatethethreatthatbehavioralhealthpersonnelfaceortoimplythattheyconfrontthesamelevelofhostileforcesasthosewhoroutinelypatrolthestreetsofBaghdadorthemountainsofAfghanistan.However,itisworthnotingthatalldeployedWarriorsworkunderadegreeofriskthattheytoocouldbehitbyenemyfire.Indirectfire,suchasrocketandmortarattacks,landindiscriminatelyonforwardoperatingbases.Thethreatofdeathorinjuryiscompoundedforthoseproviderswhoextendbehavioralhealthsupporttothecombatoutpostsandjointsecuritystationsthatproliferatedwiththeimplementationofacounterinsurgencystrategy.ImprovisedexplosivedevicesareariskforeverybodywhotravelsthestreetsandroadsofIraqorAfghanistan.Additionally,thereexiststhepotentialforcontractingseriousillnessesassociatedwithexposuretocontaminants,pollutants,andothertoxicsubstances.Vehicleaccidentssuchasrolloversoccurintheateraswell.Thethreatofbecomingacasualtyisbynomeansuniquetobehavioralhealthpersonnel,however,itshouldbeacknowledgedasafactorthatcanimpacttheconductofdailyoperationsandcancontributetotheerosionofpsychologicaldefensesneededtocopeinawarzone.Workload.Whilethebrigadebehavioralhealthteamalsoincludesanenlistedmentalhealthspecialist,theofficerisessentiallyresponsibleforsupportingapproximately4,000combattroops.Oneofthegreatsuccessesderivingfromtheattentiongiventodeploymentstressisthatmanybrigadecombatteamcommandersnowprioritizetheestablishmentofaccesstobehavioralhealthcarewheneveritisneededandtowhomeverneedsit.Thiscansignificantlystraina2-personteam.Theworkloadoftentimescannotbesharedbecausetherearenootherprovidersavailableontheforwardoperatingbase.Thedemandforbehavioralhealthservicescanbedrivenbymultiplefactors.Leadershipvariables,operationaltempo,degreeofenemycontact,livingconditions,andeventheeffectivenessofsupportsystemsforfamiliesbackhomeinfluencethelevelofstressfeltbydeployedSoldiers.Regardlessofthedemandfordirectservices,thebehavioralhealthprovidermustremainon-call24hoursaday,everyday,inordertobeavailableforcrisisinterventionthereisnotimeoffforweekendsandholidays.Ensuringaccesstocarebecomesmorechallengingwhentheunitsbattlespaceincludesnumerouscombatoutpostsandjointsecuritystations.Providingoutreachtothesesitesfurthertaxesbehavioralhealthteamssimplybyenlargingtheirgeographicareaofoperations.WhileCSCteamsareabletoassistinsomeregions,theprimaryresponsibilityforcaringfortheWarriorssecuringthesesitesremainswiththeorganicbehavioralhealthassets.THERISKOFCOMPASSIONFATIGUEInadditiontotheamountofwork,thenatureoftheworkitselfplacesbehavioralhealthprovidersat-riskfordevelopingpsychologicaldistressthatcanlastfarbeyondthedeployment.MuchoftheclinicalworkconductedbybehavioralhealthofficersinvolvesestablishingtherapeuticrelationshipswiththeSoldierstheytreat.Empathyisthebedrockofthisprocess.Thecoreaspectofempathyistheabilitytoexperienceanotherpersonsstateofbeingatanygivenmoment.13ProviderResilience:TheChallengeforBehavioralHealthProvidersAssignedtoBrigadeCombatTeams

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AprilJune200927THEARMYMEDICALDEPARTMENTJOURNALWhenclinicianslistentostoriesoffear,pain,andsuffering,suchasthosetoldbyWarriorswithcombat-relatedtrauma,theytoomayfeelsimilarfear,pain,andsuffering.14CharlesFigley,apioneerinthefield,describedcompassionfatigueasanaturalconsequenceofworkingwithindividualswhoexperienceddistressingeventsandthatbeingvicariouslyexposedtotheeventandrespondingempathicallycontributestodevelopingcompassionfatiguesymptoms.15Irritability,withdrawal,asenseofhopelessness,anger,andloweredfrustrationtolerancearecommonpsychosocialmarkersofcompassionfatigueandcanresemblePTSD.16Recentliteratureclearlydemonstratestherelationshipbetweendevelopingcompassionfatiguesymptomsandworkingwithtraumasurvivors.Boscarinoetal,inarandomsurveyof236socialworkerslivinginNewYorkCity,discoveredthatthosewhohadworkedwithsurvivorsoftheterroristattackontheWorldTradeCenterweremorelikelytodevelopsecondarytrauma.17Theauthorsfurthersuggestedthatthedegreeofexposure,personalhistory,availabilityofsocialsupport,andenvironmentalfactorswerevariablesthatinfluencedthedevelopmentofsymptoms.IndescribingtheIsraeliexperience,FraidlinandRabindiscussedtheharrowingordealofsocialworkerswhoworkwithterroristvictims,andconcludedthatrepeatedincidentsarecapableofproducingseverereactionssimilartothoseexperiencedbythecasualtiesthemselves.18Similarly,inacasestudy,TysonconnectedtheprovisionoftraumatherapybyclinicalsocialworkersintheVeteransAdministrationVetCenters(outpatientclinics)andcompassionfatigue.19Sheurgedthementalhealthfieldtorespondtotheneedsoftherapistsbydevelopinginterventionsandeducationalprogramstosupportthosewhoworkwithtraumasurvivors.In2007,Bridesstudyof300socialworkersfoundthat5%metthediagnosticcriteriaforPTSD,twicethatofthegeneralpopulation.20Thedataalsorevealedanastounding55%metatleastonediagnosticcriterionforthedisorder.Bridesuggestedthatthehighrateofsecondarytraumaamongclinicalsocialworkerscouldeventuallyleadmanytoleavetheprofession.Theriskfordevelopingcompassionfatigueisnotconfinedtothosewhoprovidebehavioralhealthcare.KennyandHull,inastudyoftheexperiencesofcriticalcarenursescaringforwarcasualties,foundincreasedstresslevelsthatresultedinsymptomsconsistentwithsecondarytrauma.21Theauthors,themselvesactive-dutyArmynurses,attributedworkloadfactors,empathicresponsestothesufferingofyoungwoundedWarriorsandtheirFamilies,aswellasdistressovertheinabilitytoalleviatepainasmajorfactorsinthecompassionfatigueresponsesofnursingpersonnel.Thehiddencostofcaringpresentschallengesforhealthcaremanagersastheymustestablishorganizationsthatprovidesupportiveenvironmentsforthosewhoworkwithtraumavictimsinordertoretainpersonnelandtosustainahighqualityofcare.22Inlightofwhatisknownaboutcompassionfatigueorsecondarytrauma,itisclearthatbehavioralhealthprovidersdeployedwithabrigadecombatteamareatanincreasedriskfordevelopingpsychosocialdistress.Aneffectivebehavioralhealthprogramincludesproactivetraumaticeventmanagementmeasures.Thispotentiallyplacesthebehavioralhealthteamineverybadsituationexperiencedbythebrigade.RespondingtotheaftermathofcombatactionsorthelossofafellowSoldierduetosuicideoranaccidentexposestheteamtotheemotionsevokedbysuchincidents.AnotherpotentiallyemotionaleventisthememorialservicethatfollowsthedeathofaWarrior.Decidingtoattendmemorialservicesisultimatelyapersonaldecisionthateachbehavioralhealthofficermustmake.However,fromaprofessionalstandpoint,thereisvaluetohavingavisiblepresenceattheserviceasitdemonstratesadesiretobeasourceofsupportfortheunitwhileexpressingrespectforthefallenWarrior,aswellasthoseleftbehindwhomustcontinuethemission.Ascasualtyratesdecline,asishopedbyall,Bartoneandhiscolleaguesconceptsofambiguityandboredom9mayrisetotheforefrontassourcesofstressforbrigadebehavioralhealthteams.Untilthatdayarrives,workloadandtheconcomitantriskofcompassionfatiguewillcontinuetoposethegreatestthreattothepsychologicalwell-beingoftheprovider,andcoulddegradethequalityofcareprovidedtoourWarriors.RESILIENCYSUPPORTPLANResilienceischaracterizedasthecapacitytomaintainrelativelystable,healthylevelsofpsychologicalandphysicalfunctioningwhenexposedtohighlydisruptivecircumstances.23Resiliencyinthefaceofpotentiallyoverwhelmingchallengescanbebolsteredbyactionstakenbyboththeorganizationandthe

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28https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1individual.Structuralsolutionsmayholdthemostpromisetoreducingthepotentialimpactofimmediatesymptomsonworkersexposedtotrauma.24Thus,theorganizationcancreateanenvironmentthatpromotesresiliencythroughtheuseofcombatstressdoctrine,personnelpolicies,andtraininginitiativesthatareconsistentwithsupportingamodularforce.Werecommend:Increasebehavioralhealthauthorizationsinthebrigadecombatteam.A2-personteamisinadequatetosupportabrigadecombatteam(BCT)withseveralthousandpersonnel.Thetaskbecomesevenmoredauntingwhentheunitisdispersedacrossabroadfront.Addinganotherbehavioralhealthofficerormentalhealthspecialist,ifnotanothercompleteteam,wouldbeprudentgiventheArmysrelianceonBCTstosupportpresentandfuturecontingencyoperations.Clarifytheroleofthebehavioralhealthofficerasabrigadeasset.Whilethebehavioralhealthteamisassignedtothemedicalcompany,brigadesupportbattalion,theteamshouldbeclearlyrecognizedasabrigadeassetinwaysthatothermedicalspecialtiesassignedtothelevelIImedicalsupportunitarenot.Thebehavioralhealthofficershouldhavethelatitudetodesignandimplementabehavioralhealthprogramthatsupportsthemaneuverunitswithouttheencumbrancesofoverly-involvedmedicalcompanyandbrigadesupportbattalioncommanders.Perhapsthebestfitistorealignthebehavioralhealthteamwithinthebrigadesheadquarterscompany.Thismovewouldbetterpositionthebehavioralhealthofficertointeractdirectlywiththebrigadecommanderandstafftoincorporatebehavioralhealthconceptsintooperationsincoordinationwiththebrigadesurgeon.EmphasizethatCSCdetachmentsprovidedirectsupporttoBCTs.IndependentCSCteamsoperatinginaBCTareaofoperationscreatesconfusionandinefficienciesinthedeliveryofscarcebehavioralhealthresources.CombatstressdetachmentsshouldpositiontheirassetstodirectlysupporttheBCTsoperatingintheirbattlespace.Toensurethisoccurs,combatstressteamsshouldbeattachedto,or,ataminimum,beoperationallycontrolledbythesupportedBCT.Brigadesur-geonsneedtobeabletodirectlyinfluencetheCSCassetssupportingthebrigadeinordertocreateacoordinatedbehavioralhealthsupportplanwithclearlinesofresponsibility.ReducethedependenceonPROFISproviders.FillingbehavioralscienceofficerauthorizationsorganictoBCTsshouldbethehighestpriorityforassigningbehavioralhealthproviders.IfpersonnelshortagesdictatethatsomeBCTpositionsrequirePROFISsupport,thenfieldgradeofficersshouldbeslottedintothesepositionssincetheirexperienceshouldmakethembetterequippedtoeffectivelyadapttothedemandsofadeployment.Combat/operationalstresscontrol(COSC)training.InDecember2008,TheArmySurgeonGeneralmandatedthatallbehavioralhealthcareproviderswill,priortodeployment,attendtheCOSCcourseconductedbytheArmyMedicalDepartmentCenterandSchool.ThecoursecurriculumreflectscurrentlessonslearnedinIraqandAfghanistan.Commandersatalllevelsshouldsupportthisinitiativebyensuringthattheirbehavioralhealthteamsattendthecourseasanessentialpartofpredeploymenttraining.ArmyProviderResiliencyTrainingProgram(PRT).TheArmysPRTprogramwasimplementedin2008tohelpreduceproviderfatigueandburnout.Commandershavearesponsibilitytotheirhealthcarepersonneltofullysupportthisimportantprogramandindividualprovidersmusttakeadvantageofthepotentialbenefitsithastooffer.Inadditiontosystemicsupport,individualscantakestepstofortifythemselvesagainsttherigorsofcom-bat.Whileaself-careplanisnecessarilyapersonalmatter,thefollowingcomponentsshouldbeconsidered:Establishasenseofmasteryinthejob.Professionaldevelopmentthroughexperienceandtrainingisessentialtogainingconfidenceinonesabilitytoperformunderthemostdifficultconditions.Youngofficerscanbenefitgreatlyfromamentoringrelationshipwithatrusted,moreexperiencedseniorofficer.Takingresponsibilityforonescareerdevelopmentwillhelpprepareyoungprofessionalstoconfidentlyconductthefullrangeofbehavioralhealthoperationswhendeployed.Maintainasocialsupportnetwork.Healthyrelationshipsarevitaltoapersonspsychologicalwell-beingandemotionalstability.FindagoodProviderResilience:TheChallengeforBehavioralHealthProvidersAssignedtoBrigadeCombatTeams

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AprilJune200929THEARMYMEDICALDEPARTMENTJOURNALbattlebuddyandbeoneinreturn.AlldeployedSoldiersshouldusethevastarrayofavailablecommunicationtools,includingoldfashionedletterwriting,tostayconnectedwithfamilyandfriendsbackhome.However,thisshouldbedonewiththeawarenessthattoomuchinformationflowinginandoutoftheatercanbecounterproductive.Nurturespiritualhealth.Frequentexposuretopainandsufferingcandimonesinnerspirit.Maketime,atleastonceaweek,toengageinanactivity,suchasattendingreligiousservices,meditating,orperformingTaiChiexercises,forexample,thatreplenishesthespirit.Conductaerobicactivities.Itisimportanttobephysicallyfitpriortodeployment.Althoughtheopportunitytoparticipateinphysicalexerciseduringadeploymentwillbedeterminedbyoperationalfactors,itisessentialthatindividualsfindawaytostrengthenthebodythroughaerobicactivities,preferably3timesaweek.Mostforwardoperatingbasesnowhaveatleastonegymsuppliedwithexerciseequipment,andsomelargerbasescanaccommodaterunning,assumingthethreatlevelallowsit.Maintainphysicalnourishmentandsleepdiscipline.Eating2to3mealsdaily,stayinghydrated,andgetting7to8hoursofsleepadayarebasictenetsofmoststressmanagementprograms.However,duringdeployments,thesesimpletasksbecomemuchmoredifficulttoachievejustastheybecomemorecriticaltothemaintenanceofeffectivefunctioning.Properhydrationisespeciallycrucialwhileconductingoperationsinanaridclimate.Gettingsufficientrestorativesleepmaybechallengingduetothedemandsofirregularworkhours,convoyschedules,andbeingawakenedtorespondtoemergenciesatnight.Nevertheless,aregularsleepscheduleshouldbefollowedasmuchaspossible.Findingameaningfulpurposeinlife.Acommit-menttofulfillameaningfulpurposeinlifecanprovidemotivation,direction,andthepeacethatcomesfromasenseofleadingasatisfyinglife.Thepathonechoosestowardsservingagreatergood,whetheritisservicetoonescountry,torelievesuffering,orfreeingtheoppressed,isrootedinpersonalvaluesandbeliefs.Operation-alizingthepursuitofonespurposeextendsfarbeyondsimplykeepingagoodattitudeduringtryingtimes.Personalsustainmentcancomefromkeepingfaithwiththosehigheridealsthatinspireustoserveotherswhencircumstancesareattheirbleakest.AsVictorFranklquotedNietzscheinhisclassicwork,MansSearchforMeaning,25REFERENCES 1.MentalHealthAdvisoryTeam(MHAT)V:OperationIraqiFreedom06-08,Iraq;OperationEnduringFreedom8,Afghanistan.Washington,DC:OfficeofTheSurgeonGeneral,USDeptoftheArmy;February14,2008:26.Availableat:http://www.armymedicine.army.mil/reports/mhat/mhat_v/MHAT_V_OIFandOEF-Redacted.pdf.2.HogeCW,CastroCA,MesserSC,McGurkD,CottingDL,KoffmanMD.CombatdutyinIraqandAfghanistan,mentalhealthproblems,andbarrierstocare.NewEnglJMed.2004;351(1):13-22.3.DefenseHealthBoardTaskForceonMentalHealth.AnAchievableVision:ReportoftheDepartmentofDefenseTaskForceonMentalHealth,June.FallsChurch,VA:USDeptofDefense;2007.Availableat:http://www.health.mil/dhb/mhtf/MHTF-Report-Final.pdf.4.RhodesS.Posttraumaticstressdisorderimpactsalllevelsofleadership.Infantry.July-August2007:5-6.5.RegerGM,MooreCJ.CombatoperationalstresscontrolinIraq:LessonslearnedduringOperationIraqiFreedom.MilPsychol.2006;18(4):297-307.6.PischkePJ,HallmanCJ.EffectivenessofcriticaleventdebriefingsduringOperationIraqiFreedomII.ArmyMedDeptJ.July-September2008:18-23.7.JointPublication1-02:DoDDictionaryofMilitaryandAssociatedTerms.Washington,DC:JointStaff,USDeptofDefense;March4,2008.Availableat:http://www.dtic.mil/doctrine/jel/new_pubs/jp1_02.pdf.8.MastroianniGR,MabryTR,BenedekDM,UrsanoRJ.Thestressesofmodernwar.In:LukeyB,TepeV,eds.BiobehavioralResiliencetoStress.BocaRaton,FL:CRCPress;2008:43-55.Hewhohasawhytoliveforcanbearanyhow.

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30https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=19.BartonePT,AdlerAB,VaitkusMA.Dimensionsofpsychologicalstressinpeacekeepingoperations.MilMed.1998;163(9):587-593.10.BartonePT.Resilienceundermilitaryoperationalstress:Canleadersinfluencehardiness?MilPsychol.2006;18(suppl):S131-S148.11.MedicalCorpsProfessionalDevelopmentGuide.FortSamHouston,TX:USArmyMedicalDepartmentCenterandSchool;March2002:27.12.OIFandOEFcasualtytotals.TheArmyTimes.February2,2009:7.13.WilsonJ,LindyJ.Counter-transferenceintheTreatmentofPTSD.NewYork:GuilfordPublications;1994.14.FigleyCR.CompassionFatigue.NewYork:Brunner-Mazel;1995.15.FigleyCR.Compassionfatigue:psychotherapistschroniclackofselfcare.PsychotherPract.2002;58(11):1433-1441.16.GentryJE.CompassionFatigue:PreventionandResiliency.EauClaire,WI:PESIHealthCare,LLC;2005.17.BoscarinoJA,FigleyCR,AdamsRE.CompassionfatiguefollowingtheSeptember11terroristattacks:AstudyofsecondarytraumaamongNewYorkCitysocialworkers.IntJEmergMentHealth.2004;6(2):57-66.18.FraidlinN,RabinB.Socialworkersconfrontterroristvictims:Theinterventionsandthedifficulties.SocWorkHealthCare.2006;43(2/3):115-130.19.TysonJ.Compassionfatigueinthetreatmentofcombat-relatedtraumaduringwartime.ClinSocWorkJ.2007;35:183-192.20.BrideBE.Prevalenceofsecondarytraumaticstressamongsocialworkers.SocWrk.2007;52(1):63-70.21.KennyDJ,HullMS.Criticalcarenursesexperiencescaringforthecasualtiesofwarevacuatedfromthefrontline:Lessonslearnedandneedsidentified.CritCareNursClinNorthAm.2008;20(1):41-49.22.WhiteD.Thehiddencostsofcaring:whatmanagersneedtoknow.HealthCareManag.2006;25(4):341-347.23.BonannoGA.Loss,traumaandhumanresilience:haveweunderestimatedthehumancapacitytothriveafterextremelyaversiveevents?AmPsychol.2004;59(1):20-28.24.BoberT,RegehrC.Strategiesforreducingsecondaryorvicarioustrauma:dotheywork?BriefTreatCrisisInterv.2006;6(1):1-9.25.FranklVE.MansSearchforMeaning:AnIntroductiontoLogotherapy.NewYork:PocketBooks,SimonandSchuster;1963:126.AUTHORS LTC(Ret)ApplewhiteisafacultymemberoftheArmyFayettevilleStateUniversityMastersofSocialWorkProgram,ArmyMedicalDepartmentCenterandSchool,FortSamHouston,Texas.Hedeployedwiththe1stBrigadeCombatTeam,1stCavalryDivisiontoTaji,IraqfromOctober2006toJanuary2008.LTC(P)ArincorayanisDeputyChief,BehavioralHealthDivision,USArmyMedicalCommand,FortSamHouston,Texas.Hedeployedwiththe4thSupportBrigade,4thInfantryDivisiontoTaji,IraqfromOctober2005toOctober2006.ProviderResilience:TheChallengeforBehavioralHealthProvidersAssignedtoBrigadeCombatTeams

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AprilJune200931BACKGROUND:THESQUAREPEGHistorically,ineveryconflictinwhichtheUShasbeeninvolved,only20%ofallhospitaladmissionshavebeenfromcombatinjuries.Theother80%havebeenfromdiseaseandnonbattleinjury(DNBI).1ExcludedfromthesefiguresarelargenumbersofservicememberswithdecreasedcombateffectivenessduetoDNBInotseriousenoughforhospitaladmission.DuringWorldWarII,itbecameapparentthatmoreactionwasneededattheunitleveltocounterthemedicalthreat.Toanswerthisneed,theunitFSTconceptwasdeveloped.Selectedmembersfromeachcompany-sizedunitreceivedspecialtraininginDNBIpreventionsotheycouldadvisethecommanderinpreventivemedicinemeasures.Thistrainingenabledtheunitcommandertoprovidearthropodcontrol,individualandunitdisinfectionofwater,andsafefoodsupplies.ThesemeasuresresultedinreducedDNBIlosses.Justasitwasconceivedover60yearsago,theunitFSTcontinuestodaytobeacriticalfrontlinedefenseagainstmedicalthreats.ANERAOFPERSISTENTCONFLICT:THEROUNDHOLEThemedicalthreattofieldforcescanbeseentodayinoperationswhereindividualpreventivemedicinemeasuresarelackingandpoorfieldhygieneandsanitationexist.Indeed,theexpeditionarynatureofourforcestodayandtheGlobalWaronTerrorismarerepeatedlyplacingUSforcesinlocationswheresignificant,seriousmedicalthreatsfrominfectiousdiseasesarecommonlypresent.ThenumberofDNBIcontinuestoreducetheeffectivestrengthofunitsandminimizecombatpower.Insomecases,Soldiersaremedicallyevacuatedfromtheaterduetopreventablediseases,suchasleishmaniasisandmalaria.Inothercases,trainingexercisesalmostgrindtoahaltduetodiarrhealillnesses.However,usuallythesemedicalthreatscanbeeasilycounteredbytheimplementationofbasicfieldhygieneandsanitationpracticesandindividualpreventivemedicinemeasures.Preventivemedicinemeasuresaresimple,commonsenseactionsthatanyservicemembercanperformandeveryleadermustknow.TheapplicationofpreventivemedicinemeasurescansignificantlyreducetimelostduetoDNBI.Bothtodaysfightandfutureengagementswillrequireourformationstooperateassmallteams,perhapsnolargerthansquad-orplatoon-sizedelementsgeographicallydispersedthroughoutanareaofoperation.Theareaofoperationwillmostlikelybeinurbanordevelopedareaswithlimitedresourcesavailable,andcharacterizedbylong,unsecuresupplylines.TheseconditionsaddtothedifficultiesofimplementingandsustainingtheunitFSTusingexistingdoctrineandtactics,techniques,andprocedures.Therefore,howdoweadapttheunitFSTconcepttomeettheneedsoftodaysfight,aswellasfutureengagements?Wemodifythepeg.TheUnitFieldSanitationTeam:ASquarePeginaRoundHoleLTCTimothyBosetti,MS,USACPTDavinBridges,MS,USA ABSTRACTBasicfieldsanitationandhygieneisalostartintoday'smodernArmy.Today,morethanever,thereisaneedfortheunitfieldsanitationteam(FST)toserveasadvisorstounitcommandersintheareaofbasicfieldsanitationandhygiene.Soldiersshouldknowhowtoconstructfieldlatrines,constructwastedisposaldevices,conductpestmanagementandcontrolactivities,disinfectfieldwatersupplies,andpracticepersonalhygieneunderfieldconditions.ThecurrentunitFSTconceptiscenteredoncompany-sizedformationsoperatinginopenterrain.Thisconceptdoesnotsupportcurrentoperations,transformedformations,rapidlychangingdoctrine,andtheexpeditionarynatureoftheArmy.Thisarticledoesnotpresentanewconcept,butratheranewlookatanexistingconceptandpracticebaseduponthelessons-learnedandafter-actionreportsfromtheGlobalWaronTerrorismtosupporttheArmyintransformationduringaneraofpersistentconflict.

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32https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1PUTTINGASQUAREPEGINAROUNDHOLETheobjectiveistodevelopasustainableprogramthatemphasizestheneedforfieldhygieneandsanitationinthefield.ThisisparticularlyimportantinanagewhereamajorityofourSoldierscomefromurbanareasandnotaccustomedtoaustereconditionsexpectedintheexpeditionarynatureofourcurrentandfutureformations.ThiscanbedonebymodifyingthecurrentunitFSTconceptbychangingcurrentdoctrine,organization,training,materiel,leadership,education,personnel,andfacilitiestoretoolthesquarepegtomeetcurrentandfutureoperationalneeds.DoctrineCurrentdoctrinestatesthattherewillbeoneunitFSTforeachcompany-sizedelement.UnderpreviousforceconstructsandColdWardoctrine,thiswasagoodconcept;however,itdoesnotfittodaysfluidenvironmentandfocusonsmall-unit,full-spectrumoperations.ThedoctrinalallocationofoneunitFSTpercompanyshouldchangetooneunitFSTperplatoon-sizedelement,ataminimum.ThischangewouldenabletheunitFSTtooperateatalowerlevelandbeabletosupportnumeroussmallcombatoutpostsinanareaofoperation.Mostofthecurrentconceptswouldstillbeapplicable,onlypusheddownoneleveltotheplatoon,ratherthanthecompany.Doctrinemustthenalsobeupdatedtokeeppacewithnewandemergingtechnologiesforwastedisposal,waterreuse,personalhygiene,personalprotectiveequipmentandmeasures,anddiseasepreventiontactics,techniques,andprocedures.OrganizationThedocumentationofunitFSTtrainingasanadditionalskillidentifier(ASI)andinclusionofthatspecialtyinthetableoforganizationandequipment*(TOE)ofallplatoon-sizedunitsshouldbeconsidered.ThiswillrequirecreationoftheASIandtheprocedurestodocumentitintheindividualspersonnelfile.IndividualSoldierstrainedinamoreintensiveunitFSTtrainingprogramwouldreceivetheASI,whichwouldthenbedocumentedonanindividualspersonnelrecordtoreducethetimeandmoneyinvolvedinrepeatedlytrainingindividuals.Inaddition,thedocumentationoftheASIontheTOEwillallowunitstohaveindividualsidentifiedasunitFSTmembers,whichcanbereportedontheUnitStatusReport(USR).ThisnotonlyformalizestheunitFSTconcept,butholdscommandersaccountablefortheimplementationoftheprogram.Justasindividualsareidentifiedasadriver(anadditionalduty)ontheTOE,membersoftheunitFSTcanbeidentifiedassuch.ThiswouldcodifytheexistenceoftheunitFSTontheTOEandbeusedtoensurethatSoldiersaretrainedinthispositionbyreceiptoftheASI.ThisprocesswouldalsoenablethetrackingoftheseitemsontheUSR,resultinginvisibilityatallcommandlevels.TrainingTheplanningandcontractingoffieldhygieneandsanitationdevicescanbeintegratedintotrainingprograms.ThiswouldallowunitcommandersandstafftoplanforandimplementtheuseofthesefacilitiesinaccordancewithArmyguidelines,ensuringthattheyareknowledgeableonthenumberandsizeofthefacilitiesrequiredtoaccommodatetheirunitandmission.SeverallessonslearnedfromoperationsinAfghanistanandIraqshowedthatindividualunitswereabletoconstructfieldhygieneandsanitationdevicesforthemselvesbutencounteredproblemswhentheirpopulationgrewortheirmissionchanged.Nowunitsareisolatedawayfromtheirrespectivebattalionsorbrigadesmakingtheunitrelyonitselfmorethanever.Propereducationandtrainingofleadersinthesizing,use,andlimitationsoffieldsanitationandhygienedevicescanalleviatetheseproblems.Commandersandstaffwillbeeducatedonwhentosequenceandconstructadditionalfacilitiestoaccommodatepopulationsurgesandmissionchanges.Moreimportantly,trainingshouldfocusontheintegrationofplanningforfieldhygieneandsanitationdevicespriortoenteringatheatertodeterminewhichmethodsaremostsuitedfortheoperationandwhatmaterialsarereadilyavailable.Itdoesnogoodtoplanfortheuseofportabletoiletswhentherearenomeanstoprocurethemintheater.MaterielTheequipmentrequiredforpersonalprotectivemeasuresandtoconductbasicunitFSTmissionsalreadyexistintheinventory.WhatchangesishowthisequipmentisallocatedtounitFSTmembers,theunit,andtheindividualSoldier.ManyoftheitemsfoundinAppendixCofArmyFieldManual4-25.122arecommontablesofallowance(CTA-50-900,-909,-970)itemswhichcouldbeissueddirectlytotheindividualSoldier,ratherthanprocuredbytheunitTheUnitFieldSanitationTeam:ASquarePeginaRoundHole *Definesthestructureandequipmentforamilitaryorgani-zationorunit.

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AprilJune200933THEARMYMEDICALDEPARTMENTJOURNALfirst,thenissuedtotheSoldier.Avoidingthemiddlemaninthiscasereducestheburdenontheunitinthepurchaseoftheseexpendablesupplies.Otheritemscouldbepackagedintoanequipmentsettoallowforpropertybookaccountabilityandroutinelycheckedaspartoftheunitscommandsupplydisciplineprogram.Technologycontinuestoadvanceandsodoinnovativemethodsforwastedisposal,waterreuse,personalhygiene,andpersonalprotectiveequipment.LeadershipandEducationTheprimaryphasetothisconceptistheintegrationofunitFSTtrainingandemphasisofitsimportanceintoalleducationsystems,beginningwithinitialentrytraining.TheunitFSTconceptandtaskswouldbepartofinitialentrytrainingforallSoldierandofficer(officercandidateschool,reserveofficertrainingcourse,USMilitaryAcademy)accessions.Soldierswouldreceiveadditionaltraininginadvanceindividualtrainingcourses,thenagainthroughoutthenoncommissionedofficereducationsystem.Likewise,officerswouldreceivetraininginallofficereducationsystemscoursesthroughouttheircareer.Thisrepetitivetrainingisdesignedtoemphasizethebasicfundamentalsoffieldsanitationandhygiene,andregainthelostartofthosedisciplines.FieldhygieneandsanitationinformationshouldbeintegratedintoallleadershipandeducationprogramsacrosstheArmy,notsolelyintheArmyMedicalDepartment(AMEDD).TheseareknowledgeandskillsthatarerequiredforforcehealthprotectionandthereductionofDNBI.EmphasisofthistrainingthroughouttheindividualscareerisvitaltothesuccessoftheprogramandtheconservationofourArmysfightingstrength.PersonnelandFacilitiesAssignmentofanASItopersonneltrainedinunitFSTprinciplesdoesnotrequireadditionalpersonnel.Thecurrentforcestructurecanbeused.Likewise,additionalfacilitiesarenotrequiredtoimplementthisprogram.Mosttrainingareasalreadyhavelocationsthathavestandingdigpermitstoallowtrainingontheconstructionofhastyfightingpositionsanddeliberatefightingpositions.WejustneedtoencouragetheuseoftheseexistingfacilitiestotraininthebasicconceptsofunitFST.CONCLUSIONAswiththeexistingunitFSTprogram,themostsignificantbarriertotheincorporationofanenhancedFSTconceptiscommandemphasis.Withoutcommandemphasis,theprogramwillcontinuetobelessthansuccessfulinthepreventionofDNBIcasualties.AswithanynewconceptorchangefromthestatusquoandthewaytheArmyhasdonethingsinthepast,therewillberesistancetochange.Overcomingthereluctancetochangewillbeamajorchallenge.ImplementationofthesechangesandtransformationoftheunitFSTrequireacoordinatedeffortbymanyorganizationsandcannotviewedasaconstraintorplacedinthetoohardtodobox.TheunitFSTprogramrequirescommandemphasisinordertobeeffective.TheunitFSTprogramisnotsolelyanAMEDDresponsibility,butratheranArmyprogramcriticaltotheconservationoffightingstrengththroughthereductionofpreventableDNBI.TobeeffectiveinmeetingtheexpeditionarynatureofourArmyinaneraofpersistentconflict,theimplementationandexecutionoftheunitFSTprogramrequiresanewlookatanoldconcept.TheevaluationofthecurrentunitFSTconceptusingthedoctrine,organization,training,materiel,leadership,education,personnel,andfacilitiesapproachpresentedinthispaperwillhopefullyencouragediscussiontotransformtheunitFSTtomeetcurrentandfutureoperationalneeds.REFERENCES 1.FieldManual21-10:FieldHygieneandSanitation.Washington,DC:USDeptoftheArmy;21June2000:p1-1.2.FieldManual4-25.12.UnitFieldSanitationTeam.Washington,DC:USDeptoftheArmy;25January2002.AUTHORS LTCBosettiisChiefoftheDepartmentofEnvironmentalSciencesattheUSArmyCenterforHealthPromotionandPreventiveMedicineEurope.CPTBridgesisanEnvironmentalScienceOfficerandtheProgramManageroftheUSArmyCenterforHealthPromotionandPreventiveMedicineEuropeDeploymentEnvironmentalSurveillanceProgram. Anequipmentallowancedocumentthatprescribesbasicallowancesofindividualororganizationalequipment,andprovidesthecontroltodevelop,revise,orchangeequip-mentauthorizationinventorydata.

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34https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1Throughoutthehistoryofmodernwarfare,accountsofprisonatrocitieshaverepeatedlysurfacedwhichdepictactiveandpassiveaggressiontowardsprisonersofwar(POWs).Yet,witheachconflict,newaccountsarebornandanundeniablerealityofwarfareinflictsfreshscarsforaggressorstobear.Itisunderstandable,basedonhumannatureandthegoalsofwarthatagovernment(oritsrepresentatives)willfeelmalicetowardenemyprisonerscapturedduringaconflict.Itisunquestionablyachallengetoovercomethathumannature,despitethestatuteswhichoutlinelawfultreatmentofPOWs.2Whilemostaspectsofwarfarehavebeenrevolutionizedthroughouthistory,themeansbywhichamilitarydealswithitsPOWsremainssomewhatmiredinthereluctanceofleaderstoacknowledgethatitwillfactorsuchintoeveryconflict.ThemanagementofPOWswill,infact,becomeasourceofcontroversyaslongasitishandledasanafterthought.Asevidencedthroughouthistory,thisarticlepresentsexamples,datingbacktotheRevolutionaryWar,ofhowlawcanonlyinfluencehumannaturetoapoint,especiallywhenresourcesarePrisonerofWarCamps:LackofaRevolutionLTCJenniferCaci,MS,USALTCJoanneM.Cline,MS,USA DISCLAIMERThedefinitionanduseofthetermprisonerofwarorenemyprisonerofwarafter1949arespecificallyoutlinedintheGenevaConventionsof1949,Convention(III)RelativetotheTreatmentofPrisonersofWar1:Art4.A.Prisonersofwar,inthesenseofthepresentConvention,arepersonsbelongingtooneofthefollowingcategories,whohavefallenintothepoweroftheenemy:(1)MembersofthearmedforcesofaPartytotheconflict,aswellasmembersofmilitiasorvolunteercorpsformingpartofsucharmedforces.(2)Membersofothermilitiasandmembersofothervolunteercorps,includingthoseoforganizedresistancemovements,belongingtoaPartytotheconflictandoperatinginoroutsidetheirownterritory,evenifthisterritoryisoccupied,providedthatsuchmilitiasorvolunteercorps,includingsuchorganizedresistancemovements,fulfillthefollowingconditions:(a)thatofbeingcommandedbyapersonresponsibleforhissubordinates;(b)thatofhavingafixeddistinctivesignrecognizableatadistance;(c)thatofcarryingarmsopenly;(d)thatofconductingtheiroperationsinaccordancewiththelawsandcustomsofwar.(3)MembersofregulararmedforceswhoprofessallegiancetoagovernmentoranauthoritynotrecognizedbytheDetainingPower.(4)Personswhoaccompanythearmedforceswithoutactuallybeingmembersthereof,suchascivilianmembersofmilitaryaircraftcrews,warcorrespondents,supplycontractors,membersoflabourunitsorofservicesresponsibleforthewelfareofthearmedforces,providedthattheyhavereceivedauthorization,fromthearmedforceswhichtheyaccompany,whoshallprovidethemforthatpurposewithanidentitycardsimilartotheannexedmodel.(5)Membersofcrews,includingmasters,pilotsandapprentices,ofthemerchantmarineandthecrewsofcivilaircraftofthePartiestotheconflict,whodonotbenefitbymorefavourabletreatmentunderanyotherprovisionsofinternationallaw.(6)Inhabitantsofanon-occupiedterritory,whoontheapproachoftheenemyspontaneouslytakeuparmstoresisttheinvadingforces,withouthavinghadtimetoformthemselvesintoregulararmedunits,providedtheycarryarmsopenlyandrespectthelawsandcustomsofwar.Terroristsdonotmeettherequirementsaboveandarethusreferredtoasunlawfulenemycombatants/detainees.ThosecapturedinIraqaftertheofficialcessationofwararereferredtoascivilianinternees/detainees.

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AprilJune200935limited,secrecyisparamount,ignoranceisareality,andaccountabilityisquestionable.DuringtheAmericanRevolutionaryWar,itwasobvioustheBritishfailedtoplanforhandlingthousandsofPOWsonforeignsoil.WithlimitedfacilitiesinNewYorkCityandfundsnotavailabletobuild,theBritishdecidedtoconvertadozenorsoun-seaworthyRoyalNavyshipsharboredintheareaintoPOWfacilities.3ThemostinfamousofthesewastheHMSJersey,aformerBritishhospitalshipinWallaboutBaynearBrooklyn,NewYork.Theshipwasoriginallybuiltasadestroyerin1736,butwasconvertedbyremovingthemastsandnailingupthegunports.4TheJerseywasdecrepitandconditionsharsh,withovercrowdinganimmediateandongoingproblem.Normally,theHMSJerseywasmannedbyacrewofabout350sailors,yetasaprisonshipithousedoverathousandPOWs.3Overcrowdingonlyworsenedasthewarprogressed,dueinlargeparttoissueswithprisonerexchange(theBritishcapturedthousandsofprisonersandGeorgeWashingtondidnotfavorexchangingveteranBritishSoldiersforsick,untrainedAmericanswhowereoftenPrivateers).5TheDepartmentofDefensecurrentlylists4,435USbattledeathsduringtheRevolutionaryWar.Another20,000diedincaptivityfromdiseaseorforotherreasons.5Historiansestimatethetotalnumberofprisonshipdeathsbetween8,000and11,644.6,7Anestimated4ofevery5prisonersontheHMSJerseydiedandasmanyas8corpsesadaywereburiedinWallaboutBay.7Theatrocioussanitaryconditionswereultimatelyresponsibleforagreatmajorityofthedeaths:communalbucketsfordefecatingresultedinwidespreaddysenteryandcholera;thousandsofmencrammedbelowdeckswithoutlightorfreshairaidedtransmissionofdiseasessuchastuberculosis,smallpox,andyellowfever;andlackoffruitandvegetablesguaranteedscurvyamongmanyprisoners.Whatsparsefoodwasprovidedtotheprisonerswasnormallymaggot-infested,moldy,orsimplyrottenbeyondconsumption.ThepoliticalsituationonlyworsenedtheprisonersfateasBritishtensionsledtoincreasedmistreatment.Withnothreatofretribution,guardsimposedinhumaneanddegradingtreatmentonprisoners,oftenleadingtoinjuryand/oraccidentaldeath.6TheRevolutionaryWarprovidedfirsthandexperienceforAmericanSoldiersandleadersontheramificationsofpoorplanningandmismanagementofprisonerscapturedincombat.However,AmericanswouldrepeatthemistakesoftheBritish.Inlessthan100years2CivilWarPOWcampswouldentertherealmofinfamy.Andersonville,theinfamousPOWcampestablishedbytheConfederacyinasmallvillageofthesamenameinSumterCounty,Georgia,wasoneofthelargestConfederatemilitaryprisonsestablishedduringtheCivilWar.8AlthoughoriginallyestablishedtomoveprisonersfromtheRichmondareatoamoresecurelocationwherefoodwasabundant,the26.5acrestockadewithitsminimalstaffingcouldnotadequatelysupportthemorethan45,000UnionSoldiersconfinedinsideitswalls.9Originallybuilttohouseonly10,000,itwasobviouswhyconditionsatAndersonvillearedescribedasworsethananyotherprisoncamp,northorsouth.10Severeovercrowding,lackofshelter,diminishingresources,andtheinevitablecontaminationofthestreamprovidingtheonlywatertothecampledtoa30%mortalityrate.10BytheendofAndersonvilles14-monthlife,nearly13,000menweredeadfrommalnutritionandthediseasesassociatedwiththedeplorableconditions.11Astheformerprisongroundsappearnow,onewouldfinditdifficulttoimaginetheconditionsandchallengesofrunningthecampin1864,however,thehistoryofAndersonvilletellsthestoryofanarmyunpreparedforvastnumbersofprisoners,alackofunderstandingorguidanceofhowtotakecareofthem,andanunfortunateofficer,CPTHenryWirz,whoworethebloodofallprisonersonhishands.11CPTWirzwasnotthefirstofficertotakechargeoftheAndersonvilleprison,norwashesolelyresponsibleforthelackoffunds,resources,orpersonneltorunthefacility.However,whenpeopleinthenorthlearnedofthehorrorsthere,hebecamethemostconvenienttarget.AlthoughtestimonyfromhistrialindicatesthatCPTWirzdidmakeanefforttoimproveconditionsafterhisarrivalatAndersonville,therealitywasthatprisonersweredyingeveryday(oneevery11minutesononeparticularlybadday)oftyphoid,gangrenousinfection,andcommunicabledisease.12Tomakemattersworse,theWarDepartmentstoppedtheprisonerexchangeprogram,furtherstressinglocalfamiliesandcontributingtothedemandforvengeance.SincetherewasnoplanforhowtohandlethesituationatAndersonvilleornorthernprisoncamps,creatingaspectacleoutoftheWirztrialdeflectedattentionawayfromthenorthandtheUSgovernment.Ironically,CPTWirzstrialandsubsequenthangingappeasedthepopulationwhichhadbeensoappalledbytheconditionsatAndersonvilleconditionswhichwere

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36https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1inpartaresultoftheWarDepartmentsterminationoftheexchangeprogram.11Therewere,infact,plentyofreasonsforthegovernmentsattemptstodeflectattentionawayfromtheUnionprisoncamps,whichharboredtheirshareofsqualoranddeath.ConditionsattheUnionPOWfacilitiesatCampDouglasinChicagoandthelesserknownprisonatElmira,NY,(frequentlyreferredtoasHelmira)rivaledthoseatAndersonville,althoughhistorylesswillinglytellstheirstory,andnoUnioncommanderwouldeverdiefortheatrocitiescommittedthere.13TheUnionArmydidnobetterthantheConfederatesinhandlingthechallengeofmanagingPOWswhen,inearly1862,CampDouglaswashastilyconvertedfromatrainingcampintoaPOWcamp,eventuallyearningthetitle,eightyacresofhell.14Althoughtheprisonerpopulationatthecampneverrivaledthe45,000housedatAndersonville,CampDouglaswasknownasthenorthernprisoncampwiththehighestmortalityrateofallUnionCivilWarprisons,equalingandsometimesexceedingthehighestdeathratesatAndersonville.13ThehastyplacementofaPOWcampinChicagowasatacticalerroronthepartoftheUnionArmy,consideringthecitywasfilledwithspiesandsouthernsympathizerswhomadeeffortstoarmtheprisoners.Initially,thelocationmaynothaveseemedillconceivedasthecityresidentsregularlyvisitedCampDouglastogawkattheConfederateprisoners,andanobservationplatformwasevenconstructedtoaidthecitizensviewing.13ConditionsinsidethecampweresodeplorablethatHenryWhitneyBellows,presidentoftheUSSanitaryCommission,wrotetoColonelHoffman,hissuperior,aftervisitingthecamp:Sir,theamountofstandingwater,unpolicedgrounds,offoulsinks,ofunventilatedandcrowdedbarracks,ofgeneraldisorder,orsoilreekingmiasmaticaccretions,ofrottenbonesandemptyingofcampkettles,isenoughtodriveasanitariantodespair.Ihopenothoughtwillbeentertainedofmendingmatters.Theabsoluteabandonmentofthespotseemstobetheonlyjudiciouscourse.Idonotbelievethatanyamountofdrainagewouldpurgethatsoilloadedwithaccumulatedfilthorthosebarracksfetidwithtwostoriesofverminandanimalexhalations.Nothingbutfirecancleansethem.15Insidetheprison,multiplemethodsoftorture,suchasreducedfoodrations,prisonerexecutions,isolationinthewhiteoakdungeon,hangingbythumbs,orbeingforcedtorideonMorganswoodenmule(withweighthungontheirfeettomakeitmorepainful)wereregularlyutilizedtokeeptheprisonerpopulationdown,tomaintainorder,andtoextractinformation.13,15In1863,75prisonersmadeatimelyescapeandmanagedtoavoidthefateofover11,000prisonerswhodiedthefollowingyear.CampDouglaswasclosedin1865whentheremainingprisonerswereaskedtotakealoyaltyoathtotheUSandthensetfree.11Despitefewerpagesinthehistorybooks,theUnionprisoncampsarenonethelessevidencethatduringtheCivilWar,neithersidewaspreparedtohandlePOWsandneitherfiguredouthowtosuccessfullyremedythesituationonceitpresenteditself.Repeatingthesamemistakesasothers,fromtheatrociousdepravitiestoestablishinginadequatefacilities,AmericanshadfailedmiserablyattheirfirsttestasguardiansofPOWs.In1899,thetermprisonerofwarwasoriginatedattheHagueConference,whichsetforththebasicprinciplesgoverningthedefinitionofaPOWandthetreatmentaffordedthem.16TheHagueConferencesof1899and1907,andthesubsequentGenevaConventionsof1929,establishedground-rulesformanagingPOWs,buttherewasnoguaranteethateverycountrywouldfollowthem.WhileitisnotunreasonableforanationtoexpectfairtreatmentofitsSoldiersiftheyaretakenprisonerbytheenemy,theexpectationisflawedbecauseitpresupposesthattheenemycanunderstandtheprincipleofsurrender.AswasobservedinWorldWarII,thisisnotalwaysthecase.WhiletherearemanyexamplesofmistreatmentofPOWsbyourenemies(ie,theGermansatBergaandtheJapaneseatCabanatuan),fewexamplescomparetoconditionsatCampODonnell,thetransientcampinthePhilippinessituatedattheendoftheBataanDeathMarchroute.CampODonnellhasbeenreferredtoasAndersonvilleRevisitedforgoodreason.17Despitethepassageof80yearsandmultipledocumentsoutliningacceptabletreatmentofPOWs,manyoftheFilipinoandAmericanprisonersheldatCampODonnellfacedthesamehorrorsofthoseinternedatAndersonville.OnedifferencebetweenthesituationswasthatduringtheCivilWar,ignorance,lackofresources,andmalicewereoftenthereasonsfortheconditions,whileatCampODonnell,theprimaryissuebehindthemaltreatmentofprisonerswasthePrisonerofWarCamps:LackofaRevolution

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AprilJune200937THEARMYMEDICALDEPARTMENTJOURNALinabilityoftheJapanesetounderstandoracceptthathonorablemenwerecapableofsurrender.TotheJapanese,thetroopswhosurvivedtheBataanDeathMarchtoreachCampODonnellwerenotPOWs,theywerenothing.18CampODonnellwasoriginallyaFilipinoConstabularyPost,partiallyconstructedandwithlittleinfrastructure.LikeAndersonville,CampODonnellcontainedonlyonewaterspigotforapproximately50,000prisonersanditwasnotunusualforaprisonertodieinlineafterwaitingalldayandnightforhisturn.18Inthefirst2monthsatCampODonnell,morethan1,500Americanand20,000FilipinoSoldiersdied,anaverageof358perday.19Thesanitaryconditionsinthecampweresodeplorablethatthemeagerservingsofricereceivedbytheprisonerswereinevitablyconsumedwhilecoveredwithblueandgreenbottleflies.18Gravediggerdetailwasacommonrequirementforprisonersstrongenoughtodig,anddigtheydid,sometimesburying400bodiesaday.Thegraveswerelargeshallowholes,whichweredugupbydogseachnightcreatingfesteringpoolsofdisease.Therewas,surprisingly,ahospitalatCampODonnell,althoughamongtheprisonersitwasbasicallyconsideredaplacewhereonewenttodie.ItisdifficulttofathomthatagroupofcivilizedpeoplecouldallowandevencondonetheconditionsatCampODonnell,buttheJapanesegovernmenthadnotsignednorapprovedoftheGenevaConvention,andthereforedidnotbelieveAmericanandFilipinoprisonerswereentitledtoanysafeguards.18Ultimately,eventheJapaneserecognizedthepotentialbacklashresultingfromCampODonnellandmovedtheprisonerstoCabanatuaninJune1942,wheremanymorewoulddiebeforetheRangersexecutedasuccessfulraidonthecamp.Unfortunately,POWcampsinWWIIwouldnotbethelasttimeinthe20thcenturythattheGenevaConventionswereignoredandanenemysignificantlymisunderstood.DuringtheKoreanWar,alackofplanningforandmanagementofKoreanandChinesePOWstakenbyUSandUnitedNations(UN)forceswasanunsurprisingshortfallinthedisjointedandlimitedpreparationforthatconflict.Whilefood,clothing,andhousingwerelistedasadequatebytheInternationalRedCross,thelargenumberofcaptives,atonetimeover80,000,madeclosesupervisiondifficult.20Maintaininggoodorderwasnearlyimpossible,withbloodyclashesacommoneventinsidethecamps.UNPOWsheldbyNorthKoreansandtheChinese,however,didnotfareaswell.ItisallegedthatNorthKoreanforcessubjectedUNPOWstoforcedlabor,beatings,starvation,andsummaryexecutions/massacressuchasthoseatHills312and303.21AmericanPOWswerefurthersubjectedtophysicalabuseandtortureatthehandsoftheChinese.USArmyPOWsdiedinlargenumbersduringthefirstpartofthewarwithamortalityrateof40%whileconfined,generallyduetouncheckeddiseases,untendedwounds,malnutrition,andextremecold.20Alarmedattheextremelyhighdeathrate,theChineseeventuallystartedtoimproveconditionsatPOWcampsandsuppliedfoodandmedicine.20UnlikeKorea,inVietnamtherewasplentyoftimepriortomajorhostilitieswhenbothsidescouldhaveplannedfortheinevitablePOWsituationthatwouldarise.InthecaseoftheNorthVietnamese,itwasnotalackofplanning,ratherapuredisdainfortheenemyanddisregardfortheprovisionsoftheGenevaConventionwhichwereupdatedin1949.Inashowofsomewhatpoeticjustice,theHoaLo,aprisonbuiltbytheFrenchtoholdVietnameseprisonerscapturedfightingfortheirindependencefromFrenchIndochina,wasusedbytheNorthVietnamesetoimprisonSoldiers,DepartmentofStatepersonnel,andsupportersoftheUSeffort.TheHoaLobecameoneofthemostfamousPOWcampsinhistory,heretoforeknownastheHanoiHilton.22AsisthecasewiththemajorityofthePOWcampsimmortalizedinhistoricalrecords,theconditionsattheHanoiHiltonweredeplorable.Notonlyweremorethan300prisonerssubjectedtomiserablesanitaryconditionsandregularboutsoftropicaldisease,thereissignificantevidencethattheprisonersattheHanoiHiltonweresystematicallyabused,bothphysicallyandpsychologically.Thisisseeminglyafact,althoughtheVietnamesegovernmentstilldeniesitandtheUSgovernmentfailedtoevertakeanyactiononit.NoneoftheVietnameseofficialsimplicatedintheabusehaveeverbeenformallychargedbytheUSoritsalliesnorhasextraditioneverbeendemanded.23Theinformationregardingabusewasfirstrevealedinthelate1960swhenreleaseofprisonersbegan,butwasnotmadeavailabletothegeneralpublicforfearthatretaliationwouldbeinflictedonthosestillincaptivity.ItiswidelyknownbytheAmericanpublicandmuch

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38https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1oftheworldthatAmericanprisonersweretorturedinNorthVietnameseprisoncamps,however,thefactthatlittleifanyactionwastakenoreventhreatenedagainstthegovernmentresponsibleforthattortureleftthestatusofPOWsinfuturewarspotentiallyuncertain.AftertheshockofSeptember11,2001,theUSgovernmentvowedthatthevictimsofthatdaydidnotdieinvain.Overthenext18months,2verydifferentfightswereinitiatedinAfghanistanandIraqaspartoftheGlobalWaronTerrorism(GWOT).WhilemanyproblemsintheGWOThavebeenexcruciatinglydissectedbyarmchairquarterbacksaroundtheglobe,thereisnoargumentwiththefactthattheincidentswhichtookplaceattheBagramandAbuGhraibprisonfacilities(althoughrealisticallynotcomparabletostoriesofprisoncampspast)putanindelibleblackmarkonUSeffortsinbothcountries,andthatalackofplanningforhandlingprisonersofwarwasinpartresponsible.InAfghanistan,itwasobviousfromthebeginningoftheconflictthatUSmilitaryleadersfailedtoappropriatelyplanforhousingdetainees(unlawfulenemycombatants)astheselectedBagramTheaterInternmentFacility(BTIF)wasnotanideallocation.OriginallybuiltbytheSovietsinthe1980sasanaircraftmachineshop,thefacilitywasretrofittedwithwirecagesandwoodensegregationcells(laterupgradedtoconcretesegregationroomswithlatrineandsink).24Initiallyintendedtoserveasatemporaryfacility,theBTIFhasnowhouseddetaineeslongerthanGuantanamoBay.25Intheearlydaysoftheconflict,conditionsinsidetheBTIFmirroredthoseofUSSoldiers(exceptforthewirecages)toincludeburnoutlatrinesandmakeshiftwoodenflooring.25Overthenextseveralyears,numerousupgradesandexpansionprojectsensued.Nevertheless,eventoday,guardforcepersonnelremainextremelylimitedinthenumberandqualityofimprovementstheycanmakeduetothephysicallocationofthefacilityandlandspaceallocation.Withlimitedplanning,littletonoformaltraininginhandlingdetaineesormanagingdetaineecamps,shortfallsinmilitaryreferencematerial,andtheissuingofconfusing,oftenconflicting,higherheadquartersguidance,itdidnottakelongforallegationsofabuse,torture,andmaltreatmenttosurface,eventhoughmostwereunsubstantiated.Onesucheventinvolvedthedeathsof2AfghandetaineesinDecember2002,whileinthecustodyofUSforcesattheBTIF.Allegationsofbeatings,bluntforcetrauma,anddegradingtreatment,aswellastheallegedcover-upofthecircumstancessurroundingtheirdeathsquicklyreachedseveralnewsoutlets.TheUSCriminalInvestigationCommandinitiatedaninvestigationandinOctober2004,determinedtherewasprobablecausetocharge27Soldierswithcriminaloffenses.26DuringthisinvestigationitwasalsodiscoveredthatsomeoftheseindictedSoldiershaddeployedandhelpedestablishtheinterrogationanddebriefingcenterinAbuGhraib,Iraq.26Inlate2002,LTGRichardCodydirectedabottom-upreviewoftheMilitaryPoliceCorps(MPC)structure;largelyasameansofmakingitbettersuitedtohandletheinternment/resettlement(I/R)mission,andpotentiallyasaresultoftheincidentattheBTIF.27Thisindicatesthelikelihoodthatsomeone,somewhererecognizedthepotentialforaPOWsituationtodevelopinthependingwarinIraq,andtheneedforameansofdealingwithit.Unfortunately,thatforesightdidnotchangethefactthat,althoughsignificantlylimitedatthetime,theexistingI/RassetsoftheMilitaryPoliceCorpsmayhavehadapositiveimpactonthedetaineesituationinIraqandcouldhavelessenedthelikelihoodofadetainee-relatedscandalhadtheybeendeployed.Instead,thepotentialforasignificantPOWsituationwasunderestimated,thepowerofhumannaturewasonceagaindeniedoratbestmisunderstood,andmilitarypolicemenandwomenwhosefellowSoldiersweresimultaneouslythreatenedonthestreetsaroundBaghdaddailywereexpectedtodenytheirinstinctivedesireforvengeanceandguardenemyprisonerswithoutincident.Notonlywasthisatasktheywerenotproperlytrainedtoexecute,butalsoataskthattheirnonhabitualhigherchainofcommandwasnottrainedtosupervise.WhilewedonotbyanymeanscondonetheactionsoftheSoldiersinvolved,itwaslikelyinevitablethatascandalofthisnaturewouldoccur,consideringthecircumstancesandthepowerofhumannature.TheBaghdadCentralConfinementFacility(BCCF)wasestablishedattheAbuGhraibprisoncompound,32kmwestofBaghdad.InternationallyknownasSaddamstorturehouse,thefacilitywasusedbytheBaathgovernmenttotortureandexecutepresumeddissidents.28ItwasrenamedBCCFafterUSforcesexpelledtheformerIraqigovernment.ThedecisiontousethisfacilityasaPOW(detainee)camp,alreadyPrisonerofWarCamps:LackofaRevolution

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AprilJune200939THEARMYMEDICALDEPARTMENTJOURNALtaintedinternationallyduetothethousandsexecutedbytheSaddamregime,waspresumablyatacticalerror.DifficulttoresupplyduetoitscloseproximitytoFallujahandmajorcombatoperationsearlyinthewar,AbuGhraibalsostoodamongheapsoftrashand,allegedly,thebonesofpreviousoccupants.Soldierswerehousedinformerprisonstructures,completewithtorturehooksandtheghostsofthepast.Ironically,incloseproximitytothehardsite(nowinfamousasthesitewhereUSforcesabuseddetainees),severaltentcampswereconstructedtoholdtheever-increasingnumberofdetainees,anecessaryactionreminiscentofconflictspast.Anumberoffactorscontributedtotheoverallsituationandmindsetofbothguardsandprisoners:harshenvironmentalconditions,lackofadequateinfrastructuretoprovidebasicsanitationandhygieneconveniences,andashortageofoverheadprotectionfromcombatoperationswithinthesetentcamps.ThesewereproblemsthatonlyexacerbatedthechallengesatAbuGhraib.Inaddition,thesheercraftinessofdetaineestocontinuallycircumventandnegateanyattemptbytheguardforcetoimproveconditionsforthemsetthestageforabattleofhumanwillandnature.Awindowintothisdarkersideofhumannaturewasilluminatedover30yearsagoduringtheStanfordPrisonExperimentledbyProfessorPhilipZimbardo.29Thestudyselectedcollege-agedmenwithpositiveattitudesandapparentgoodmentalhealthandthenstudiedthesituationalforcesandpsychologicaleffectsofthembecomingeitheraprisonerorprisonguard.Zimbardowrites:Myguardsrepeatedlystrippedtheirprisonersnaked,hoodedthem,chainedthem,deniedthemfoodorbeddingprivileges,putthemintosolitaryconfinement,andmadethemcleantoiletbowlswiththeirbarehands.2Thestudywashaltedafteronly6daysduetotheseveretreatmentofprisonersandtheresultingpsychologicaltrauma.Zimbardoconcludes:Inasituationthatimplicitlygivespermissionforsuspendingmoralvalues,manyofuscanbemorphedintocreaturesalientoourownnature.2ParallelsexistbetweenthisstudyandtheactionsoftheSoldiersindictedintheAbuGhraibscandal.ThesituationalforcespresentatAbuGhraibinlate2003certainlysetthestageforthesuspensionofmoralvalues.Undoubtedlythereweremultiplehumanfactorsexistingatthefacility,includinginadequatetraining,lackofproficiencyinbasicSoldieringskills,under-manning,frictionbetweendifferentchainsofcommand,poormorale,staffinefficiencies,andvariouspsychologicalfactorssuchasthedifferencesincultures,Soldierqualityoflife,realpressuresofmortaldangeroverextendedperiodsoftime,andafailurebythecommandtorecognizeandmitigatethesefactors.27Ultimately,thesefactorsculminatedinthenowinfamousactionsofthoseinvolvedinthescandalatAbuGhraib.WhiledirectparallelsbetweenthedetentioncampsoftodayandthePOWcampsofthepastdoexist,itwouldbeinaccuratetoconcludethatnoimprovementshavebeenmadeinhowtheUShandlesPOWs(andotherdetainees).TypicaltrendsandproblemsfromthepastdonotexisttodayinUSheldcamps,suchasmalnutrition,poormedicalcare,andhighmortalityrates.AccountabilityforindividualactionsviolatingtheGenevaConventionsorhumanetreatmentpoliciesisenforcedasisevidentbythelegalactiontakenagainstthoseinvolvedwiththecasesdiscussedabove.Furthermore,prisonerstodayareprovidedmedicalcarefarsuperiortothatreceivedbymostotherlocalnationals.Yetwithallthevaluableinsightgainedfromourrichhistoricalpast,weremainapredominantlyreactiveratherthanproactiveorganization.DepartmentofDefenseandgovernmentaloversightoffacilities(RedCross,combatantcommandassessmentteams,congressionalhearings,etc)increasedasareactiontoAbuGhraib,asdidthenumberofinternment/resettlementunits,policies,regulations,andguidance.Yetnoneofthesecorrectthelackofplanningforfuturewars,northeneedtobettertrainleadersinthesiteselectionandorganizationofPOWcamps,managementstrategies,andlegalrecourse,functionsancillarytothebasichousingofprisoners,andculturalsensitivity/diversity(ie,AfghanistanisnotIraq).Theselessonsmustbelearnedtoovercomeourreactivenature.EnemyPOWsareaninextricablefacetofwarfare.AcknowledgementofthisfactiscriticalifeveraconflictistobeengagedwiththehopeofavoidingalegacyofaccountscomparabletothosefromtheHMSJerseytoAbuGhraib.In2005,SenatorJohnMcCainproposedanamendmenttobanthemilitaryandgovernmentagenciesfromengagingincruel,inhuman,ordegradingtreatmentofdetaineesbecauseapparentlytheGenevaConventiondoesnotdothatalready.30WhilewesupportSenatorMcCainseffortstoensurethatwhathappenedtohimshouldnever

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40https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1happentoanyoneelse,especiallyatthehandsofAmericans,wesubmitthatifproperplanningforthehandlingofPOWsinwartimeisexecutedandthemissiontaskedtothosewhoareproperlytrainedtofulfillit,thehorrificstoriesofPOWcampspastmaytrulybehistory.ACKNOWLEDGEMENT OurthankstoDrJeroldBrownattheArmyCommandandGeneralStaffCollegeforhispositiveinitialreviewofthebasedocumentforthisarticle.Withouthisconfidentendorsementin2006,itwouldhavemostcertainlyremainedunpublished.REFERENCES 1.DiplomaticConferenceofGenevaof1949:Convention(III)RelativetotheTreatmentofPrisonersofWar.[InternationalCommitteeoftheRedCrosswebsite].August12,1949.Availableat:http://www.icrc.org/ihl.nsf/7c4d08d9b287a42141256739003e636b/6fef854a3517b75ac125641e004a9e68.AccessedMay12,2009.2.ZimbardoPG.PowerturnsgoodSoldiersintobadapples.TheBostonGlobe.May9,2004;Opinionsection.Availableat:http://www.boston.com/news/globe/editorial_opinion/oped/articles/2004/05/09/power_turns_good_soldiers_into_bad_apples/.3.TheAmericanRevolutionaryWarwebsite.RevolutionaryWarPrisonersofWar.Availableat:http://www.myrevolutionarywar.com/pow/.AccessedJanuary11,2009.4.POWsoftheAmericanRevolution[DVD].TheHistoryChannel;2006.Availableat:http://shop.history.com/detail.php?p=69115&v=history_subject_war-and-warfare_revolutionary-war.AccessedMay1,2009.5.Wikipedia.comwebsite.HMSJersey(1736).Availableat:http://en.wikipedia.org/wiki/HMS_Jersey_(1736).AccessedJanuary11,2009.6.DeWanG.Thewretchedprisonships.Newsday.com.Availableat:www.newsday.com/community/guide/lihistory/ny-history-hs425a,0,6698945.story?coll=ny-lihistory-navigation.AccessedJanuary11,2009.7.BoatnerMMIII..EncyclopediaoftheAmericanRevolution.NewYork:McKayPublishers;1974.8.Wikipedia.comwebsite.AndersonvilleNationalHistoricSite.Availableat:http://en.wikipedia.org/wiki/andersonville_prison.AccessedJanuary12,2009.9.CattonB.TheAmericanHeritagePictureHistoryoftheCivilWar.NewYork:AmericanHeritagePublishingCompanyInc;1960.10.TheWaroftheRebellionwebsite.Andersonville(CampSumter)PrisonerofWarCamp.Availableat:http://www.mycivilwar.com/pow/ga-andersonville.htm.AccessedJanuary12,2009.11.EicherD.TheLongestNight:AMilitaryHistoryoftheCivilWar.NewYork:Simon&Schuster;2001.12.TheHorrorsatAndersonvillePrison[DVD].TheHistoryChannel;2006.PartofTheUnknownCivilWarCollection[DVD].TheHistoryChannel.Availableat:http://shop.history.com/detail.php?p=77698&v=.13.BurnhamP.TheAndersonvillesofthenorth.In:CowleyR,ed.WithMyFacetotheEnemy:PerspectivesontheCivilWar.NewYork,NY:GPPutnamsSons;2001:367.14.EightyAcresofHell[DVD].TheHistoryChannel;2006.Availableat:http://shop.history.com/detail.php?p=69494&v=history_subject_war-and-warfare_civil-war&pagemax=all.15.Wikipedia.comwebsite.CampDouglas(Chicago).Availableat:www.en.wikipedia.org/wiki/Camp_Douglas_(Chicago).Accessed11January2009.16.LawsandCustomsofWaronLand.HagueConferenceof1899:HagueII.NewHaven,Connecticut;YaleUniversityLillianGoldmanLawLibrary,TheAvalonProject.Availableat:http://avalon.law.yale.edu/19th_century/hague02.asp#art1.AccessedMay12,2009.17.SidesH.GhostSoldiers.NewYork,NY:JohnWiley&SonsInc;2002.18.ChalekW.GuestoftheEmperor.SanJose,CA:WritersClubPress;2002.19.TheBataanSurvivorAssociation.2006.http://www.bataansurvivor.com.20.FactSheet:PrisonersofWarintheKoreanWar.UnitedStatesofAmericaKoreanWarCommemorationwebsite.Availableat:http://korea50.army.mil/history/factsheets/pow.shtml.AccessedJanuary12,2009.21.Wikipedia.comwebsite.KoreanWar.Availableat:www.en.wikipedia.org/wiki/Korean_war#crimes_against_pows.AccessedJanuary13,2009.22.Wikipedia.comwebsite.HanoiHilton.Availableat:http://en.wikipedia.org/wiki/Hanoi_Hilton.AccessedMay12,2009.PrisonerofWarCamps:LackofaRevolution

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AprilJune200941THEARMYMEDICALDEPARTMENTJOURNAL23.LanderM.McCain,inVietnam,FindsthePastIsntReallyPast.[Hanoiparis.comwebsite].April27,2000.Availableat:http://www.hanoiparis.com/construct.php?page=actutxt&idfam=26&idactu=305.AccessedMay12,2009.24.Wikipedia.comwebsite.BagramTortureandPrisonerAbuse.Availableat:http://en.wikipedia.org/wiki/Bagram_torture_and_prisoner_abuse.AccessedJanuary13,2009.25.Wikipedia.comwebsite.BagramTheaterInternmentFacility.Availableat:http://en.wikipedia.org/wiki/Bagram_theater_internment_facility.AccessedJanuary13,2009.26.JehlD.ArmydetailsscaleofabuseinAfghanjail.NewYorkTimes.March12,2005;Worldsection.Availableat:http://query.nytimes.com/gst/fullpage.html?res=9F01EFD9143CF931A25750C0A9639C8B63&scp=80&sq=&st=nyt.AccessedMay12,2009.27.Article15-6:Investigationofthe800thMilitaryPoliceBrigade[In:TheTagubaReportontheTreatmentofAbuGhraibPrisonersinIraq].Availableat:http://news.findlaw.com/hdocs/docs/iraq/tagubarpt.html.AccessedJanuary15,2009.28.Wikipedia.comwebsite.AbuGhraibPrison.Availableat:http://en.wikipedia.org/wiki/abu_ghraib_prison.AccessedJanuary15,2009.29.ZimbardoPG.StanfordPrisonExperiment[website].Availableat:http://www.prisonexp.org.AccessedJanuary15,2009.30.CohenR.WedontwantaHanoiHilton.WashingtonPost.October27,2005;Editorialsection:A27.AUTHORS LTCCaciistheEnvironmentalScienceOfficer,USSpecialOperationsCommand,FortBragg,NorthCarolina.LTCClineisChief,PreventiveMedicinePlansandOperations,OfficeoftheCommandSurgeon,USArmyCentral,FortMcPherson,Georgia. USArmyCentral UnitedStatesSpecialOperationsCommand

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42https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1BACKGROUNDThediagnosisofmalariashouldbeconsideredwhenafebrilepatientpresentswithahistoryofprolongedoverseastravelandorhadworkedinmalaria-endemicregions.AshrewdandperceptivemedicalprovidershouldsuspectandrecognizethisdiseasesincemostmalariaintheUnitedStatesareimportedfromothercountries.1TheCentersforDiseaseControlandPreventionconsidersmalariaasapotentialmedicalemergency.2Technologicalandclinicalcompetenciesarerequiredtoavoiddiagnosticdelaysandjudgmenterrors.Thegoldstandardisstillamalarial-smearthatdemonstratestheparasitebutrequirestechnicalskilltoperform.Since2000,whentheUSmilitaryforcesincreaseditsoverseasoperationsinmalaria-endemicareas,increasingnumbersofmalariacaseshavebeenreportedthroughitssurveillancedatabase.Foryears,thenumbersofunspecifiedmalariaasadiagnosishadvariedwidelyfrom6%(4of69in2002)to33%(15of45in2005),withanoverallaverageof19.6%(83of423from2000to2005).3ThesenumberscomeonlyfromtheReportableMedicalEventSystemoftheUSmilitaryanddoesnotincludeotherreportsthatshowunspecifiedmalaria,withanalarmingproportionof83%(1,140of1,381),obtainedfroma10-yearmalariaquery-reportoftheDefenseMedicalSurveillanceSystem(DMSS).ThisstudyanalyzesthecasesreportedasunspecifiedmalariaandmakesrecommendationstoimprovesurveillanceofmalariaamongUSservicemembers.Anexaminationoftheoutcomesacrossalongitudinal90-dayfollow-upperiodofunspecifiedmalariafromalloutpatient,inpatient,andreportablemedicaleventdatabasereportsoftheDMSSfromJanuary1,1998,toDecember31,2007,wasperformed.AsshowninFigure1,therewere3outcomesreported:A.Malariawhichwaslater-specifiedorlater-con-firmed(aspecificmalaria-specieswasidentifiedwithinthe90-daytimeframe).B.Diagnosesthatremainedunspecifiedbutprobablemalaria,assignedifanyoneofthefollowingwaspresentwithinthe90-dayperiod:Anotherdiagnosisofunspecifiedmalariashowedonsubsequentfollow-up,orthepatientwashospitalizedwithaprimaryorsecondarydiagnosisofunspecifiedmalaria.Adiagnosisoffeverorpyrexia30daysbeforethediagnosisofunspecifiedmalaria.Thepatienthadapriorviralinfection30daysbeforethediagnosisofunspecifiedmalaria.Amalarial-smearprocedurewasperformedduringanyoftheclinicvisits.Theunspecifiedmalariawasreportedinthereportablemedicalsurveillancesystem.C.Diagnosesthatremainedunspecifiedbutpossiblemalaria,assignedtothosewhohadeitheronlyoneclinicvisitwhereadiagnosisofunspecifiedwasmade,orwhodidnothaveanyofthepreviouslyenumeratedfeaturesoftheprobablemalaria.METHODSEachmilitaryserviceisrequiredtoreportallmalariacasesthroughtheirownpublichealthreportingTheReportingandRecordingofUnspecifiedMalariaintheMilitary,19982007LTCJosephK.Llanos,MC,USA Unspecifiedmalarian=1,637 Excludedcasesduetopriorhistoryofspecifiedmalarian=256 Remained-unspecifiedmalaria(after90days)n=1,140 Later-specifiedmalariawithin90daysn=241 Unspecifiedandprobablemalarian=226 Unspecifiedandpossiblemalarian=914 Figure1.DistributionofunspecifiedmalariacasesretrievedfromtheDefenseMedicalSurveillanceSystemdatabasefortheperiodJanuary1,1998,throughDecember31,2007.

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AprilJune200943systems.ThesereportsarethenforwardedtotheArmedForcesSurveillanceHealthCenter,wheretheyaremergedintotheDMSS,andacentralrepositoryofmilitaryhealthsurveillancedatafortheDepartmentofDefense.TheDMSScontainslongitudinalrecordsofallservicememberspersonnel,med-ical,andserologicalinformation.3AretrospectivequerywasperformedonthepopulationhealthdatafordiseasesurveillanceonunspecifiedmalariahavinganICD-9CM4codeof084.6,labelingthisastheindexcase.ThedatawasloadedintotheDMSSbetweenJanuary1,1998,andDecember31,2007.Allcomponentservices(ActiveandReserveArmy,MarineCorps,AirForce,Navy,CoastGuard)weretaken,andanincidencerulewasappliedrequiringonlyoneun-specifiedmalariadiagnosis.Eachunspecifiedmalariareportincludeddemographicinformation,dateofdiagnosis,andwhetheramalarialsmearwasperformed.Otherqueriesaddedwerediag-nosisoffever,recurrent/relapsing/5-dayfever,malariafever,periodicfever,3-dayfever,viralinfectionwithin30dayspriortotheindexcase,andeitheraKoreaorAfghanistandeploymenthistorywithin2yearspriortotheunspecifiedmalariadiagnosis.TheICD-9CMcodeused084.6forunspecifiedmalaria.Thiscodewasalsousedformalariafeverandrecurrentfever.Fever,relapsingfever,5-dayfever,periodicfeverand3-dayfeverwerequeriedusing780.6,087.9,083.1,277.31,and066.0respectively.Thecurrentproceduralterminologycodesforbloodormalarialsmearsusedwere85060,86750,86753,87015,87207,87177,and87209.TheinpatientICD-9proceduralcodesusedwere90.5,91.5,v75.ThedatawasanalyzedusingSASversion9.1software(SAS,Cary,NC)tabulations.ThedatawasobtainedfromthehealthsurveillanceoftheUSmilitarypopulationandinformedconsentwasnotrequiredforthispurpose.RESULTSDuringthe10-yearperiod,1,637casesofunspecifiedmalariawerereportedamongUSservicemembers.Forthepurposesofthestudy,256recordsofthosewhohadaprior(90daysbefore)historyofaspecificmalaria-speciesdiagnosiswereexcluded.Theremainingpopulation,totaling1,381,waslabeledasunspecifiedmalariaindexcasesandselectedforanalysis(Figures1and2).DemographicandClinicalFeatures(Tables1and2)Later-specifiedorprobablemalariawasfoundmostlyamongtheyoung(24-yearsoldandyounger)intheenlistedranksofE-4andbelow,intheActivecomponentoftheirservice,mostprobablytheArmy.Incontrast,possiblemalariawasfoundamongtheolder(82%),commissionedorwarrantofficers(85%),intheAirForce(91%),intheReserve/Guardcomponent(75%).Clinicalfeaturesshowedthatthemajorityhadnofeverhistory30daysbefore(75%),didnothaveanyviralinfection(67%),hadnohistoryofpriorAfghanistanandorKoreatours(81%),andhadnobloodsmeartaken(68%).FrequencyofVisitsFigure3presentsthefrequencyoffollow-upvisitsamongthe3groups.Thedataforlater-specifiedandprobablemalariashowedthatthemajorityofthoserequired2or3officevisits,whereasthosediagnosedwithpossiblemalariahadmostlyonevisit(>90%).TEN-YEARUNSPECIFIEDMALARIAREPORTFigure4isastacked-columnchartwhichillustratestheyearlyreportedandrecordedunspecifiedmalariadiagnosesacrossthe10-yearspan.Theoutcomesduringthefirst5years(1998to2002)werecomparedtothelast5years(2003to2007).Possiblemalariadiagnosesdeclined40%duringthelast5years.Likewise,thespecifiedandprobablemalariadiagnosesincreased70%inthoselast5years.DISCUSSIONThearticleexaminesthemeaningandsignificanceofunspecifiedmalariabydefining3diagnosticoutcomeswithina90-dayfollow-upperiod:specified,probable,andpossiblemalaria.Thecriteriacharacterizingeach Unspecified-probablen=226(16%) Later-specifiedn=241(17%) Unspecified-possiblen=914(57%) Figure2.Unspecifiedmalariaclassifi-cationsofdiagnosesattheendof90-dayfollow-upperiod.

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44https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1outcomewasestablishedbeforethedatabasequeriesweredesigned.TheICD-9CMandCPTcodesusedforretrievingfever,viralinfection,andbloodsmeardatawereexhaustiveandwereagreeduponatthebeginningofthestudy.Thechoiceof90daystomakeafurtherdistinctionbetweenprobableandpossiblewasarbitrary.Theassumptionwasthatpatientswhoreallyhadmalariawouldmostlylikelyhaverepeatedmedicalcarewithinthisselectedtimeframe.Therewasnootherwayofvalidatingthefindingsexceptbyareexaminationofmedicalrecords,whichwasimpractical,andprobablyimpossible.Thefindingthat83%(1,140of1,381)ofthecasesremainedunspecified90daysaftertheinitialdiagnosiswasmade,andonly17%(241)werelaterclassifiedwithaspecificmalaria-speciesdiagnosisisalarmingandneedsurgentexaminationandscrutiny.Thisarticleisahelpfulreminderforresponsiblepartiesinvolvedwithpatientcare,bothdirectlyandindirectly,thatpromptattentiontothefollowingareasisrequired:Encourageimmediatespeciationandaccuraterecordingofmalariadiagnosis.Medicalprovidersshouldconsidermalariaintheirdifferentialdiagnosisamongservicemembersreturningfromtheaterwithdemographicandclinicalattributesdescribedearlier.Thisreportalsoemphasizedtheneedforclinicianstopossesshighindexesofsuspicionwhenconfrontedwithnonspecificillnessamongmilitarypersonnel.Thedemographiccharacteristicssuggestiveofcluestothediagnosisincludeyoung,activeenlisted,20to24yearsofage,withapriorexposureineitheranAfghanistanorKoreatour.Thisreportalsodemonstratedthatamajorityofthesecaseswillclinicallypresenttotheclinicianwithconditionsotherthanfeverorevenotherthanacommonviralinfection30dayspriortotheTheReportingandRecordingofUnspecifiedMalariaintheMilitary,19982007Note:Percentages(%)intablerowsarecalculatedonthenumberofcases(n)givenforthatdemographicclassification.*Demographicinformationmissingfor6recordsinthiscategory.Demographicinformationmissingfor1recordinthiscategory.Demographicinformationmissingfor7recordsinthiscategory.Later-SpecifiedMalaria*n=241(17%)ProbableMalarian=226(16%)PossibleMalarian=914(66%)MilitaryPayGrade E1-E4(n=509) 120(23.5%) 103(20.2%) 286(56.1%)E5-E6(n=390)83(21.2%)66(16.9%)241(61.7%) E7-E9(n=130) 12(9.2%) 25(19.2%) 93(71.5%)Officers(n=338)20(5.9%)31(9.1%)287(84.9%)AgeCategory under20(n=52) 3(5.7%) 11(21.1%) 38(73.0%)20-24(n=381)102(26.7%)73(19.1%)206(54.0%) 25-29(n=280) 55(19.6%) 58(20.7%) 167(59.6%)30-34(n=221)39(17.6%)28(12.6%)154(69.6%) 35-39(n=208) 24(11.5%) 26(12.5%) 158(75.9%)40+(n=225)12(5.3%)29(12.8%)184(81.7%)BranchofService Army(n=750) 184(24.5%) 172(22.9%) 394(52.5%)Marines(n=83)13(15.6%)11(13.2%)59(71.0%) Navy&CoastGuard(n=152) 23(15.1%) 22(14.4%) 107(70.3%)AirForce(n=382)15(3.9%)20(5.2%)347(90.8%)Component Active(n=1,205) 220(18.2%) 199(16.5%) 786(65.2%)Reserve/NationalGuard(n=162)15(9.2%)26(16.0%)121(74.6%) Table1.Demographicdistributionoftheinvestigatedunspecifiedmalariacases. Table2.Clinicalfactorsoftheinvestigatedunspecifiedmalariacases.Later-SpecifiedMalaria*n=241(17%)ProbableMalarian=226(16%)PossibleMalarian=914(66%) PriorFeverHistoryNo(n=1,225)173(14.1%)138(11.2%)914(74.6%)Yes(n=156)68(43.5%)88(56.4%)0 PriorViralInfectionNo(n=1,309)223(17.0%)205(15.6%)881(67.3%)Yes(n=72)18(25.0%)21(29.1%)33(45.8%) PriorTourinAfghanistanorKoreaNo(n=955)81(8.4%)101(10.5%)773(80.9%)Yes(n=426)160(37.5%)125(29.3%)141(33.0%) Malarial-smearNo(n=1,330)221(16.6%)195(14.6%)914(68.7%)Yes(n=51)20(39.2%)31(60.7%)0 Note:Percentages(%)intablerowsarecalculatedonthenumberofcases(n)givenforthatclinicalfactor.*Demographicinformationmissingfor6recordsinthiscategory.Demographicinformationmissingfor1recordinthiscategory.Demographicinformationmissingfor7recordsinthiscategory.

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AprilJune200945THEARMYMEDICALDEPARTMENTJOURNALindexevent.Themorefrequentnumberofvisitswasconsideredsuggestiveofaprobablemalariaoutcomerequiringclosefollow-upcarebythecliniciandespiteremainingunspecifiedthroughouttheentirefollow-upperiod.Animportantfindingcallingforimmediateimprovementisthereportinganddocumentationofmalarialsmearsperformedwithinmilitarytreatmentfacilities(MTF).Eventhelater-specifiedmalariagroupthatconfirmedthespecificmalarialspeciesbysmearsfailedtodocumentthisprocedurein92%ofcases(221of241).MTFsshouldrevisitandreviewtheprocessofdatarecording,proceduredocumentation,andcorrectnessoraccuracyoftheICD-9CM,currentproceduralterminology,andinpatientICD-9proceduralcodesused.Thelimitationofthisstudyistheinabilitytoconfirmsomeassumptionsmadewithoutlookingatthemedicalrecords.The90-daytimeperiodwaschosentofollow-upunspecifiedmalariaoutcomeswithanassumptionthatpatientswhohavemalariawillmostlikelyseekmedicalcarewithinthiswindow.REFERENCES1.VanVoorhisWC,WellerPF.Infectiousdisease:XXXIVprotozoaninfections.ACPMed.November2004update.Availableat:http://www.acpmedicine.com/acpmedicine/institutional/instHtmlReader.action?readerFlag=chapt&chapId=part07_ch34.2.Malariahomepage.CentersforDiseaseCon-trolandPreventionwebsite.Availableat:http://www.cdc.gov/malaria/diagnosis_treatment/diagnosis.htm.Accessed20May2008.3.CimineraP,BrundageJ.MalariaintheUSmilitaryforces:Adescriptionofdeploymentexposuresfrom2003through2005.AmJTropMedHyg.2007;76(2):275-279.4.InternationalClassificationofDiseases,NinthRevision,ClinicalModification.Hyattsville,MD:Na-tionalCenterforHealthStatistics;2009.Availableat:http://www.icd9data.com/2009/Volume1/default.htm.AUTHOR LTCLlanos,assignedtotheWalterReedArmyInstituteofResearch,Washington,DC,iscompletinghisresidencyinOccupationalMedicineattheUniformedServicesUniversityoftheHealthSciences,Bethesda,Maryland.FrequencyofVisits(days) P e r c e n t a g e 0 10 20 30 40 50 60 70 80 90 100 0 10 20 30 40 50 60 70 80 90 100123456789 Later-specifiedmalaria Probablemalaria Possiblemalaria Figure3.Frequencyoffollow-upvisitsofpatientsrelativetotheeventualclassificationoftheirmalariadiagnoses. Figure4.Distributionbyyearofdiagnosisofcasesinitiallydiagnosedasunspecifiedmalariaaftera90-dayfollow-upperiod. 20%40%60%80%100%0% 19981999200020012002200320042005200620071416151372724314633819181415403217492918156110115898395815648 Unspecifiedbutpossiblymalaria Later-specifiedmalaria Unspecifiedbutprobablymalaria UNIFORMEDSERVICESUNIVERSITYoftheHealthSciences

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46https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1INTRODUCTIONThefederalgovernment,includingtheDepartmentofDefense(DoD),isincreasinglyreliantoncontractorstocarryoutsupportfunctionsincontingencyoperations.1TheestimatednumberofprivatecontractorsworkinginIraqmaynowtop100,000andcouldexceedtheactualnumberoftroopsintheater.2InadditiontoUScontractorsandthirdcountrynationalsbroughtintoIraqtoworkforcontractingfirms,CoalitionforcesarealsocontractingservicesfromlocalnationalsathundredsofsmallerCoalitionoutpostsandjointsecuritysites.ContractingoffersnumerousadvantagestotheDoD.Itisaneffectivewaytofurnishthemassivemanpowernecessarytoconstructandsustainbasecamps,thusfreeingSoldiersfromtheseonerousdutiesandenablingthemtofocustheirenergiesonwinningthecounterinsurgencyfight.Contractingprovidestechniciansandotherhighly-skilledprofessionalssuchasArabicinterpreters,lawenforcementtrainers,intelligenceanalysts,firefighters,andunmannedaircraftoperatorsthatareeithercriticallyshortorunavailableamongtheDoDcivilianandservicememberworkforce.ContractingalsoaidsinstimulatinghostnationeconomiesbypumpingAmericandollarstolocalbusinessesandemployinglargenumbersoflocalnationals.Ontheflipside,thephenomenalgrowthincontractinghastaxedDoDsoversightandaccountabilitysystems.This,inturn,hasmadethwartingmalfeasance,fraud,abuse,andsecondrateperformancemoredifficult.THEFORCEHEALTHPROTECTIONCHALLENGESOFCONTRACTINGMostofthebasiclifesupportservicesdeliveredbycontractorshavedirectimpactsonSoldierhealth.Theseservicesincludepestmanagement,waterworks(ie,potablewaterproduction,storage,transport,anddistribution),trashdisposal,anddiningfacilityoperations.3Heighteneddiseaseandnonbattleinjuryratesintheformofwaterborne,foodborne,orvectorbornediseaseoutbreakscouldresultifthesevitalservicesaredeliveredinasubstandardmanner.ThecontractorsthemselvescanposeahealththreattoSoldiers.Mostthirdcountrynationalworkersoriginatefromlessdevelopedcountries,wheremedicalcareispoorornonexistent,andcommunicablediseasessuchastuberculosisandhepatitisarehighlyendemic.Thesameconditionsholdtruefortheirlocalnationalcounterparts.Withoutproperprecautions,thirdcountrynationalsandlocalnationalscantransmitdiseasestoSoldiers.Mostcontractsrequireworkerstopassahealthexamorscreeningasaconditionforemployment.Therearegenerallynocontractprovisionsstipulatingwherethesescreeningsoccur.Asaresult,themajorityofscreeningsareconductedabroadorinthehostnationatnonaccredited,insufficientlyequipped,andmeagerlystaffedclinics.ImprovementofForceHealthProtectionThroughPreventiveMedicineOversightofContractorSupportMAJScottA.Mower,MS,USA ABSTRACTUnprecedentednumbersofcontractorsareusedthroughouttheIraqtheaterofoperationstoalleviatemilitarymanpowershortages.Atvirtuallyeverymajorforwardoperatingbase,US-basedcontractorsperformthepreponderanceofessentiallifesupportservices.Atmoreremotesites,localnationalcontractorsareincreasinglyreliedupontomaintainchemicallatrines,removetrash,deliverbulkwater,andexecuteotherjanitorialfunctions.Vigorousoversightofcontractorper-formanceisessentialtoensureservicesaredeliveredaccordingtospecifiedstandards.Pooroversightcanincreasetheriskofcriminalactivities,permitsubstandardperformance,elevatediseaseandnonbattleinjuryrates,degrademorale,anddiminishSoldierreadiness.AstheprincipalforcehealthprotectionproponentsintheDepartmentofDefense,pre-ventivemedicineunitsmustbetightlyintegratedintotheoversightprocesses.Thisarticledefinestheforcehealthpro-tectionimplicationsassociatedwithservicecontractsandproviderecommendationsforstrengtheningpreventivemedi-cinesoversightrole.

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AprilJune200947Theseclinicshortcomings,coupledwithrampantcor-ruptionandseveraltuberculosisoutbreaksamongpre-screenedthirdcountrynationalcontractorpopulations,makesmostscreeningresultsdubiousatbest.ContractsutilizingthirdcountrynationalsandUSworkersusuallyobligatethecontractortofurnishmedicalcaretotheiremployees.Casesofnoncompliancearequitecommonwithsignificantnumbersoflaborersarrivingintheaterwithoutthesupport,equipment,andpharmaceuticalsnecessarytomedicallysustainthem.Whenthisoccurs,theburdenofcarefallsontheDoDmedicalfacilities.Presently,thereisnostandardizedmechanismfortheDoDtochargethecontractorfordeliveredmedicalservices,thusallowingthecontractortooftenescapepayingcompensationandpenaltiesforthiscontractualviolation.BasesemployingthirdcountrynationalandlocalnationallaborersaremorevulnerabletoattacksoncriticalinfrastructureandintentionalcontaminationoffoodandwatersuppliesshouldthecontractorsharborhostilitytowardsCoalitionforces.Asresidentsandfrequentvisitorstothebases,theselaborerscanpoisonwells,bottledwaterstocks,andstoredrations.Theycouldalsodestroycriticalinfrastructuresuchasreverseosmosiswaterpurificationunitsandradarsystemsbysabotageorrelateinvaluabletargetingintelligencetoinsurgentgroups.Evenwithouthostileintent,theworkerscouldstealunsecuredrationsorbringunapprovedandcontaminatedfoodsuppliesontothebasetosellorservetoSoldiersAstheprincipalproponentforforcehealthprotection(FHP),preventivemedicine(PM)unitsmustplayadecisiveroleinthecontractingprocess.Theirabilitytorecognizehealththreats,assesscampsanitationcon-ditions,discernfoodandwatersystemvulnerabilities,anddevisediseasepreventionstratagemsarecrucialtowardsresolvingthesedauntingFHPchallenges.TYPESOFSUPPORTCONTRACTSThetwomaintypesofbasiclifesupportservicecontractsutilizedwithintheIraqtheaterofoperationsareLogisticsCivilAugmentationProgram(LOGCAP)andcontingencycontractsintheformofpurchaserequestandcommitments(PR&Cs).Eachcontracttypehasitsownuniquequalityassuranceandqualitycontrolprocesses.Foreffectiveoversighttooccur,PMmustunderstandtheseprocessesandthedifferencesbetweencontracttypes.LOGCAPisaworldwidecontingencyservicecontractthatreinforcesmilitaryassetswithciviliancontractsupportprimarilyfocusedontheprovisionofbasiclifesupportservicestoCoalitionforces.ThesoleLOGCAPproviderinIraqfortheArmyisKBR,Inc(Houston,Texas)whichembedsitspersonnelwithinthelogisticdivisionsonthecontingencyoperatingbases.LOGCAPservicesarenotcontractuallyauthorizedforoutlyinglocationswithlessthan150Soldiers,withtheexceptionofrepairsessentialtotheprotectionoflife,health,andsafety.4UnderLOGCAP,contractadministration,propertyadministration,andqualityassuranceareperformedbytheDefenseContractManagementAgency(DCMA).5Themorenumerousandausterecontingencyoperatinglocations,suchasjointsecuritysitesandCoalitionoutposts,areunsupportedbyLOGCAP.Atthesesites,PR&Csareenactedthatemploylocalnationalcontractorsforservicesthatcannotbeprovidedbyorganiccombatsupport/combatservicesupportassetsduetocompetingmissionsorlackofskillsets.4PR&Csareusuallyinitiatedatthebattalioncommandlevelandmustincludedetailedstatementsofwork(SOWs)and3bids/estimatesfromdifferentcontractors.Underuniquetime/safety/missioncircumstances,asole-sourcecontractormaybeused.4TheSOWsandothersupportingdocumentsarecompiledintoapacketstaffedthroughbrigade,division,andcorpsheadquartersbeforereceivingulti-mateapprovalorrejectionfromtheJointContractingCommand-Iraq.Theentirevettingprocesscantakeseveralweeks,especiallyifthepacketisincompleteandtheSOWistoovagueorpoorlywritten.FORCEHEALTHPROTECTIONSHORTFALLSINTHELOGCAPOVERSIGHTPROCESSTheDCMAqualityassurancerepresentativesaretaskedwithmonitoringthequalityofLOGCAPcontractorworkandassessingtheirperformance.Theyexecutethismissionbyauditingcontractorprocesses,projects,andinternalmanagementcontrolsandreceivingmonthlyassessmentsconductedbycontractingofficerrepresentatives(CORs)onspecificbasiclifesupportservices.6Intheory,personneldesignatedasCORsareprofessionallytrainedandsubjectmatterexpertswhopossessthetechnicalwherewithaltoevaluatetheirbasiclifesupportarea.Inreality,unqualifiedindividualsarefrequentlyassignedCORresponsibilitiesforexpediencysake.Thishasbeenespeciallyproblematicintheselectionof

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48https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1waterworksandpestmanagementCORs,serviceswhichPMpersonnelareuniquelyqualifiedtoassess.BothqualityassurancerepresentativesandCORsusecheckliststoperformtheirassessments.Thesecheckliststypicallymirrorcheck-listsfoundinexistingDoDpolicydocuments.Forexample,thediningfacilityoperationschecklistcloselyresemblesArmyForm5162-R,RoutineFoodEstablishmentInspectionReport,whichisfoundinArmyTechnicalBulletinMED530.7Eachrequirementlistedonthechecklistisfurnishedwiththenameandparagraphnumberofitscorrespondingreferencedocument.IfthereisnorelevantDoDreferencedocument,therequirementisreferencedagainstitscorrespondingLOGCAPcontracttaskorderandsectionnumber.ResponsestoinquiriesmadetoDCMAbythisauthorsuggestthatPMreviewsofchecklistsandtaskordersrelevanttoforcehealthprotectionoccursporadically,butarenotinstitutionalizeddocumentdevelopmentrequirements.FORCEHEALTHPROTECTIONSHORTFALLSINTHEPR&COVERSIGHTPROCESSManyofthebattalioncontractingofficerstaskedwithdevelopment,submission,andmanagementofPR&Csreceivenoformaltrainingontheirdutiesbeforetheyarenamedtothepositions.Sincethepositionisconsideredanadditionalduty,theappointingauthoritiesoftenmakeopportuneappointmentsandnotnecessarilyassignthepersonbest-suitedfortheposition.Ingeneral,thesecontractingofficersareunfamiliarwithPMandfailtorecognizetheFHPimplicationsofthecontracts.WhencoupledwithnoPMoversight,thisunfamiliarityisarecipefordisasterandhasledtoshoddycontractworkandincreasedhealthrisks.Examplesofthisincludetheinteriorcoatingofpotablewaterstoragetankswithpaintsmixed/thinnedwithhazardoussolvents,anattempttopurchaseandinstalla$108,000commercialreverseosmosiswaterpurificationsystemincapableoftreatingtheexceptionallysaltywaterfromajointsecuritysitegroundwatersource,andeffortstoutilizelocalnationalpersonnelwhohavenotreceivedfoodservicesanitationtrainingormedicalscreeninginfoodpreparationpositions.LevelIIPM(ie,brigadecombatteamPMsectionsanddivisionsurgeonsectionPMofficers)canpreventPR&CshortfallsbycarefullyreviewingandinsertingFHPstipulationsintostatementsofwork.Thiswillprovidethecontractingofficerwithadefenseagainstpoorperformancesincethecontractcanbeterminatedifthelocalnationalcontractorfailstoexecutetheserviceinamannerprotectiveofhealthandsafety.Atightly-writtenstatementofworkalsoofferstheadditionaladvantageofeducatinglocalnationalcontractorsonacceptableCoalitionperformancestandards,which,innumerousinstances,differfromtheirown.ExamplesofFHPstipulationsthatareoftenmissingincommontypesofPR&CsstatementsofworkareshownintheFigure.STEPSTOENHANCECONTRACTOVERSIGHTBYPREVENTIVEMEDICINEThefollowingchangesinPMdoctrine,training,leadership,andeducationpracticeswillstrengthenPMsroleincontractoversightprocesses:ClearlydefinecontractoversightresponsibilitiesinPMpolicydocuments.Currentdoctrineiswoefullyinsufficientonthissubject.Forexample,thereisnodiscussionofcontractoversightinArmyFieldManual4.02-17,8theArmyspremiereguidancedocumentontheorganization,mission,function,capabilities,andemploymentofdeployedPMelements.EstablisharapportbetweenHeadquarters,DCMA,andtheservicemedicalauthoritiestoensureFHPisintegratedintoLOGCAPandPMinputisincorporatedintocontractingofficerrepresentativechecklists.AjointworkinggroupcomprisedofArmy,Navy,andAirForcePMexpertscouldbecreatedtocollectivelyaddressFHP-relatedcontractingissues,shouldexcessiveconfusionarisefromeachoftheindividualservicesrespectivePMproponentsinteractionswithDCMA.TheArmedForcesPestManagementBoard,ajointlystaffedorganization,ispursuingthisapproachtoaddressvectorcontrolservices.ThejointworkinggroupcouldalsoincludehealthcareadministratorstodiscussthecompensationmechanismsassociatedwithcontractlaboruseofDoDmedicalassets.ImprovementofForceHealthProtectionThroughPreventiveMedicineOversightofContractorSupport Iraqicontractorandhissonmaintainingatrashburningpointatajointsecuritysite(February11,2008).

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AprilJune200949THEARMYMEDICALDEPARTMENTJOURNALAppointPMofficersandnoncommissionedofficers(NCOs)asthewaterworksandpestmanagementcontractingofficerrepresentativesatLOGCAPsites.SincetheseSoldiersreceiveextensivetrainingonwaterproductionandstoragesiteinspections,watersystemvulnerabilityassessments,andintegratedpestmanagementpractices,anddeploywiththeequipmentneededtomonitorwaterqualityandconductpestsurveillance,theyareideallysuitedtoassumecontractingofficerrepresentativeresponsibilities.Atforwardoperatingbases,wherebothlevelIIandlevelIIIPM(ie,PMdetachments)arepresent,levelIIIPMshould;bydefault,bedesignatedastheleadevaluators.Thisisindeferencetotheirgreaterprofes-sionalexperienceandhigherrankcommandstructure.TaskPMdetachmententomologists(areaofcon-centration72B)toprovidetechnicalsupporttoallpestmanagementcontractingofficerrepresentatives(CORs)withintheirrespectivegeographicalmissionsupportareas.WithaminimumofamastersdegreeinentomologyandgraduationfromtheDoDcertifiedpesticideapplicatorcourse,theyarethebest-trained,uniformed,pestmanagementprofessionalsintheater.TheirexpertiseshouldbeputtogoodusetrainingCORsintheevaluationofperformanceoversightrolesandperformancestandards.IntroducecontractoversightandPR&Cstatementofworkreviewsaspartofthe6A-F5:PrinciplesofPreventiveMedicineCourse,andthe6A-F6:PreventiveMedicineProgramManagementCourse,bothofwhicharetaughtattheArmyMedicalDepartmentCenterandSchool.IncorporatecontractoversightandstatementofworkreviewintoCombatTrainingCenterscenariosandUSArmyCenterforHealthPromotionandPreventiveMedicine(USACHPPM)technicalassistancevisits.RecommendthatallofficersandseniorNCOsas-signedtolevelIIandlevelIIIPMunitsenrollandcompletetheDefenseAcquisitionUniversitysonlineCORcourse.*ThecourseprovidesanexcellentoverviewofCORethics,duties,andresponsibilities.CoursecompletionisaprerequisiteforCORpositionassumption.Completionpriortodeploymentisprefer-ableduetotheconnectivitychallengesandonlinetimeconstraintscommonlyencounteredintheater.FurnishCORsofotherbasiclifesupportserviceswithcopiesofrelevantinspectionsandalertthemtoforcehealthprotectionrelateddeficiencieswhicharedetectedduringPMassessmentsandinspections.Forexample,thefoodserviceandMorale,Welfare,andRecreationCORsshouldbenotifiedwhencontractor-operateddiningfacilitiesandfitnessfacilitiesfailtheirroutinesanitationinspections.ThiswillaidthoseCORstomoreaccuratelyassessperformanceandexerttheirconsiderableinfluenceinrectifyingdeficiencies.ArchivecompletedwaterworksandpestmanagementCORchecklistsintheUSACHPPMoccupationalandenvironmentalhealthsurveillancedataarchive.Competentanddiligentperformanceoftheseservicesisvitalforthecreationofsalubriousenvironmentalhealthconditionsatbasecamps.Thehealthconsequencesofsubstandardperformancecanbesevereandmaynotbecomeevidentuntillongafterthe ContractedService NecessaryForceHealthProtectionStipulationsChemicallatrines(portabletoilets)MountandmaintainhandsanitizerdispensersUse62%ethanol-basedhandsanitizersRefillwithabluewatersolutionafteremptying Trashremoval Pressurewash/cleandumpstersonamonthlybasisRequirefunctioningdumpsterlidsandreplacementwhenbrokenRequestmetaldumpstersratherthanplastic(metaldumpstersarepreferablesincetrashcanbeburnedinsidethemwhenoverfilledorthecontractorfailstoemptythemonschedule)BulkwaterdeliveriesDeliveredwatermusthaveaminimum2PPMandmaximum5PPMresidualchlorineTruckmustbecleanedandinspectedbyfieldsanitationteammemberbeforeacceptanceofdeliveryWatermustmeetacceptableaestheticqualities(color,odor,andclarity)asdeterminedbyPM Localnationaljanitorialsupport Restrictlaborersfromdirectfoodhandling,preparation,andservingProhibitsickindividualsfromworkingBuildingrenovationandconstructionprojectsBanuseofpaintswithaddeddieselfuel,benzene,andotherthinnersInstructcontractortousepracticesthatminimizeaerosolizationofpaintchips,insulation,andotherdebristoreduceexposureriskstoCoalitionforcesExamplesofforcehealthprotectionstipulationsthatshouldbeincludedinpurchaserequestandcommitmentstatementsofwork. *Informationavailableathttps://acc.dau.milInformationavailableatoehs@amedd.army.mil

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50https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1deployment.Byarchivingthechecklists,epidemiologistscouldbetterunderstandsitehealthconditionsanddiagnosethecausesofpostdeploymentmedicalproblemsweretheytoarise.AssistcontractingofficersinpreparingtheinitialPR&Cstatementsofwork.ThisstepwouldfosterteamworkbetweenPMandbattalioncontractingofficers,strengthentheFHPprovisionswithinthestatementsofwork,reduceapprovaldelays,andbettereducatethecontractingcommunityabouttheimportanceofPMandhowtowritecontractsprotectiveofhealth.FormalizethePR&CpacketstaffapprovalprocesstomandatelevelIIPMreviewofallstatementsofworkbearingFHPimplications,withtheinitialandfinalPMreviewsperformedbybrigadecombatteamanddivisionsurgeonsectionPMofficers;respectively.SuchaprocesswouldensurethatFHPconcernsareaddressedatthelowestlevels,expeditingpacketapprovalandcontractletting.ThiswasdonewithmuchsuccessbytheMultinationalDivisionBaghdad(MND-B)staffthroughanautomatedprocessthatpermittedeachsectiontoexaminescannedstatementsofworkindigitizedpacketsonthesecureinternetprotocolrouteremailandeitherapprove,approvewithcomments,orrejectthecontract.CONCLUSIONWhetheritisLOGCAP-providedcooksfeedingheadcountsintothethousandsatalargeforwardoperatingbasediningfacility,oranIraqientrepreneurpumpingoutchemicallatrinesatajointsecuritysiteorCoalitionoutpost,contractorsarenowthemainprovidersofbasiclifesupportservicesatforwardoperatingbases.ContractorperformancedirectlyimpactsthehealthandwelfareofourSoldiers,butthecurrentoversightmechanismsnecessarytochampionforcehealthprotectionareinsufficient.Thesolutionstothisproblemwillrequireaconcertedeffortbycommanders,logisticians,andthePMcommunity,andimplementationofnumerousenhancementstocontractoversightprocesses.ACKNOWLEDGEMENTS IwishtoextendspecialthankstoLTCPeytonPotts,MND-BG4LOGCAPOfficer,andMAJRobertHuber,MND-BContractingOfficer,fortheirreviewandinputonthecontractingprocesses.Also,LTCDavidRistedt,MND-BDivisionSurgeon,TroyRoss,theMND-BPreventiveMedicineOfficer,andMAJJamesWaddick,MND-BDeputyDivisionSurgeon,providedinvaluableinputtothisarticle.REFERENCES 1.OfficeoftheComptrollerGeneraloftheUnitedStates.DefenseManagement:DoDNeedstoReexamineItsExtensiveRelianceonContractorsandContinuetoImproveManagementandOversight.Washington,DC:USGovernmentAccountabilityOffice;March11,2008.Availableat:http://www.gao.gov/new.items/d08572t.pdf.2.GregoryL.IncreasingrelianceonprivatecontractorsinIraqraisesquestions.ChattanoogaTimesFreePress.May2,2008;LocalNews.Availableat:http://timesfreepress.com/news/2008/may/02.3.LlamaW.ContingencycontractingandLOGCAPsupportinMND-B,Iraq.ArmyLogistician.2007;37(5):28-29.Availableat:http://www.almc.army.mil/alog/issues/SepOct07/browse.html.4.PottsP.PresentationtotheVictoryBaseComplexPreventiveMedicineForum.January2008;CampLiberty,Iraq.5.SpencerGT.DCMASupportingMulti-NationalForcesinIraq.[Newsrelease,DefenseContractManagementAgencyWebsite].September13,2005.Availableat:http://www.dcma.mil/communicator/news_release/2004/NR_091304.htm.6.OfficeoftheAssistantSecretaryoftheArmyforAcquisition,Logistics,andTechnology.MemorandumforRecord.Subject:ContractAdministrationandSurveillanceforServiceContracts.Washington,DC:USDeptoftheArmy;February9,2007.7.TechnicalBulletinMED530:OccupationalandEnvironmentalHealthFoodSanitation.Washington,DC:USDeptoftheArmy;October30,2002.8.FieldManual4-02.17:PreventiveMedicineServices.Washington,DC:USDeptoftheArmy;August28,2000.AUTHOR MAJMowerwastheMultinationalDivision-BaghdadEnvironmentalScienceOfficerduringOperationIraqiFreedom07-09.ImprovementofForceHealthProtectionThroughPreventiveMedicineOversightofContractorSupport

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AprilJune200951OVERVIEWHealthsectordevelopmentisacriticalcomponentofnation-buildingandacornerstoneofanyexitstrategyforUSandcoalitionforcesinAfghanistan.Thecurrentfragmentedorganizationalstructureofmilitaryhealthcareassetsisnotconducivetocomprehensivedevelopmentefforts.1CentralizedplanninganddirectionareessentialtounityofeffortandanecessaryingredienttothecoordinationofhealthsectordevelopmentinAfghanistan.Anorganizationalstructureisneededthatenablesleaderswithvisiontovectormilitaryhealthsectorstrategydevelopment.ThedirectionmustbealignedwiththeAfghanNationalDevelopmentStrategy,civilianorganizations,andcoalitionpartnersoperatingthroughoutthetheatre.Asalessonforfuturenation-buildingoperationsandreinforcementoftheconceptsoutlinedinthispaper,Jonesetal2observedthatsuccessfulhealthsectordevelopmenteffortsmustincludeeffectiveplanning,coordination,andleadership.Thepriceoffailuretoactcanbequantifiednotonlyinfiscalandmaterialterms,butinhumantragedyaswell.INTRODUCTIONHealthsectordevelopmentinAfghanistanisfoundationalforthefutureviabilityofthegovernmentofAfghanistanandthehealthandwelfareofitspeople.2Infact,asstatedbytheUSJointForcesCommand,aviablehealthsectorisvitaltoanationswell-being.3(p7)StatisticsfromUNICEF,presentedintheTable,shownearlyzeroimprovementinunder-5mortalityandinfantmortalityrates,amongothersignificantpublichealthmeasures.4Unfortunately,healthsectordevelopmentinAfghanistanissufferingfromalackofcentralizedplanninganddirection.Whilenumerousmilitaryprofessionalsofallbackgroundsandaffiliationsaredoingagreatdealofthingstotrytohelpthepeople,government,andcountryofAfghanistan,thereisatremendouslackofunityofeffortwithinthemilitarystructureinthearenaofhealthsectordevelopment.Thewayaheadwillrequiresignificantchange,includingareorganizationofhealthcareservicesintheatre,dynamicleadership,andthedevelopmentofanachievableandcoordinatedstrategicplanthatwillgenerateunityofeffort.ORGANIZATIONALSTRUCTUREOrganizationalstructureservesasanenablingbackbone.InAfghanistan,theorganizationofhealthcareservicesisfractured,particularlyasitpertainstohealthsectordevelopment,resultinginadysfunctionalexecutionofstrategy.TheAfghanhealthsystemhas3majorcomponents:theMinistryofPublicHealth(MoPH)fortheciviliansector,theMinistryofDefense(MoD)fortheAfghanNationalArmy,andtheMinistryoftheInterior(MoI)fortheAfghanNationalPolice,amongothersecurityservices.AllofthesecomponentscontributetothenationalhealthofAfghanistan.ThehealthcareassetsofcoalitionforcesinAfghanistanalsohaveanumberofmajorcomponents(Figure1).OneelementoftheUSForces-AfghanistanisastaffHealthSectorDevelopmentinAfghanistan:TheWayForwardMajPaulBrezinski,MSC,USAFLtColMontserratEdie-Korleski,MSC,USAFCPTTimurS.Durrani,MC,USARColDouglasHoward,NC,USAFCOLMichaelManansala,AN,USAComparativechildsurvivalandbirthsta-tisticsforAfghanistanshowingessentiallynoimprovementina17-yearspan.Source:UnitedNationsChildrensFund4Childrenunderage5mortalityrate(per1,000livebirths)CalendarYear19902602007257Infant(under1year)mortalityrate(per1,000livebirths)19901682007165Crudebirthrate(numberofbirthsper1,000population)197052199052200748

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52https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1medicalplannerwhohasrecentlyarrivedonscene.TheInternationalSecurityAssistanceForces(ISAF)staffheadquartershasprimaryresponsibilityforstrategicguidanceregardingreconstructionanddevelopment.TheISAFmissionconsistsof41nations.Thereare28provincialreconstructionteams(PRTs)locatedacrossAfghanistan,taskorganizedundermaneuvertasksforceswithinregionalcommandswithamissiontohelpdevelopandaidingovernanceanddevelopment.Tocomplicatetheorganizationalstructure,thePRTsaresituatedacross5regionalcommands,eachwithadifferentleadnation.Tocomplicatetheorganizationalstructure,thePRTsarelocatedin5regionalcommands,eachwithadifferentleadnation.TheCombinedSecurityTransitionCommand-Afghanistan(CSTC-A),whoseeffortsaredirectedattheAfghanNationalArmyandNationalPolice,isresponsibleforembeddedtrainingteamsandpolicementorteams.TheCombinedJointSpecialOperationsTaskForce-Afghanistan,withitsuniquemission,providesdirectpatientcareofanepisodicnatureinhighvaluegeographiclocations.Inthenearfuture,amedicalcommandwillbeaddedtothefray.Finally,thereareanumberoftaskforcemaneuverunitswhicharriveandoperatewiththeirownmedicalassetsunderthecontrolofalinecommander.Theendproductofthisconglomerationisacommandandcontrolsystemwhichhaslittleunityofefforttowardhealthsectordevelopment.Thereare11unitswithmedicalassetslocatedatBagramAirBasealone.Eachofthosemedicalresourcesisorganictoacombatarmsunitandarededicatedsolelytothatspecificunit.Consequently,thosemedicalassetsareatriskofbeingunderutilizedintheirmedicalspecialties(dependingontheoperationstempo)andunavailabletoprovidesupporttoothermedicalfunctionswithoutpriorcoordinationandauthorization.Whileeachunitbringsskills,expertise,andworkloadcapacitytoBagramAirBase,thereislittlecoordinationofeffortontheinstallation.AsisthecaseinmanylocationsandinmanyorganizationsacrossAfghanistan,therearesuperbmedicsinthetaskforcesthataredoinggreatthingsinisolation.However,becausethereisverylittleunityofeffort,theseadvancesareoftenunsustainable.Thisistheendresultofanabsenceofanenablingstrategyforcomprehensivehealthsectordevelopment.FurthercomplicatingtheorganizationalstructureofhealthservicesinAfghanistanaretheexistenceofnumerouscivilianorganizations.TheUnitedNationsAssistanceMissioninAfghanistanisacoordinatingbodytowhichaUSmilitaryliaisonofficerisassigned.TheEuropeanCommissionworkswithmultiplenongovernmentalorganizations(NGOs),includingtheInternationalMedicalCorps,AideMedicaleInternational,HealthNetInternational,MedicalRefresherCourseAfghanistan,amongothers.TheUSAgencyforInternationalDevelopment(USAID)alsoworkswithnumerousNGOsincludingBactarDevelopmentNetwork,NorwegianAfghanCorps,SanayeeDevelopmentOrganization,AfghanDevelopmentAssociation,AdventistDevelopmentandReliefAgency,amongothers.5Manyoftheseorganizationshavedesignatedgeographicresponsibilitiesandallareheavilyinvolvedinhealthsectordevelopmentefforts.Militaryunitsandcivilianagencies,alongwithAfghanorganizations,contributetohealthsectordevelopment.Attimes,themissionsoftheseorganizationsintersect,however,theireffortsareoftenuncoordinated.Infact,astove-pipedstructureoffundingandleadershiphasevolvedwhichlimitsvisionandinhibitscooperation.Thereisapublishedcommandersintentwhichenablesdecentralizedexecution,butthereislittleornoHealthSectorDevelopmentinAfghanistan:TheWayForwardTFEagle TFWarrior TFDuke TFCurrahee TFSparta TFMED RC-East/CJTF-101 ISAFUSFOR-A CJSOTF-A CSTC-A Figure1.ThecommandorganizationofcoalitionforceswithhealthcareassetsinAfghanistan.5GlossaryISAF:InternationalSecurityAssistanceForcesUSFOR-A:USForces-AfghanistanRC:RegionalCommandCJTF:CombinedJointTaskForceCSTC-A:CombinedSecurityTransitionCommand-AfghanistanCJSOTF-A:CombinedJointSpecialOperationsTaskForce-AfghanistanTF:TaskForce

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AprilJune200953THEARMYMEDICALDEPARTMENTJOURNALcentralizedplanningorcontrolasadvocatedinjointdoctrine.6(pIV-16)Thefracturedstructuredatesbackseveralyearsandislikelyanevolutionaryresultoffundsallocationintheareaofresponsibility.Inpracticethereislittle,ifany,interagencycoordination.ThefundingenvironmentinAfghanistanisextremelycomplex.Anumberofcolorsofmoneyexistincluding:CommandersEmergencyResponseProgramfundswhichareearmarkedforurgenthumanitarianreliefandreconstruction.AfghanistanSecurityForcesFunds,oftenreferredtoasTitle22,whichareprovidedthroughCSTC-AfortrainingandsustainingAfghanistanNationalSecurityForces.TitleXfundsforactivedutypersonnelandoperations,FieldOrderOfficerfundsusedforUSForcesonlyandgenerallyavailableforexpenseslessthan$10,000.OverseasHumanitarianDisasterandCivicAssistancefundssponsoredbytheUSStateDepartment.Inaddition,organizationssuchasUSAID,theEuropeanCommission,andnumerousNGOs,aswellastheMoPH,havetheirownfundingsources,rules,andregulations.Givenallthesecolorsofmoney,therearefundsavailableforcomprehensivehealthsectordevelopmentandcapacitybuildingmissions,butthecomplexityrequiredinthissystemencouragesthinkingwithintheconfinesofthefundingstream.Inaddition,eachtypeoffundingcomeswithitsownadministrativerulesandreviews.7WhathasevolvedisasystemofdecentralizedplanningandexecutionamongthemanyuncoordinatedagenciesandunitsinAfghanistan.Essentially,manycivilianagenciesandmilitaryunitsaremovingforwardintheirrespectivelanesastheyunderstandandinterprettheirrolewithintheAfghanNationalDevelopmentStrategy(ANDS)construct,andthestrategicandoperationalenvironment.Theconsequenceofthisuncoordinatedapproachisisolatedprogresswhichisunsustainableoverthelong-term.ThisunsustainableprogresswillpotentiallyunderminethecredibilityofthecoalitionandthegovernmentofAfghanistanintermsofhealthsectordevelopment.However,thecoordinationandcombinedeffortsofhealthcareresourcesinAfghanistancouldhaveapositivetangibleandsustainedimpactonthecountryshealthcareinfrastructure.STRATEGICDIRECTIONWithintheframeworkoftheANDS,anewandcomprehensivestrategicdirectionisnecessaryforthefutureofhealthsectordevelopmentinAfghanistan.WhileUSandcoalitionforcesprovidesuperiorandwell-coordinatedcaretowoundedWarriors,thehumanitariansupportandinfrastructuredevelopmentmissionsareshroudedinfogandfriction,notcausedbythewar,butproductsoftheorganizationalstructureandbureaucracythathasdevelopedovertime.ThewayforwardliesinimprovingthecapacityandcapabilityoftheAfghanhealthsystemthroughtrainingandskillsdevelopmentofhealthcareprofessionalsandsupportstaff,aswellasthroughbricksandmortar.Whiletrainingandcapacitybuildingareintegratedintosomeexistingstrategy,includingthatofCombinedJointTaskForce-101(CJTF-101),executionismoreproblematic.Asoneexample,theInternationalMedicalMentorshipandTrainingProgram(IMMTP)isdesignedtoimprovethehumancapacityofAfghanphysiciansacrossthecountryandissynergisticwitha2-weekprogramtargetedatAfghannursesandancillarymedicalstaff.TheprogramappliestoallthemajorhealthcareentitiesinAfghanistan,includingMoPH,MoD,andMoI,andisacooperativeeffortamongtheUS,Korean,andEgyptianhospitalsonBagramAirBase.Unfortunately,thefundingmechanismsinplacearenotstructuredtosupportsuchaprogram,asitcrossesfundingstreams.Despiteanominalcostandsupportbythecommandinggeneral,CJTF-101,fundingremainselusive.Asaconsequence,insteadofreceivingtraining6daysaweekover90daysin3coalitionhospitals,thefirst5physiciansintheprogramtraveledtoandfromBagramAirBasefromoutlyingareas2daysaweekoverthe90-dayperiod.ThesecondclassstartedinFebruary2009,withsubsequentcohortsofstudentsenteringtrainingevery6weeks.However,attendanceofcohortsinthefutureisatseriousriskiffundingissuesarenotresolved.Currently,thecommitmentoftheAfghangovernmentisillustratedbytheagreementoftheMoPH,MoDandMoItofundthesalariesoftheirstudentsforthedurationoftheprogram.After5yearsoffailedattemptsatstartingsuchaprogram,theIMMTPhas

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54https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1begunandhastakenamajorstepforwardinbuildingrelationshipsandcapacitywithintheAfghanhealthsystem.AsstatedbytheUSJointForcesCommand,Sustainableprojectsthatrestoreandbuild[hostnation]capacity,especiallyinpublichealthsystems,achievelongerandwiderspreadresultsthanlimitedscopedirectpatientcareprojects.Capacitybuildingalsogarnerspositivegoodwillandpoliticalcapitalwithoutcreatingmisplaceddependencyanddoesnotundermine[hostnation]legitimacytogovern.3(p10)TheUSiscurrentlyinjeopardyoflosingonegreatopportunity.ThereareanumberofviablesolutionstothestrategicquandarythatexistsforhealthsectordevelopmentinAfghanistan.First,anumberofmedicalchallengesmustbeunderstood,includingtheirregularenvironment,thehealthandsecurityrelationship,andtheaccomplishmentofahealthsectorassessmentthatenablesthedevelopmentofastrategythatleadstoaculturallyappropriatehealthsectorcapacitythatgarnerslong-termpositiveeffectsforthecommander.3(p3)TheAfghanNationalDevelopmentStrategyshouldserveasaguideforsucheffortsforbothmilitaryaffiliatedandcivilianresourcesincountry.ThefifthpillaroftheANDS,healthandnutrition,isbaseduponthebasicpackageofhealthservices(BPHS)andtheessentialpackageofhospitalservices(EPHS),whicharefoundationalinmeetingthehealthcareneedsofthepeopleofAfghanistanoverthelong-term.ThestatementfromJointPublication1,Attainingunityofeffortthroughunityofcommandmaynotbepoliticallyfeasiblegiventhesometimesdivergentmissionsofalltheinvolvedorganizations,butitshouldbeagoal6(pxix)isdirectlyapplicabletothecoalition.Thecommandandcontrolnetworkformilitaryhealthsectordevelopmentshouldbereorganized,includingaplanforintegrationthatlinksthemajorplayersintheareaofresponsibilityandcreatesacentralvision.AccordingtotheDoctrinefortheArmedForcesoftheUnitedStates,Integrationisachievedthroughjointoperationplanningandtheskilledassimilationofforces,capabilities,andsystemstoenabletheiremploymentinasingle,cohesiveoperationratherthanasetofseparateoperations.6(pIV-17)Leadershipwillbecriticaltothisend,includingthoseofappropriaterankandabilitytoexecutesuchamonumentaltask.Afundingsystemthatcanaccommodatetheuniquenessandneedsoftheenvironmentwillbeessentialtothedevelopmentandsupportofanystrategicinitiative.Inaddition,theestablishmentandmeasurementofimportantobjectives,baseduponpublichealthgoalsasadvocatedintheBPHSandEPHS,areessential.Theadoptionoflong-termpublichealthmeasures,suchasinfantmortalityandmalnutrition,willforceaparadigmshiftinhowbusinessisnormallyconducted.Finally,perspectiveoftimehastoadjustfromonefocusedonshort-termgoalstiedtoannualpersonnelevaluationsanddeploymentrotations(6to12months)toonefocusedonrealsubstantivechangein5to10years.TheUSanditscoalitionpartnerscannotaffordtocontinuetofightoneyearwars,particularasthatfightpertainstohealthsectordevelopment.RECOMMENDATIONSthejointmedicalcommunitymustexpanditsinteragencyandmultinationalrelationships;jointforcecommandersshouldseekinnovativewaystoemploymedicalcapabilitiestohelpachievesecurityandstability;3(p3)Beyondthejointforce,itisimperativethattheeffortsofthejointandcombinedforcebealignedwiththemultitudeofNGOsandaidagenciesoperatinginAfghanistantopotentiateandsustaintheeffects.Threespecificrecommendationsinclude:1.Dedicateresourcesspecificallyforhealthsector developmentandclearlyalignthehealthsectordevelopmentmissionunderonejointmedicalcommandandcontrolelement(JMC2E).*A.Obtainafundingsourcededicatedentirelytohealthsectordevelopment.B.FundingisappropriatedtotheJMC2Eforexecution.ThemedicalcommandthatiscurrentlyintheprocessofdeployingtoAfghanistanhasthepotentialtobeasignificantfactorintheunityofcommandthroughtheprovisionofacentralizedplanningframework.Moreimportantly,themedicalcommandstructureshouldbeHealthSectorDevelopmentinAfghanistan:TheWayForward *TheconceptofamedicalcommandandcontrolelementwasoriginatedbyLTCMarkMcGrail,thentheCJTF-101Surgeon.

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AprilJune200955THEARMYMEDICALDEPARTMENTJOURNALmodifiedtobecomeaJMC2Efunction.TheprimarymissionofUSmilitarymedicalunitsistoprovidecaretoUSservicemembers.Theprobabilityofmakingreal,timely,sustainedprogresswouldrisedramaticallyifthehealthsectordevelopmentfunctionwasestablishedasaseparateandimportantmission,recognizedasanessentialelementofanyexitstrategy,andspecificallyallocatedtotheJMC2Ewhichwasthengiventheappropriateresourcestoexecutethatmission.AproposedorganizationalstructureispresentedinFigure2.Asitcurrentlystands,healthsectordevelopmentisasecondarymissionformostunitsoperatingintheatre.TheempowermentoftheJMC2Emustincludeplanningresponsibilityforallmilitarymedicalassetsintheatre,includingthoseofCSTC-A,CJTF,andtheCombinedJointSpecialOperationsTaskForce,ensuringunityofeffort.AnyhealthcareleadinAfghanistanmustbejointinstructureandoperation.EstablishingtheJMC2ESurgeonastheUSForces-AfghanistanSurgeonisabeginning.However,providingtheelementwiththenecessaryresources,includingfundsearmarkedforhealthsectordevelopment,wouldgivetheelementboththeauthorityandtheresponsibilitytoexecuteitsmission.Ifhealthsectordevelopmenttrulyisimportant,significantresourcesmustbededicatedtoit.Intheshortterm,thiscanbeaccomplishedbyaddingmorepersonnelwithpublichealthtrainingtoincomingmedicalunitssuchasthemedicalcommand.Inthelong-run,successwillrequirechangestocurrentphilosophyandchangestoorganizationalstructuretocompletehealthsectordevelopmentmissions.Fundingmechanismsmustbeestablishedthatdonotinvolveaninordinateapprovalprocessthatimpactsthetimelinessofexecutionofhealthsectorinitiatives.AcongressionalmandatethroughtheDepartmentofDefensemayberequiredtoestablishtheauthoritytofundhealthsectordevelopmentdirectlyandeliminatecompetitionwithotherdevelopmentalinitiatives.2.Ensuretherightpeople(leaders)areintheright placeswiththerighttrainingandcredentials.Strongandvisionaryleaderswillbecriticaltochangingcourseandaligningmedicalresourcesin-country.Leadersforhealthsectordevelopment,attheJMC2Eandinsupportingunits,must,ataminimum,havepublichealtheducation,background,and/orexperienceandrankappropriatefortheauthority,responsibility,andimportancethefunctionholds.AsshowninFigure2,thestaffresponsibleforhealthsectordevelopmentplanningneedtohaveanappropriatemixtureofadministrativeexperiencecriticaltoplanningandprocess,clinicalexperiencenecessaryformedicaldevelopment,andmobilityenoughtoengageinrelationshipbuildingandsustainingthoserelationshipsacrossAfghanistan.ItisunknownatthistimeiftheJMC2Ewillhavethiscapability;howevertheelementmustbesupportedthroughjointactionbythemilitaryandotherUSandinternationalagencies(AirForce,Navy,Army,PublicHealth,USAgencyforInternationalDevelopment,EuropeanCommission,UnitedNationsAssistanceMissioninAfghanistan,etc)toprovidethemanpowerneededtoexpanditsmissionofhealthsectordevelopment.Presently,medicalleadersareexpectedtohaveexperienceinhealthsectordevelopment.Themilitarywouldbebetterpositionediftrainingweremodeledinhomogeneouscurrencybasedplatformsacrossallservicestodevelopthecriticalskillsneededtocontributetohealthsectordevelopment,similartotheAirForcesFlightPathmethodologyforpersonneldevelopment.8Thisapproachwouldbeparticularlyeffectiveifthehealthsectordevelopmentmissionisincorporatedintoeachunit.Coordinationofeffortsshouldnotbeexpectedbutrequired,thusoptimizingunityofeffort.Ifhealthsectordevelopmentisnotmadeapriorityformilitaryunits,thecombinationoflowpriority,alackoftraining,fewavailableresources,andleadershipthatisnotdedicatedtothemissionwillleadtofailure.3.Developalong-termstrategyformilitarymedical assetsthatestablishesclearobjectivesandalignsresourcestowardaccomplishingAfghanNationalDevelopmentStrategyobjectives.ThestrategyshouldfollowANDSgoalsandbecoordinatedwithallmedicalagenciesinAfghanistan,includingUSAID,theEuropeanCommission,andassociatedNGOs.Partnershipswithothermilitaryandcivilianorganizationsareessentialforsuccessfulhealthinterventionsduringstabilityoperations.3TheJMC2E

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56https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1HealthSectorDevelopmentinAfghanistan:TheWayForward LiaisonOfficerCellsItispreferablethateachLNOcomefromtheirrespectiveorganization,ie,USAIDLNOisanUSAIDemployee;otherwisetheUSmilitarymayprovideanLNO.Facilitatehealthsectordevelopmentinformationandrelationships.ProvidemilitarycommandersinformationandresourcestoimplementtheMoPHhealthsectordevelopmentstrategy.Coordinateallmilitaryhealthsectordevelopmentwithcivilianandgovernmentagencyefforts. TrainingCellProvidemilitaryunitswithAfghanistanappropriateplansandprogramstoachievespecificANDSgoals.EnsurethatallmilitarymedicalassetsunderstandAfghanNationalDevelopmentStrategy.Ensureallmilitarymedicalassetsareempoweredtoaccomplishhealthsectordevelopment.Promotetrainingofalltypesforwomen.PublicHealthCellCreateandpromotetrainingprogramsformedicalprofessionaldevelopment,medicaladministration,qualityassurance,medicalequipmentmaintenanceandmedicalfacilitymaintenance.CirculatewithinAfghanistanprovidingexpertise,guidanceandsupporttoanymilitaryassetsinvolvedinmedicaltrainingprograms.Promotemilitarycommanderawarenessofpersonneltrainingprograms.Plans,Programs,andOperationsCellCoordinateallhealthsectorplanswithMoPH,civilian,governmentalandindividualmilitaryunits.Ensurehealthsectordevelopmentissynchronizedwithallothersecurityanddevelopmentefforts.Developandpublishnation-wide,long-termhealthsectordevelopmentplans.FinanceManageallhealthsectordevelopmentfunding.Assistinallaspectsofacquiringfundingforhealthsectordevelopmentprojects.Establishlong-termfundingsolutions.PromotestabilityoftheAfghanmedicalcommunitybydevelopingeconomicincentives.FacilitaterelationshipswithWorldBank,EU,andotherinternationaldonors. MinistryofInteriorLiaisonOfficer MinistryofPublicHealthLiaisonOfficer Plans,Programs,andOperations Finance PublicHealthTeam(notallspecialtiesincluded) EuropeanCommissionLiaisonOfficer UNAMALiaisonOfficer USAIDLiaisonOfficer Training DisabilityHealthBenefits MentalHealth CommunicableDisease/PreventiveMedicine MedicalLogistics/HealthFacilitiesPlanner PublicNutrition ChildHealthandImmunizations MaternalandNewbornHealth JMC2ESurgeon/USFOR-ASurgeon CombatHealthServiceSupportFunction HealthSectorDevelopmentCell Figure2.TheproposedjointmedicalcommandandcontrolelementorganizationandstructureforAfghanistan.

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AprilJune200957THEARMYMEDICALDEPARTMENTJOURNALwouldberesponsiblefornurturingrelationshipswithotheragenciesinAfghanistanandcoordinatingeffortsacrossorganizationstoamplifytheeffectofhealthsectordevelopmenteffortsandinitiatives.GiventhattheUSmilitarywillbeinAfghanistanforanextendedperiodoftime,theJMC2Eisreallyasolutionof2to3yearsinduration.Amorerobustorganization,designedaroundtheconceptsandprinciplesdescribedinthispaper,willhavetobeestablishedtosupportanenduringefforttodeveloptheAfghanmedicalinfrastructure.Moreover,asustainableeconomicmodelwithanentrepreneurshipbentisacriticalpartofthestrategicdirectionneededtoensurethefiscalviabilityofthehealthcaresystem.AfghanmedicalprovidersneedeconomicsecurityandincentivestokeepthemfromseekingopportunitiesintheUnitedStatesorabroad.Thetimeforactionisnow.Militaryparticipationinhealthsectordevelopmentiscriticaltonationbuildingeffortsandanyexitstrategy.Lives,limbs,andlivelihoodsofUSSoldiers,MarinesSailors,andAirmen,aswellasthoseofourcoalitionpartnersandtheAfghanpeoplehanginthebalance.ACKNOWLEDGMENT Theauthorsacknowledgetheparticularcontributionstothecontentandmessageofthisarticlebythefollowingcolleagueswhowerealsoservingand,insomecases,continuetoserveinAfghanistan:CPTKristyLinginfelter,SP,USAR,Surgeon/PhysicianAssistant,426thCivilAffairsBattalionLtColGarryFeld,MSC,USAF,DeputyCommanderofAdministration,JointTaskForceMEDColDouglasAnderson,MSC,USAF,LeadMentor,CSTC-AAfghanNationalPoliceCDREvelynQuattrone,NC,USN,OfficerinCharge,CooperativeMedicalAssistTeamMAJMaureenNolen,AN,USA,TaskForceMEDJ-5,PlansandProgramsLtColTamaraAverett-Brauer,NC,USAF,ChiefNurse,TaskForceMEDWethankallofyouforyourinsight,service,anddiligenceinworkingtoleaveAfghanistanbetterthanyoufoundit.REFERENCES1.ThompsonDF.TheroleofmedicaldiplomacyinstabilizingAfghanistan.DefHoriz.May2008;63.2.JonesSG,HilborneLH,AnthonyCR,etal.SecuringHealth:LessonsfromNation-BuildingMissions.SantaMonica,CA:RANDCorporation;2006.Avail-ableat:http://www.rand.org/pubs/monographs/2006/RAND_MG321.pdf.3.EmergingChallengesinMedicalStabilityOperationsWhitePaper.Norfolk,VA:USJointForcesCom-mand;October4,2007.4.Afghanistaninformationpage.UnitedNationsChil-drensFundwebsite.Availableat:http://www.unicef.org/infobycountry/afghanistan_statistics.html.5.WhitescarverHL,HaleTE.PresentationatCombinedJointTaskForceSurgeonsHealthSectorDevel-opmentConference;December17,2008;BagramAirBase,Afghanistan.6.JointPublication1:DoctrinefortheArmedForcesoftheUnitedStates.Washington,DC:JointStaff,USDeptofDefense;March20,2009[ch1].Availableat:http://www.dtic.mil/doctrine/jel/new_pubs/jp1.pdf.7.CJTF-101ChiefofStaffMemorandum:FiscalYear2008ResourceManagementPolicyandProcedures.July1,2008.8.RoudebushJG.Medicalreadiness.PresentationtotheMilitaryPersonnelSubcommittee,CommitteeonArmedServices,USHouseofRepresentatives,StatementofAirForceSurgeonGeneral,LtGenJamesG.Roudebush;8May2008;Washington,DC.Availableat:http://www.sg.af.mil/shared/media/document/AFD-070427-005.pdf.AUTHORS Whenthisarticlewaswritten,thecoauthorswereassignedasfollows:MajBrezinskiwasPlansandProgramsOfficer(J-5),TaskForceMED,BagramAirBase,Afghanistan(Sept2008-Jan2009).LtColEdie-KorleskiwasPlansandProgramsOfficer(J-5),TaskForceMED,BagramAirBase,Afghanistan(Jan2009-July2009).CPTDurraniwastheSeniorPublicHealthAnalyst,CJTF-101,CJ-9,BagramAirBase,Afghanistan.ColHowardwastheDeputyCommander,CraigJointTheatreHospital,BagramAirBase,Afghanistan.COLManansalawastheDeputyCommander,CJTF-101,TaskForceMED,BagramAirBase,Afghanistan.

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58https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1Changeishardbecausepeopleoverestimatethevalueofwhattheyhaveandunderestimatethevalueofwhattheymaygainbygivingthatup.1INTRODUCTIONThroughoutmilitaryhistory,preservationofthehealthoftheforcehasbeenoneofthegreatestcombatmultipliers.Soundpreventivemedicine(PM)mitigatesdiseaseandnonbattleinjuriesandkeepstheSoldierfittofight.In2004,ArmytransformationbegantodrasticallychangehowPMsupportisprovidedtocombatunitsinthedeployedenvironment.TheauthorexperiencedtransformationofdivisionPMassetsfirsthandwhenservingasthedivisionenvironmentalscienceandengineeringofficer(ESEO)intheArmyslastremainingmainsupportbattalion,andthendeployingtoMulti-NationalDivisionNorth,Iraqwiththerestructured1stArmoredDivisionheadquartersasthestaffESEOfromSeptember2007toDecember2008.Fromadivisionstaffofficerperspective,thisarticleprovidesadescriptionofhowforcehealthprotectionforthegroundSoldierwasmoreeffectivelydeliveredasaresultofArmytransformation.FieldcommandersandmedicalpersonnelatalllevelsshouldbeawareofremainingchallengesandopportunitiesresultingfromthereorganizationofPMassetsacrosstheoperationalenvironment.TheinformationpresentedheremayalsoserveasausefulafteractionreviewtoolforanyPMSoldierthatmightpotentiallyserveatthebrigadecombatteamordivisionlevelinacounterinsurgencyenvironment.BACKGROUNDPriortotheArmyTransformationin2004,divisionPMpersonnelwhoprovidedlevelIIsupportwerecolocatedwithinthemedicalcompanyofthemainsupportbattalion.ModularizationessentiallydecentralizedthedivisionsPMpersonnel.AsdiscussedbyCiesla,2thisprofoundlyincreasedthedemandforESEOsandplacedamuchgreateremphasisonforcehealthprotection.WhilethepreviousmodelassignedoneESEOinsupportofanentiredivision,3modularizationplacesanESEOonthedivisionstaffandoneineachbrigadecombatteam(BCT).4The1stArmoredDivisionservedastheheadquartersforTaskForceIronduringtheOperationIraqiFreedom07-09rotation.TaskForceIronwascomposedofmorethan24,000USservicemembersthroughoutnorthernIraq,andincluded4brigade-sizedmaneuverelements(BCTs*).The3rdArmoredCavalryRegimenthadnotyettransformedandwasassignedonepreventivemedicinespecialist(staffsergeant,militaryoccupationalspecialty68S30).Theother3brigadesweremodularinstructure,andeachwasassignedoneESEOandonePMspecialist.WiththerapidexpansionofbasecampstoaccommodatecounterinsurgencyoperationsinMosulCity,USSoldierslivedandoperatedoutofmorethan90differentbasecampsacrossthedivisionoperationalenvironment.Basecampsincludedcontingencyoperatingbases,contingencyoperatingsites,andcontingencyoperatinglocationswhichdifferedbasedonthesizeandnumberofpersonnelsupported.Forexample,thelargest,acontingencyoperatingbase,maysustainbetween20,000and25,000personnel,whileacontingencyoperatinglocationusuallyhadnomorethanaplatoonofSoldiersonsite.CHALLENGESRegardinghisstrategyofestablishingjointsecuritystationsinkeylocations,GeneralPetraeussaidyoucan'tsecurethepeopleifyoudon'tlivewiththem.5ArmyTransformationandLevelIIPreventiveMedicineWithinaDeployedDivisionTaskForceMAJKennethD.Spicer,MS,USA *Throughoutthisarticle,brigade-sizedmaneuverelementsarereferredtoasBCTs.Theyincludeinfantrybrigadecombatteam,heavybrigadecombatteam,strykerbrigadecombatteam,armoredcavalryregiment,andstrykercavalryregiment.TheAuthor

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AprilJune200959Tacticaldispersionofmultiple,austerebasecampsinurbanareasrequiredadditionalfieldsanitationandPMsupport.LevelIPM-FieldSanitationTeamsDoctrinerequireseverycompany-sizedunittohavefunctionalfieldsanitationteams(FSTs).6Generally,TaskForceIronBCTswithorganicPMassetsmettheFSTrequirementforeachcompany.TheESEOandPMspecialistconductedpredeploymenttrainingandcertification.UnitsFSTpersonnelweretrackedbynameandheldresponsibleforconductinglevelIPMintheirrespectiveoperationalenvironment.Fieldsanitationteamswereusuallydysfunctionalornonexistentatcontingencyoperatinglocationswheresmallmilitary,police,orbordertransitionteamslivedandworkedcloselywithIraqiSecurityForcesinextremelyaustereenvironments.Althoughbasicfieldsanitationispartofpredeploymenttraining,andteammedicsreceivea2-hourblockofinstructionuponarrivingintheater,theytypicallydonotreceivethecomprehensive40-hourFSTcertificationcourseattheirrespectivehomestations.Asaresult,organiclevelIPMwasnotadequateattransitionteamsites,especiallyatthebeginningofateamsdeployment.Healthcarespecialistsintheoperationalenvironmentshouldtakeownershipofthisimportantresponsibility.Inthecurrentoperationalenvironment,medicalpersonnelbearthebruntofFSTdutieswhethertheyareFSTtrainedornot.CurrentdoctrinestatesthatatleastoneFSTmembermustbeamedic,ifavailable.ThisdoctrineshouldbeamendedtomandatethatallmedicsfulfillFSTduties.Further,initialtrainingformedicsshouldbeexpandedtoincludedetailedfieldsanitationtopics.Withthistraining,theFSTprograminacombatunitcanbetransitionedsolelytomedicalpersonnel.LevelIIPMTeamsStretchedThinEvenwithacceptablelevelIFSTsupportatthemajorityofbasecamps,levelIIPMpersonneloperatedatmaximumcapacityforthedurationoftheirdeployment.Withadivisionoperationalenvironmentconsistingofover90basecamps,eachofthe4brigadePMteamscoveredanaverageof23sites.ForthemodularBCTswithanESEOandaPMspecialist,thiswasadauntingtask.ThejobwasvirtuallyimpossibleforthestaffsergeantPMspecialistwhowassolelyresponsibleforupto25sitesinthe3rdArmoredCavalryRegimentoperationalenvironment.Thegoalwastoconductamonthlybasecampassessmentofeverysite.Giventheworkloadandlimitedpersonnel,itwasuptoeachlevelIIPMteamtoprioritizesiteassessmentsbasedonneed,numberofpersonnelsupported,anddegreeofcontractedlifesupport.Smallbasecampsinaustereenvironmentsusuallyhadthegreatestneed.Largercontingencyoperatingsitesandbaseshadmanymorepersonnel,morecontractedlife-supportfunctions,andoverallbetterfieldsanitation.AccordingtoArmyFieldManual4-02.17,7TacticaldispersionplacescombatelementslargelyontheirownforPMself-protection;however,thereareopportunitiesforPMdetachmentstoprovidesupportinthesesituations.ThedetachmentsmustseekoutsuchopportunitiesandgiveprioritytothecombatelementsPreventivemedicinedetachmentsprovidethemostresponsivesupportwhentheyworkdirectlywithunitsatthegreatestrisk.TwoPMdetachments,eachwithamodifiedtableoforganizationandequipment*authorizationof13Soldiers,providedlevelIIIsupportintheTaskForceIronoperationalenvironment.TheyfocusedtheiroperationsprimarilyonthehighlypopulatedlogisticalhubsofContingencyOperatingBaseSpeicherandJointBaseBalad.AftertherapidexpansionofbasecampsinMulti-NationalDivisionNorth,bothoftheseunitssteppedupandprovidedvitalsupporttotheTaskForceIronBCTPMassets.SincethePMdetachmentshigherheadquarterswasthemedicalbrigadeandnotTaskForceIron,thedivisionsurgeoncoordinatedwiththeMNC-IsurgeonforPMsupportfromthemedicalbrigadefor12differentbasecamps.ThissynchronizationofeffortbetweenBCTlevelIIPManddetachmentlevelIIIPMpaidtremendousdividends.DoctrinalchangeforthecompositionofBCTPMassetsiswarrantedinatimeofpersistentcounterinsurgencyoperationsthatinvolvemultipledispersedbasecampsinharshenvironments.Samesetal8notesthataBCTPMteamiscomposedof2relativelyjuniorpersonnel.PMdetachmentswillhavetocontinuetofillthegapbyperformingalevelIIPMmissionifnodoctrinalchangeismade.TheBCTESEOandPMspecialistshouldbeaugmentedwithanother,moreexperiencedPMspecialisttoensuremorethoroughbasecampcoverage.Alternatively,thejuniorPMspecialistcouldbereplacedwithaseasoned *Definesthestructureandequipmentforamilitaryorgan-izationorunit.

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60https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1noncommissionedofficer,significantlyboostingtheexperienceleveloftheBCTPMteamandhelpingtofacilitatepractical,simple,andefficientsolutionstounitsfieldsanitationconcerns.PMRelationshipswiththeIraqiSecurityForcesHelpingotherstohelpthemselvesiscriticaltowinningthelongwar.9AddressingfieldsanitationandgeneralPMissueswithourIraqiSecurityForcecounterpartswasaconstantchallenge.TheprimaryfocuswasissueresolutioninconjunctionwithIraqiSecurityForceself-sustaina-bility.Poorinfrastructure,resourceavailability,andculturaldifferencescontributedtoconditionsthatoccasionallythreatenedthehealthofTaskForceIronpersonnel.TransitionteamslivingonbasecampsadjacenttoIraqiSecurityForcebasecampsweremostoftenaffected.Examplesincludeaburstmainsewerlineandanentiresewersystemthatsuddenlystoppedfunctioningduetolackoffuelforthegenerator-poweredliftstations.TheBCTPMteamidentifiedtheimmediatehealththreatfromsewageoverflowandimplementedbasicpersonalprotectivemeasuresagainstvector-bornediseases.ThelargerproblemsdealtwithIraqiSecurityForcesustainabilityandpreventionofsimilarincidents.Whorepairsthepipe?Whosuppliesgasforthegenerators?Withwhatmoney?Howcantheliftstationsbeconnectedtothelocalgridsogeneratorpowerisunnecessary?ThedivisionESEOcollaboratedwithotherkeystaffsectionssuchasdivisionengineer(G-7),logistics(G-4),andIraqiSecurityForcestofacil-itatelong-term,self-sustainablesolutionstoproblemsthathadpublichealthrepercussionstoTaskForceIronpersonnel.ThisisaclearadvantageresultingfromtransformationandthedivisionstaffESEOposition.OPPORTUNITIESModularityandtheresultingreorganizationofPMpersonnelinBCTsandthedivisionheadquartershavecertainlyprovidednewopportunitiesandallowedforcreativesolutionstopublichealthconcernsinthedeployedenvironment.MobilityTravelingacrosstheoperationalenvironmenttoaccomplishthePMmissionwasoneofthegreatesthurdlestoovercome.Travelbyhelicopterwaslimitedtohoursofdarkness,requiredextensivecoordination,wasnotoriouslyunreliable,andhadlimitedspaceforPMequipment.GroundconvoyorcombatlogisticspatrolswereusedtoconductthemajorityofPMmissions.ThelocationoftheBCTPMteamwithinthebrigadesupportbattalionwasidealforcoordinationofpredictableandreliabletraveltoallbasecamps.ForceProtectionDogsUSArmy5thCorpsGeneralOrderNumber1(March19,2003)forbidtheuseoradoptionofmascotanimals,buttheprohibitionwasroutinelyignoredthroughoutIraq.Mascotdogswerepresentonapproximately20%ofthebasecampsthroughouttheTaskForceIronoperationalenvironment.Toaddresstheissue,alldivisionESEOscollaboratedwiththeMNC-Iforcehealthprotectionofficeandtheaterveterinaryofficialstoestablishaforceprotectiondogprogram.Theanimalwouldnolongerbeclassifiedamascotifitwas:Employedasalegitimateforceprotectionasset(ie,patrolling,earlywarning,watchdog),Examinedbyaveterinarianandreceivedarabiesimmunization,andPostedonofficialorderssignedbytheunitcommander.BCTPMteamsfacilitatedthesuccessofthiseffortbyassistingwithtransportationofveterinaryassetsandmaintainingaccountabilityofcompliantversusnoncompliantanimalsintheirrespectiveoperationalenvironments.Over40dogsinMulti-NationalDivisionNorthwerepartoftheprogram,whichultimatelyallowedtheunittokeeptheanimalforalegitimatepurposewhilemitigatingtheassociatedhealthrisk.DivisionForceProtectionWorkingGroupThedivisionESEOservedasthesurgeoncellrepresentativeontheforceprotectionworkinggroup.OtherteammembersincludedseniornoncommissionedofficersandofficersfromtheG-7,safety,andprovostmarshalcells.Focusingonthesmallerbasecampsmorevulnerabletoenemyactionandfieldsanitationissues,teammemberspersonallyvisited95%ofallcontingencyoperatingsitesandcontingencyoperatinglocationsintheTaskForceIronoperationalenvironment.Thiswasanexcellentchancetoredefinetraditionalforceprotectionthatfocusesonbarriersandconcertinawire.IncorporatingforceArmyTransformationandLevelIIPreventiveMedicinewithinaDeployedDivisionTaskForce

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AprilJune200961THEARMYMEDICALDEPARTMENTJOURNALhealthprotection,specificallypreventivemedicine,intothisdivision-levelworkinggroupaccomplished4significantobjectives:InsertedamedicalaspectintoprotectingtheforceandkeepingSoldiersinthefight.ThiscombatmultiplierdemonstratedtotheWarfighterthatmedicalauthoritiesbringmorethantraditionalpatientevacuationandtreatmenttothefight.IncreasedcommandemphasisofpreventivemedicineissuesandthewillingnesstofollowthroughwithBCTPMteamrecommendations.Unitleadersonthegroundweremorereceptivetoadivision-levelassessmentteamwithanESEO(rankofMajor)conductingaPMassessment.ThedivisioncommanderprovidedcommandemphasisatthehighestlevelwhenhedirectedthatallrecentlycompletedPMassessmentsandoutstandingissuesbebriefedattheweeklybattleupdateassessment.ThistrulyputPMattheforefrontandfacilitatedtheBCTPMteammission.AllowedthedivisionESEOtotravelthroughouttheentireoperationalenvironment[arareopportunityfordivisionstaffofficers]andreallyunderstandissuestheBCTPMteamswerefacing.ThejuniorBCTESEOs,mostofwhomhadlessthanayearofserviceintheArmy,accompaniedtheforceprotectionworkinggroupteamwhenpossible.Theywereabletoreceiveface-to-faceinstructionandmentoringfromamoreseasonedESEO.Facilitatedthequalityoflifeworkinggroup,achaplain-ledinitiativetoimprovethegenerallivingconditionsatsmallandausterebasecamps.EffectivePMisakeycomponentofforceprotection,aswellasanimportantpieceoftheSoldiersqualityoflife.CONCLUSIONThepracticeofPMoperationsinacounterinsurgencyenvironmentremainsverycomplexandisconstantlychanging.InnovativeandmoreefficientsolutionstoPMconcernsarealwaysneededintheoperationalenvironment.ArmytransformationhascertainlyhelpeddeliverbetterPMsupporttoSoldiersontheground.ThedecentralizationofPMpersonnel,increasednumberofESEOs,andadditionofafieldgradestaffESEOintodaysmodularizeddivisionhaspaidtremendousdividends.Inspiteofthesegains,thesuggesteddoctrinalandpersonnelchangesmustbeconsideredforoptimalforcehealthprotectionontodaysnonlinearbattlefield.REFERENCES 1.BelascoJA,StayerRC.FlightoftheBuffalo:SoaringtoExcellence,LearningtoLetEmployeesLead.NewYork,NY:GrandCentralPublishing;1994.2.CieslaJJ.TheevolvingroleofenvironmentalscienceofficersandenvironmentalengineersintheMedicalServiceCorps.ArmyMedDeptJ.April-June2006:20.3.FieldManual4-02.6:TheMedicalCompany.Washington,DC:USDeptoftheArmy;1August2002:3-7.4.Division/BrigadeCombatTeamModifiedTableofOrganizationandEquipmentAuthorizations.UnitedStatesArmyForceManagementSupportAgency,ForceManagementSystemwebsite[Restrictedaccessdocument].Availableat:https://webtaads.belvoir.army.mil/protected/WebTAADS/Frame_DocTypes.asp?GUID=1247913902.5.PetraeusDH.Interview[transcript].BritishBroadcastingCorporation.September11,2008.Availableat:http://news.bbc.co.uk/2/hi/middle_east/7610405.stm.6.ArmyRegulation40-5:PreventiveMedicine.Washington,DC:USDeptoftheArmy;25May2007:4.7.FieldManual4-02.17:PreventiveMedicineServices.Washington,DC:USDeptoftheArmy;28August2000:p4-3.8.SamesWJ,DelkTC,LyonsPJ.Fieldpreventivemedicine:challengesforthefuture.ArmyMedDeptJ.April-June2006:40-45.9.OfficeoftheSecretaryofDefense.QuadrennialDefenseReviewReport.Washington,DC:USDeptofDefense;February6,2006.AUTHOR MAJSpiceristheDivisionEnvironmentalScienceandEngineeringOfficerforHeadquarters,FirstArmoredDivision,Wiesbaden,Germany.

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62https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1BACKGROUNDInsupportofOperationIraqiFreedom(OIF)06-08,abrigadecombatteam(BCT)assignedtoMulti-NationalDivision-CenterwaslocatedincentralIraq,southwestofBaghdad.TheBCTsoperationalenvironmentconsistedmostlyofruralfarmlandsandvillages.FertilefarmlandandvegetationwasrelativelyprevalentthroughouttheareaduetotheproximityoftheEuphratesRiver,whichsuppliesfarmswithwaterthroughirrigationcanals.Theirrigationcanalshistoricallyhavebeenvitaltothelivelihoodofthosewholiveinthearea.TheCommonReed(Phragmitesaustralis)andtheGiantReed(Arundodonax)growalongroadsidesadjacenttotheseirrigationcanals.1Manyoftheprimaryandsecondarycanalsparallelroadsusedasalternatesupplyroutesbycoalitionforcestoconductpatrolmissions.Improvisedexplosivedevices(IEDs)weretheprimarycasualty-producingweaponsofchoiceforinsurgentsagainstcoalitionforcesduringOIF06-08.ThemajorityofcasualtiesoccurredduringmountedoperationswhenSoldiersweretravelinginarmoredvehiclesalongroadsthroughoutthecountry.AsshowninFigures1and2,thereeds(14to20feettallinstandsupto30feetwide)growalongtheroadsidescreatinganalley-likeeffectthatprovidesexcellentconcealmentforinsurgentstoemplaceanddetonateIEDswithminimalriskofbeingobserved,thuscreatingeasyaccessandevasionroutes.ThereedsconcealIEDsfromearlydetectionbymountedpatrolsandalsocreatelimitedvisibilityandfieldsoffirearoundruralcombatoutpostsandpatrolbases.TheincreasedIEDriskassociatedwiththevegetationwasaconstantcriticalthreattotheBCTduringcounterinsurgencyoperations,especiallyduringtheestablishmentandsupportofremotepatrolbases.Asaresult,removalofthereedswasahighpriorityforcommandersthroughouttheBCT.Thenecessityforvegetationcontrolalongruralrouteswilllikelyremainforfuturecounterinsurgencyoperationsandtheatersofconflict.TARGETSPECIESControlofthevegetationalongtheruralroutesthroughouttheBCTsoperationalenvironmentwastargetedprimarilytowards2specificreedspecies.Understandingthereproductivephysiologyofthesetargetspeciesiscriticaltoimplementingeffectivecontrolmeasures.ThetargetreedspeciescommontothecentralmarshesinIraqarePhragmitesaustralisandArundodonax.1Theyarelarge,perennial,rhizomatousgrassesthatarefoundoneverycontinentexceptAntarcticaandmayhavethewidestdistributionofanyfloweringplant.2Thereedsarecommoninandnearfreshwaterandbrackishwetlandsthroughouttheworldstemperatezones.Thereedshaveagreataffinityforgrowthalongrailroadtracks,roadsideditches,andslightdepressionsholdingwater,astheythrivethroughextensivewateruptake.Theseperennialsareknowntoliveforthreetosixyears.3Thereedsaretypicallythedominantspecieswheretheyexistthroughformationofrobustmonocultures.Theyarecapableofvigorousvegetativereproductionthroughundergroundrhizomesandoftenformdense,monospecificstandswhichcanbeover30feetindiameter.TheplantsgenerallyflowerandsetseedbetweenJulyandOctober.3Despitethelargequantitiesofseedsproduced,mostarenotviable.Undergroundrhizomesaretheprimarymeansofreproduction.Followingmaturityandseedset,themajorityofthenutrientsaretranslocatedbackintotherhizomes(upto6feetindepth)andtheabovegroundportionsoftheplantdiebackforthedormantseason.2InIraq,nutrienttranslocationwasobservedtooccurapproximatelyinlateNovember,withnew,above-groundgrowthappearinginmid-March.AstheControlofConcealingVegetationAlongRuralRoutesinIraqCPTDennisM.Rufolo,MS,USAMAJRebeccaA.Zinnante,MS,USACPTRyanBible,MS,USA

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AprilJune200963 nutrientstranslocateunderground,thedeadvegetationremainsstandinguntilthenextgrowingseason,providingyear-roundconcealment.VEGETATIONCONTROLMEASURESINOPERATIONIRAQIFREEDOM06-08ThroughouttheoverlappingperiodsthattheauthorswereindividuallydeployedtoIraq(September2006toJune2008),maneuvercommandersconsideredthereedstobeadirectthreattoSoldierslives,andtookconsiderablemeasurestocontrolthem.Threemethodsofvegetationremovalwereusedintheoperatingenvironmentduringthistimeframe:controlledburning,mechanicalremovalusingroadsideflailmowers,andmanualremovalbycontractedlocalnationals.Theprimarymethodofreedremovalalongalternatesupplyroutes(ASRs)wasthroughcontrolledburnsconductedbymilitarypersonnelasshowninFigure3.Soldiersafetywasofparamountconcernduringtheburnoperations,andadivisionlevelsafetystandardoperatingprocedurewascreatedandimplementedspecificallyforthecontrolledburnmission.Duetothehighwatercontentofthevegetation,theadditionofanexternalfuelsourcewasrequiredtoinitiateandsustaintheburn.TheexternalfuelsourceusuallyconsistedofacombinationofJP-8(aviationfuel)andgasoline,whichwassprayedonthereedspriortoignition.Thismethodwasveryeffectiveforshorttermcontrol,butwasineffectiveforsustainedremoval.Burningalonedoesnotreducethegrowthofreedsunlesstherootsburn,whichseldomoccursbecausetherhizomesareusuallycoveredbyalayerofsoil,mud,and/orwater.4Reedburnsconductedattimesotherthanlatesummer(whenthemajorityoftheplantsnutrientswereaboveground)resultedinreemergingstandswithgreaterpopulationdensities.5Ultimately,duetotheinabilityofthecontrolledburnstodestroythereedsrhizomes,repetitiveburningmissionsoverthesameASRswerenecessarythroughoutthedeployment.Mechanicalremovalthroughcuttingormowingisanothermethodofsuppressingreedgrowth,butitiscriticaltoperformthecutduringthepeakgrowingseasoninordertohaveasignificantimpactonreemergenceofthereeds.Theoptimaltimeformechanicalremovaliswhenmostofthenutrientreservesareintheaerialportionoftheplant,reducingitsvigoruponcutting.Impropertimingmayincreasestanddensity.6AsshowninFigure4,theBCToperatedflailmowers(nicknamedRazorbacks)thatweremountedonarmoredtruckswhichallowedroadsidecuttingupto15feetfromthebaseofthemower.ThistechniqueallowedSoldierstoremainwithinthearmoredvehicleswhilecuttingreeds,buttheequipmentandtechniquereceivedmixedreviews Figure1.Atypicalexampleofthedensevegetationgrowth,includingtheCommonReed(Phragmitesaustralis)andtheGiantReed(Arundodonax),alongIraqroadsides,whichaffordsexcellentconcealmentforinsurgentstoemplaceanddetonateroadsidebombs.

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64https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1frombrigadesupportbattalionandforwardsupportcompanySoldierswithregardtoitseffectiveness.Repetitivemissionsoverthesameruralroadsideswereagainrequiredthroughoutthedeploymentduetothelackofrhizomedestruction.Utilizingcontractedlocalnationalworkersforthemanualremovaloftheroadsidevegetationadjacenttotheirvillagesdidnotresultineffectivecontrol.Usingmachetesand/orweedwhackers,theworkersattemptedtoremovethereedsfromtheroadsides.Thismethodwasmuchmoretimeconsumingthaninitiallyanticipated,andposedanincreasedthreattotheworkersphysicalwell-beingbythosewhousedthereedsforIEDconcealment.Theextendeddurationofinitialremovalwascompoundedagainbytheneedforrepetitivemissionsduetolackofrhizomedestruction.PROPOSEDCHEMICALVEGETATIONCONTROLMETHODImplementingachemicalvegetationcontrolmethodinconjunctionwithphysicalremovalmethodsmentionedabovecouldhelpcontrolreedgrowththroughoutthereedsactivegrowingseasonandimproveroutesecurity.UseofaUSEnvironmentalProtectionAgency(EPA)approvedherbicidethattargetsplantsandisrelativelynontoxictohumansandfishminimizestherisktothelocalnationalsandtheenvironmentofIraq.TheimmediatebenefitassociatedwiththismethodtowardsthedirectprotectionofhumanhealthfromIEDsoutweighstherelativelyminorriskofanyenvironmentalimpactpotentiallyassociatedwitheliminationofthisriparianzonevegetation.ProcurementoftheappropriatesprayequipmentcouldallowunitstotreatroadsideswithchemicalherbicidesquicklyunderthesupervisionofDepartmentofDefense(DoD)certifiedpesticideapplicators,whilereducingtheirexposuretoenemycontact.However,presidentialapprovaloranexceptiontopolicyofExecutiveOrder118507isrequiredpriortotheimplementationofanymethodusingherbicides.TheproposedtechniqueforreedremovalalongruralroutesistheimplementationofanherbicideapplicationmethodthroughuseofaDoDapprovedpesticideandaright-of-waysprayingsystemforthesustainedcontrolofreeds.The2necessarychemicalcomponentsfortheproposedchemicalvegetationcontrolmethodareanherbicideandasurfactant.Theherbicideshouldbenonpersistent,nonselective,water-soluble,anddesignedtocontrolthegrowthofherbaceousandwoodyplants.Asurfactantisacombinationwettingagent,activator,andpenetrator;itsmodeofactionbreaksdownthewaxycuticleonleafsurfaces,allowingherbicidepenetrationintotheconductivetissue.Theherbicidethenflowsthroughouttheplant(mostimportantlytotheundergroundControlofConcealingVegetationAlongRuralRoutesinIraq Figure2.AnotherexampleofdensereedgrowthalongsidearuralroadinIraq. Figure3.Controlledburnofroadsidereedgrowthusinganexternalfuelsource.

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AprilJune200965THEARMYMEDICALDEPARTMENTJOURNALrhizomesandroots)forpermanentdestruction.BothchemicalsaredesignedtobiodegradequicklyandcompletelyintoCO2,N,H2O,andphosphates,result-inginlittletonopersistenteffectsontheenvironment.ForchemicaldispersalalongtheASRs,useofaright-of-waysprayingsystem,suchasthosecommonlyusedintheUnitedStatesbystate-leveldepartmentsofagricultureandtransportation,isrecommended.Thesesystemsarebuiltonsteelframesandcanbemountedeasilyonanarmoredmilitarytruck.Boomlesshydraulicsprayers(10-to30-ftspraydistance)arecontrolledusinganinstrumentpanelinsidethevehicle,affordingmaximumprotectiontoSoldiersfromdirectfireandIEDs.Sprayersarepoweredbyaninternalengineandhaveattachedpolyethylenestoragetanks,allowinguptoa500galcapacitywithjetagitation,whichpermitsadequatetreatmentoflongrouteswithoutthenecessitytostopandremix.Additionally,300-fthoseswithretractablereelsareavailabletoallowdismountedsprayingaroundwalls,fences,etc.Optimalapplicationwithinthevehiclecanoccuratspeedsof7to10mph,whichiscomparabletospeedstypicallyusedtotravelalongtheedgesoftheseroadsallowingvigilanceforsignsofIEDs.Thecombinationofacontrolledburnwithoutanexternalfuelsourcefollowingherbicideapplication,orroadsidemowingpriortoherbicidedispersal,couldbeeffectiveinsustainedreedremovalalongroadsides.AcombinationofprescribedburningafterchemicaltreatmentwasreportedlysuccessfulalongtheeastcoastoftheUnitedStates.4,8Theproposedchemicalvegetationcontrolmethodpotentiallycouldbeeffectiveinpersistentreedremovalalongroadsidesandwouldposeminimalnegativeimpacttothehostnation.Whenconsideringtheuseofchemicalmethodsforvegetationcontrol,thepotentialenvironmentalimpactwithinlocalregionsmustbeafactorofconsideration,comparedwiththecurrentlyusedmethods.UseoftheaboveproposedchemicalvegetationcontrolmethodbytheUSmilitaryisrestrictedbyExecutiveOrder11850:RenunciationofCertainUsesinWarofChemicalHerbicidesandRiotControlAgents,enactedon8April1975,byPresidentGeraldFord.ThefollowingisanexcerptfromExecutiveOrder11850:TheUnitedStatesrenounces,asamatterofnationalpolicy,firstuseofherbicidesinwarexceptuse,underregulationsapplicabletotheirdomesticuse,forcontrolofvegetationwithinUSbasesandinstallationsoraroundtheirimmediatedefensiveperimeters.TheSecretaryofDefenseshalltakeallnecessarymeasurestoensurethattheusebytheArmedForcesoftheUnitedStatesofchemicalherbicidesinwarisprohibitedunlesssuchusehasPresidentialapproval,inadvance.7Therefore,theabilitytousecommerciallyavailable,EPA-approvedherbicidestomitigatethethreattoUSforcesbyimprovingthedetectionofIEDsalongtheruralroadwaysofIraqisimpededbyExecutiveOrder11850,issued34yearsago.IntheaftermathoftheattackswithintheUnitedStatesonSeptember11,2001,andthestartoftheGlobalWaronTerrorism,thenatureofmilitaryoperationshaschangedsignificantlyforUSforces.TheprimarythreattowardsSoldiersdeployedtotheUSCentralCommandareaofoperationsisnotdirectattacksontheirdefensiveperimeters(whereExecutiveOrder11850allowstheuseofherbicidestoreduceconcealment),butratherthroughattacksonmountedpatrolsandconvoys,andbyIEDsemplacedalongroadways.DuetothelimitationsplacedoneffectivevegetationcontrolbyEO11850,itisimperativethatareviewofEO11850beconductedtoobtaineitheranexemptionforthechemicalcontrolmethodsdiscussedabove,orpresidentialapprovalfortheiruseduringcurrentcontingencyoperations.AnexceptiontopolicyorspecificpresidentialapprovalmayincreasetheabilitytoeffectivelycontrolvegetationalongtheseroadwaysinordertoincreaseforceprotectionfortheSoldiers. Figure4.Flailmowermountedonanarmoredtruck.

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66https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1CONCLUSIONDuetotheglobalpresenceofPhragmitesaustralis,Arundodonaxandrelatedspecies,thereispotentialforthesituationpresentedhereintoremainarecurringthreattodeployedSoldiersascounterinsurgencyoperationscontinuethroughouttheworld.Theenvironmentalscienceandengineeringofficers,workinginconjunctionwithentomologistsintheater,havetheabilitytoassistcommanderscounterthisthreatbyimplementingmeasuresthatwouldminimizeconcealmentofIEDsandthosewhoemplacethem,therebymitigatingtherisktoSoldiers.Forcehealthprotectionpersonnelpossessthetoolsnecessarytoaidcommandersinreducingthevegetationassociatedriskthroughuseofanenvironmentalmanagementalternative,butonlyifexceptionfromExecutiveOrder11850isobtained.Controllingthevegetationwilldramaticallyimprovevisibilityalongroadways,enhancingSoldiersabilitytobetteridentifytheIEDspriortodetonation.BettervisibilityandidentificationofIEDsalongroadwayswilllikelysaveSoldierslives.ControlofConcealingVegetationAlongRuralRoutesinIraqREFERENCES 1.BaileyP.FactSheetonVegetationoftheTigrisandEuphratesRiversandAssociatedMarshland.Washington,DC:USArmyEngineerResearchandDevelopmentCenter;February2007.2.BattersonTR,HallDW.CommonReed-Phragmitesaustralis(Cav.)Trin.exSteudel.Aquatics.1984;6:16-20.3.WrittenFindingsoftheStateNoxiousWeedControlBoard.Olympia,WA:WashingtonStateNoxiousWeedControlBoard;2003.Availableat:http://www.nwcb.wa.gov/weed_info/Phragmites_australis.html.4.BeallDL.BrigantineDivision-MarshVegetationRehabilitation-ChemicalControlofPhragmites.UnpublishedreportbyUSFishandWildlifeService;Oceanville,NewJersey.1984.5.CrossDH,FlemingKL.ControlofPhragmitesorCommonReed.FishandWildlifeLeaflet13.4.12.Washington,DC:USDeptoftheInterior,FishandWildlifeService;1989.Availableat:http://www.nwrc.usgs.gov/wdb/pub/wmh/13_4_12.pdf.6.OsterbrockAJ.Phragmitesaustralis,theproblemandpotentialsolutions.Cincinnati,OH:OhioFieldOffice,Stewardship;1984.7.ExecutiveOrder11850.RenunciationofCertainUsesinWarofChemicalHerbicidesandRiotControlAgents.OfficeoftheFederalRegister;April1975.Availableat:http://www.archives.gov/federal-register/codification/executive-order/11850.html.8.LehmanWC.ProjectBenchmark:EcologicalFactorsGoverningGrowthofPhragmitesandPreliminaryInvestigationsofPhragmitesControlwithGlyphosate.Dover,DE:DelawareDivisionofFishandWildlife;1984.AUTHORS CPTRufoloisaprojectofficer,EnvironmentalHealthEngineeringDivision,USArmyCenterforHealthPromotionandPreventiveMedicine-West,FortLewis,Washington.PreviouslyhewastheEnvironmentalScienceOfficer,2ndBrigadeCombatTeam,10thMountainDivisiondeployedtosouthwestBaghdadfromSeptember2006toNovember2007.MAJZinnanteiscurrentlyattendingresidentintermediateleveleducationatFortLeavenworth,KS.PreviouslyshewastheEnvironmentalScienceOfficerassignedtoHeadquartersCompany,1stCavalryDivision,FortHood,Texas.ShedeployedtotheMulti-NationalDivision-BaghdadfromOctober2006toFebruary2007.CPTBibleiscurrentlyenrolledintheUniversityofWashingtonsMastersofPublicHealthprogram.Previously,hewastheTaskForceMarne(3dInfantryDivision)EnvironmentalScienceOfficerforMulti-NationalDivision-Center,Baghdad,Iraq,fromMarch2007toJune2008.

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AprilJune200967INTRODUCTIONTheArmyHearingProgram(AHP)isevolvingfromitspredecessor,theArmyHearingConservationProgram(AHCP).TheAHPstrivestopreventnoiseinducedhearinglossduringtraininganddeploymentoperationswithoutcompromisingcombateffective-ness.Incontrast,theolderAHCPisagarrison-basedmodelwhichworkedwellinpeacetime,butfellshortofthemarkwiththeonsetofOperationsEnduringFreedomandIraqiFreedom.1Thefailuresofthegarrison-basedAHCPwerewell-documentedbyHelferetal2whoinvestigatedtheratesofnoise-inducedhearinglossamongseveralaudiologyclinicsinmilitarytreatmentfacilitiesacrosstheArmy.TheyfoundthatSoldierswhohaddeployedtoacombatzoneshowedexponentiallyhigherratesofnoise-inducedhearingloss,acoustictrauma,permanentthresholdshift,tinnitus,eardrumperforation,andH3orH4profile(definedinTable1)comparedtothosewhohadnotdeployed.InaccordancewithArmyRegulation600-60,3SoldierswithH3andH4hearingprofilesarenondeployablependingadjudicationbyaretentionboard.3(p8)Often,itisseniornoncom-missionedofficerswithpriorcombatexperiencewhoarereassignedtoanon-noise-hazardousmilitaryoccupationalspecialty(MOS)orseparatedfromtheArmybecauseoftheirH3orH4profile.Thus,alargelypreventable,noise-inducedhearinglossdeprivestheArmyofinvaluableleadershipforjuniorSoldierswithless(orno)combatexperience.Ournationalsecuritydependsonhavingwell-trainedSoldiersonthebattlefield,andthatiswhytheArmyHearingProgramsgrowth,andgrowingpains,haveinvolvedmuchmorethananamechange.TheUSArmyMedicalCommand(MEDCOM)AutomatedStaffingAssessmentModelforPreventiveMedicine(ASAMPM)currentlyrecommendsoneArmyaudiologistand2.5audiologytechniciansforevery18,000Soldiersasaminimumstaffingmodel.5TheASAMPMmodelreflectsthegarrison-basedAHCP,andisnotcompatiblewiththeoperationalhearingservicesrequirementsofthenewArmyHearingProgram.InJanuary2008,FortCarsonreceivedauthorizationforasecondArmyaudiologistinpreventivemedicineaspartoftheAHPpilotstudyauthorizedbytheMEDCOMChiefofStaff.Thisgaveusaratioof2Armyaudiologistsand5audiometric/hearinghealthtechniciansforourapproximately18,500SoldiersorganictoFortCarson(doublewhatthecurrentASAMPMmodelrecommends).ThemetricspresentedinthefollowingsectionsshowthatthelatterratioresultedinahighernumberofSoldiersfitfordeploymentandadecreaseintheamountofhearinglossatFortCarsonwithinunitsengagedincombatoperationsoverthelastcalendaryear.ThedatademonstrateshowtheASAMPMmodelmustevolvealongwiththenewArmyHearingProgram.THEARMYHEARINGPROGRAMATFORTCARSONFortCarson,locatedinColoradoSprings,Colorado,isquicklygrowingintooneoftheArmyslargestArmyForcesCommandbases.FortCarsoncurrentlyhasapopulationofapproximately18,500Soldiersingarrison.FortCarsonsSoldierpopulationisexpectedtogrowto29,000bytheyear2011withtheadditionof2morebrigade-sizedelements.FortCarsonisalsoaprimaryprojectionplatform:inadditiontoourownorganicunits,hundredsmoreSoldiersfromtheArmyNationalGuardandfromtheArmyReservesareactivatedanddemobilizedfromtheirdeploymentsthroughouttheUnitedStates,Europe,andthemiddleFortCarson:AnArmyHearingProgramSuccessStoryCPTLeanneCleveland,MS,USA Table1.ArmyHearingProfiles4(p80)H1Audiometeraveragelevelforeachearnotmorethan25dBat500,1000,2000Hzwithnoindividuallevelgreaterthan30dB.Notover45dBat4000Hz. H2 Audiometeraveragelevelforeachearat500,1000,2000Hz,ornotmorethan30dB,withnoindividuallevelgreaterthan35dBatthesefrequencies,andlevelnotmorethan55dBat4000Hz;oraudiometerlevel30dBat500Hz,25dBat1000and2000Hz,and35dBat4000Hzinbetterear.(Poorerearmaybedeaf.)H3Speechreceptionthresholdinbestearnotgreaterthan30dBHL,measuredwithorwithouthearingaid;oracuteorchroniceardisease. H4 FunctionallevelbelowH3

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68https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1easteveryyearattheFortCarsonSoldierReadinessProcessingCenter.AspartofthedrasticArmy-widemilitarytocivilianconversionofaudiologistauthorizationsinthelate1990sandearly2000s,theArmyaudiologistauthor-izationatFortCarsondisappearedin2002,concurrentwiththeonsetofOperationsEnduringFreedom(October2001)andIraqiFreedom(March2003).Figure1showsthatin2003,theFortCarsonannual(permanent)significantthresholdshift[ametricdetailedonpage70]ratejumpedfrom12%to16%.ThisreflectsthelargenumberofSoldierswhoredeployedtoFortCarsonfromcombattheaterswithhearingloss.InJune2006,theauthorizationforanArmyaudiologistwasreinstatedundertheDepartmentofPreventiveMedicine,andtheArmyHearingProgramwasimplemented.ConsiderforamomentwhythecurrentASAMPMstaffingmodelisimpractical.ThehighnumberofSoldiersrequiringclinicalhearingservices(diagnosticaudiologicalevaluations)wouldpreventasoleaudiologistfromeverleavingtheclinic.Thismeansthatthereisnotimeavailableforthesingleaudiologisttotrainmedicsandothernoise-exposedmilitarypersonnelonearplugfittings,notimetoconductannualhearinghealthbriefings,andnotimeforinspectionsofnoisehazardousareas.Whenpreventiveeffortsareincompleteornonexistent,theratesofhearinglosswillperpetuate,whichwillfurtherpreventtheaudiologistfromworkingoutsideoftheclinicaldemands.FourelementscomprisetheArmyHearingProgram:HearingreadinessClinicalhearingservicesOperationalhearingservicesHearingconservationAlthougheachelementisdistinct,thefailureofoneareawillhaveadirectinfluenceontheotherthree.AdetailedexplanationoftheArmyHearingProgramcanbefoundinSpecialText4-02.501:ArmyHearingProgram.6HEARINGREADINESSHearingreadinessimpliesthatSoldiershavetherequiredhearingcapabilities,personalprotectiveequipment,andmedicalequipmentfordeploymenttoacombatzone.RequiredhearingcapabilitiesaresetbyArmyRegulation40-501.4SoldierswithH1orH2hearingprofile(definedinTable1)aredeployable,providedthereisnosignificant,underlyingpathologyoftheouter,middle,orinnerear.EverySoldieronFortCarsonisrequiredtotakeanannualhearingtest,apredeploymenthearingtest,andapostdeploymenthearingtestusingtheDefenseOccupationalandEnvironmentalHealthReadinessSystemHearingConservation(DOEHRS-HC)audiometers.TheDOEHRS-HChearingprofiledatafeedsintotheArmyMedicalDepartmentMedicalProtectionSystem(MEDPROS)medicalreadinessdatabase,whichassignsahearingreadiness(HR)category(definedinTable1)toeachSoldierrangingfromClassItoClassIVasshowninTable2.TheFortCarsonHearingProgram(FCHP)trackstheHRstatusforallSoldiersonamonthlybasis.Figure2illustrates3importantfacts:ThehearingreadinessGOratehasincreasedsteadilysincetheadditionofasecondArmyaudiologistinJanuary2008.ThenumberofSoldierswhoarenondeployable(NO-GO)duetohearinglosshassteadilydecreased.FortCarson:AnArmyHearingProgramSuccessStory Figure1.PercentageoftestedFortCarsonSoldierswithsignificantthresholdshift(STS)fortheyears2000through2007.Note:Numbersinparentheses(numberdemonstratingSTS/totalnumbertested)

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AprilJune200969THEARMYMEDICALDEPARTMENTJOURNALThepopulationofFortCarsonhasincreasedbyalmost3000SoldiersfromJune2007(16,722)toDecember2008(19,140).ComparethistoFigure1.In2000,only5,075ofFortCarsonsSoldiersreceivedaDOEHRS-HChearingtestandearplugfitting.Thatnumberhasnearlyquadrupledin8yearsasaresultoftheHRcategoryonMEDPROS.Ourgoalistocontinuetomaintainaminimumof80%ofFortCarsonSoldiersatHRClassIorII.LookingatFigure2,notehowitappearswefellshortofourgoalofan80%GOratefromAugusttoNovember2007.ThesenumbersrepresenttheSoldiersfromthe2ndInfantryDivisionwhoweredeployedinsupportofOperationIraqiFreedomfor15months.MEDPROSautomaticallyidentifiedmanyofthoseSoldiersasHearingReadinessClassIVbecausetheywereoverduefortheirannual(12-month)hearingtest.ThenextversionofDOEHRS-HCwillincludeanalgorithmthattakesintoconsiderationthe15-monthdeploymentcycle.TheFCHPemphasizestheimportanceofappropriateearplugfittingbyqualifiedmedicalpersonnelattheHearingReadinessSection,locatedattheSoldierReadinessProcessingCenter.EverySoldierseenforahearingtestisrequiredtoshowtheirearplugsanddemonstrateknowledgeonhowtoproperlyinsertthem.IftheSoldierdoesnotbringearplugswiththemonthedayoftesting,theyarerefittedbythehearingreadinessaudiologytechniciansatthattime.TheflowchartinFigure3illustratesthemainprocessesfollowedbythehearingreadinessstaffatFortCarson.CLINICALHEARINGSERVICESClinicalhearingservicesarerequiredinbothgarrisonanddeployedsettings.Althoughthereissomeoverlap,thevarianceinservicesdeliveredbetweenthese2environmentsisoperationallydriven:Ingarrison,comprehensivediagnosticaudiologicalservicesareprovidedtoSoldiersinHRClassIIIandIVstatus.Diagnosticaudiologyservicesincludefitnessfordutyevaluations,hearingprofilesforreadiness,speechrecognitioninnoisetestsforSoldierswithH3hearingprofile,significantthresholdshiftfollow-up,acoustictraumainjuries,anddifficulttotestpatients(includingSoldierswhoattempttofeignorexaggeratehearingloss). Figure2.ThemonthlyhearingreadinessstatusoftheSoldierpopulationofFortCarsonfor2008.Note:NumberinparenthesesistotalnumberofSoldiersonFortCarsonasshownintheMEDPROSdatabase. Table2.ArmyHearingReadinessCategories4(p114)CLASSISoldiersunaidedhearingiswithinH1standardsforbothears.Nocorrectiveactionisrequired. CLASSII SoldiersunaidedhearingiswithinH2orH3standards.Soldierhasacurrenthearingprofileassigned(H2orH3),andacompletedMilitaryOccupationalSpecialtyMedicalRetentionBoard(H3)withnoactivemiddleeardiseaseormedicalpathologyintheear.IfaSoldierwearshearingaids,hemusthavehearingaidsappropriateforhearinglossandasixmonthsupplyofbatteries.Nocorrectiveactionisrequired.CLASSIIISoldiersunaidedhearingiswithinH2orH3standards.Soldierhasacurrenthearingprofileassigned(H2orH3),andacompletedMilitaryOccupationalSpecialtyMedicalRetentionBoard(H3)withnoactivemiddleeardiseaseormedicalpathologyintheear.IfaSoldierwearshearingaids,hemusthavehearingaidsappropriateforhearinglossanda6-monthsupplyofbatteries.Nocorrectiveactionisrequired. CLASSIV SoldierswhodonothaveaDOEHRS-HCaudiogramintheirmedicalrecordwithinoneyear.Soldierrequiresahearingexamination.ThisincludesSoldierswithoutareferencebaselineaudiogramorwhoselastperiodicaudiogramisgreaterthanone-yearold.Hearingreadinessclassificationisunknown.

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70https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1 Indeployedsettings,hearinginjurytreatmentservicesmaybeprovidedwithintheconfinesofthecombatsupporthospital.TheprimarypurposeofdiagnostichearingcareintheateristodetermineaSoldiersfitnessfordutystatusandtoensurethatonlySoldiersinneedofadvancedaudiologicalcareareevacuatedoutoftheater.Thesignificantthresholdshift(STS)criteriaisafamiliarmetricusedtodocumenttrendsovertime,andwebelievedittobethemostappropriatetooltoevaluatehearinglosstrendsandourclinicalhearingservicesatFortCarson.STSiscalculatedbyaveragingthepatientshearingthresholdsat2000Hz,3000Hzand4000Hz.Ifthechangefromthereference(baseline)audiogramisgreaterthanorequalto+10dB,apositiveSTSisrecorded.ReferringtoFigure1,notethattheFortCarsonSTSratein2002wasequivalenttotheArmyaverageSTSrateof12%.In2003,theSTSrateincreasedto16%.Webelievetheincreaseistheresultof2factors:TheinitialgroupofSoldierswhoweredeployedtothefirstcycleofOperationIraqiFreedomdidsowithoutthecombatarmsearplugswhicharecurrentlyarapidfieldinitiativeissuetoalldeployingSoldiers.Thecombatarmsearplugs(CAE)allowlowlevelsoundssuchasspeechtopassthroughunimpeded.ThenonlinearfilterintheCAEdampenshighlevelimpulsenoisesuchasweaponsfire.Aswithallearplugs,propersizeandfitarecrucial.Duringtheinitialdeploymentsfortheglobalwaronterror,theCAEandconventionalearplugsforSoldierswereoftennotavailable,notwanted,ornotfittedproperly,whichresultedinthedramaticSTSincreasein2003.TheeliminationoftheArmyaudiologistsauthorizationfromFortCarsonin2002resultedintheabandonmentofkeyconcepts,suchashearinglosspreventioneducationandtheemphasisonhearingprotectiondevicesandtheirproperuse.Generationofrelativevalueunits(RVUs)inaclinicalaudiologysettingwastheonlyoutcomemeasureusedbythecommandatthattime.Figure1alsoshowshowtheFortCarsonSoldierSTSratedecreasedto10%(onaverage)duringcalendaryear2007.Figure4showsabreakdownofcalendaryear2008andacurrentaverageSTSrateoflessthan11%.ThisrepresentsthelowestrateofSTSonFortFortCarson:AnArmyHearingProgramSuccessStory Figure3.ThehearingreadinessscreeningprocessforallFortCarsonSoldiersasimplementedbytheFortCarsonHearingProgram.Notes:ForallcasesofSoldiersreportingacutehearingloss,orsuspectedactivepathology(TMperforationorbulgingTM,orsuspectedmalingering),contactthemilitaryaudiologistattheHearingReadinessClinictobookanappointmentsothattheconditioncanbeconfirmed.ALLSOLDIERSMUSTcomethroughHearingReadinessfirst.TheHRtechnicianswillrefertotheArmyAudiologistsifrequired.DONOTbookSoldierappointmentswiththecivilianAudiologistintheENTclinic.DONOTbookaSoldierappointmentwithanENTphysicianwithoutgoingthroughHearingReadinessfirst. CheckinatHearingReadinessSection/SoldierReadinessProcessingCenter1042OConnellDrive OtoscopicExam FitEarplugs DoesSoldierhaveacurrenthearingtest/profile/MMRBonrecord? Yes Yes No DOEHRS-HCaudiogramatHearingReadinessSection,SoldierReadinessProcessingCenter UpdateMEDPROSandDOEHRSDR,counselonhearingprotection,clearSoldierfordeployment,PCS,orretirement STS? H1? Appointmentwithclinical(Army)audiologistatHearingReadinessSection,SoldierReadinessProcessingCenter(notENTclinic!!) Yes No No UpdateMEDPROS&DOEHRSDR,counselonhearingprotection,clearSoldierfordeployment,PCS,orretirement Yes Sendforearflushandcleaning No Earcanalsclear?

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AprilJune200971THEARMYMEDICALDEPARTMENTJOURNALCarsonsincetheyear2000whenwewereapeacetimeArmy.ThehighSTSratesinAugust2008(14%)andinDecember2008(15%)areoutliers,andreflectalackofcompliancewiththehearingprogramfor2unitsundergoingpredeploymenthearingreadinessevaluationscomparedtosimilarunitsatFortCarson.Evenwiththeoutliers,however,thedatainFigure4demonstratesthattheimplementationoftheArmyHearingProgramatFortCarsonhasreducedtheSoldiersoverallSTSratetolessthan11%duringaperiodofcontinuousactivecombatdeployments.Eliminatingthe2outliersfromthepostaverageputstherestofFortCarsonsSTSrateatlessthan10%.AcivilianaudiologistworksintheEar,NoseandThroat(ENT)ClinicaspartoftheFortCarsonHearingProgram.ThecivilianaudiologistsmainroleistoprovidediagnosticaudiologyservicestoTRICARE*eligiblefamilymembers,dependentsandretirees.UndertheArmyHearingProgramatFortCarson,thecivilianaudiologistonlyseesSoldierswhoarereferredbyoneoftheactivedutyArmyaudiologists,orbyoneoftheENTphysicians.ThecivilianaudiologistsresponsibilitiesforSoldiercareincludeclinicalrehabilitativeservices(suchasdispensinghearingaids),oradvancedclinicaltesting(includingelectrophysiologicaltestsandvestibulartests).ThecivilianaudiologistalsorunsthenewbornhearingscreeningprograminthehospitalandprovidesdiagnosticandrehabilitativecareforTRICAREeligiblefamilymembers.ItiscrucialtodistinguishtheverydifferentrolethatthecivilianclinicalaudiologistintheENTordepartmentofsurgeryhasfromtheactivedutyArmyaudiologist(alignedunderthedepartmentofpreventivemedicine).Thoseaudiologistsrolesareentirelyclinicalandrehabilitativeinnature,andtheirpatientpopulationconsistsprimarilyofcivilians.Conversely,theactivedutypreventivemedicineaudiologistsroleisonly50%clinicalinnature.Theother50%ofthetimeispreventiveandspentoutsideoftheclinic,involvedineducationandsiteinspections.Theirprimarymissionisthepreventionofnoise-inducedhearinglossandtheimprovementofhearingreadiness,inthehopethatahearingaidisnotrequiredforasmanySoldiersinthefuture.ThepreventivemedicineaudiologistspatientpopulationconsistsalmostentirelyofSoldiers.Figure5illustratesthedifferentclinicalhearingservicesmissionsofthepreventivemedicine(activeduty)andtheENT(civilian)diagnostic,clinical,andrehabilitativecare.OPERATIONALHEARINGSERVICESWebelievethereducedSTSrateatFortCarsonisadirectresultofourfocusonoperationalhearingservicesintheFortCarsonHearingProgram.TheprimaryobjectiveofoperationalhearingservicesistheenhancementofSoldiersurvivability.Hearingisacriticalsensethatdirectlyaffectsmissionsuccess.TheabilitytohearinacombatenvironmentiscriticalbecausenormalhearingallowsaSoldiertodetecttheenemyandmaintaineffectivecommunicationabilityandsituationalawarenessinnoise.Operationalhearingservicesincludeeducationandinstructionintacticalcommunicationandprotectionsystems(TCAPS),noisesurveillanceofhazardousandnuisancenoiseenvironments,guidanceonnoiseabatementandcontrol,andemphasisonpreventionofhearinginjuriesthrougheducationandreadinesstomaximizethewarfighterlethalityandsurvivabilityonthebattlefield,withoutcompromisingcommunicationandsituationalawareness.Commandersenhancetheirunitseffectivenessbyensuringtroopsareequippedwithproperhearingprotectionand/orTCAPS. Figure4.PercentageoftestedFortCarsonSoldierswithsignificantthresholdshift(STS)foreachmonthof2008.Note:Numbersinparentheses(numberdemonstratingSTS/totalnumbertested) *TRICAREistheDoDhealthcareprogramformembersoftheuniformedservices,theirfamilies,andtheirsurvi-vors.Informationavailableathttp://www.tricare.mil.

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72https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1 Commandersmustensuretheirunitsareprovidedtheopportunitytotrainwiththesedevicesandunderstandtheiruseandimportanceinmaintainingeffectivecommunicationandsituationalawareness.Themetricswedevelopedmonitoroperationalhearingservicesingarrison,withtheintentthatSoldierswillfightastheytrain,andtransferthetrainingandskillstheylearnedingarrisonontothebattlefield.WefollowedguidancefromtheDepartmentoftheArmyPamphlet40-501,whichstatesthatcommandersofnoise-exposedpersonnelmustappointaunithearingconservationofficer.7Weincorporatedthisrequirementintoapost-widestandingoperatingprocedure(SOP),whichwasendorsedbytheFortCarsoninstallationcommander.TheSOPstatesthateachunitonFortCarsonisrequiredtoformallyappointacompanylevelhearingprogramofficer(HPO).EachHPOmustcompleteahalfdayoftrainingunderthesupervisionofatleastoneoftheFCHPArmyaudiologists.Thefirstportionoftheclassexplainsthe4elementsofthehearingprogram,andtheHPOsroleasextensionsoftheFCHPcorestaff.Thesecondportionoftheclassinvolvesseveralpracticalexercisesincluding:examinationoftheouterearcanalwithanotoscope;determinationofthepropersizeearplugforboththemselvesandtheirfellowSoldiers;understandingnoisereductionratios;andunderstandingthatnotallearplugsareequallyprotectivesomemayinfactover-protect.AttenuationoftoomuchambientnoisecouldcauseaSoldiertorejectallhearingprotectionbasedonanegativeexperiencewithonetype.EachHPOmustpassawrittenandapracticalexamination.Graduatesareissuedacertificateofcompletionandapocketotoscope,whichbecomespropertyoftheircompanywhentheSoldierleavestheunit.HPOsareexpectedtoarrangefortheirunittoparticipateinanannualhearinghealthbriefingfromoneoftheFCHPpreventivemedicineaudiologists.HPOsarealsoexpectedtobereadyforasitevisittoFortCarson:AnArmyHearingProgramSuccessStory Explainresultstopatient,profileasnecessary,documentinAHLTA,MEDPROS,andDOEHRSDR.TemporaryprofilesarenondeployablependingmedicalclearanceH1&(P)H2:Fitforduty(ArmyRegulation40-5014).Insomecases,referforHAEbasedonSoldierscandidacy.(P)H3:NondeployablependingMMRBadjudication(ArmyRegulation600-603).FaxpaperworktoMMRB.Referforhearingaidevaluationbasedoncandidacy. Isthereanysuspectedunderlyingpathologythatmustberuledout? CheckinatHearingReadinessSection,SoldierReadinessProcessingCenter1042OConnellDriveSoldierwithascheduledappointment Armyaudiologistreviewspastmedicalandhearinghistory Armyaudiologistcompletesdiagnosticevaluationtodeterminefitnessforduty SensorineuralSTS? Orderadditionaltestsandreferasnecessary UpdateMEDPROS&DOEHRSDRandclearSoldierfordeployment,PCS,orretirement Conductivepathology?Vestibular?Tumor?Acuteacoustictrauma? No Yes Yes Yes No No Civilianaudiologistreviewspastmedicalandhearinghistoryandcompletesdiagnosticevaluation,ordersadditionaltests,andreferstootherspecialistsasnecessary.CivilianaudiologistalsoconductshearingaidevaluationsforSoldiersreferredfromtheArmyaudiologistONLY. CheckinatClinicalAudiology,ENTClinic,EvansArmyCommunityHospital ExplainresultstopatientanddocumentfindingsinAHLTA.CivilianaudiologistdoesNOTissueprofilestoSoldiersTricareeligiblefamilymembersandretireeswithscheduledappointments Figure5.The2distinctprocessesforclinicalhearingservicesforSoldiersandothersatFortCarson.SoldiercareistheexclusiveresponsibilityoftheArmyaudiologist,whocanmakeanecessaryreferral.PatientswhoarenotSoldiersareseenbythecivilianaudiologistthroughtheENTclinicattheEvansArmyCommunityHospital.

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AprilJune200973THEARMYMEDICALDEPARTMENTJOURNAL theirareafromtheFCHPstafftoensuretheircompliancewiththehearingprogram.TheflowchartinFigure6illustratesthe3branchesoftheoperationalhearingservicesmissioningarrisonatFortCarson.Figure7showsthattheFCHPhastrained321companylevelhearingprogramofficersinthelast2calendaryears.Insodoing,weexceededourgoaloftraininganHPOfor222(80%)ofthecompaniesonFortCarson.Unfortunatelywehavefallenshortofourothergoalsforoperationalhearingservicesintheareasofeducationandinspections.Wehadhopedtopresentanannualhearingsafetybriefingtothesame222companies,butonlymanagedtoprovide15companylevelhearinghealthbriefings.Wealsofailedinourgoaltoinspectnoisehazardousareasforthesame222companies,only14noisehazardousareaswereinspectedoverthelast2years.WebelievethisshortfallwasduetothedeploymentofoneofouractivedutyaudiologiststoIraqfor120days,andherresidencytrainingattheCaptainsCareerCourseforanother9weeksin2008.Duringherabsence,thetableofdistributionandallowances*showedthatFortCarsonhad2uniformedaudiologistsonpostrunningthehearingprogram,whileinreality;onlyonepersonwasavailableformorethanhalfofthe2008calendaryear.Thesenumbersfurthersupportourbeliefthatthepreventivemedicinestaffingmodelisinaccurateinitsestimationthatonemilitaryaudiologistand2.5audiologytechniciansarecapableofprovidingadequatepreventivemeasuresforevery18,000SoldiersundertheArmyHearingProgram.UsingtheoldstaffingmodelwiththenewAHPsetsArmyaudiologistsupforfailure.HEARINGCONSERVATIONThefourthelementoftheFCHPishearingconservation.Thehearingconservationelementisdesignedtoprotectnoise-exposedgovernmentcivilianpersonnelemployedatFortCarsonfromhearinglossduetooccupationalnoiseexposure.Thiselementfollowsthegarrison-basedArmyHearingConservationProgram,butappliestonoiseCompanyisaGO AnnualHearingHealthBriefingcomplete? RequestbriefingfromPreventiveMedicineHearingProgramstaffasrequiredbyDAPamphlet40-5014andFtCarsonSOP. No Inspectionofnoisehazardousareasandrangescomplete? InviteHearingProgramstaffforaninspectionorawaitasurpriseinspection. No Yes Yes YesGarrisonTrainAsYouFight! AssignHearingProgramOfficerwhoattendsHPOclassasrequiredbyDAPamphlet40-5014andFtCarsonSOP. CompanylevelHPOassigned? No Figure6.OperationalhearingservicesprovidedundertheFortCarsonHearingProgram. Figure7.Thecumulativenumberoftrained,companylevelhearingprogramofficersinFortCarsonunits,thenumberofhearinghealthbriefingspresented,andthenumberofnoiseinspectionsperformedshownonamonthlybasisfor2007and2008. *Prescribestheorganizationalstructure,personnelandequipmentauthoriza-tions,andrequirementsofamilitaryunittoperformaspecificmissionforwhichthereisnoappropriatetableoforganizationandequipment.

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74https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1exposedciviliansonly,anddoesnotincludeourSoldierpopulation.Thereare7essentialelementsincludedinthehearingconservationcomponentoftheFCHP:NoisehazardidentificationEngineeringcontrolsHearingprotectorsMonitoringaudiometryHealtheducationEnforcementProgramevaluationFigure8showstheannualSTSrateforournoise-exposedcivilianemployeeswhoareenrolledintheHearingConservationSectionoftheOccupationalHealthClinicundertheFCHPandtheDepartmentofPreventiveMedicine.AlthoughwetracktheoverallSTSratemonthly,weonlygraphtheyearlypercentageofSTSduetothesignificantlylowernumberofciviliansenrolled(411totalin2008).In2000,30%ofthe128noise-exposedciviliansonFortCarsonshowedanannualsignificantthresholdshift.TheSTSrateforourcivilianworkforcein2008hasdroppedto6%,thelowestithasbeeninmorethan8years,eventhoughthenumberofcivilianstestedhasmorethantripledduringthesametimeperiod.WecontributeoursuccessestoincreasedinteractionwiththerangecontrolofficeonFortCarson.TheFCHPisinvolvedinrangecontrolstrainingclassesforrangesafetyofficers.WedonotrequirethecivilianpopulationtoparticipateintheHearingProgramOfficerCourse,butinterestingly,severalnoise-exposedcivilianshavelearnedofourclassandaskedtoparticipatesothattheycouldassumetheresponsibilityasthehearingprogramofficersfortheirworkareas.Ofcoursewehavebeenhappytoobligeandaccommodatetheminourclasses.CONCLUSIONTheFortCarsonHearingProgramhasdocumentedmetricswhichshowthenewArmyHearingProgramdoctrinesuccessfullydecreasedthispostsSoldierandcivilianSTShearinglossratetolevelspredatingtheGlobalWaronTerror,whilewehavebeenanArmyatwar.Additionally,thedatashowsthattheadditionofasecondArmyaudiologistincalendaryear2008resultedinanincreaseofmorethan3,000Soldierswhowerefullyreadytodeploy,comparedtocalendaryear2007.Oursuccessisattributedtoanincreasedemphasisinoperationalhearingservices,eventhoughwefellshortofourgoalofprovidingafullspectrumandtriadofoperationalhearingservicesto80%ofFortCarsonscompaniesingarrison.TheFCHPmetricsshowpositivetrendsinall4elements:hearingreadiness,clinicalhearingservices,operationalhearingservices,andhearingconservation.ThemetricsalsosuggestthattheArmyMedicalCommandspreventivemedicinestaffingmodelscurrentrecommendationofoneaudiologistand2.5techniciansforevery18,000Soldiersisinsufficientandpredestineshearinglosspreventioneffortsforfailure.Finally,theFCHPshowsthatcommandemphasisiscrucialforasuccessfulhearingprogram.COLKathyGates,AudiologyConsultanttoTheSurgeonGeneral,succinctlystatesthecurrentreality:TheArmynolongerneedstoaccepthearinglossasaninevitablebyproductofmilitaryservice.FortCarson:AnArmyHearingProgramSuccessStory Figure8.PercentageofnoiseexposedcivilianemployeeswhoareenrolledintheHearingConservationSectionoftheOccupationalHealthClinicwithsignificantthresholdshift(STS)fortheyears2000through2008.Note:Numbersinparentheses(numberdemonstratingSTS/totalnumbertested)

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AprilJune200975THEARMYMEDICALDEPARTMENTJOURNALACKNOWLEDGEMENTSIthankthefollowingpeoplefortheirassistanceinpreparationandreviewofthispaper:COLKathyGates,AudiologyConsultanttoTheSurgeonGeneralandDirectoroftheArmyAudiologyandSpeechCenteratWalterReedArmyMedicalCenter.COLJamesTerrio,ChiefofPreventiveMedicineatEvansArmyCommunityHospital,FortCarson.LTCVickiTuten,AudiologyStaffOfficer,ProponencyforOfficeofPreventiveMedicine,OfficeofTheSurgeonGeneral.LTCNicholasPiantanida,DeputyCommanderforClinicalServices,EvansArmyCommunityHospital,FortCarson.DrKennethStone,MD,ChiefoftheOccupationalHealthClinic,DepartmentofPreventiveMedicine,EvansArmyCommunityHospital,FortCarson.CPTJennyDavis,HearingProgramAudiologist,Occu-pationalHealthClinic,DepartmentofPreventiveMed-icine,EvansArmyCommunityHospital,FortCarson.MsJanetKlieman,MedicalLibrarianatEvansArmyCommunityHospital,FortCarson.REFERENCES 1.McIlwainD,CaveK,GatesK,CiliaxD.EvolutionoftheArmyhearingprogram.ArmyMedDeptJ.April-June2008:62-66.2.HelferT,JordanN,LeeR.PostdeploymenthearinglossinUSArmySoldiersseenataudiologyclinicsfromApril1,2003,throughMarch31,2004.AmJAudiol.2005;14(2):161-168.3.ArmyRegulation600-60:PhysicalPerformanceEvaluationSystem.Washington,DC:USDeptoftheArmy;February28,2008:8.4.ArmyRegulation40-501:StandardsofMedicalFitness.Washington,DC:USDeptoftheArmy;September10,2008:80.5.USArmyMedicalCommandAutomatedStaffingAssessmentModelforPreventiveMedicine.Availableat:https://www.us.army.mil/suite/page/29142.(restrictedaccess)AccessedDecember31,2008.6.SpecialText4-02.501:ArmyHearingProgram.FortSamHouston,Texas:USArmyMedicalDepartmentCenter&School;February1,2008.Availableat:http://militaryaudiology.org/site/wp-content/images/st_4_02_501.pdf.AccessedApril28,2009.7.DepartmentoftheArmyPamphlet40-501:HearingConservationProgram.Washington,DC:USDeptoftheArmy;December10,1998:2.AUTHOR CPTCleveland,AuD,isChiefoftheFortCarsonHearingProgramattheOccupationalHealthClinic,DepartmentofPreventiveMedicine,EvansArmyCommunityHospital,FortCarson,Colorado. USArmyMedicalDepartmentActivityFortCarson,Colorado

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76https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1BACKGROUNDHistorically,80%ofallhospitaladmissionshavebeenfromdiseaseandnonbattleinjuries.1Preventivemedicinemeasuresaresimple,commonsenseactionsthatanyservicemembercanperformandtowhicheveryleadercansubscribe.Inthepreventivemedicineworld,therehavealwaysbeendifficultiesensuringthesafetyofgeographicallyseparatedSoldiers.DuringOperationJointEndeavourin1995,basecampassessmentteamswereestablishedtoevaluatequalityoflifeatforwardoperatingsitesinBosnia.Currently,wehaveSoldierslocatedinmanypartsoftheworld,easternEurope,themiddleeast,southwestAsia,andintheBalkans.Thenameschange,butthebasicconceptofabasecampassessmentteamremainsthesameandisalwaysapplicable.Itiseasywhenanentirebrigadecombatteamisonasingleforwardoperatingbase,butwhatdoyoudowhentherearemanyforwardoperatingbases?Forexample,whiledeployedtoAfghanistanin2006forOperationEnduringFreedom,mybrigadewasdispersedover12geographicallyseparatedforwardoperatingbases.Sinceyoucannotbeeverywhereatonetime,howdoyoupreventmissionfailureduetoenvironmentalhealthissues?Theremustbeaprogramtoorganizeasystematic,holisticapproachtoplan,develop,implement,andmaintainenvironmentalhealthsurveillanceattheseforwardbasecamps.Thatprogramisthebasecampassessmentprogram.Implementationofabasecampassessmentprogrambeginspriortoarrivalin-theater.BASECAMPASSESSMENTPROGRAMThe2mainreferencesthatformthebasisofanenvironmentalhealthsurveillanceprogramareDepartmentofDefenseInstruction6490.03,2andJointChiefsofStaffMemorandumMCM0028-07.3Thesedocumentsdefineenvironmentalhealthsurveillanceastheregularorrepeatedcollection,analysis,archiving,interpretation,anddisseminationofdatarelatedtodeploymentoccupationalandenvironmentalhealth.Thebasecampassessmentprogramusesenvironmentalhealthsurveillancedataforhealthmonitoring,thedeterminationofpotentialhealthhazardimpactonapopulationorindividualpersonnel,andforthetimelyinterventiontoprevent,treat,orcontroltheoccurrenceofdiseaseorinjurywhendeterminednecessary.2,3Thisisthestartingpoint.DepartmentoftheArmyPamphlet40-11(DAPAM40-11)4definestheprogramsandserviceswithinthemedicalfunctionalareaofpreventivemedicine.AllpreventivemedicineSoldiersshouldreadthispamphlettoidentifyUSArmypublicationsthatdelineatefunctionsandcontainthedetailedEstablishingaBaseCampAssessmentProgramforaForwardOperatingBaseCPTDavinBridges,MS,USALTCTimothyBosetti,MS,USA ABSTRACTOccupationalandenvironmentalhealthhazardscanseriouslyimpactthemissionanderodepublicconfidenceinthemilitarysabilitytoprotectUSpersonnel.Withanyforwardoperatingbase,itiscriticaltoestablishacomprehensivebasecampassessmentprogramtooptimizehealthreadinessandprotectdeployedDepartmentofDefensepersonnelfromoccupationalandenvironmentalhealthhazards.Itisanongoing,never-endingdutytoeducateandperformsanitaryinspectionsaswellaswater,soil,andairsurveillance.Establishingabasecampassessmentprogramforaforwardoperatingbaseiscriticaltoensurecontinuousmonitoringwhenthelocationdoesnothaveapermanentenvironmentalscienceofficerorpreventivemedicinespecialistonsite.Thespecificgoalofthebasecampassessmentprogramistoreducediseaseandnonbattleinjury.Lessons-learnedhaveshowntheimportanceofaccuratereportingandinterpretationofenvironmentalhealthassessmentstoreducediseaseandnonbattleinjury.

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AprilJune200977instructions,guidance,andproceduresnecessaryforimplementingthepoliciesandresponsibilitiesoutlinedinArmyRegulation405.5Atthispointmanywillsay,thosearegarrisonprograms,Iaminthefield.Whileitistruethatthesearepredominatelygarrison-basedprograms,theyshouldnotbeexcluded.Wherebettertofindoutwhatyoucanandshouldbedoingthanbymirroringanestablishedgarrison-basedprogram.Trainasyoufight.DAPAM40-114outlinesalloftheenvironmentalhealthprogramsincludedinabasecampassessmentprogram.Itismorethanjustcheckingtrashcansandsniffinglatrines.OVERVIEWThebasecampassessmentisthekeyinanactivepreventivemedicineprogram;however,thereneedstobeaclearunderstandingofthepurposeofthebasecampassessmentprogram.TheprogramistheassessmentoftheoverallhealthstatusofSoldiers.TheprogramshouldbeflexibleenoughtomeetthecontinuallyevolvingneedsoftheSoldierandtoaccommodatetheoperationandchangesinpatternsofdiseaseandinjury.Thegoaloftheprogramistodevelopacomprehensivepreventivemedicineprogramtoreducediseaseandnonbattleinjurythroughproactivemeasures.COMPONENTSOFTHEPROGRAMUsingDAPAM40-114asaguide,abasecampassessmentprogramcancomprisemanycomponents.Theindividualcomponentswillvarydependingontheforwardoperatingbaseandthematurityofthetheater.Typically,abasecampassessmentprogramwillconsistofwatersurveillance,foodserviceinspections,livingareainspections,wastedisposal,pestmanagement,climaticinjuryprevention,andbasiccampsanitationinspections.Butitneednotbelimitedtothese(Figure1).Asthecampandtheatermature,someprogramswillbecomeroutine,whileotherswillemergeasgreaterrisks.Thismaysoundlikeadauntingtaskandonethatisbeyondthescopeofasmallpreventivemedicinecellwithinabrigadecombatteam.However,itiswhatyoualreadydo.Thebasecampassessmentjustbringsitalltogether.COMPREHENSIVEASSESSMENTS:AHOLISTICAPPROACHDevelopmentofabasecampassessmentprogramforaforwardbasecampshouldfollowaholisticapproach.Focusingonafewindividualcomponentswillnotbesufficientinestablishingasuccessfulbasecampassessmentprogram.Itneedstoaddressthefullspectrumofpreventivemedicineprograms.Akeytoasuccessfulbasecampassessmentprograminvolveslinkingtogetherwhatyoualreadydo,asillustratedinFigure2.Theproblemisthatwetypicallydonotlookattheseprogramsonacontinuum.Instead,weapproachthemasindividualstovepipesandmissoroverlookthewarningsigns.Typically,itisonlyafteranoutbreakoranincreasedincidenceofdiseasethatwestartlookingatthedifferentenvironmentalhealthprogramsholistically.Sicknesscancomefasterthanyoucananticipate.Beingproactivewithyourpreventivemedicinedutiesisessentialinstoppingapossiblemissionfailure.SomethingassimpleasSoldiersnotwashingtheirhandscouldhaveacatastrophiceffectonaplatoon.Highlightingthissimplefailureasthestartingpointforanexampleofthespreadofinfection/disease/illness:aSoldieracquiresgastrointestinaldisease,he/she WaterSupplyFoodServiceSanitationTroopBilleting/SleepingAreaWasteDisposalPestManagementNoiseHazardIdentification&ControlFieldSanitationTeamsBarbershopSanitationHeatInjuryPreventionFigure1.Typicalcomponentsofabase campassessment(listnotexhaustive). BaseCampAssessment Documentwhatyoualreadydo! Heat/ColdInjuryLivingAreaBACTWaterDFACInspection SanitaryInspectionSiteRecon/Assessment/Walkthrough CHPPMOEHSReportsCheckingUnitFST Ento EPIDNBI HearingConservationIndustrialHygiene EPIDNBI CheckingUnitFST DFAC*Inspection WaterBacteriology IndustrialHygiene CHPPM#OEHS**Reports Entomology Heat/ColdInjury LivingArea SanitaryInspection SiteRecon/AssessmentWalkthrough DocumentWhatYouAlreadyDo! HearingConservation Figure2.Asuccessfulbasecampassessmentprograminvolveslinkingtogetherwhatyoualreadydo.*DiningfacilityEpidemiologyDiseaseandnonbattleInjuryFieldsanitationteam#CenterforHealthPromotionandPreventiveMedicine**Occupational&EnvironmentalHealthSurveillance

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78https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1couldeasilyspreadthatillnesstoallhis/herfellowSoldiersbyplayingcards.Iftheplatoonisineffectivebecauseofsickness,themissionwillsuffer.Thiscouldhaveadominoeffectthatcouldimpactthebattalion.Thebreakinthepreventivemedicinemeasureschaincanputothermissionsonhold.ItisourjobnotonlytogetthewordouttotheSoldier,butalsotoensuretheSoldierispracticinghis/herpreventivemedicinemeasures.Aproperbasecampassessmentprogramattemptstotiethedifferentpreventivemedicineandenviron-mentalhealthprogramsintoasingleassessment.Theaimistobeproactive.Todothis,weneedtolookatthesecondandthirdordereffectsoftheindividualfindings.Thenaskourselvesifanyofthemarerelated.Dothelessthansatisfactorysanitationpracticesinthediningfacility,nochlorineresidual,andaslightincreaseinsickcallnumbershaveanythingincommon?Isitasignofabiggerproblem?Thesearesomeofthequestionsweshouldaskourselveswhenwelookatthisholistically.COMPOSITERISKMANAGEMENTTheactualassessmentportionofabasecampassessmentrequirestheuseoftheinformationcollectedfromyourfindingstoidentifyhazards,assessthepotentialrisks,determineappropriateriskcontrolmeasures,andcommunicatetheriskstotheforcesusingcompositeriskmanagement(CRM),graphicallyportrayedinFigure3.HazardseverityisameasureoftheimpactoftheinteractionofthehealthhazardsonSoldiers.Hazardprobabilityisdeterminedbyestimatingthepercentageofthepopulationthatcouldbeexposedtothathazard.Finally,theoverallhealthriskestimateisdeterminedbyusingtheCRMmatrixinTable3-3oftheUSArmyCenterforHealthPromotionandPreventiveMedicine(USACHPPM)TechnicalGuide2306andArmyFieldManual5-19.7UsingCRMdoctrinewillenableyoutoconveyyourmessageinaclearanduniversallyunderstandablelanguage:green,amber,red,andblack.Afterdeterminingthehealthrisk,setinplaceariskcommunicationplantodeliverkeymessagesofthehealthriskandtherecommendationstolowertherisk.COMMUNICATIONCommunicationconsistsof3keycomponents:document(eg,report),inform,andarchive(Figure4).Documentationofeverythingisnotonlycriticalforpresentingaccurateresultstoyourchainofcommand,itisessentialforfuturemissions.Havinggreatdocumentationcaneffectivelyhelpthenextpreventivemedicineteamthatfollowsyou,andretainscomplete,accuraterecordsofyourfindingsandrecommendations.Documentthenegativeandthepositivefindings,and,keepyourfindingsstraightforwardsothathigherleadershipwillunderstand.Thereportdoesnotneedtobecomplexoralengthydissertation:keepitsimple.Useanexecutivesummaryfortheseniorcommandersandstaff.Ideally,itshouldbeaone-pagesnapshotofyourwork.Graphicsaregood.Thereportshouldbedetailedenoughtopaintapictureofthehealthstatusofyourforwardoperatingbase.Ifyouhavethecapability,includeallofyourinspectionformsasenclosures.Documentnegativefindings;ifyoulookedatsomethingandfoundnothing,stateit.Itisimportanttonotewheneverythingwasokay.Weinpreventivemedicinedonotdoagoodjobinthisarea.Weareverygoodaboutdocumentingwhenweseedeficiencies,butfailtoproperlyrecordandreportwheneverythingwassatisfactory.Keepyourcommandinformed.Routinereportingofyourbasecampassessmenttoyourcommandkeepsthemapprisedofthepreventivemedicinehealthoftheircommandandtheywillcometoexpecttoseeyourreport.Itisnotwhomyouinclude,itiswhomyouleaveEstablishingaBaseCampAssessmentProgramforaForwardOperatingBase MISSIONS Step1:IdentifyHazards Step4:ImplementControls Step2:AssessHazards Estimateprobability Estimateseverity Determinerisklevelforeachhazardandoverallmissionrisk Step3:DevelopControlsandMakeRiskDecision Developcontrols Makedecision Determineresidualrisklevelforeachhazardandoverallmissionrisk Step5:Supervise&Evaluate Evaluate Supervise LessonsLearnedNewHazards Figure3.Theriskmanagementprocess.

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AprilJune200979THEARMYMEDICALDEPARTMENTJOURNALout.Informcriticalpersonnel,keystaff,andcommandersonaregularbasis.Documentandkeeprecordsofwhomyouinform.Archivingthebasecampassessmentreportsisimportant.AllofyourinspectionformsandreportsshouldbearchivedbysubmittingdirectlytotheDefenseOccupationalandEnvironmentalHealthReadinessSystemdataportal.*Usehistoricaldataforthatspecificsitetodevelopanenvironmentalhealthsurveillanceprogramforaspecificforwardbasecamp.ContactUSACHPPMtoreceiveinformationonthatsite/location,usingtheGlobalThreatAssessmentProgram.SOMETACTICS,TECHNIQUES,ANDPROCEDURESPuttingpreventionintopracticeisnotalwayseasy.Inspect,monitor,andrecordalldocumentsfordiningfacilities,barbershops,gymnasiums,detentioncells,foodestablishments,andwaterstoragecontainerstoensurethesafetyoftheSoldiers.Thereareanumberofwaystoaccomplishthismission,hereareafewtips:1.Knowdoctrineandtheregulationsbackwardsandforwards.Ifyouknowdoctrine,youwillknowwhentofollowitandwhentomodifyitaccordingtoyoursituation.Remember,doctrineisastartingpoint.Likewise,regulationscanassistyouinknowingwhatyouneedtodo.2.Establishfieldstandardoperatingproceduresandsmart-bookchecklistsbeforeyoudeploy.Testyourprogramingarrison,whatbetterwaytorunabattledrillandgetyourcommandfamiliarwithyourreportsandpreventivemedicine.Usehistoricaldataforthatspecificsitetodevelopyourbasecampassessmentprogramforaspecificforwardbasecamp.ContactUSACHPPMtoobtaininformationonthatsite/location,usingtheGlobalThreatAssessmentProgram.3.Donotsettleforthestatusquo.Onceyouhaveestablishedthebasicprogramsandtheyarerunningsmoothly,expandthoseprograms.Increasethelevelofexpectationasfacilitiesandsupportservicesincreasetheirabilitytoprovidesafer,betterqualityservices.Ifcontractedservicesareused,besureyoucoordinateactionsthroughthecontractingoffice.4.BeanevangelisticpreventivemedicineSoldier.Youshouldbegettingoutandreachingouttoall.Everyoneshouldknowyou.Duringmeetings,haveatipoftheweekforyourcommander.Getoutandgotoeverymeeting.Bearoundatalltimes.Nomatterwhattypesofquestionstheyask,theystillknowwhoyouare.Thesemanagerswanttodowhatisright.Helpingthemsucceedmeansyouhaveabetterchancetosucceedinyourpreventivemedicinemission.Inaddition,developpersonalworkingrelationshipswiththemayorscell,basecampcommander,andthecontractingofficeontheforwardoperatingbase.CONCLUSIONThebasecampassessmentisnotanotherrockinyourrucksack;itisaholisticapproachtopreventivemedicinethatenablesyoutointerconnecttheinspectionsyouroutinelydoinordertogaugetheoverallhealthandsanitationofyourforwardoperatingbase.Itiswhatyoualreadydo:justadifferentapproachtopackagingthefindings.Usethiscollectionofdatatolowerthepossibilityofmissionfailureandmaximizethefightingstrength.Haveanestablishedbasecampassessmentprogramforforwardbase *http://doehrswww.apgea.army.mil/doehrs-oehs/emailaddress:chppm-gtap@amedd.army.mil COMMUNICATIONDocumentReportDocumentnegativefindingsExecutivesummary(keepitsimple)InformKeepbasecamp&taskforcecommandersinformedSetroutineschedule/timelineforreportGetinvolvedArchiveDataandReportsSubmitdirectlytoDOEHRSdataportalhttps://doehrswww.apgea.army.mil/front.htmSubmitviaemailUnsecured-oehs@apg.amedd.army.milSecured-oehs@usachppm.army.smil.milSubmitviaregularmailUSACHPPMAttn:MCHB-TS-RDDBldgE-16755158BlackhawkRoadAberdeenProvingGround,MD21010-5403Figure4.Theelementsofariskcommunication plan.

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80https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1 campstomonitorallaspectsofpreventivemedicine.TheprogramisdynamicandmustreadilychangeandadaptasSoldiersandmissionschange.Theoverallresultofasuccessfulbasecampassessmentprogramforforwardbasecampsislowernumbersofcasualtiesduetodiseaseandnonbattleinjury.REFERENCES 1.FieldManual21-10:FieldHygieneandSanitation.Washington,DC:USDeptoftheArmy;June21,2000.2.DepartmentofDefenseInstruction6490.03:DeploymentHealth.Washington,DC:USDeptofDefense;August11,2006.3.OfficeoftheChairman,JointChiefsofStaff.MemorandumMCM0028-07,ProceduresforDeploymentHealthSurveillance.WashingtonDC:USDeptofDefense;November2,2007.Availableat:http://amsa.army.mil/Documents/JCS_PDFs/MCM-0028-07.pdf.4.DepartmentoftheArmyPamphlet40-11:MedicalServices:PreventiveMedicine.Washington,DC:USDeptoftheArmy;October20,2008.5.ArmyRegulation40-5:PreventiveMedicine.Washington,DC:USDeptoftheArmy;May25,2007.6.TechnicalGuide230:ChemicalExposureGuidelinesforDeployedMilitaryPersonnel.Version1.3.AberdeenProvingGround,MD:USArmyCenterforHealthPromotionandPreventiveMedicine.May2003.Availableat:http://chppm-www.apgea.army.mil/documents/tg/techguid/tg230.pdf.7.FieldManual5-19:CompositeRiskManagement.Washington,DC:USDeptoftheArmy;August21,2006.AUTHORS CPTBridgesisanEnvironmentalScienceOfficerandtheProgramManageroftheUSArmyCenterforHealthPromotionandPreventiveMedicineEuropeDeploymentEnvironmentalSurveillanceProgram.LTCBosettiisChiefoftheDepartmentofEnvironmentalSciencesattheUSArmyCenterforHealthPromotionandPreventiveMedicineEurope.EstablishingaBaseCampAssessmentProgramforaForwardOperatingBase

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AprilJune200981HISTORICALBACKGROUNDFollowingthe1990-1991PersianGulfWar,manyservicemembersreportedhealthproblemsandbelievedtheseproblemswereassociatedwiththeirmilitaryserviceinthePersianGulf.Apaucityofhealthanddeploymentdataseverelylimitedtheabilitytoinvestigatethenatureandcausesoftheseillnesses.TheNationalDefenseAuthorizationActforFiscalYear1998,1enactedinNovember1997,directedtheDepartmentofDefense(DoD)toestablishasystemtoassessthemedicalconditionofservicemembersbeforeandafterdeployments.In2002,theGovernmentAccountingOffice(GAO)wasaskedtodetermineifthemilitaryservicesmetDoDsforcehealthprotectionandsurveillancerequirementsforservicemembersdeployinginsupportofOperationEnduringFreedomincentralAsiaandOperationJointGuardianinKosovo,andifDoDhadcorrectedproblemsrelatedtotheaccuracyandcompletenessofdatabasesreflectingwhichservicemembersweredeployedtocertainlocations.ThefindingsofthisGAOstudywerepublishedinSeptember2003.2TheGAOfoundthattheArmyandtheAirForcedidnotcomplywiththeDoDsforcehealthprotectionandsurveillancepoliciesformanyactivedutyservicemembers,includingtherequirementthattheybeassessedbeforeandafterdeployingoverseas,thattheyreceivecertainimmunizations,andthathealth-relateddocumentationbemaintainedinacentralizedlocation.TheGAOsreviewof1,071servicemembersmedicalrecordsfromauniverseof8,742atselectedArmyandAirForceinstallationsparticipatinginoverseasoperationsdisclosedthat:From38%to98%weremissingoneorbothoftheirhealthassessments.From14%to46%weremissingatleastoneoftherequiredimmunizations.Thestudy2alsofoundthattheDoDdidnotmaintainacomplete,centralizeddatabaseofservicemembersmedicalassessmentsandimmunizations.Health-relateddocumentationmissingfromthecentralizeddatabaserangedfrom0%to63%forpredeploymentassessments,11%to75%forpostdeploymentassess-ments,and8%to93%forimmunizations.Addition-ally,therewasnoeffectivequalityassuranceprogramattheOfficeoftheAssistantSecretaryofDefenseforHealthAffairsorattheArmyorAirForcethathelpedtoensurecompliancewithpolicies.TheGAObelievedthatthelackofsuchaprogramwasamajorcauseofthehighrateofnoncompliance.TheGAOwasconcernedthatcontinuednoncompliancewiththesepoliciesmightresultinthedeploymentofservicememberswithhealthproblems,ordelaysinobtainingcarewhentheyreturn.Basedonthesefindings,theGAOrecommendedthattheSecretaryofDefensedirecttheAssistantSecretaryofDefenseforHealthAffairstoestablishaneffectivequalityassuranceprogramthatwouldhelpensurethatthemilitaryservicescomplywiththeforcehealthprotectionandsurveillancerequirementsforallserviceArmyForceHealthProtection:Past,Present,andFutureE.WayneCombs,PhD,RN ABSTRACTFollowingthe1990-1991PersianGulfWar,manyservicemembersreportedhealthproblemsandbelievedtheseproblemswereassociatedwiththeirmilitaryserviceinthePersianGulf.Apaucityofhealthanddeploymentdataseverelylimitedtheabilitytoinvestigatethenatureandcausesoftheseillnesses.Basedonthefindingsfroma2002study,theGovernmentAccountingOfficerecommendedthattheSecretaryofDefensedirecttheAssistantSecretaryofDefenseforHealthAffairstoestablishaneffectivequalityassuranceprogramthatwouldhelpensurethatthemilitaryservicescomplywiththeforcehealthprotectionandsurveillancerequirementsforallservicemembers.InNovember2003,TheSurgeonGeneraloftheArmytaskedtheUSArmyCenterforHealthPromotionandPreventiveMedicine(USACHPPM)withthedevelopmentofaDeploymentHealthQualityAssuranceProgramfortheArmy.Since2003,ateamfromUSACHPPMhasvisitedapproximatelyoneArmyinstallationperquarter.Overtime,therehasbeenremarkableimprovementnotedinArmydeploymenthealthmetricsandpractices.

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82https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1members.TheDoDconcurredwiththisrecommendation.InNovember2003,TheSurgeonGeneraloftheArmytaskedtheUSArmyCenterforHealthPromotionandPreventiveMedicine(USACHPPM)withthedevelopmentofaqualityassuranceprogramfordeploymenthealth.TheArmyDeploymentHealthQualityAssurance(DHQA)Programwasdesignedtoprovideacapacityforon-siterecordreviewsaswellasasystemforaccountability(compliancewithstandardsandpubliclaw),qualityassurance,andreporting.Latein2003,USACHPPMsent2teamstoconductthefirstArmydeploymenthealthqualityassurancesitevisitsatFortStewart,FortDrum,FortLewis,FortHood,andFortMcCoy.Thevisitsconsistedofreviewsofoutpatientrecords,discussionswithmedicalstaffandmedicalsupportstaff,andvisitstodeploymentprocessingcenters.Duringthesefirstvisits,theteamsfoundagenerallackofknowledgeamongmedicalstaffandmedicalsupportstaffregardingdeploymenthealthpoliciesandrequirementsfordeployingSoldiers.Atthattime,thedeploymenthealthassessmentformswerecompletedbyhand,intriplicate,andthecopieswereforwardedtotheArmyMedicalSurveillanceActivity(AMSA).Oncereceived,theformswerescannedintoacentralizedelectronicdatabase.InJanuary2004,TheAssistantSecretaryofDefenseforHealthAffairsissuedHAPolicy04-001,3whichoutlinedspecificguidancefortheDoDDeploymentHealthQualityAssuranceProgram.ThemajorrequirementsofthispolicyincludedReportsoncentralizedpre-andpostdeploymenthealthassessmentsReportsonservice-specificdeploymenthealthqualityassuranceprogramsVisitstomilitaryinstallationstoassessdeploy-menthealthcomplianceandeffectivenessMajorfindingsandrecommendationssummarizedinanannualreportandcoordinatedthroughtheForceHealthProtectionCouncilPROGRESSSINCE2003Chapter7ofTheDepartmentoftheArmyPersonnelPolicyGuidance(PPG)4andDepartmentofDefenseInstruction6490.035serveasreferencesforcompli-ancestandards,metrics,andreportingrequirementsforArmyDHQAactivities.ThePPGisupdatedfrequentlyandisreviewedroutinelyforthelatestguidance.CurrentrequirementsoftheArmyDHQAprograminclude,butarenotlimitedtoDeploymenthealthassessmentsApredeploymenthealthassessment(DDForm2795)mustbecompletedforallSoldiersandDepartmentoftheArmy(DA)civiliansbeforeamajordeployment,asprescribedbyDoDandDApolicy,andarchivedelectronicallyattheArmedForcesHealthSurveillanceCenter(AFHSC)(formerlyAMSA).TherequiredmethodforcompletingandforwardingdeploymenthealthformsistheArmyMedicalDepartmentMedicalProtectionSystem(MEDPROS).Apostdeploymenthealthassessment(DDForm2796)mustbecompletedforallSoldiersandDAciviliansuponredeploymentasprescribedbyDoDandDApolicy,andarchivedelectronicallyatAFHSC.Apostdeploymenthealthreassessment(DDForm2900)mustbecompletedforallSoldiersandDAciviliansuponredeploymentasprescribedbyDoDandDApolicyandarchivedelectronicallyatAFHSC.Deploymentserumspecimens.ApredeploymentserumspecimenmustbedrawnforallSoldiersandDAciviliansasprescribedbyDoDandDApolicyandforwardedtoAFHSCforstorageintheDoDSerumRepository(DoDSR).Similarly,apostdeploymentserumspecimenmustbedrawnforallSoldiersandDAciviliansasprescribedbyDoDandDApolicyandforwardedtoAFHSCforstorageintheDoDSR.Immunizations.ArecordofeachimmunizationrequiredfordeploymentwillbedocumentedusingMEDPROS.Immunizationrequirementsvarybydeploymentdestination(forspecificguidance,seeArmyRegulation40-5626andthePPG4).Screeningtests.Arecordofpredeploymenttestingfortuberculosisinfectionandhumanimmunodeficiencyvirusinfection,performedasprescribedbyDoDandDApolicy,willberecordedArmyForceHealthProtection:Past,Present,andFuture

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AprilJune200983THEARMYMEDICALDEPARTMENTJOURNALusingMEDPROS.Arecordoftestingfordeployment-relatedtuberculosisinfection,asprescribedbyDoDandDApolicy,willalsoberecordedusingMEDPROS.Deploymenthealthcare.Healthcareprovidedduringdeploymentmustbedocumentedeitherelectronically,whereavailable,oronappropriateforms(eg,DDForm2766andSF600).OthermetricsasrequiredKeyelementsoftheArmyDHQAprogram:Periodicstatusreportsoncentralizeddataandserumspecimens.AFHSCprovidesreportsasrequiredondeploymenthealthassessmentdatatotheForceHealthProtectionQualityAssurancecoordinatorattheOfficeoftheDeputyAssistantSecretaryofDefenseforForceHealthProtectionandReadiness(DASD/FHP&R).Siteassistancevisitstoassessdeploymenthealthprograms.Onsiteassistancevisitscomplementthecorporate-levelperiodicreports.Sitevisitsalsoprovidetheopportunitytoobtainanoperationalperspectiveonthedeploymenthealthprogram,identifythemostefficientandeffectivepractices,andhighlightqualityassuranceandprocessimprovementactivities.Thetiming,siteselection,andscopeofthesitevisitsaredeterminedbyneedandcurrentissues.Visitsaredesignedtomaximizeutilizationofstaffresourceswhileminimizinginterruptionofinstallationactivities.Since2003,ateamfromUSACHPPMhasvisitedapproximatelyoneArmyinstallationperquarter,includingonevisitperyearwithateamfromDASD/FHP&R.Thesevisitsfocusprimarilyonforceprojec-tionsitesandhaveincluded,amongothers,FortBraggandFortBliss,aswellasreturnvisitstoFortDrum,FortMcCoy,andFortLewis.USACHPPMalsovisitedtheUSArmyCorpofEngineersHeadquartersinWinchester,VA,attheirrequest,toprovideguidanceandrecommendationsfordeployingDAcivilianengineers.USACHPPM,withassistancefromAFHSC,providesallrequiredreportstoDASD/FHP&RontheArmysdeploymenthealthqualityassuranceprogram.Overtime,therehasbeenremarkableimprovementnotedindeploymenthealthmetricsandpractices.Electroniccompletionandcaptureofdeploymentrelatedhealthforms,archivingdeploymenthealthrelatedformsanddatainthecentralizeddatabaseatAFHSC,andtheuseofsystemslikeMEDPROStodocumentandmonitordeploymenthealthrelatedrequirementshaveallimproveddramatically.MEDPROSwasdevelopedbytheArmyMedicalDepartmenttotrackallimmunizations,medicalreadiness,anddeploymentdataforallactivedutyandreservecomponentSoldiersoftheArmy,aswellasDAcivilians.Itisapowerfultoolallowingthechainofcommandtodeterminethemedicalanddentalread-inessofindividuals,units,andtaskforces.Command-ersandleadersatvariouslevelsareresponsiblefortheuseandimplementationofMEDPROStomonitortheirunitsand/orindividualreadinessstatus.ComprehensivemedicalreadinessdatainMEDPROSincludesallmedicalanddentalreadinessrequirements.Includedareimmunizations,permanentphysicalprofiles,eyeglasses,bloodtype,medicalwarningtags,medications,pregnancyscreening,DNA,HIV,anddentalstatus.DeploymenthealthassessmentformscannowbecompletedelectronicallyusingtheMEDPROSlinkintheMyMedicaltabontheArmyKnowledgeOnlinewebsite.TheseformsareautomaticallyforwardedelectronicallytoAFHSCtobearchivedinthecentraldatabase.FUTUREDIRECTIONSDepartmentofDefenseInstruction6200.057imple-mentspolicy,assignsresponsibilities,andprescribesproceduresforestablishingacomprehensiveDoDForceHealthProtectionQualityAssurance(FHPQA)Program;andexpandsdeploymenthealthqualityassuranceactivitiesbyapplyingFHPQAtokeyelementsthroughouttheentireperiodofanindividualsmilitaryservice.TheDoDFHPQAProgramisdesignedtoensurethatthehealthofservicemembers,aswellasapplicableDoDcivilianandcontractorpersonnel,iseffectivelymonitored,protected,sustained,andimprovedacrossthefullrangeofmilitaryactivitiesandoperations.FHPQAisfocusedon:Thepromotionandsustainmentofahealthyandfitforce.

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84https://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1Thepreventionofillnessandinjuries,andprotectionoftheforcefromhealththreats.Theprovisionofmedicalandrehabilitativecaretothesickandinjured.CONCLUSIONTheArmyremainscommittedtoprovidingqualityhealthcareandmaximumprotectiontoitsSoldiers,regardlessofgeographiclocationandcircumstances.ThenewForceHealthProtectionQualityAssuranceProgramisaforcemultiplier,designedtoprovidenotonlyasystemforaccountability(compliancewithstandards),butalsoasystemtoassurequalityandcontinuousimprovementinthecareprovidedtoourSoldiersandDAciviliansthroughouttheircareers.REFERENCES 1.PubL.No.105-85,111Stat1629.2.USGeneralAccountingOffice.DefenseHealthCare:QualityAssuranceProcessNeededtoImproveForceHealthProtectionandSurveillance.Washington,DC:USGeneralAccountingOffice;September19,2003,ReportGAO03-1041.Availableat:http://www.gao.gov/new.items/d031041.pdf.AccessedApril27,2009.3.HAPolicy04-001:PolicyforDepartmentofDefenseDeploymentHealthQualityAssuranceProgram.Washington,DC;AssistantSecretaryofDefenseforHealthAffairs:January9,2004.Availableat:http://fhp.osd.mil/pdfs/ha_memo_dep_health_quality_assure_prog.pdf.AccessedApril27,2009.4.DepartmentoftheArmyPersonnelPolicyGuidanceforContingencyOperationsinSupportofGWOT.Washington,DC.USDeptoftheArmy;February13,2008.[updatedApril13,2009]Availableat:http://www.armyg1.army.mil/militarypersonnel/PPG/PPG.AccessedNovember1,2008.5.DepartmentofDefenseInstruction6490.03:DeploymentHealth.Washington,DC:USDeptofDefense;August11,2006.6.ArmyRegulation40-562:ImmunizationsandChemoprophylaxis.Washington,DC:USDeptoftheArmy;September26,2006.7.DepartmentofDefenseInstruction6200.05:ForceHealthProtectionQualityAssuranceProgram.Washington,DC:USDeptofDefense;February16,2007.AUTHOR DrCombsisaCommunityHealthNurseattheUSArmyCenterforHealthPromotionandPreventiveMedicine,AberdeenProvingGrounds,Maryland.ArmyForceHealthProtection:Past,Present,andFuture

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SUBMISSIONOFMANUSCRIPTSTOTHEARMYMEDICALDEPARTMENTJOURNALTheUnitedStatesArmyMedicalDepartmentJournalispublishedquarterlytoexpandknowledgeofdomesticandinternationalmilitarymedicalissuesandtechnologicaladvances;promotecollaborativepartnershipsamongtheServices,components,Corps,andspecialties;conveyclinicalandhealthservicesupportinformation;andprovideaprofessional,highquality,peerreviewedprintmediumtoencouragedialogueconcerninghealthcareissuesandinitiatives.REVIEWPOLICYAllmanuscriptswillbereviewedbytheAMEDDJournalsEditorialReviewBoardand,ifrequired,forwardedtotheappropriatesubjectmatterexpertforfurtherreviewandassessment.IDENTIFICATIONOFPOTENTIALCONFLICTSOFINTEREST1.Relatedtoindividualauthorscommitments:Eachauthorisresponsibleforthefulldisclosureofallfinancialandpersonalrelationshipsthatmightbiastheworkorinformationpresentedinthemanuscript.Topreventambiguity,authorsmuststateexplicitlywhetherpotentialconflictsdoordonotexist.Authorsshoulddosointhemanuscriptonaconflict-of-interestnotificationsectiononthetitlepage,providingadditionaldetail,ifnecessary,inacoverletterthataccompaniesthemanuscript.2.Assistance:AuthorsshouldidentifyIndividualswhoprovidewritingorotherassistanceanddisclosethefundingsourceforthisassistance,ifany.3.Investigators:Potentialconflictsmustbedisclosedtostudyparticipants.Authorsmustclearlystatewhethertheyhavedonesointhemanuscript.4.Relatedtoprojectsupport:Authorsshoulddescribetheroleofthestudysponsor,ifany,instudydesign;collection,analysis,andinterpretationofdata;writingthereport;andthedecisiontosubmitthereportforpublication.Ifthesupportingsourcehadnosuchinvolvement,theauthorsshouldsostate.PROTECTIONOFHUMANSUBJECTSANDANIMALSINRESEARCHWhenreportingexperimentsonhumansubjects,authorsmustindicatewhethertheproceduresfollowedwereinaccordancewiththeethicalstandardsoftheresponsiblecommitteeonhumanexperimentation(institutionalandnational)andwiththeHelsinkiDeclarationof1975,asrevisedin2000.IfdoubtexistswhethertheresearchwasconductedinaccordancewiththeHelsinkiDeclaration,theauthorsmustexplaintherationalefortheirapproachanddemonstratethattheinstitutionalreviewbodyexplicitlyapprovedthedoubtfulaspectsofthestudy.Whenreportingexperimentsonanimals,authorsshouldindicatewhethertheinstitutionalandnationalguideforthecareanduseoflaboratoryanimalswasfollowed.GUIDELINESFORMANUSCRIPTSUBMISSIONS1.Articlesshouldbesubmittedindigitalformat,preferablyanMSWorddocument,eitherasanemailattachment(withillustrations,etc),orbymailonCDorfloppydiskaccompaniedbyoneprintedcopyofthemanuscript.Ideally,amanuscriptshouldbenolongerthan24double-spacedpages.However,exceptionswillalwaysbeconsideredonacase-by-casebasis.Ingeneral,4double-spacedMSWordpagesproduceasinglepageof2columntextintheAMEDDJournalproductionformat.2.TheAmericanMedicalAssociationManualofStylegovernsformattinginthepreparationoftextandreferences.Allarticlesshouldconformtothoseguidelinesascloselyaspossible.Abbreviations/acronymsshouldbelimitedasmuchaspossible.Inclusionofalistofarticleacronymsandabbreviationscanbeveryhelpfulinthereviewprocessandisstronglyencouraged.3.Acompletelistofreferencescitedinthearticlemust beprovidedwiththemanuscript.ThefollowingisasynopsisoftheAmericanMedicalAssociationreferenceformat:Referencecitationsofpublishedarticlesmustincludetheauthorssurnamesandinitials,articletitle,publicationtitle,yearofpublication,volume,andpagenumbers.Referencecitationsofbooksmustincludetheauthorssurnamesandinitials,booktitle,volumeand/oreditionifappropriate,placeofpublication,publisher,yearofcopyright,andspecificpagenumbersifcited.Referencecitationsforpresentations,unpublishedpapers,conferences,symposia,etc,mustincludeasmuchidentifyinginformationaspossible(location,dates,presenters,sponsors,titles).4.Eithercolororblackandwhitephotographsmaybesubmittedwiththemanuscript.Colorproducesthebestprintreproductionquality,butpleaseavoidexcessiveuseofmultiplecolorsandshading.Digitalgraphicformats(JPG,GIF,BMP)andMSWordphotofilesarepreferred.Printsofphotographsareacceptable.PleasedonotsendphotosembeddedinPowerPoint.Imagessubmittedonslides,negatives,orcopiesofX-rayfilmwillnotbepublished.Forclarity,pleasemarkthetopofeachphotographicprintontheback.Tapecaptionstothebackofphotosorsubmitthemonaseparatesheet.Ensurecaptionsandphotosareindexedtoeachother.Clearlyindicatethedesiredpositionofeachphotowithinthemanuscript.5.Theauthorsnames,ranksoracademic/certificationcredentials,titlesorpositions,currentunitofassignment,andcontactinformationmust beincludedonthetitlepageofthemanuscript.6.Submitmanuscriptsto:EDITOR,AMEDDJOURNALATTN:MCCSDT2423FSH-HOODSTFORTSAMHOUSTON,TX78234-5078 DSN471-6301Comm210-221-6301Email:amedd.journal@amedd.army.mil