One of the first joint operations that involved American forces was the almost forgotten War of Jenkins’ Ear. In the early part of the 18th Century, after Spanish privateers sliced off the ear of a British sea captain and bid him to present it to the Prime Minister, Parliament decided to rid the Caribbean of its Spanish presence once and for all. The plan was to deploy British naval and army forces to Jamaica where they would rendezvous with a colonial contingent from North America. This combined joint force would assault the city of Cartagena and drive the Spanish from their Caribbean stronghold. Unfortunately, for the British, the operation ended in complete disaster.

It was not, however, Spanish combat prowess that defeated the British and Americans. Rather, it was the latter’s own inattentiveness to the health of the command. Only 10 percent of the 9,000 man combined force were wounded or killed in action; the majority of the casualties, well over 6,000 men, occurred because of spoiled food, a lack of potable water, intense heat, and indigenous disease. Today we refer to this type of casualty as a Disease and Non-Battle Injury (DNBI).

Of course, one might protest, this debacle happened over 300 years ago, and military medicine has come a long way since then. While this is undeniably true, we still frequently forget that the greatest threat to our forces is not enemy guns.

• 50% of the U.S. marines deployed to Lebanon in 1958 were incapacitated with severe diarrhea.
• 80% of the U.S. sailors deployed in the Suez in 1975 were stricken with dysentery.
• 30% of the U.S. soldiers deployed to the Sinai in 1982 became dehydration casualties.
• And 30% of the U.S. soldiers participating in a combined exercise in Botswana in 1992 returned home with Spotted Fever Rickettsiosis.
  
  
In his Civil War memoir, then Major Jonathan Letterman—father of modern U.S. military operational medicine—wrote the following passage: 


A corps of medical officers was not established solely for the purpose of attending the wounded and sick. . . . The leading idea, which should be constantly kept in view, is to strengthen the hands of the Commanding General by keeping his army in the most vigorous health, thus rendering it, in the highest degree, efficient for enduring fatigue and privation and for fighting.


Clearly, Major Letterman understood that one of the keys to a successful military campaign is the implementation of preventive procedures to reduce DNBI rates. More recently, two widely recognized authorities in military preventive medicine—Llewellyn Legters and Craig Llewellyn of the Uniformed Services University of the Health Sciences (USUHS)—highlighted the four main objectives of a successful preventive medicine program. 


• To determine the nature and magnitude of the disease and injury threats in the planned area of operations before deployment.
• To identify the principal countermeasures that must be emphasized to reduce the threats to acceptable levels.
• To train individuals in the use of these countermeasures.

And, to rigorously enforce these countermeasures in the operational area.

Prior to any deployment, a line commander desires an intelligence preparation of the battlefield (IPB). The command surgeon should, just as strongly, desire a medical IPB (MIPB). [I have a copy of master's thesis on MIPB from CPT Joe Laundree of AFMIC.  I haven't had a chnce to covert it to html files yet, but I'm sure he could send you a zip file if you'd like a copy.]  Too often, however, the medical officer asks, "I wonder where I can get pertinent and timely medical intelligence information?" In fact, there are many sources. 

The first place to search for information is in the office of the Unified Command Surgeon with geographic responsibility for the area into which the joint task force is being deployed. The surgeon’s preventive medicine officer should be intimately familiar with the region’s medical threats. If the preventive medicine officer does not have specific information right at her or his finger tips, he or she probably has access to a library of applicable medical threat data. One text that is easily obtainable is FM 8-33, Control of Communicable Diseases in Man. 

The second and, probably, best single source of medical intelligence is the Armed Forces Medical Intelligence Center (AFMIC), Ft. Detrick, Maryland. The center produces a wide range of publications that can assist the in developing an MIPB. Five important publications that a JTF Surgeon will find very useful are the Disease and Environmental Alert Reports (DEAR), the Medical Capabilities Studies (MEDCAP), the World-Wide Medical Facilities Handbook, the Special Series documents, and the Weekly wire (a periodic message update of worldwide medical concerns). Additionally, AFMIC has published much of its unclassified information on a multi-platform CD titled Medical Environmental Disease Intelligence and Countermeasures (MEDIC). For information on how to obtain these publications contact AFMIC, Building 1607, Fort Detrick, MD 21701-5004; telephone: (301) 619-3837; DSN: 343-3837. Some of AFMIC’s information can also be retrieved by using its Bulletin Board System (AFMIC BBS). You can get more information about accessing the AFMIC BBS by contacting the System Operator (SYSOP) at (301) 619-2686 or DSN 343-2686. 

A third source is the Defense Pest Management Information Analysis Center (DPMIAC) of the Armed Forces Pest Management Board (AFPMB). This organization publishes an excellent series of Disease Vector Ecology Profiles (DVEP) on many foreign countries. The profiles include information regarding disease risks, infectious agents, modes of transmission, geographic and seasonal incidence, and prevention and control recommendations. The center can be contacted at DPMIAC, Armed Forces Pest Management Board, Forest Glen Annex, Walter Reed Army Medical Center, Washington, DC 20307-5001. Some of its other publications are also available on-line. 

A fourth resource is the Navy Preventive Medicine Information System (NAPMIS). NAPMIS maintains up-to-date information like Disease Risk Assessment Profiles (DISRAP) and Disease Vector Risk Assessment Profiles (VECTRAP). Surgeons and planners can tap into NAPMIS by contacting the Navy Environmental Health Center, Norfolk, Virginia 23511; telephone (757) 444-7575 ext 456 or DSN 564-7575 ext 456. The Navy also operates regional Naval Environmental and Preventive Medicine Units (NEPMU) that publish periodic Fleet Public Health Bulletins and provide assistance throughout the world (NEPMU 2, Norfolk; NEPMU 5, San Diego; NEPMU 6, Pearl Harbor; and NEPMU 7, Sigonella, Italy). Navy DiseaseVector Ecology and Control Centers located at Bangor, Washingon, and Jacksonville, Florida, can provide assistance as well. 

A fifth publication of value is the quarterly Communicable Disease Report published by the Walter Reed Army Institute of Research (WRAIR). It identifies disease outbreaks worldwide. Additionally, WRAIR quickly responds to ad hoc queries and provides timely regional medical assessments. Information can be requested from the Division of Preventive Medicine, WRAIR, Washington, DC 20307; telephone (202) 782-1352. 

A final military source is the U.S. Army Research Institute of Environmental Medicine (USARIEM). USARIEM publishes an excellent series of "deployment manuals" which address soldier health and performance in a wide variety of environments. For additional information, contact USARIEM at Bldg 42, Kansas St., Natick MA 01760-5007. 

Still other sources of medical intelligence are available from agencies external to DOD. The State Department publishes Background Notes, a series of publications on selected countries and regions. The series can be obtained through the Government Printing Office, telephone (202) 783-3288, and is usually current within one or two years. 

The Center for Disease Control and Prevention (CDC) publishes Health Information for International Travel, a document often referred to as the Yellow Handbook, which identifies current vaccination requirements, immunization and prophylaxis recommendations, and regional health hazards. This document, too, can be ordered from the Government Printing Office. CDC also publishes the Morbidity and Mortality Weekly Report (MMWR) which can be requested from Editor, MMWR Series, Mailstop C-8, Center for Disease Control and Prevention, Atlanta, GA 30333. 

The World Health Organization (WHO), publishes Vaccination Certificate Requirements and Health Advice for International Travel, a document that is similar to the Yellow Handbook and can be obtained from the WHO Washington office; telephone (202) 861-3396. WHO also publishes the Weekly Epidemiological Record (WER). Hard copy subscriptions to WER are available from WHO, Distribution and Sales, 20 Avenue Appia, CH-1211 Geneva 21, Switzerland. 

And finally, don’t neglect looking through the world-wide travel sections at local libraries and bookstores. Frequently, they have books with surprisingly extensive medical sections. 

Once data have been accumulated, a second question normally strikes the surgeon or medical planner, "How can I distill and organize the data into something that is usable to me and my commander?" 

First, determine whether or there are any endemic or epidemic diseases within the planned JOA. This examination includes not only identifying any communicable, to include sexually transmitted, diseases present in the area, but also determining the level of endemicity and known resistance to chemoprophylactic medications. 

It is also important to identify the locations of any specific diseases, strains of bacteria, insects, harmful vegetation, snakes, fungi, spores, and other harmful organisms. This, in turn, should trigger inquiries into arthropod resistance to available pesticides and the availability of antivenins. Current and potential animal and plant diseases, especially those transmissible to humans, must be noted. Crops and livestock in the region should be evaluated for potential problems; and any specific FDA plant and animal importation restrictions for the area should be determined. 

The region’s public health standards and local health problems must be assessed. This assessment includes the area’s water quality and its distribution system as well as risks associated with the consumption of local food and the method and quality of the public waste disposal system. 

The potential impact of foreign weapon systems as they relate to casualty production must be considered. This includes identification of any possible use of laser weapons, laser range finders, chemical munitions, or biological agents. This information may be readily available from the JTF Intelligence Officer (J2). 

All commanders appreciate knowing the enemy force’s state of health and fitness as it relates to its ability to conduct combat operations. The JTF Surgeon should be able to describe the enemy’s ability to medically support its combat forces and any unique characteristics of the civilian medical infrastructure. Unique characteristics include information about medical supply status, the range and availability of medical services, the location and capabilities of medical facilities, and the number and specialties of trained HSS personnel. 

During NEOs, medical units must be aware of the number of noncombatants known to require medical care, their locations, and the embassy’s plan for their collection. Knowledge of the State Department and FDA policies regarding evacuation and quarantine of animals may expedite NEO planning should an ambassador decide that evacuees will be allowed to take their pets with them. 

Finally, physical data, such as altitude, temperatures, terrain, and road/transportation networks, should be evaluated to assess how they may affect the health of the command and HSS operations, especially treatment facility location and patient evacuation. 

Drs. Legters and Llewellyn, in Public Health & Preventive Medicine, noted two distinct approaches to countering a threat—individual prophylactic measures and environmental controls. They consider the effectiveness of individual prophylactic measures (e.g. immunizations, chemoprophylaxis, insect repellents and clothing treatments, protective clothing, and safety equipment) as generally ". . . inversely proportional to the effort demanded of the individual. . . . Nevertheless, in the highly mobile tactical operations characteristic of modern warfare, it is frequently necessary to place virtually total reliance for disease and injury prevention on the use of individual prophylactic methods applied under the supervision of leaders of small tactical units." 

Up-to-date immunizations prior to deployment are crucial. The quadriservice document Immunizations and Chemoprophylaxis (AR 40-562,/NAVMEDCOMINST 6230.3/AFR 161-13/CG COMDTINST M6230.4D) provides detailed guidance, as shown in the following table.

Additionally, JTF Surgeons should use Annex Q to identify any environmental controls to be exercised by individual units for their own protection or by combat service support units on an area-wide basis. The focus of these controls should be in areas where a relatively small number of trained specialists can concentrate their effort (e.g. water and food supplies, vector control, and waste disposal). Because much of this work will be done by non-medical personnel or non-medical units, the JTF Surgeon should clearly identify which medical units, activities, or personnel will provide technical supervision. Also remember that as special staff officers, JTF Surgeons do not have tasking authority. Specific environmental control tasks for specific units that are not identified in Annex Q must be published by commanders or their operations officers. 

Although training of personnel in preventive medicine countermeasures is a service responsibility, JTF Surgeons must understand that standards differ between services. Therefore, it may be appropriate to identify and disseminate specific procedures to the CJTF and recommend that he direct that training will be conducted to ensure compliance. The Army produces a series of pocketsize factsheets and individual training aids (poisonous snakes, venomous arthropods, injurious plants, ticks-borne diseases, cold injuries, etc.) that are suitable for distribution to all JTF members. 

This brings up another key point. It is important that surgeons at all levels convince commanders of the importance of countering the medical threat because, without command support and enforcement, medical threat assessment and preventive medicine countermeasures efforts will be wasted. 

Military units must operate in varied climates and geographical regions. The contrasting characteristics of these regions present a unique set of medical considerations. 
 

Jungle Operations. Extremes of heat and humidity can result in dehydration, exhaustion, cramps, and heatstroke. Drops in temperature, especially at night, can cause extreme discomfort. Mosquitoes ( to include malaria vectors), wasps, bees, centipedes, scorpions, and poisonous snakes are common. Leeches may be found in swampy areas and streams; while nonpoisonous, their bites may easily become infected and result in ulcers or sores. Wild animals and "domesticated" wild animals, like water buffalo and elephants, may be encountered. All large animals can be dangerous if cornered or startled at close quarters. Poisonous plants are prevalent. While these are all significant concerns, an aggressive preventive medicine program can negate most of the medical threat. 

• Insects and malaria. Enforce prevention measures to include the use of insect repellent and mosquito nets, the wearing of clothes that cover as much of the body as possible, the avoidance of known infestations, and the administration of malaria chemoprophylaxis. Boots, blankets, sleeping bags, and clothing should be shaken before they are used. Special consideration must be given to immobilized casualties and patients; they are easy prey for ants and other insects.
• Leeches. Problems can be prevented by brushing leeches from skin or clothing before they attach. Trousers should be securely tucked into boots, and straps should be wrapped around the pants just above the boot top. These leech straps will help prevent leeches from crawling up the legs and into the crotch area.
• Snakebites. Medics and corpsmen should carry snakebite kits, and antivenin for indigenous species of poisonous snakes should be maintained at treatment facilities.
• General health and hygiene. Immunizations should be current before deployment. Personnel should be in top physical condition and have received hygiene instructions. Time should be allocated to allow personnel to acclimate. Water use policies stressing the drinking, but not rationing, of water must be enforced. Every individual should understand the sources of endemic disease.
• Waterborne diseases. Drinking water must be purified and plentiful at approved water points. Collection of rainwater is not recommended as impurities from the jungle canopy may have washed into collection containers. Swimming and bathing in untreated water should be prohibited, and the body should be kept fully clothed when crossing water obstacles.
• Fungal diseases, immersion foot, and chafing. Personnel should bathe and air dry the body as often as possible. Quick drying jungle fatigues and boots should be issued. Clothing should be kept dry, clean, and loose. Never allow personnel to sleep in wet, dirty clothing. Underwear should not be worn in consistently wet weather. Boots should be removed and feet should be massaged frequently. Socks require frequent changing and, along with feet and boots, should be dusted often. Hair should be kept short.
• Heat injuries. Require personnel to consume adequate amounts of water. Ensure salt is being consumed with meals. Advise the CJTF to slow down operations if necessary.

• Acclimatization. An acclimatization program that gradually increases physical exercise, to include marches and rock climbs, should be mandatory. After a month of training, military personnel should be able to perform at about 70% of their sea level capacity at an altitude of 4,200 meters.
• Sunburn and snow blindness. Personnel should be issued and required to use sunscreen. Snow blindness can be prevented by wearing goggles. Sunglasses that do not block light from below and from the sides are inadequate.
• Frostbite. The potential for frostbite injuries increases with altitude as blood flow to the extremities is reduced. Personnel must be kept in proper uniform. Face and hands must be protected, especially when subjected to high winds or propeller/rotor blast. Clothing and bodies should be kept dry. Outer clothing layers should be removed during heavy work to minimize perspiration. A buddy system can significantly reduce the frequency of frostbite injuries.
• Nutrition and dehydration. Loss of appetite is frequent at high altitudes. Personnel must be supervised to ensure that they are eating properly. At least one hot meal should be served daily. Heat tablets should be issued, if possible, with combat rations. As in any environment, water to be consumed must be potable. Snow, streams, and lakes may appear pure, but must be treated anyway. Fruits, fruit juices, and soups should be used to supplement water intake.
• Hygiene. Daily shaving requirements should be enforced. Beards add little in the way of insulation and may conceal frostbite or lice. Weekly bathing is recommended, and armpits, crotch, and feet should be washed daily. Feet should be massaged and powdered when socks are changed daily. Underwear should be changed at least twice each week. Sleeping bags must be shaken out and aired regularly as should clothing if changes are not available.
• Sanitation. Although it may be impossible to dig in rocky or frozen ground, latrines should still be established. Excreta will freeze and can be covered with snow or pushed into a crevasse. In rocky areas, waste can be covered with stones.

• Acclimatization. At least two weeks are needed for the body to develop efficiency in its cooling process. During this time, personnel should gradually increase their exposure and exertion. If it is not possible to fully acclimatize personnel before engaging in heavy work, labor should be limited to cooler hours. Frequent rest periods should be taken.
• Radiant light. Personnel should attempt to gradually acquire a suntan to gain some protections against sunburn. Sunscreen must be issued and its use enforced. Personnel should remain fully clothed in light, loose-fitting clothing. Sunbathing should be prohibited. Remember, the sun is just as dangerous on a cloudy day; sunscreen does not provide complete protection; and sunbathing or sleeping in direct sunlight can be fatal.
• Wind and sandstorms. Lip balm as well as skin and eye ointments can help prevent wind and sand irritation of mucous membranes, lips, and other exposed surfaces. Goggles should be worn when needed and always when riding in vehicles. This can help prevent irritative conjunctivitis.
• Water, dehydration, and heat injuries. A plentiful, potable water supply is essential to successful desert operations. Personnel cannot be trained to adjust to reduced water intake. Personnel should be encouraged to drink small quantities of water frequently as opposed to large quantities of water on an irregular basis. As much as one pint per hour may be needed to replace fluid lost through perspiration. Lister bags should be used to cool water. If possible, drinking water should be maintained between 50 and 60 degrees Fahrenheit. While water consumption must be encouraged, personnel must be trained not to be wasteful. Care must be taken not to pollute water sources. If rationing is in effect, it must be closely supervised. Clothing may be moistened to help cool the body; water that is too salty to drink, but not otherwise dangerous, can be used for this purpose. A buddy system can reduce the frequency, quantity, and severity of heat injuries.
• Diseases and infections. A predeployment immunization program will negate most of the threat from endemic diseases. Clothes should be frequently changed to prevent prickly heat and fungal infections. Personnel should be frequently checked for minor injuries as desert dirt and insects can cause serious infections.
• Snakebites. Medics and corpsmen should carry snakebite kits and antivenin for indigenous species should be available at medical facilities.
• Hygiene and sanitation. Daily shaving and bathing should be required if water is available. If not, electric razors should be used. Body areas that sweat heavily should be cleaned daily, and underwear should be changed often. If sufficient water for showers is not available, personnel should take sponge baths, use solution-impregnated pads, or wipe themselves with clean dry cloth. Latrines should be deep as shifting sands can expose shallow diggings.