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Health is an essential element of militaryreadiness, and prevention is and alwayswill be the best way to health. Preventingdiseases and conditions that threaten thehealth of the warfighter is moreoperationally sound since it maximizesavailable manpower. It is more beneficialto the Soldier, from a well-beingperspective, to stay healthy and avoid allthat the hospital has to offer, such as longwaiting room times, diagnostics, andtreatment. When considering healthcarecosts, both short-term and long-term,prevention again wins out. In an idealworld, the military would be able tominimize disease and nonbattle injuries(DNBI), through prevention and healthpromotion, while optimizing therestorative medicine resources andapplying them toward those diseases andconditions that are not readilypreventable, especially combat injuries.This article takes a brief look at military preventivemedicine, its background, its current status, and somefuture considerations for its use in improving thehealth of our warfighters.

Currently, in our nation, approximately 97% of ourmedical costs are focused on the “restorative” aspectof health care or “fixing” our medical problems. Theother 3% goes to governmental public healthexpenditures.1 Military health expenses are similar.Over the past century, applying the appropriate levelsof proactive and responsive approaches to health careseems to have worked well. Figure 1 shows thedramatic decrease in both DNBI and battle injuries(BI), using hospitalization rates, during various warsand conflicts from World War II, through OperationsEnduring Freedom and Iraqi Freedom (OEF/OIF),including Operations Desert Shield and Desert Storm(ODS/S). The rates for Operations Enduring Freedomand Iraqi Freedom are approximately one-tenth that of

World War II and the Korean Conflict. However, theproportion of hospitalizations for DNBI compared toBI has not changed significantly and is actually almostthe same or higher now than during the conflicts inKorea and Vietnam, as shown in Figure 2. In otherwords, while Army medicine has dramaticallyimproved overall, the Army is still forced to dedicate atremendous amount of resources to DNBI. The Armymust do a better job of prevention, ultimately requiringa larger investment than the current 3%.

Leadership clearly recognizes the value of prevention.The recent Department of Defense (DoD) QuadrennialDefense Review Report (6 February 2006), states: “It isthe Department’s goal to have a lifetime relationshipwith the entire Department of Defense family whichmaximizes prevention, wellness and personal choices,and responsibility.”3 The DoD Force HealthProtection Capstone Document adds: “Medical assetsmust be configured to support health promotion, health

Prevention is the Best Way to HealthBG Michael B. Cates, VC, USA

BG Cates is the Commanding General, US Army Center for Health Promotion and Preventive Medicine,Aberdeen Proving Ground, Maryland, and the Functional Proponent, US Army Preventive Medicine.

WWII Korea Vietnam ODS/S OEF/OIFFigure 1. Decrease in DNBI and BI during US conflicts.2,*

*Statistics for OEF/OIF were obtained from the US TransportationCommand Regulating, Command and Control Evacuation System(TRAC2ES)

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hazard assessment, implementation ofcountermeasures and the provision ofessential care of the injured and ill intheater and their rapid evacuation todefinitive medical care outside of theaterof operations. Force Health Protectionsupports service members with a fullspectrum of health services that (1)emphasize fitness, preparedness, andpreventive medicine; (2) improve themonitoring and surveillance of forces inmilitary operations; (3) enhance Soldiers’and Commanders’ awareness of healththreats before they can affect the force;and (4) support the healthcare needs ofthe fighting forces and their familiesacross the continuum of medicalservices.”4 DoD Directive 6200.4 directsall members of the Active Componentsand the selected Reserve Components tobe physically and mentally fit.Commanders, supervisors, individualservice members, and our health systemhave been given the responsibility to“promote, improve, conserve, and restore the physicaland mental well being of members of the Army Forcesacross the full range of military activities andoperations.”5 Specific verbiage regarding preventionincludes its requirements for all service components to“promote and sustain a healthy and fit force, preventinjury and illness, [and] protect the force from healthhazards.”5

The Army’s “bible” for these preventive measures isArmy Regulation 40-5, in which preventive medicineis described as “the anticipation, prediction,identification, surveillance, evaluation, prevention, andcontrol of diseases and injuries.”6 The regulation alsodelineates 9 major functional areas of support tomilitary personnel and their families, in garrison anddeployed settings, throughout the world. What is keyto this publication is that responsibilities for preventivemedicine are given to a wide variety of people, from 3different assistant secretaries of the Army, to 4primary deputy chiefs of staff, The Surgeon General,major commands, regional medical commands,military treatment facilities, veterinarians, dentists,commanders at all levels, installation commanders,leaders, supervisors, and individuals.6 Dr. CraigLlewellyn, in the Textbook of Military Medicine…,7

talks of the far-reaching scope of preventive medicinethroughout the entire military force. He says the

“promotion and preservation of health and theprevention of illness and injury can rarely beaccomplished solely through medical channels.”

What we call preventive medicine encompasses a verybroad spectrum of identifying, assessing, andmitigating health risks to our personnel. Because theArmy deploys globally, those health risks are spreadout geographically as well as culturally. In today’sworld of easy, quick transportation, one country’sendemic diseases can become an outbreak in anothercountry’s populace almost overnight. Public health inone country clearly influences public health in manyother countries. Laurie Garrett, in Betrayal of Trust,the Collapse of Global Public Health, agrees, saying“Public Health needs to be—must be—globalprevention.”8 With the stresses and operational tempoof our military deployments, it is imperative torecognize the potential for exposures to unusualdiseases and environmental conditions. Also, lifestyle,nutrition, vehicles, weapons and equipment, anddisease vectors all have potential impact on theSoldier’s health. The proactive approach towardminimizing the negative effects of these health impactsis critical, not only to the individual Soldiers but alsoto their units, our nation, and our nation’s healthcaresystem. There are multiple examples of preventivemedicine successes and failures throughout our

Figure 2. Proportion of hospitalizations for DNBI and BI from WWII toOperations Enduring Freedom and Iraqi Freedom.2,*

*Statistics for OEF/OIF were obtained from the US TransportationCommand Regulating, Command and Control Evacuation System(TRAC2ES)

WWII Korea Vietnam ODS/S OEF/OIF

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military history. The Textbook of Military Medicinenames many successes, including yellow fever in Cubaand skin disease in Vietnam. Failures include Britishdealings with typhoid fever in the Second Boer Warand with malaria in World War I, and the USinvolvement with heat and cold injuries in World WarII. It should be noted that all were heavily influencedby command emphasis on prevention, or the lackthereof.7

In today’s world, there are emerging or reemergingdiseases, such as tuberculosis, malaria, Acinetobacterinfections, leishmaniasis, and E.coli O157:H7infections; zoonotic diseases associated with theanimals of the various regions; chronic diseases, manyof which are related to nutrition and other lifestylechoices, such as heart disease, lung cancer, diabetes,etc; and illnesses related to exposure to toxic industrialchemicals, toxic industrial materials, and pesticides.Our Soldiers deploy to locations with threateningenvironmental conditions, where the soil, air, water,and food, in many cases, pose far different threats thanmost areas of the US. Our military personnel useweaponry, vehicles, and other equipment that presentinherent risks to hearing, vision, and other organfunctions. Occupational and environmental exposuresgo beyond just the deployed setting; the garrisons, andtheir buildings, roads, property, and waterways can bedangerous as well. Natural and man-made disasters onour own soil and in other nations have presented theirown form of health threats and, accordingly, the needfor public health-related interventions.

The Army Medical Department (AMEDD) preventivemedicine team encompasses a wide range of expertisein a myriad of locations, with the ability and flexibilityto provide local support while maintaining the abilityto project wherever and whenever the need arises. TheProponency Office for Preventive Medicine isresponsible for policy making and oversight in theOffice of The Surgeon General. The US Army Centerfor Health Promotion and Preventive Medicineprovides the operational foundation for Army militarypublic health, preventive medicine and healthpromotion. The Center is globally positioned, withcapabilities which are easily projected when needed.Smaller but fully functional capabilities are found withindividual officers and enlisted Soldiers assigned tobrigade combat teams, preventive medicinedetachments assigned to medical brigades and medicalcommands, the two area medical laboratories, and the

preventive medicine departments found at the Armymilitary treatment facilities. From local installationsupport (such as industrial hygiene, immunizations andoccupational health services) to the projected supportprovided by deployed individuals, detachments, andSpecial Medical Augmentation Response Teams–Preventive Medicine to Iraq and Afghanistan, theCenter’s entire team does a lot with relatively fewresources. After Hurricane Katrina hit the southern UScoast, military preventive medicine personnel weredeployed quickly. When the earthquake hit Pakistan in2005 and the US Army sent medical personnel to help,preventive medicine experts were an important andvisible part of the humanitarian assistance operation.When there were potential outbreaks of hepatitis C inEl Paso, meningococcal disease in Europe, ortuberculosis in Afghanistan, preventive medicineexperts were on the scene to determine the cause of thedisease and the potential health threats to personnel.Health promotion initiatives continue to be an integralpart of preventive medicine to drive down injuries,tobacco use, and alcohol abuse while enhancingnutrition and overall fitness. We are part of thecontinuing surveillance of occupational andenvironmental health threats to our military personnel,both in deployed and garrison settings, providingbroad-ranging, very effective, globally committedpreventive medicine capabilities, with constrainedresources.

At the national level, there has been a renewed focuson health promotion and prevention, as evidenced bythe Healthy People 2010 initiative by the Departmentof Health and Human Services. This initiative has setout to “identify the most significant preventable threatsto our health and to establish national goals to reducethose threats.” Certain statistics justify this effort:Heart disease and stroke account for 40% of all USdeaths each year, 64% of US adults are obese oroverweight, and 31 million have asthma.9 Diabetesnow affects 20.8 million Americans, 7% of ourpopulation and a 6.3% increase since 2002.10 Like themilitary, the US as a whole spends an inordinateamount on health care—15% of the gross domesticproduct in 2003, the highest of any member country ofthe Organisation for Economic Cooperation andDevelopment (OECD). The US spends over $5,600per capita on total health care, more than twice theOECD average; despite that, there are indications weare no healthier than other developed countries.11

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As the Army moves forward, our deployments arelonger and more dispersed throughout the world.Therefore, environmental exposures will increase indiversity as well as intensity. The AMEDD preventivemedicine teams must keep up their vigilance ofmedical and environmental surveillance,communicating quickly and effectively whennecessary to correct deficiencies and have a positiveimpact on the health of individual Soldiers or units.Health promotion efforts must continue to beaggressive. Similar to our civilian counterparts, themilitary has to contend with many of the heath risksassociated with lifestyle choices, such as tobacco use,poor nutrition, and alcohol abuse. Among maleSoldiers age 18 to 25, 48% use tobacco. Over 27% ofour military personnel, age 26 to 34, are overweight(with body mass index as the indicator), and over 40%of our Soldiers engage in “binge drinking” (that is, 5or more drinks at one occasion at least once in 30days).12 These statistics present short-term and long-term implications, impacting not only individuals butalso entire units, our military as a whole, and ourmilitary healthcare system. In the future, medicaltechnology will help us do a better job of identifying,assessing, and mitigating health risks, and, hopefully,leaders at all levels will become actively engaged inpromoting better prevention and the overall medicalreadiness of their Soldiers.

Just as preventive maintenance is a crucial aspect ofthe logistics community, drastically improving theavailability, workability, and durability of ourequipment and vehicles, preventive medicine is crucialto our most important resource—our people. Fixingsomething much more inefficient than sustaining,maintaining and improving it; this directly applies toour health. Maintaining and even improving aSoldier’s health is a much more appropriate, wiser useof resources than waiting until that Soldier becomessick or is hospitalized. The more we prevent diseasesand improve poor environmental conditions, the moreresources will be available to apply to those things wecannot prevent. Prevention efforts have been and stillare effective, invaluable pieces of the medical healthsystem. And while there is continuing and growingemphasis on proactive approaches to health in today’ssociety and military, we must all strive towardtranslating that into real, even greater long-terminvestments in the future health of our personnel.

REFERENCES

1. Honore PA, Amy BW. Public health finance:advancing a field of study through public healthsystems research. J Public Health Manage Pract.2005;11(6):571-573.

2. Jones BH, Perotta DM, Canham-Chervak ML, NeeMA, Brundage JF. Injuries in the military: a reviewand commentary focused on prevention. Am J PrevMed. 2000;18(3 Suppl):71-84.

3. Quadrennial Defense Review Report. Washington,DC: US Dept of Defense. February 6, 2006.Available at: http://www.defenselink.mil/pubs/pdfs/QDR20060203.pdf.

4. Force Health Protection Capstone Document. FallsChurch, VA: US Dept of Defense, Office of theAssistant Secretary of Defense (Health Affairs),TRICARE Management Activity; 2004. Available at:http://www.ha.osd.mil/forcehealth/library/main.html.

5. DoD Directive 6200.4: Force Health Protection(FHP). Washington, DC: US Dept of Defense;October 9, 1994.

6. Army Regulation 40-5: Preventive Medicine.Washington, DC: US Dept of the Army; 22 July2005.

7. Textbook of Military Medicine: Military PreventiveMedicine, Mobilization and Deployment.Washington, DC: US Dept of the Army, Office ofThe Surgeon General, Borden Institute; 2003.

8. Garrett L. Betrayal of Trust: The Collapse of GlobalPublic Health. 1st ed. New York, NY: Hyperion;2000.

9. Healthy People 2010: The Cornerstone forPrevention. Washington, DC: US Dept of Health andHuman Services, Office of Disease Prevention andHealth Promotion; 2005. Available at: http://www.healthypeople.gov/document.

10. National Diabetes Fact Sheet. Washington, DC: USDept of Health and Human Services, Centers forDisease Control and Prevention; 2005. Available athttp://www.cdc.gov/Diabetes/pubs/estimates05.htm.

11. OECD Health Data 2005: How Does the UnitedStates Compare. Organisation for EconomicCooperation and Development; June 2005. Availablea t h t t p : / / w w w . o e c d . o r g /dataoecd/15/23/34970246.pdf.

12. Bray R, Hourani L, Rae K, et al. 2002 DoD Survey ofHealth Related Behavior Among Military Personnel:Final Report. Research Triangle Park, NC: US Deptof Defense, Research Triangle Institute; 2003.