preventive medicine considerations in planning

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Preventive Medicine Considerations in Planning Multiservice and Multinational Operations

Chapter 12

PREVENTIVE MEDICINE CONSIDERATIONSIN PLANNING MULTISERVICE ANDMULTINATIONAL OPERATIONS

INTRODUCTION

OFFICE OF THE ASSISTANT SECRETARY OF DEFENSE (HEALTH AFFAIRS)

US ARMY FIELD PREVENTIVE MEDICINE

US NAVY AND US MARINE CORPS FIELD PREVENTIVE MEDICINE

US AIR FORCE FIELD PREVENTIVE MEDICINE

PREVENTIVE MEDICINE IN THE US COAST GUARD AND OTHER FEDERALAGENCIES

THE RESERVE COMPONENTS

THE PREVENTIVE MEDICINE MISSION IN SPECIAL OPERATIONS

THE PREVENTIVE MEDICINE MISSION IN CIVIL AFFAIRS

MANAGING PREVENTIVE MEDICINE ASSETS IN THE FIELD

CONCLUSION

LAUREL BROADHURST, MD, MPHDAVID ARDAY, MD, MPHKENT BRADLEY, MD, MPHRICHARD S. BROADHURST, MD, MPHHOPPERUS BUMA, MDBRIAN J. COMMONS, MSPH, MSDAVID COWAN, PHD, MPHSTEPHEN CRAIG, DO, MTM&H

ROBERT LANDRY, MSRELFORD E. PATTERSON, MD, MPHRICHARD W. SMERZ, MD, MPHHENRY P. STIKES, MD, MPHRICHARD THOMAS, MD, MPHRICHARD WILLIAMS, MDJAMES WRIGHT, MD

Military Preventive Medicine: Mobilization and Deployment, Volume 1

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L. Broadhurst, Staff Physician, Weaverville Family Medicine Associates, Weaverville, NC; Medical Advisor, North Carolina Departmentof Motor Vehicles, Raleigh, NC; formerly, Major, Medical Corps, US Army; Epidemiology Consultant, 7th MEDCOM and 10th MEDLAB,APO AE 09180

D. Arday, Medical Epidemiologist, Office of Clinical Standards and Quality, Health Care Financing Administration, 7500 SecurityBlvd., Baltimore, MD 21244; formerly, Assistant to Chief, Clinical Medicine and Wellness Programs Division, Health and SafetyDirectorate (G-WKH); US Coast Guard, Washington, DC 20593

K. Bradley, Lieutenant Colonel, Medical Corps, US Army; 7th Infantry Division Surgeon, Fort Carson, CO 80913

R. S. Broadhurst, Colonel, Medical Corps, North Carolina Army Guard, Commander, Company C, 161st Area Support MedicalBattalion; formerly, Lieutenant Colonel, Medical Corps, US Army; Chief, Preventive Medicine and Medical Intelligence, US Army Spe-cial Operations Command, Fort Bragg, NC 28307

APCCH. Buma, Commander, Medical Branch, Royal Netherlands Army; Head of Naval Medical Training; P.O. Box 1010 (MCP24D), 1201 DA Hilversum, The Netherlands

B. J. Commons, Colonel, Medical Service, US Army; US Army Center for Health Promotion and Prevention Medicine, Europe;CMR 402; APO AP 09180

D. N. Cowan; PhD, MPH, Lieutenant Colonel, Medical Service, USAR; Special Projects Officer, Division of Preventive Medicine,Walter Reed Army Institute of Research, Silver Spring, MD 20910-7500

S. Craig, Colonel, Medical Corps, US Army; Chief, Preventive Medicine, Keller Army Community Hospital, West Point, NY 10996;formerly, Surgeon, 96th Civil Affairs Battalion, Fort Bragg, North Carolina

R. Landry, Colonel, Medical Service, US Army; HHC, 18th MEDCOM, Unit 15281, APO AP 96205-0054

R. E. Patterson, Colonel, Medical Corps, US Air Force (Retired); formerly, Director, Military Public Health, Clinical Services, Officefor the Assistant Secretary of Defense (Health Affairs); currently, Medical Director, General Motors Corporation Truck Group As-sembly Plant, 2122 Broenig Highway, Baltimore, MD 21224

R. W. Smerz, Colonel, US Army (Retired); formerly, Surgeon, USSOCOM, 7701 Tampa Point Boulevard, MacDill Air Force Base, FL33608-6001

H. P. Stikes, Colonel, Medical Corps, US Army; Commander, Lawrence Joel US Army Health Clinic, 1701 Hardee Avenue, SW; Ft.McPherson, GA 30330-1062; formerly, US Preventive Medicine Staff Officer, US Forces Command

R. Thomas, Captain, Medical Corps, US Navy; Naval Environmental Health Center, 2510 Walmer Ave., Norfolk, VA 23513-2617

R. Williams, Captain, Medical Corps, US Navy; Chief Clinical Consultant, Armed Forces Medical Intelligence Center, Fort Detrick,Bldg. 1607, Frederick, MD 21702-7581

J. Wright; Colonel, Medical Corps, US Air Force (Retired); formerly, AL/AOE, 2601 West Road, Suite 2, Brooks Air Force Base,Texas 78235-5241; currently, Occupational Medicine Physician, Concentra Medical Centers, 400 East Quincy, San Antonio, TX 78215

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In the US military of the 1990s, large unit opera-tions have most often been joint operations, that is,operations composed of personnel from two ormore of the services. This is not a new concept—many operations during World War II were joint,such as the amphibious invasions in the Pacific the-ater. Overall, military campaigns are won by occu-pying territory, which requires land forces of theArmy or Marine Corps. But the Army and the Ma-rine Corps cannot reach the area of operations with-out the Air Force, and the Navy and Marine Corpsemphasis on mobility and flexibility means thatthey may require extensive Army logistics supportonce they have depleted their own combat servicesupport. The services of the US military are inter-dependent for mission success.

Today’s military units with significant preven-tive medicine (PM) assets, which generally resideat the division level and above, must interact withpersonnel from other services while sharing PM andother support assets. Additionally, Preventive Medi-cine Officers (PMOs) are placed in advisory posi-tions to the Surgeons of joint forces, unified com-mands, and combined commands and so must befamiliar with joint PM considerations. (Joint forcescontain elements of at least two US military services;unified commands contain significant componentsof more than one US military service; and combinedcommands contain forces from more than one na-tion.) US military operations are conducted withsuch shared resources as a Joint Task Force (JTF)Surgeon, a Joint Blood Program Office, and a JointMedical Regulating Office. In addition, increasedUS involvement in United Nations operations has

INTRODUCTION

meant that the operational force is likely to be acombined task force, which is sometimes called amultinational force. The PM planner in combinedoperations faces the difficult challenge of develop-ing a comprehensive plan to keep the combinedforce healthy.

Major General Jonathan Letterman, Medical Di-rector of the Army of the Potomac during the Ameri-can Civil War, underscored the essential role of PMin military operations when he said:

The leading idea, which should be constantly keptin view, is to strengthen the hands of the Com-manding General by keeping his army in the mostvigorous health, thus rendering it, in the highestdegree, efficient for enduring fatigue and privation,and for fighting.1(p100)

That timeless wisdom calls on the medical leadershipto employ PM to strengthen the warfighting capabil-ity of the commanding general of any task force,whether individual service, joint, combined, or uni-fied. The essentials for planning and executing PMoperations in joint, unified, and combined operationsinclude knowledge of the policy-making process inthe Office of the Assistant Secretary of Defense (HealthAffairs) and the organization of PM in the Army, Navy,Marine Corps, Air Force, Coast Guard, and Reservecomponents. The PM mission in Civil Affairs andSpecial Operations is also relevant because these twoorganizations are often deployed as parts of joint, uni-fied, or combined operations. Understanding the dif-ferences in structure and capabilities of these organi-zations is necessary to coordinate their efforts and pro-vide effective PM services to all personnel.

OFFICE OF THE ASSISTANT SECRETARY OF DEFENSE HEALTH AFFAIRS

Preventive Medicine and Military PublicHealth Policy

The Assistant Secretary of Defense (HealthAffairs)—the ASD (HA)—is the principal staffassistant and advisor to the Secretary of Defenseand Under Secretary of Defense for Personnel andReadiness for all Department of Defense (DoD)health policies, programs, and activities. Preventivemedicine is a principal component of the DoD’smedical mission to maintain readiness, providemedical services and support to the armed forcesduring military operations, and provide continuingmedical services and support to members of thearmed forces, their dependents, and others entitled

to DoD medical care. Current Joint Health ServiceSupport Strategy demands delivering a healthyforce and preventing and minimizing disease andnonbattle injury (DNBI).

Organizational Structure

Reporting to the ASD (HA) through the Princi-pal Deputy Assistant Secretary are five Deputy As-sistant Secretaries (DASDs); they are responsible forthese functional activities: Clinical Services (CS),Health Budgets and Programs, Health Services Fi-nancing, Health Services Operations and Readiness(HSO&R), and Policy and Planning. The DASD (CS)establishes policies, procedures, and standards that


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govern DoD medical programs, such as quality man-agement programs, human immunodeficiency virusprograms, women’s health issues, graduate medicaleducation, health-related research, PM and publichealth, and all matters involving clinical policy. Whilethe responsibility for formulation of PM and publichealth policy resides primarily with the DASD (CS),policy is routinely coordinated with two other offices.The first is the office of the DASD (HSO&R), which isresponsible for assuring the adequacy of medical re-sources to meet the needs of national emergencies andarmed conflict and for dedicating resources and per-sonnel to implement policies affecting military pub-lic health. The other office with which the DASD (CS)coordinates is that of the Joint Staff’s Deputy Direc-tor for Medical Readiness (J-4 MED) in the office ofthe J-4 (logistics). The Joint Staff performs military stafffunctions, which are discussed later in this chapter,for the Joint Chiefs of Staff (JCS). The J-4 MED pro-vides the vital mechanism to implement PM policiesaffecting deployed forces and to incorporate them intoJCS operations plans and joint doctrine.

The J-4 MED develops the joint force medical pro-tection policy and PM strategies for diseases of op-erational importance, biological warfare, and theeffects of exposure to environmental hazards. The mis-sion of the J-4 MED Office is to plan for comprehen-sive medical readiness to support the national mili-tary strategy, while staying synchronized with therequirements of the Commander in Chief and thecapabilities of the services; it also influences resourceallocation and priority. The Office must coordinatewith the services and defense agencies to determinePM requirements and capabilities. The officer fillingthis position at the J-4 MED also represents the JointStaff on the Joint Preventive Medicine Policy Group,the Armed Forces Epidemiological Board, and theDoD’s Global Surveillance and Response Committee.

Policy Formulation

It is DoD policy to enhance mission readiness, unitperformance, and the health and fitness of individualmilitary servicemembers (including Reserve and Na-tional Guard personnel), beneficiaries, and civilianemployees through comprehensive health promotionand disease prevention programs and to providehealthy environments for workers and visitors. PMpolicy issues may emerge from the office of the ASD(HA), from the services, from legislative mandate, orfrom operational requirements. The process can becomplex, involving interaction among multiple agen-cies within the DoD, including Health Affairs, Gen-eral Counsel, Legislative Affairs, Comptroller, and

Public Affairs. For example, the policy determiningthe use of tick-borne encephalitis vaccine by US forcesduring Operation Joint Endeavor in Bosnia involvedextensive review and coordination among the afore-mentioned DoD offices, the Centers for Disease Con-trol and Prevention, and the Armed Forces Epidemio-logical Board.

The office of the ASD (HA) relies on internal ana-lysts to formulate policy; however, it routinely solic-its external review and consultation from the SurgeonsGeneral, the Armed Forces Epidemiological Board, theArmed Forces Medical Intelligence Center (AFMIC),and civilian public health institutions. PM expertiseis provided through the Surgeons General from theCenter for Health Promotion and Preventive Medi-cine, Aberdeen Proving Ground, Md; the Naval En-vironmental Health Center, Norfolk, Va; and the AirForce’s Institute of Environmental Risk Analysis, SanAntonio, Tex. On occasion, as in the situation involv-ing the health concerns of Persian Gulf War veterans,external institutions such as the National Academyof Sciences may be commissioned to provide consul-tation and recommendations. As policies are formu-lated, they are coordinated by the Surgeons Generalof the various services.

Priority Programs

As the office of the ASD (HA) prepares for the chal-lenges of the 21st century, several PM issues will likelypredominate. Experiences in the aftermath of the Per-sian Gulf War have increased the emphasis beingplaced on comprehensive medical surveillance. Thismedical surveillance will integrate and fully coordi-nate the efforts of the Surgeons General, JCS, and sub-ordinate units before, during, and after deployment.As the nature of modern warfare evolves, participa-tion in low-intensity conflict and humanitarian assis-tance operations will become increasingly important.Prevention and control of DNBI will continue to be ofparamount importance, but surveillance systems mustalso be capable of detecting chronic morbidity thatmight be associated with participation in deploy-ments.

The DoD, which administers the largest managedcare organization in the United States, has begun torecognize the potential benefit of PM approaches tothe assessment of health services. Quality manage-ment review will become increasingly important tostudy the performance and outcomes of key clinicalpreventive services, such as screening tests, routinecounseling, and immunizations, and has been incor-porated into health care benefit plans for active dutyand other DoD enrollees.

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US ARMY FIELD PREVENTIVE MEDICINE

sures are practiced. The team instructs, supervises,assists with, inspects, and reports on field sanitationactivities. Field sanitation teams are required forunits that are company- or battery-sized or larger.3,5

The field sanitation team normally consists ofcompany medics, trained medically as military oc-cupational specialty designation 91As. If these spe-cialists are not available, at least two soldiers in theunit will be picked and trained; at least one mustbe a noncommissioned officer (NCO). They aretrained in the use, maintenance, and care of the fieldsanitation team equipment, such as water purifica-tion kits, food service disinfectant, personal protec-tive equipment, tools needed for spraying insecticide,mouse and rat traps, and rodenticide. The team mem-bers provide unit training in personal protective mea-sures for disease control. They also inspect the unit’sfood service operations, ensure that the unit leadersare supervising the disinfection of the unit’s watersupply, and instruct the troops in methods of indi-vidual water purification. The team members moni-tor the construction of garbage and soakage pits andinspect the arrangements for waste disposal. Thefield sanitation team also monitors the constructionof field latrines and urinals and inspects them regu-larly. They use arthropod and rodent control, andsometimes this includes pesticide spraying.5

Divisional Preventive Medicine Assets

The PM sections of the divisions and armoredcavalry regiments are responsible for assessing themedical threat and determining PM countermea-sures; advising commanders and staffs of PM re-quirements; training, monitoring, and providingtechnical assistance to unit field sanitation teams;monitoring the training of all soldiers in PM mea-sures; and conducting surveys, inspections, andcontrol activities. Divisional PM assets include a PMphysician, an environmental science officer or sani-tary engineer, and PM NCOs and enlisted special-ists. Division PM sections are typically located inthe medical company of the main support battal-ion. Within the armored cavalry regiment, a singlePM NCO is assigned to the medical troop of theregimental support squadron.2

Preventive Medicine Assets at Echelons Abovethe Division Level

Above the division level, direct PM support istypically provided by the PM section of the area

Army field PM is organized and staffed to pro-vide soldiers and commanders with the same PMservices in the field environment as they have ingarrison. These services are critical to soldiers,whether they are engaged in training exercises ordeployed in combat operations. The prevention ofdisease and injury reduces manpower losses, pa-tient loads, and evacuation requirements. Thetimely and effective implementation of appropri-ate PM measures to counter the medical threatserves as a combat multiplier, enhancing unit ef-fectiveness and reducing the individual soldier’sexposure to disease and environmental threats.Command interest and commitment to the PM pro-gram are essential to its success, since the militarypublic health program is a command program andnot actually a medical program.2

The scope of field PM services available in a the-ater of operations includes providing assistance to thecommander in preparing staff estimates by identify-ing the medical threat and recommending appropriatePM countermeasures. PM assets provide oversight forthe health-related aspects of water and ice production,distribution, and consumption; entomological controlmeasures; environmental conditions; and waste dis-posal practices. Another key responsibility is the train-ing and assessment of field sanitation teams.3

Unit-Level Preventive Medicine Assets

PM functions are performed at the soldier and unitlevel across the theater, from the forward line of troopsto the rear areas. Specialized PM personnel are organicto the divisions and armored cavalry regiments, aswell as to medical functional units at echelons abovethe division level. These personnel are trained andready to provide flexible PM assistance within theirareas of concern. But PM support for both trainingand combat operations begins with the individualsoldier and continues up through the unit and higherechelons. Individual- and unit-level PM measures area command responsibility. The individual soldiermust perform basic PM measures, such as maintain-ing physical and mental fitness and guarding againstheat and cold injury, other physical injury, biting in-sects, and diarrhea. Organic medical personnel andthe unit field sanitation team provide assistance.2–4

The field sanitation team advises the unit com-mander on issues essential to reducing DNBI. It alsoensures that appropriate field sanitation facilities areestablished and maintained, effective sanitary andcontrol measures are applied, and effective PM mea-


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support medical battalion (ASMB) or by specializedPM detachments attached to the battalion. The ASMBincludes a PM section identical to that found in thedivisions. The staffing of this section permits it to havean extensive capability for epidemiologic (eg, infec-tious disease) investigations and sanitary engineer-ing support. PM personnel conduct evaluations toidentify actual and potential health hazards, recom-mend corrective measures, and assist in training per-sonnel in disease prevention programs. Support iscoordinated with PM detachments and other unitswithin the ASMB. As PM detachments are normallyattached to an ASMB, the PM section within the ASMBassumes technical supervision of the attached detach-ments to coordinate assignment of specific missions.ASMBs and PM support are normally allocated basedon the anticipated medical threat and the mission.6

PM general support at echelons above the divisionlevel is provided by functional teams on an area ba-sis. On occasion, these teams can be attached to spe-cific units in a direct support role and may be used asfar down the organization chain as the division level.These functional PM teams provide support within atheater of operations in the specialties of epidemiol-ogy, entomology, environmental science, and environ-mental engineering. Teams are allocated based on thenumber of troops supported and the medical threat.These teams depend on other units for logistical sup-port. The two types of teams presently available are(1) the Medical Detachment, Preventive Medicine (En-tomology) and (2) the Medical Detachment, Preven-tive Medicine (Sanitation). The teams are similar instructure and function but differ in their primary em-phasis. They both have an entomologist, an environ-mental science officer or sanitary engineer, and en-listed technicians. Both types of team are capable of

monitoring vector control activities, field sanitation,water treatment and storage, waste disposal, andDNBI control practices within their assigned area andof making appropriate recommendations. Other func-tions they perform include medical data collection,investigations, and environmental sampling. Capabili-ties unique to the entomology team include area andaerial spraying.2

PM consultative capabilities are organic to the medi-cal command and control elements at the corps leveland above. The medical group’s capabilities includeconsultation services and technical advice in PM, en-vironmental health, and sanitary engineering. Themedical brigade provides similar consultation andtechnical services, plus medical entomology and ra-diological health. At the theater level, the medical com-mand is also staffed to provide PM consultation andtechnical services. PM consultative services at all theselevels include assessment of the medical threat, evalu-ation of the PM program, technical advice on medicalaspects of nuclear, biological, chemical, and directed-energy weapons, and staff coordination of PM services.2

An additional theater asset currently available isthe Theater Army Medical Laboratory. This Laboratoryprovides a broader range of laboratory functions thanthose normally found in theater hospitals, to includemicrobiological identification and characterization,biochemical and toxicological analyses, and serologicaltesting for disease diagnosis and prevention. Otherfunctions it provides include food contaminationanalyses, detection and diagnosis of zoonotic diseases,entomological laboratory support, epidemiologicanalyses, and environmental health assessments(Exhibit 12-1). Army PM assets are also found in CivilAffairs and other Special Operations units and arediscussed later in this chapter.

EXHIBIT 12-1THE CAPABILITIES OF THE THEATER AREA MEDICAL LABORATORY

• Provides analytical, investigative, and consultative capabilities to identify nuclear, biological, and chemicalthreat agents and other samples from the area of operations

• Provides analytical, investigative, and consultative capabilities to assist in the identification of occupationalhealth, environmental health hazards, and endemic diseases

• Provides special environmental control and containment to evaluate biomedical specimens for the presenceof highly infectious or hazardous agents of operational concern

• Provides data and data analysis to support medical analyses and operational decisions• Provides medical laboratory analysis to support the diagnosis of zoonotic and significant animal diseases

that impact on military operations• Provides tailorable force projections to support war and operations other than war

Source: Chambers WR. Command Briefing, 520th Theater Army Medical Laboratory, 1997.

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Future Directions

As part of the Medical Reengineering Initiativeprocess, several changes to this PM organization areplanned. The current entomology and sanitationdetachments are to be replaced with consolidateddetachments that retain the capabilities of thetwo detachments while removing the duplica-tion. A disease surveillance system that is effective,

timely, and responsive to the line commander’sneeds is key to the future PM mission and is beingdeveloped. The Theater Area Medical Laboratoryis to be reorganized to create a corps-level area medi-cal laboratory, with its focus on endemicdisease and environmental and occupational healththreats. It is anticipated that these changes, amongothers, will make the PM support in the field evenmore effective.

NAVY AND MARINE CORPS FIELD PREVENTIVE MEDICINE

The US Navy and Marine Corps are two separateyet interdependent services within a single militarydepartment. The organization of PM services in theNavy and Marine Corps reflects this dichotomywithin the Department of the Navy. Medicalsupport is provided to both services by the NavyMedical Department in three ways: (1) directsupport from Navy medical personnel assigned toNavy ships, squadrons, and units, (2) direct medicalsupport from Navy medical personnel assigned toMarine Corps units, and (3) medical support toNavy and Marine Corps units from (BUMED)activities such as hospital, clinics, and PM units.

Preventive Medicine Services in Peacetime

Key PM support to operational units during rou-tine operations is provided by Preventive MedicineTechnicians (PMTs) assigned to medium- and larger-sized ships (ie, aircraft carriers and most amphibiousships) and by Independent Duty Corpsmen provid-ing some PM services to smaller ships such as destroy-ers. Approximately 50% of ships with sailors andMarines are at sea at any one time. Programs in theprevention of foodborne and waterborne illnesses,heat injuries, communicable diseases, and occupa-tional injuries and illnesses are active on all ships.Operational staffs may have PM personnel, such asAerospace Medicine residency–trained flight sur-geons, Environmental Health Officers, IndustrialHygiene Officers, and PMTs, filling staff positions.

PM support to Marine units consists of PMTs dis-tributed to battalions and squadrons; a larger PM sec-tion is located within the medical battalion and con-sists of Environmental Health Officers, Entomologists,and PMTs. Marine staffs may have PM personnel in-volved with contingency and exercise planning. Ex-amples include a physician PMO and a PMT assignedto the Marine Expeditionary Force (Command Ele-ment) staff, a residency-trained flight surgeon andPMT on the Marine Air Wing Staff, and an Environ-mental Health Officer and a PMT assigned to the

Marine Division staff.PM support from BUMED activities includes per-

sonnel from hospitals and clinics. They provide an en-tire spectrum of occupational health and PM services toNavy and Marine Corps units and commands bothafloat and ashore. A major focus of PM programs hasbeen at recruit commands, which have had recurrentcommunicable disease problems.7 Navy– and MarineCorps–wide programs in all areas of PM, occupationalhealth, and environmental programs are developedand managed by the Navy Environmental HealthCenter, Norfolk, Va, and its subordinate units: fourNavy Environmental and Preventive Medicine Unitsand two Disease Vector Ecology and Control Cen-ters, which specialize in entomological threat reduction.

At any time, PM personnel are forward deployedin Aircraft Carrier Battle Groups, in AmphibiousReady Groups, and at overseas bases throughout theworld providing “routine” public health services andparticipating in combined and joint military exercises.PM plays a major role in complex humanitarian re-lief operations, such as those in Rwanda, GuantánamoBay, and Haiti8; in civic action programs associatedwith annual military exercises, such as OperationCobra Gold in Thailand; and in public health train-ing operations deployed with engineering and den-tal units in the Caribbean region.

Preventive Medicine During Mobilization

During a major mobilization, additional PM per-sonnel are assigned from BUMED activities and theNaval Reserve to operational units. Two major ad-vancements occurred in field PM during the Per-sian Gulf War: (1) the development of methodolo-gies to collect disease rates faster and provide com-manders a real-time assessment of DNBI rates thathad previously been available months to years af-ter a conflict, and (2) the formation of Navy For-ward Deployable Laboratories, through the effortsof personnel from the Navy Medical Research andDevelopment Command, the Environmental and


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Preventive Medicine Units, and the Disease VectorEcology and Control Centers, to provide public healthservices beyond the capabilities of operational units.9

These units have been so successful that those labo-ratories are now part of Navy medical doctrine.10

The Navy Forward Deployable Laboratory is anadvanced infectious disease diagnostic laboratory thatcan aid in the recognition and treatment of clinicalinfectious disease cases, as well as the detection ofbiological warfare agents. The Laboratory is designedto function anywhere, from the cramped quarters ofNavy ships to tents in remote Third World locations.Its diagnostic capabilities are extensive, including theclassic bacteriological culture methods but also pro-viding antibiotic susceptibility testing, enzyme-immu-noassay, fluorescent microscopy, diagnostic DNAprobes, and polymerase chain reaction. It is designedto function as a state-of-the-art, comprehensive, on-site diagnostic laboratory when large numbers of sail-ors and Marines are deployed to regions with a highrisk of infectious disease transmission.9

In a major regional conflict, an entire PM unit ofapproximately 40 personnel, who provide environ-mental health, entomology, industrial hygiene, andepidemiologic specialty services, can be deployed aspart of the Navy Advanced Base Functional Compo-nent system. This is a major-theater asset, but it is lim-ited by the extensive airlift capability it requires andby the engineering, transportation, and logistical sup-

port it needs when deployed.PM in the Fleet Marine Force reflects the task or-

ganization philosophy behind the differing sizes ofMarine Air Ground Task Forces formed to meet thepotential threat.11 The smallest of the task forces isa Marine Expeditionary Unit, which is routinely de-ployed in both the Pacific and the Atlantic andMediterranean regions; it consists of 2,000 Marinesand sailors deployed on three to five amphibiousships. Its PM support consists of PMTs assigned tothe Ground and Air Combat Elements, with a largerPM section in the Combat Service Support Element.The task forces increase in size in increments untilthey become a Marine Expeditionary Force (MEF)of 50,000 Marines and sailors fully equipped for 60days of sustained combat. All the PM assets as-signed to a MEF in garrison would deploy, as wellas active duty and reserve billets that are only filledat mobilization. The majority of PM services residein the medical battalion, the unit that is responsiblefor providing additional support (from the Com-bat Service Support Element) above what organicunit personnel can provide. Specific additional ca-pabilities can be added from the Navy deployablelaboratories and the Advanced Base FunctionalComponents, if needed. Each MEF can also betasked to perform such operations as humanitar-ian relief or the evacuation of US or allied nationnoncombatants from a combat or disaster situation.

AIR FORCE FIELD PREVENTIVE MEDICINE

Air Force PM manpower assets differ markedlyfrom those of the other services. General PM phy-sicians are few in number and assigned primarilyto the Force Health Protection and SurveillanceBranch and the Office for Prevention and Health Ser-vices Assessment, both at Brooks Air Force Base inSan Antonio, Tex. PM and public health duties at AirForce bases are performed by flight surgeons, publichealth officers, and bioenvironmental engineers.

Flight surgeons are physicians who complete a7-week course in Aerospace Medicine. This train-ing includes some public health and environmen-tal medicine. Larger bases or bases with more com-plex missions or disease risks have flight surgeonsassigned who are graduates of the residency inAerospace Medicine.

Air Force public health officers may be veterinar-ians, nurses, or biomedical specialists. Many have aMaster of Public Health degree, and all attend a 10-week course in public health and environmentalhealth. They receive extensive training in all aspects

of public health, including epidemiology, environ-mental sanitation, food safety, occupational health,and medical entomology. They are trained to conducthealth threat assessments before deployments anddisease surveillance during deployments.

Most medical facilities have several flight sur-geons, two public health officers, and two bioenvi-ronmental engineers. These officers, along withpublic health and environmental technicians, com-pose the PM team that manages all aspects of pub-lic health, occupational health, and environmentalsurveillance. Bioenvironmental engineers must pos-sess a degree in engineering and attend a 3-monthcourse at the School of Aerospace Medicine, withextensive training in water sanitation, pollutioncontrol, industrial hygiene, and occupational andenvironmental surveillance.

Deployed PM assets vary, depending on the sizeand type of the operation. Air Force squadrons onroutine deployments are accompanied by a Squad-ron Medical Element, which provides basic medi-

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cal and public health support. A typical SquadronMedical Element comprises a flight surgeon, anaeromedical technician (trained in basic medicalcare and administration), and a public health tech-nician. It will be supplemented with an additionalflight surgeon for prolonged deployments. Theseelements are not normally deployed for operationsother than war. In those types of deployments(which include humanitarian crises, natural disas-ters, and peacekeeping operations), additional phy-sicians, such as family practitioners, could be as-signed. An Air Transportable Clinic (ATC) or an AirTransportable Hospital (ATH) are normally de-ployed for these operations. As training for thesetypes of operations is limited, experienced flightsurgeons and public health officers are deployed.

When wing-size organizations are deployed, anATC is usually deployed. The ATC has basic medi-cal care capability similar to a clinic and has PMassets. Flight surgeons, family practice physicians,and surgeons provide basic medical care, whileflight surgeons and public health officers and tech-nicians provide PM and public health expertise.Bioenvironmental engineers and technicians areresponsible for water testing and sanitation, pollutioncontrol, and surveillance for and decontamination ofnuclear, biological, and chemical contamination.

In organization- or theater-size deployments, anATH is deployed. An ATH provides medical and

surgical capability with minimal laboratory andradiological services. PM assets are similar to thoseof an ATC and include flight surgeons, public healthofficers, bioenvironmental engineers, and techni-cians. The flight surgeon is normally residencytrained in Aerospace Medicine and has public healthexperience. Additional PM assets may be requestedby the theater commander or theater surgeon.

Specialized PM assets exist at the EpidemiologicResearch Division at Brooks Air Force Base. Nor-mally these officers provide epidemiologic, publichealth, and travel medicine consultation to all AirForce medical treatment facilities and conduct dis-ease surveillance for the Air Force. The LaboratoryServices Branch of the Epidemiologic Research Di-vision provides extensive reference laboratory ser-vices to Air Force facilities worldwide and exten-sive microbiology laboratory services to physiciansduring disease outbreak investigations.

The Epidemiologic Research Division can fieldtwo theater epidemiology teams to provide de-ployed Air Force units with health threat assess-ments, public health consultations, disease surveil-lance capability, and on-site disease outbreak inves-tigations. Each team has one PM physician, onepublic health officer, and one public health techni-cian. The team can be supplemented with an ento-mologist, a laboratory officer, or an infectious dis-ease physician as needed.

PREVENTIVE MEDICINE IN THE US COAST GUARD AND OTHER FEDERAL AGENCIES

6,000 civilian, and 36,000 auxiliary personnel in1995.14 The Coast Guard Reserve is organized into51 groups and 311 units, which are controlled di-rectly by the Commandant, US Coast Guard,through the headquarters operations and person-nel directorates. In addition, there are nondrillingready reservists who, as in the DoD, may be mobi-lized for domestic emergencies or military supportoperations, as well as national emergencies and war.The Coast Guard’s four main missions are maritimelaw enforcement, maritime safety, environmentalprotection, and national security.

Most Coast Guard units are organized, trained,and equipped to perform more than one of thosefour main missions and cannot be neatly typed byfunction. While most units are armed, they are usu-ally equipped with only small arms and defensiveweapons and are not designed to operate indepen-dently in a high-threat environment. Because of itshistoric relationship with the Navy, the Coast Guardfrequently trains and operates with naval units and

US Coast Guard

Although it is one of the five armed forces of theUnited States, during peacetime the US Coast Guardis an agency within the Department of Transporta-tion. Coast Guard medical assets are limited andfocus on primary care and support of operationalrequirements. Units deployed outside the UnitedStates during contingency operations generally relyon collocated DoD units for care beyond that whichcan be provided by an independent duty medicalcorpsman. Although PM is emphasized throughoutthe Coast Guard medical program, there is no for-mal PM structure. The Director of Health and Safetyis responsible for the medical and safety programs andis the primary point of contact for any medical issuesinvolving coordination with outside agencies.12

The Coast Guard endeavors to be the world’sleading maritime humanitarian and safety service.13

It is the smallest of the military services, consistingof approximately 37,000 active duty, 8,000 reserve,


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can be most easily integrated into the Navy’s struc-ture during contingencies.15 Specific duties usuallyassigned to Coast Guard units participating in con-tingency operations are port safety and security,search and rescue, law enforcement (eg, interdic-tion of merchant vessels for contraband), and en-suring the safety and security of maritime com-merce and transportation.

Forces most likely to work closely with DoD unitsduring contingency operations include port secu-rity units (Figure 12-1) and visit and search teams,in addition to forces on cutters, patrol boats, andaircraft. Elements may be assigned individually tocontingency operations or, more likely, they may bepart of organized, larger joint harbor defense com-mands or composite naval coastal warfare units.

There are four methods under three legal authori-ties that may be used to place Coast Guard forcesunder DoD operational control: declaration of war[14 USC 3], presidential action [14 USC 3], assis-tance to other federal agencies [14 USC 141], andtraining and education [14 USC 144-145]. The Presi-dent may direct by executive order that either theentire Coast Guard or part of it become a service inthe Department of the Navy. The exact status ofsupport for those forces would be negotiated at thetime of the transfer. Under the statute allowingtransfer for assistance to other federal agencies, theSecretary of Transportation may allow Coast Guardforces to work for the DoD when the Secretary ofDefense so requests. Assignments are made for spe-cific purposes and can be of unlimited duration.Return of forces is automatic when the purpose isended, the DoD releases the forces, or the Depart-

ment of Transportation revokes its consent.15 Cur-rently, there are two major field command, control,and support elements—Atlantic and Pacific Areas—each of which is subdivided into several districts.Operational units, such as cutters, small boat stations,air stations, and marine safety offices, report to theirrespective districts for tactical command and control.

The Coast Guard is extensively involved in stop-ping illegal immigration into the United Statesthrough alien migrant interdiction operations. Dur-ing the summer of 1994, Coast Guard units involvedin Operations Able Manner and Able Vigil inter-cepted 56,000 Haitian and Cuban boat people in theCaribbean Sea.16 Boats containing alien migrantsare often unseaworthy, overcrowded, and unsani-tary (Figure 12-2). These operations may expose USpersonnel to foreign nationals and environmentsharboring communicable diseases. The Coast Guardhas taken an active approach to controlling thehealth risks associated with alien migrant interdic-tion operations by such methods as education insanitation practices, selective immunization andchemoprophylaxis, appropriate use of personal pro-tective equipment, and operational policies.17

Federal Emergency Management Agency

The Federal Emergency Management Agency(FEMA) is responsible for coordinating disaster as-sistance to states and territories; this assistance saveslives and protects public health, safety, and property.FEMA prepares the Federal Response Plan (FRP)18 incompliance with the provisions of the Stafford Act.19

The FRP is designed to address the consequences ofany disaster or emergency situation in which there isa need for federal assistance. The FRP applies to natu-ral disasters, technological emergencies (eg, hazard-ous material spills), and certain other incidents. Dur-ing the period immediately following a disasterrequiring a federal response, FEMA directs otherfederal agencies to identify requirements and mobi-lize and deploy resources to the affected area in ac-cordance with the FRP.

The FRP outlines the organization and contains theresponsibilities of the various federal agencies taskedto provide assistance in any of twelve emergency sup-port functions: transportation, communications, pub-lic works and engineering, firefighting, informationand planning, mass casualty care, resource support,health and medical services, urban search and rescue,hazardous materials, food, and energy. Under the cur-rent FRP, the DoD has primary responsibility in twoareas, public works and engineering and urban searchand rescue, but has supporting roles in all other areas.20

Fig. 12-1. US Coast Guard members of a Port SecurityUnit are operating under the command and control ofthe US Navy in the Persian Gulf during the Persian GulfWar. Photograph: US Coast Guard.

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US Public Health Service

The US Public Health Service is an agency withinthe Department of Health and Human Services thathas the lead federal role in coordinating and ensuringpublic health and medical services during any federaldisaster response.21 The Public Health Servicesponsors a number of Disaster Medical AssistanceTeams across the country, as part of the NationalDisaster Medical System. Most of these are locallysponsored, community-based teams of approximately35 civilian volunteers with skills and experience inboth hospital and field emergency service. Theseteams can be rapidly mobilized, at which time themembers temporarily become federal employees.21 Inaddition to the local teams, the Public Health Servicemaintains a larger team (the PHS-1 DMAT), based inWashington, DC, which is mostly made up of officers

of the Public Health Service Commissioned Corps.This team can rapidly deploy to disaster sites toprovide both acute medical care and PM services,including basic field sanitation, water potabilitytesting, and entomological assessments. The PHS-1DMAT is generally the first medical disaster team tobe sent to a federally declared disaster area when localresources have been overwhelmed.22

The Public Health Service Commissioned Corps isa uniformed, nonmilitary corps of more than 6,000officers, including medical, dental, nursing, engineer-ing, and sanitarian professionals. With the exceptionof the DoD and the Department of Veterans Affairs,federal agencies rely on the Public Health ServiceCommissioned Corps as a source of professionalmedical personnel and expertise. By law, this Com-missioned Corps is a source of personnel to augmentDoD health care activities in the United States and,on a limited basis, other activities during nationalemergencies.23 The Corps is the only uniformed back-up to the armed services that can be rapidly mobi-lized and ordered into areas of danger for indefiniteperiods of time. Since 1988, there has been a memo-randum of understanding between the Public HealthService and the DoD outlining procedures for themobilization and deployment of Public Health Ser-vice commissioned officers to the DoD, includingemergency mobilization services.24

The Centers for Disease Control and Prevention(CDC) is another Public Health Service agency that hasmajor responsibilities for preparing for and respond-ing to public health emergencies, such as disasters, andfor conducting investigations into the health effects andmedical consequences of disasters.25 It is also a sourceof epidemiologic and scientific support services andinformation, and it publishes numerous materials thatcan be useful for operational planning.26,27

Fig. 12-2. This boat overcrowded with alien migrants isabout to be boarded by Coast Guard personnel as part ofits alien interdiction mission. Photograph: US Coast Guard.

THE RESERVE COMPONENTS

There are Reserve branches in all the military ser-vices: the Army Reserve (USAR), the Naval Reserve(USNR), the Marine Corps Reserve (USMCR), and theAir Force Reserve (USAFR). The Reserves are elementsof and are directly controlled by the individual ser-vices, and their primary function is to augment andsupport the service in periods of war or other nationalemergency.

The Reserve components consist of the above ele-ments and the two National Guards: the Army Na-tional Guard (ARNG) and the Air National Guard(ANG). Both are normally controlled by the states,with the governor of each state serving as the com-mander-in-chief of guardsmen in his or her state dur-

ing peacetime. All 50 states, the District of Columbia,Guam, Puerto Rico, and the US Virgin Islands haveNational Guard units. The primary role of the Guardduring peacetime, operating as a state agency, is toassist in natural or other disasters and to aid in thecontrol of uprisings or civil disturbances. During war-time, the Guard can be federalized, becoming assetsof the Army and Air Force. The National Guard canalso be federalized during national emergencies andmay come under the control of FEMA.

In any future military action, the medical assets,including PM units, of the various Reserve compo-nents will be mobilized and integrated into the activemilitary forces. There are no PM units in the ARNG,


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but there are two types of units in the USAR: sanita-tion detachments and entomology detachments, withabout 10 of each currently in existence. Each detach-ment or team includes two officers and nine enlistedtechnicians and has its own transportation assets.These teams have the same primary missions as theiractive component counterparts.28

The Reserve force structure, including PM andother medical assets, is currently under review, andthe structure and mission may change substantiallyin the future. It is anticipated that by 2001, the ento-mology and sanitation teams will be reconfigured asPM detachments, with one environmental science of-ficer and one entomologist per team. Two enlistedtechnicians will be added, bringing team strength to13. These new teams will have both environmentalsanitation and entomology functions, as well as othergeneral PM missions. New equipment will improvethe mobility and communications capability of the de-tachments and will allow for real-time transmission

of health and disease data. Approximately 16 teamswill be assigned to the USAR.29

The Air Force, including its Reserve component, isalso changing its PM structure. PM teams have beendeveloped to be deployable at the wing level. Theseteams will likely be composed of a flight surgeon, abioenvironmental engineer, a public health officer, andenlisted personnel (including public health, bioenvi-ronmental, and emergency medical technicians). Therole of this team will be to advise the wing commanderon the health of the airmen, identify health threatsand environmental and occupational hazards, evalu-ate general sanitation, approve food and watersources, direct the control of disease vectors, controlcommunicable diseases, and perform disease surveil-lance and epidemiologic investigations of disease out-breaks. The force structure will be similar in activeduty, USAFR, and ANG units, but the ANG may haveadditional PM and epidemiologic assets at the the-ater, base, and wing level.30

THE PREVENTIVE MEDICINE MISSION IN SPECIAL OPERATIONS

While Special Operations Forces (SOF) have playeda role in US military operations throughout ournation’s history, it was only during World War II thatthe concept and organization of SOF became more for-mally developed. The Office of Strategic Services wascreated to provide unconventional and psychologi-cal warfare capabilities at the strategic and tactical lev-els. The 1st Ranger Battalion, Alamo Scouts, 1st Ma-rine Raider Regiment, Navy Combat Demolition Unitsand Underwater Demolition Teams, and the 885thBomb Squadron are a few of the units in the servicesthat provided specialized tactical support to conven-tional forces.

Until the 1980s, these forces were considered un-conventional, outside of mainstream military opera-tions. During the 1980s, SOF assets and capabilitiesbecame integrated into strategic and tactical planningand then established in individual service and jointdoctrine. The US Special Operations Command(USSOCOM) was created on 16 April 1986, consist-ing of the Air Force Special Operations Command,the Naval Special Warfare Command, the US ArmySpecial Operations Command (USASOC), and theJoint Special Operations Command31 (Figure 12-3).

Missions

Primary SOF missions include Special Reconnais-sance, Foreign Internal Defense, Direct Action, Un-conventional Warfare, Combating Terrorism,

Counterproliferation, Civil Affairs, PsychologicalOperations, and Information Warfare/Command andControl Warfare.31 These missions frequently placethe special operations servicemember under physi-cal, mental, and environmental stresses not generallyencountered by conventional forces. These stresses arecompounded by isolation from conventional militarysupport elements.

PM is involved in the success of SOF from selec-tion and training through mission completion. Spe-cial medical fitness requirements ensure the SOF can-didate is physically and mentally equipped to meetphysical challenges and perform specialized duties,such as parachuting, flying, and scuba diving.32 En-vironmental education and training ensures thatSOF personnel understand the importance of fieldsanitation and hygiene and can operate in the ex-tremes of heat, cold, and altitude. Missions fre-quently place SOF personnel in isolated areas inclose contact with indigenous populations wherediseases not seen in the United States are common.Under such conditions, susceptibility to endemicand epidemic disease is increased. SOF personnelare also often isolated from upper echelon medicalcare provided by conventional support units. PM is-sues that are critical to mission success include de-tailed disease and vector threat information, recom-mendations for special immunizations, chemoprophy-laxis, special equipment (eg, individual water filters),and postmission disease surveillance.

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ARMYSPECIAL FORCESRANGERSAVIATIONPSYCHOLOGICAL OPERATIONSCIVIL AFFAIRS

SEAL TEAMSSPECIAL BOAT UNITSSEAL DELIVERY TEAMSPATROL COASTAL SHIPS

AVIATION - FIXED WING - ROTARY WINGSPECIAL TACTICS GROUP

NAVY AIR FORCEJOINT SPECIAL

OPERATIONS COMMAND

JO

INT

SP

EC

IA

LO P E R AT I ON

SC

OM

MA

N

D

UN I T E D S TAT E S

NA

VA

LS

P

EC I A L W A R F A R E

CO

MM

AN

D

SP

EC

I AL

OP E R A T I O N S

CO

MM

AN

DSP

EC

I AL

OP E R A T I O N S

CO

MM

AN

D

UN

I T E D S TATES

Fig. 12-3. The organization of the US Special Operations Command.Source: US Special Operations Command. Special Operations in Peace and War. SOC: 1996.

Preventive Medicine Assets in SpecialOperations Forces

PM assets are found at all levels of command inSOF. At USSOCOM, a PM sciences officer coordi-nates PM planning and execution for the commandsurgeon. The Joint Special Operations CommandSurgeon has a full-time PMO on staff. Due to itsmission requirements for extensive operations indeveloping countries with tremendous diseasethreats, the Army’s SOF command has more PMpersonnel than the other SOF commands. PMOs andNCOs are assigned to USASOC and the US ArmyCivil Affairs and Psychological Operations Com-mand. Each Special Forces Group has an environ-mental science officer; Special Forces medics, highlytrained in PM techniques, are organic to each group,battalion, company, and operational detachment.PM NCOs are assigned to the Special Forces battal-ions, the Special Operations Support Command, theSpecial Operations Medical Training Center, and thecivil affairs units.

The Navy Special Warfare Command and the AirForce Special Operations Command have no dedi-cated PM specialists on staff. Navy Independent DutyMedical Technicians and Corpsmen (on duty withSEAL [Sea Air Land] teams and Special Boat Squad-rons) and Air Force Pararescuemen are trained in ba-sic PM techniques to support their missions.33 Physi-cians and physician assistants serving as unit flightsurgeons, diving medical officers, general medicalofficers, and in other similar positions provide lim-ited PM expertise to support these NCOs.

Deployment Considerations

SOF mission planning and preparation musthave a different focus than that of conventionalforces. Since SOF have very limited organic medi-cal assets, units place greater emphasis on prevent-ing health problems and quickly addressing thosethat do develop. Intelligence preparation must bedetailed and extensive, including the locations andcapabilities of host-nation hospitals. Evacuation


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routes must be coordinated, to include possible mili-tary transport from isolated countries. Unusual orinvestigational immunizations, along with an em-phasis on personal protective measures and educa-tion, allow SOF to maintain a high posture of pre-vention against environmental and infectious dis-ease threats.

Even with meticulous execution, preventive strat-

egies can fail. SOF use post-deployment PM brief-ings to remind servicemembers about disease ex-posures, the need for continuing chemoprophylaxis,and actions to be taken should symptoms arise andto establish appropriate postdeployment surveil-lance systems in garrison. Illnesses can thus be di-agnosed and treated in a timely fashion, with a highindex of suspicion for exotic diseases.

THE PREVENTIVE MEDICINE MISSION IN CIVIL AFFAIRS

The need to deal effectively with a civilian popu-lace in military operations has long been under-stood. According to US Army doctrine, the missionof Civil Affairs (CA) is to support the commander’srelationship with civil authorities and the civilianpopulace, promote mission legitimacy, and enhancemilitary effectiveness.34 The first CA division wasactivated on March 1, 1943, in response to the an-ticipated demands of dealing with the civilianpopulation of Europe during World War II. CA per-sonnel had previously been under the purview ofthe Provost Marshal.35 The end of the Cold War didnot end conflict, though. CA has an important roleto play during conflict and immediately after a con-flict. However, CA has become actively involved inoperations during peacetime to support nationalstrategic objectives.

Mission and Role

The role of PM in CA is to alleviate human suf-fering among civilians in accordance with Article56 of the Geneva Convention, prevent and controlcommunicable disease that may impede militaryoperations, and institute necessary health measuresin the reconstruction of a country’s public healthprogram.36 This role can be expanded based on thenature of the environment in which CA forces maybe deployed. In a Foreign Internal Defense (FID)mission, the role of public health teams may be toprovide individual or team advisors or provide as-sistance in the conduct of civic action projects. Inpeacetime, public health teams may be required toprovide support operations and render humanitar-ian assistance. Public health specialists or teams inCA are often the coordinators and planners of ac-tion to accomplish the mission. CA units have a re-gional focus; they are often trained in languagesspecific to their region, and they understand thecultural complexities of their area of concern.37

The public health team has various responsibili-ties based on its mission. Generally, direct involve-ment in the provision of health services is not its mis-

sion except for the Foreign Internal Defense CA bat-talion. The team is best suited to provide guidance,assessments, and oversight. The actual rendering ofrecommended services or interventions requires ef-fective coordination with medical assets from otherUS military units, the host nation, or donor agencies.Humanitarian assistance missions often involve otheragencies outside of the DoD, such as the State Depart-ment, and they may be designated lead agent for aparticular operation. CA personnel often find them-selves working with personnel from the State Depart-ment and various United Nations organizations. Intheir delivery of public health services to a commu-nity, the CA units coordinate closely with agencies incountry (eg, UN High Commissioner for Refugees,UN Development Program, US Agency for Interna-tional Development, various non-governmental orga-nizations) regarding any ongoing projects. Publichealth teams must ensure their activities are in sup-port of national strategic objectives and in accordancewith embassy guidance.

Capabilities and Structure

Only the Army and Marine Corps have CA units,and the vast majority (approximately 96%) are in theReserves. Many of the personnel in the CA units per-form jobs in their civilian life that directly enhancetheir ability to perform their CA mission. For example,a public health physician may work in their statehealth department as a civilian and then be the pub-lic health team leader in his or her CA unit. Althoughmedical skills can be transferred to the civilian arena,this may not be the case in all of the 20 functional ar-eas of CA expertise (Exhibit 12-2).34 There are five CAcommands or brigades in the Army, each of which isaligned with one of the five regionally oriented uni-fied commands. Embedded within the CA structureare significant public health assets. The only physi-cians in the structure by doctrine are public health orpreventive medicine specialists. In the RC, physicianstrained in various specialties perform the role of a PMphysician (Exhibit 12-3).

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Deployment Considerations

Before deployment, PM personnel will need to per-form a thorough mission analysis. CA units are ex-

pected to develop extensive country studies, whichinclude the epidemiology of diseases in the area ofoperations and the health of the indigenous popula-tion. Other information of concern includes the medi-

EXHIBIT 12-2

FUNCTIONAL SPECIALTIES IN CIVIL AFFAIRS

Government Section Public Facilities Section Economic SectionCivil defense Public communications Civilian supplyLabor Transportation Economics and commerceLegal Public works and utilities Food and agriculturePublic administration Property controlPublic education Special Functions SectionPublic health Arts, monuments, and archivesPublic safety Civil informationPublic welfare Cultural affairs

Dislocated civilians

EXHIBIT 12-3

MEDICAL PERSONNEL IN CIVIL AFFAIRS (CA) UNITS

Medical Personnel at the CA Brigade Level

Government Team Public Health TeamPublic Health Physician (Team leader) Public Health Physician (Team leader)Veterinarian VeterinarianCommunity Health Nurse Environmental Science OfficerHealth Service Material Officer Sanitary Engineer OfficerEnvironmental Science Officer Medical NCOSanitary Engineer Officer Professional Service NCO

Medical Personnel at the CA Battalion Level (Foreign Internal Defense/Unconventional Warfare)

Public Health Team Civic Action TeamPublic Health Physician (Team leader) Veterinarian (Team leader)Veterinarian Environmental Science OfficerField Medical Assistant Physician AssistantSanitary Engineer Officer Emergency Treatment NCODental Officer Preventive Medicine NCOEntomologist Animal Care NCOMedical Supply NCOChief Dental NCO

Direct Support TeamMedical NCO

Medical Personnel at the 96th CA Battalion Level (only CA unit on active duty)Public Health Physician (Team leader)VeterinarianSpecial Forces Medic (one per Tactical Support Team)


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cal capabilities of the country; the number, type, andlocation of non-government organizations in the area;

and any unique cultural considerations in dealingwith the indigenous population.

MANAGING PREVENTIVE MEDICINE ASSETS IN THE FIELD

To the casual observer, US military operationsconducted in recent years may not appear to meetthe common definition of war. In fact, each of thesemissions falls somewhere on the spectrum of op-erations between war at one end and peace at theother and are termed operations other than war. Hu-manitarian assistance and peacekeeping operationsin Somalia and Haiti are examples, as are non-com-batant evacuations, hostage rescues, raids, showsof force, and other operations short of war. The rulesof engagement and the logistics required to supportthese operations change with the type of mission.The mission may change its focus and move fromone category to another (eg, peacekeeping to raids).These types of operations tend to be multi-serviceor multinational, requiring coordination amongsupporting services and countries and thus increas-ing the logistical challenges. There are three corePM missions that support any of these operations:identification of all medical threats, developmentof countermeasures to those threats, and surveillancefor diseases and injuries. To achieve success, eachPMO must effectively manage the assets available,then provide the resulting PM information to the unitsurgeon and elicit support from unit commanders.

Variables Influencing Management Structure

A number of factors must be considered whenestablishing an organizational structure for the ef-fective utilization of PM assets. The size and geog-raphy of the area of operations will influence thedistribution of PM personnel and equipment. Thepresence of a Theatre Army Medical Laboratory(TAML) or Forward Deployed Laboratory (FDL)and the specific PM specialties represented, suchas entomology, influence the services that can beoffered. These can be augmented by host-nation andcontractor service agreements. The health status anddemographic profile of the indigenous population,as well as that of coalition forces, may become im-portant if the PMO is called on to use PM resourcesto support them. Finally, the facilities for eating, liv-ing, and sanitation for all populations supportedmay demand undue attention if they are not prop-erly maintained. Often the PMO will have very lim-ited authority over PM assets in theater but retainresponsibility for the overall success of the PM mis-sion in the eyes of the command. Consequently,

negotiation skills, networking skills, and determina-tion are invaluable. On arrival in theater, the PMOmust rapidly assess the PM capabilities and materielavailable and review the medical surveillance planwith personnel at each medical treatment facility.

Mission Planning Process

Regardless of the type of mission, the militaryfollows a deliberate decision-making procedure toplan and direct the operation. Medical officers, andPM personnel in particular, must understand thissystem to have an impact when they address pub-lic health and general medical issues. Typicallywhen a warning order or mission is received, theunit staff refers to the standing operational plan(OPLAN) for that particular situation and beginsmission analysis, which is covered in some detailbelow. The staff then develops a specific missionand briefs this restated mission to the unit com-mander. After it is approved, the mission is used asthe basis for the staff to develop several courses ofaction (COAs) to achieve the mission. During COAdevelopment, the staff analyzes, compares, and“wargames” each COA, finally deciding on one torecommend to the commander. When the com-mander approves the COA, the staff modifies theOPLAN, complete with specified, implied, and es-sential tasks for subordinate units to complete. Thisslow process is inadequate when staffs are respond-ing to an emergency situation. Crisis action plan-ning was developed to address this problem and isless complex and faster. Because of the imminentdeadline for the OPLAN, the commander may workmore closely with the staff, since they cannot af-ford the time to digress or consider many COAs.Consequently, the commander will probably forgoformal briefings and approve the results from theworking sessions.38

Mission Analysis

During mission analysis, unit surgeons andPMOs must seize the opportunity to provide medi-cal input into the OPLAN and its medical annex.To provide intelligent and cogent comments, medi-cal personnel must assemble information fromvarious sources, including the TAML and FDL staffsections at the unit headquarters. Copies of both the

245


warning order from the higher command and thecommander’s guidance should be kept in the Opera-tions Section: S-3 at battalion and brigade, G-3 at di-vision and corps, and J-3 at joint staffs. The Intelli-gence Section (S-2, G-2, or J-2 at the respective levels)develops the Intelligence Preparation of the Battle-field. This document analyzes the enemy’s capabili-ties, weaknesses, and strengths, as well as the terrain,the weather, and other relevant factors, and it mayinclude information from the Defense IntelligenceAgency and the Central Intelligence Agency. TheOperations Section will also develop the Concept ofthe Operation, based on the information from the in-telligence staff and the commander’s guidance. Medi-cal personnel must be familiar with this documentsince it describes what the unit will do and what themedical assets will have to support. In a similar fash-ion, the Logistics Section (S-4, G-4, or J-4) will developthe Logistics Estimate, which describes what support,including medical, will be provided.38,39

To provide optimum service to the unit and com-mander, the PMO must work closely with the com-mand surgeon and interact with the other staff ele-ments. With the surgeon and the Personnel Section(S-1, G-1, or J-1), the PMO should help develop casu-alty estimates and reports with a DNBI emphasis,because rates of DNBI always exceed rates of combatinjuries. Additionally, the PMO should review the planfor handling enemy prisoners of war and refugeesfrom a disease control and public health perspective.The S-2, G-2, or J-2 is the source to answer questionsfrom or research any intelligence requirements neededby medical and nonmedical planners about such is-sues as enemy medical care facilities and equipment,nuclear, biological, and chemical weapons types andcapabilities, and weather projections to support aero-medical evacuation. Medical personnel must workvery closely with unit support components to developa good Service Support Annex to the OPLAN. ThePMO in particular should review this document andcan have a tremendous public health impact. ThePMO can ensure the appropriate provision of fieldservices, including such issues as food (ie, its selec-tion, procurement, storage, preparation, and disposal),water (adequate amounts and safe), laundry, gravesregistration, and hazardous waste disposal.2,39

As a part of the Service Support Annex, theSurgeon’s Office should write Annex Q, Health Ser-vice Support. This document should have several sec-tions, including one on PM (an example of which canbe seen in Chapter 13, Preventive Medicine and theOperation Plan). The PM portion should emphasizeDNBI and public health by including recommendedcountermeasures to the threat, estimates of the im-

pact of DNBI on combat power, information on edu-cating servicemembers and commanders, immuniza-tion and chemoprophylaxis recommendations, out-break investigation guidance, and occupational andenvironmental health requirements. The Logisticsportion of Annex Q should address whether the Armywill be the Class VIII (medical supply) source for theDoD, as is usually the case; the support relationshipsbetween medical units and their associated line units;the use, source, safety, and transport of blood; andwhether or not coalition partners will use combinedlogistics, in which the US bears a disproportionatelylarge burden of support, or national logistics, in whicheach country supports itself. Annex Q should alsodiscuss veterinary services such as food supply in-spection and zoonoses, which are also of interest tothe PMO.

PMOs may interact with clinicians when review-ing casualty reports and conducting epidemiologicalinvestigations of disease outbreaks. Of particular in-terest must be the reports of nuclear, biological, orchemical weapons casualties, since the PMO may bethe local “expert” for medical issues regarding weap-ons of mass destruction. Clinicians and PM person-nel in subordinate units will need to know the levelof medical support available, so the location and di-agnostic capability of supporting laboratories mustbe included in Annex Q, as well as the locations andsupport relationships of combat stress control teams.Finally, subordinate PM units must know the iden-tity and location of their next higher echelon of medi-cal support for additional PM expertise, medical sup-ply, and similar issues.3

Preventive Medicine Assets in Joint Operations

The JTF commander does not have ultimate author-ity over joint operations. That responsibility rests withthe Commander-in-Chief (CINC) for that geographi-cal portion of the worldwide system of unified com-mands, such as the Southern Command (Figure12-4). The CINC, in turn, answers to the NationalCommand Authority in the person of the Secretary ofDefense or the President. For a specific or limitedpurpose, the CINC, as combatant commander, will re-linquish operational control of various forces of anyservice under his control to the JTF commander, whois often from a different service38 (Figure 12-5). Withoperational control, the JTF commander can controlthe events in the entire area of operations.

The PMO in the JTF functions just as he or shewould in a single service force, except that require-ments and resources of all services must be consid-ered and coordinated (Figure 12-6). For example, the


246

Marines Corps, unlike the Army, has no dedicatedmedical evacuation helicopters and must request thissupport from other services. And Air Force involve-ment in an operation can make it easier to obtain aMobile Aeromedical Staging Facility to hold and pro-cess casualties for fixed-wing evacuation.2

Preventive Medicine Assets in Unified Commands

The role of the PMO at the unified command isbroad in scope and deep in responsibility; it is alsoextremely vital to the unified commander and thesurgeon in both peace and war. Each geographic CINCis a combatant commander with a broad, continuingmission and significant components from two or moreservices. The CINC also has the responsibility for co-ordinating and integrating health service supportwithin the theater of operation and exercising thisresponsibility directly through the unified commandsurgeon. The surgeon’s joint staff must coordinatemedical initiatives, solutions to regional medical is-sues, standardized approaches to national issues, andinteroperability, and the health service support plans

and operations of subordinate units. The surgeon’soffice must be able to assess the health service sup-port requirements and capabilities of component com-mands and provide guidance to enhance their effec-tiveness. Each unified command surgeon should havea PMO on staff whose primary function is to addressthe medical threats in the entire theater of operations.Similar to PMOs at other levels of command, he orshe then promulgates recommended policies andcountermeasures to obviate or mitigate those threats,monitors the health of deployed forces through anestablished surveillance mechanism, and modifiesand updates policies and countermeasures based onever-changing intelligence and surveillance data.An asset that must be employed early in operationsis the TAML, which is designed to operate directlyfor the theater surgeon. This asset provides the the-ater surgeon a rapid diagnostic capability to moni-tor the health of the force and identify biological orchemical threats early. At the unified commandlevel, the impact of medical threats as contributingfactors to social, political, and economic stabilityin both peace and other operational environments

Fig. 12-4. The Geographic Commanders in Chief Special Operating Forces with Integrating Elements.Source: US Special Operations Command. Special Operations in Peace and War. SOC: 1996.

SOC: Special Operations CommandJSOCC: Joint Special Operations Component CommanderCVBG/ARG: Carrier Battle Group/Amphibious ReadyGroupAFSOF: Air Force Special Operations Command

NAVSOF: Navy Special Operations CommandARSOF: Army Special Operations CommandSOCOORD: Special Operations Coordination ElementSOLE: Special Operations Liaison ElementNSWTU: Naval Special Warfare Task Unit

Geographic CINC

MarineComponent

AFSOF

NAVSOF

ARSOF

SOC�(JSOCC)

NavalComponent

CVBG/ARG

NSWTU

Air ForceComponent Component

SOLE

Army

Corps

Operational ControlLiaison

SOCOORD

�

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must be considered. In addition to the traditionalthreat assessment, then, the PMO must attempt todetermine the adequacy of the health infrastructurein the various countries in the theater and, in col-laboration with civil affairs teams and the respec-tive ministries of health, may be called on to makeappropriate recommendations for amelioratingthese deficiencies under unstable conditions.

Preventive Medicine Assets in CombinedOperations

A combined task force, frequently referred to asa multinational force, consists of the forces of twoor more nations acting together for the accomplish-ment of a single mission, and it may be organizedfrom an alliance or coalition of nations. An allianceis the product of a longstanding, formalized agree-ment among political, diplomatic, and military of-ficials. It offers the advantage of time for plannersto adopt uniform warfighting (including PM) doc-trine and standards among participating nations.Member nations of the North Atlantic Treaty Orga-

nization have worked for decades on developingmany of the standarization agreements (known asSTANAGS) now in effect. Implementing PM coun-termeasures and conducting medical surveillancein a combined task force derived from a coalitionpresents the most difficult challenge in military PM.Coalitions are less formal, ad hoc agreementsamong nations organized to meet short-term objec-tives.38 In 1990, President Bush spearheaded a coa-lition that contributed to the combined force thatremoved the Iraqi Army from Kuwait. Before ar-riving in the theater of operations, contingents hadno time to agree on standard procedures.

In US operations in the 1990s, including the Per-sian Gulf War and missions in Haiti and Bosnia, theUnited States participated in combined operationswith forces from allies and other friendly countries.This added many layers of complexity to an alreadymassive PM undertaking. Additional countries bringadditional cultures and languages and different mili-tary training, doctrine, equipment, and objectives.Participating nations may have very limited healthservices support doctrine or capability, particularly

Fig. 12-5. The Organization of a Joint Task Force.Source: US Special Operations Command. Special Operations in Peace and War. SOC: 1996.

�United Nations�Security Council

National�Command Authorities

Chairman of the�Joint Chiefs of Staff

Theater�Commander In Chief

US�Ambassador

US Gov'tAgencies

Service Components Special�Operations Command

Military Assistance�Advisory Group/Military�

Group (Assigned to�American Embassy�

in Host Nation)

Combined�Forces

Liaison Officer

Host Nation Forces�

Liaison Officer

*

*

�

�

�

�Coordination normally required for CINC/JFC direction to form a CMOC Strategic and Operational Direction Combatant Command Operational Control Support/Coordination

Organizations and relationships are scenario dependentAugmented by/comprised multi-lateral military and civilian personnel�

For UN sanctioned operations

(CONUS)

(CONUS)

Service Components

Joint Civil-Military�Operations Task Force

Ground Forces�CS/CSS Units

Civil-Military�Operations Center

Joint�Task Force

US Special�Operations Command

Nongovernmental Organization/�Private Voluntary Organization


248

in PM issues. Attitudes about staying healthy andpatient care may differ markedly among the nationalcomponents of a combined force. In other cases, forceelements may share doctrine and cultural attitudesbut lack essential resources. Health services supportplanning also may be influenced by the nationality ofthe combined force commander or the combined forcemedical authority. For these and other reasons, pro-vision of health services support typically remains anational, not a combined, responsibility.

Most military forces of the world depend on do-mestic civilian resources for all aspects of their healthcare. These forces typically are not strategic and rarelydeploy beyond their borders unless assisted. There-fore, military personnel from these countries are un-likely to encounter exotic health threats with any

greater frequency than the civilian population theycome from. Consequently, the military organizationsof most countries lack an organized PM capability.Only those countries, such as the United States,Canada, and France, that routinely deploy strategicground forces beyond their borders are likely to havedeveloped military PM doctrine. In combined opera-tions, the obvious implication of this situation is thatthe responsibility for military PM operations falls tothe country fielding the capability. If any part of theforce lacks the capability to employ PM countermea-sures or rejects employing them for cultural reasons,the public health threat to the entire force increases.The keys to success of combined operations are trustand teamwork.

Compared to joint operations, assessing the

Fig. 12-6. Joint Task Force Relationships.Source: US Department of the Army. Operations. Washington, DC: DA; 1993. Field Manual 100-5.

of theArmy

NationalCommandAuthority President

Secretary ofDefense Chairman

Joint Chiefs ofStaff

Departmentof theNavy

Departmentof the

Air Force

CombatantCommand

Joint Task Force

ArmyComponent(ARFOR)

Air ForceComponent(AFFOR)

DepartmentComponent

(AFFOR)

Special

Component

NavyComponent(NAVFOR)

Marine CorpsComponent(MARFOR)

OperationsJoint Task

Force

Uni-ServiceForce

ServiceFunctionalElement

ServiceFunctionalElement

Combatant commandTransmits communications/advisesStrategic and operational directionOperational controlAdministration and logistical support

SubordinateJoint

Task Forces

Departmentof theArmy

DefenseAgencies

249


health threat in combined operations is more com-plicated because the health status among the com-bined force lacks homogeneity. However, each par-ticipating contingent joins the combined forcehealthy by its own set of deployability standardsand shares a unique disease exposure and immuni-zation history. Servicemembers may join a com-bined force harboring active infections endemic totheir country of origin but exotic to other contin-gents of the force. For example, the exposure expe-rience to hepatitis or Japanese encephalitis amongThai soldiers is greater than that of their US or Ca-

nadian counterparts.In combined operations, medical surveillance

techniques and procedures are limited to NorthAtlantic Treaty Organization alliance forces. Agree-ment among contingent forces on conducting medi-cal surveillance is unlikely until the operation isweeks old. Consequently, useful medical surveil-lance of the combined force during the most criti-cal early phase of an operation is unlikely. Exceptin those contingents with the most sophisticated PMcapability, environmental survey and lab supportcapability will not be available.

SUMMARY

For the PMO or other health services planner tounderstand how to properly plan and execute PMservices on deployments, it is essential to appreciatethe big picture of military preventive medicine. Thischapter has reviewed the process of PM policydevelopment from the strategic JCS level to theoperational JTF level to the tactical field unit.Although there are unique aspects to PM among thedifferent US military services and these must be

anticipated in the planning of any joint operation, thereare additional considerations in providing PM supportto government agencies or to operations with units fromthe Reserve Component, combined forces, Civil Affairs,or Special Operations Forces. With an understanding ofthese differences and an appreciation of the intricaciesand complexities of military planning and operations,PM personnel can provide great benefit in conservingthe fighting strength for their unit or command.

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