Army transformation and level II preventive medicine within a deployed division task force.

Change is hard because people overestimate the value of what they have--and underestimate the value of what they may gain by giving that up. (1)

INTRODUCTION

Throughout military history, preservation of the health of the force has been one of the greatest combat multipliers. Sound preventive medicine (PM) mitigates disease and nonbattle injuries and keeps the Soldier fit to fight. In 2004, Army transformation began to drastically change how PM support is provided to combat units in the deployed environment.

The author experienced transformation of division PM assets first hand when serving as the division environmental science and engineering officer (ESEO) in the Army's last remaining main support battalion, and then deploying to Multi-National Division North, Iraq with the restructured 1st Armored Division headquarters as the staff ESEO from September 2007 to December 2008. From a division staff officer perspective, this article provides a description of how force health protection for the ground Soldier was more effectively delivered as a result of Army transformation. Field commanders and medical personnel at all levels should be aware of remaining challenges and opportunities resulting from the reorganization of PM assets across the operational environment. The information presented here may also serve as a useful after action review tool for any PM Soldier that might potentially serve at the brigade combat team or division level in a counterinsurgency environment.

BACKGROUND

Prior to the Army Transformation in 2004, division PM personnel who provided level II support were colocated within the medical company of the main support battalion. Modularization essentially decentralized the division's PM personnel. As discussed by Ciesla, (2) this profoundly increased the demand for ESEOs and placed a much greater emphasis on force health protection. While the previous model assigned one ESEO in support of an entire division, (3) modularization places an ESEO on the division staff and one in each brigade combat team (BCT). (4)

The 1st Armored Division served as the headquarters for Task Force Iron during the Operation Iraqi Freedom 07-09 rotation. Task Force Iron was composed of more than 24,000 US service members throughout northern Iraq, and included 4 brigade-sized maneuver elements (BCTs *). The 3rd Armored Cavalry Regiment had not yet transformed and was assigned one preventive medicine specialist (staff sergeant, military occupational specialty 68S30). The other 3 brigades were modular in structure, and each was assigned one ESEO and one PM specialist. With the rapid expansion of base camps to accommodate counterinsurgency operations in Mosul City, US Soldiers lived and operated out of more than 90 different base camps across the division operational environment. Base camps included contingency operating bases, contingency operating sites, and contingency operating locations which differed based on the size and number of personnel supported. For example, the largest, a contingency operating base, may sustain between 20,000 and 25,000 personnel, while a contingency operating location usually had no more than a platoon of Soldiers on site.

CHALLENGES

Regarding his strategy of establishing joint security stations in key locations, General Petraeus said "you can't secure the people if you don't live with them." (5) Tactical dispersion of multiple, austere base camps in urban areas required additional field sanitation and PM support.

Level I PM--Field Sanitation Teams

Doctrine requires every company-sized unit to have functional field sanitation teams (FSTs). (6) Generally, Task Force Iron BCTs with organic PM assets met the FST requirement for each company. The ESEO and PM specialist conducted predeployment training and certification. Units' FST personnel were tracked by name and held responsible for conducting level I PM in their respective operational environment.

Field sanitation teams were usually dysfunctional or nonexistent at contingency operating locations where small military, police, or border transition teams lived and worked closely with Iraqi Security Forces in extremely austere environments. Although basic field sanitation is part of predeployment training, and team medics receive a 2-hour block of instruction upon arriving in theater, they typically do not receive the comprehensive 40-hour FST certification course at their respective home stations. As a result, organic level I PM was not adequate at transition team sites, especially at the beginning of a team's deployment.

Healthcare specialists in the operational environment should take ownership of this important responsibility. In the current operational environment, medical personnel bear the brunt of FST duties whether they are FST trained or not. Current doctrine states that at least one FST member must be a medic, if available. This doctrine should be amended to mandate that all medics fulfill FST duties. Further, initial training for medics should be expanded to include detailed field sanitation topics. With this training, the FST program in a combat unit can be transitioned solely to medical personnel.

Level II PM Teams--Stretched Thin

Even with acceptable level I FST support at the majority of base camps, level II PM personnel operated at maximum capacity for the duration of their deployment. With a division operational environment consisting of over 90 base camps, each of the 4 brigade PM teams covered an average of 23 sites. For the modular BCTs with an ESEO and a PM specialist, this was a daunting task. The job was virtually impossible for the staff sergeant PM specialist who was solely responsible for up to 25 sites in the 3rd Armored Cavalry Regiment operational environment.

The goal was to conduct a monthly base camp assessment of every site. Given the workload and limited personnel, it was up to each level II PM team to prioritize site assessments based on need, number of personnel supported, and degree of contracted life support. Small base camps in austere environments usually had the greatest need. Larger contingency operating sites and bases had many more personnel, more contracted life-support functions, and overall better field sanitation.

According to Army Field Manual 4-02.17, (7)

   Tactical dispersion places combat elements largely on
   their own for PM self-protection; however, there are
   opportunities for PM detachments to provide support in
   these situations. The detachments must seek out such
   opportunities and give priority to the combat
   elements ... Preventive medicine detachments provide
   the most responsive support when they work directly
   with units at the greatest risk.

Two PM detachments, each with a modified table of organization and equipment * authorization of 13 Soldiers, provided level III support in the Task Force Iron operational environment. They focused their operations primarily on the highly populated logistical hubs of Contingency Operating Base Speicher and Joint Base Balad. After the rapid expansion of base camps in Multi-National Division North, both of these units stepped up and provided vital support to the Task Force Iron BCT PM assets. Since the PM detachments' higher headquarters was the medical brigade and not Task Force Iron, the division surgeon coordinated with the MNC-I surgeon for PM support from the medical brigade for 12 different base camps. This synchronization of effort between BCT level II PM and detachment level III PM paid tremendous dividends.

Doctrinal change for the composition of BCT PM assets is warranted in a time of persistent counterinsurgency operations that involve multiple dispersed base camps in harsh environments. Sames et al (8) notes that a BCT PM team is composed of 2 relatively junior personnel. PM detachments will have to continue to fill the gap by performing a level II PM mission if no doctrinal change is made. The BCT ESEO and PM specialist should be augmented with another, more experienced PM specialist to ensure more thorough base camp coverage. Alternatively, the junior PM specialist could be replaced with a seasoned noncommissioned officer, significantly boosting the experience level of the BCT PM team and helping to facilitate practical, simple, and efficient solutions to units' field sanitation concerns.

PM Relationships with the Iraqi Security Forces

   Helping others to help themselves is critical to winning
   the long war. (9)

Addressing field sanitation and general PM issues with our Iraqi Security Force counterparts was a constant challenge. The primary focus was issue resolution in conjunction with Iraqi Security Force self-sustainability. Poor infrastructure, resource availability, and cultural differences contributed to conditions that occasionally threatened the health of Task Force Iron personnel. Transition teams living on base camps adjacent to Iraqi Security Force base camps were most often affected. Examples include a burst main sewer line and an entire sewer system that suddenly stopped functioning due to lack of fuel for the generator-powered lift stations. The BCT PM team identified the immediate health threat from sewage overflow and implemented basic personal protective measures against vector-borne diseases.

The larger problems dealt with Iraqi Security Force sustainability and prevention of similar incidents. Who repairs the pipe? Who supplies gas for the generators? With what money? How can the lift stations be connected to the local grid so generator power is unnecessary? The division ESEO collaborated with other key staff sections such as division engineer (G-7), logistics (G-4), and Iraqi Security Forces to facilitate long-term, self-sustainable solutions to problems that had public health repercussions to Task Force Iron personnel. This is a clear advantage resulting from transformation and the division staff ESEO position.

OPPORTUNITIES

Modularity and the resulting reorganization of PM personnel in BCTs and the division headquarters have certainly provided new opportunities and allowed for creative solutions to public health concerns in the deployed environment.

Mobility

Traveling across the operational environment to accomplish the PM mission was one of the greatest hurdles to overcome. Travel by helicopter was limited to hours of darkness, required extensive coordination, was notoriously unreliable, and had limited space for PM equipment. Ground convoy or combat logistics patrols were used to conduct the majority of PM missions. The location of the BCT PM team within the brigade support battalion was ideal for coordination of predictable and reliable travel to all base camps.

Force Protection Dogs

US Army 5th Corps General Order Number 1 (March 19, 2003) forbid the use or adoption of mascot animals, but the prohibition was routinely ignored throughout Iraq. Mascot dogs were present on approximately 20% of the base camps throughout the Task Force Iron operational environment. To address the issue, all division ESEOs collaborated with the MNC-I force health protection office and theater veterinary officials to establish a force protection dog program. The animal would no longer be classified a mascot if it was:

* Employed as a legitimate force protection asset (ie, patrolling, early warning, watch dog),

* Examined by a veterinarian and received a rabies immunization, and

* Posted on official orders signed by the unit commander. BCT PM teams facilitated the success of this effort by assisting with transportation of veterinary assets and maintaining accountability of compliant versus noncompliant animals in their respective operational environments. Over 40 dogs in Multi-National Division North were part of the program, which ultimately allowed the unit to keep the animal for a legitimate purpose while mitigating the associated health risk.

Division Force Protection Working Group

The division ESEO served as the surgeon cell representative on the force protection working group. Other team member s included senior noncommissioned officers and officers from the G-7, safety, and provost marshal cells. Focusing on the smaller base camps more vulnerable to enemy action and field sanitation issues, team members personally visited 95% of all contingency operating sites and contingency operating locations in the Task Force Iron operational environment. This was an excellent chance to redefine traditional force protection that focuses on barriers and concertina wire. Incorporating force health protection, specifically preventive medicine, into this division-level working group accomplished 4 significant objectives:

* Inserted a medical aspect into protecting the force and keeping Soldiers in the fight. This combat multiplier demonstrated to the Warfighter that medical authorities bring more than traditional patient evacuation and treatment to the fight.

* Increased command emphasis of preventive medicine issues and the willingness to follow through with BCT PM team recommendations. Unit leaders on the ground were more receptive to a division-level assessment team with an ESEO (rank of Major) conducting a PM assessment. The division commander provided command emphasis at the highest level when he directed that all recently completed PM assessments and outstanding issues be briefed at the weekly battle update assessment. This truly put PM at the forefront and facilitated the BCT PM team mission.

* Allowed the division ESEO to travel throughout the entire operational environment [a rare opportunity for division staff officers] and really understand issues the BCT PM teams were facing. The junior BCT ESEOs, most of whom had less than a year of service in the Army, accompanied the force protection working group team when possible. They were able to receive face-to-face instruction and mentoring from a more seasoned ESEO.

* Facilitated the quality of life working group, a chaplain-led initiative to improve the general living conditions at small and austere base camps. Effective PM is a key component of force protection, as well as an important piece of the Soldier's quality of life.

CONCLUSION

The practice of PM operations in a counterinsurgency environment remains very complex and is constantly changing. Innovative and more efficient solutions to PM concerns are always needed in the operational environment. Army transformation has certainly helped deliver better PM support to Soldiers on the ground. The decentralization of PM personnel, increased number of ESEOs, and addition of a field grade staff ESEO in today's modularized division has paid tremendous dividends. In spite of these gains, the suggested doctrinal and personnel changes must be considered for optimal force health protection on today's nonlinear battlefield.

REFERENCES

(1.) Belasco JA, Stayer RC. Flight of the Buffalo: Soaring to Excellence, Learning to Let Employees Lead. New York, NY: Grand Central Publishing; 1994.

(2.) Ciesla JJ. The evolving role of environmental science officers and environmental engineers in the Medical Service Corps. Army Med Dept J. April-June 2006:20.

(3.) Field Manual 4-02.6: The Medical Company. Washington, DC: US Dept of the Army; 1 August 2002:3-7.

(4.) Division / Brigade Combat Team Modified Table of Organization and Equipment Authorizations. United States Army Force Management Support Agency, Force Management System web site [Restricted access document]. Available at: https://webtaads.belvoir.army.mil/protected/ WebTAADS/Frame_DocTypes.asp?GUID=1247913902.

(5.) Petraeus DH. Interview [transcript]. British Broadcasting Corporation. September 11, 2008. Available at: http://news.bbc.co.uk/2/hi/middle_east/7610405.stm.

(6.) Army Regulation 40-5: Preventive Medicine. Washington, DC: US Dept of the Army; 25 May 2007:4.

(7.) Field Manual 4-02.17: Preventive Medicine Services. Washington, DC: US Dept of the Army; 28 August 2000:p4-3.

(8.) Sames WJ, Delk TC, Lyons PJ. Field preventive medicine: challenges for the future. Army Med Dept J. April-June 2006:40-45.

(9.) Office of the Secretary of Defense. Quadrennial Defense Review Report. Washington, DC: US Dept of Defense; February 6, 2006.

MAJ Kenneth D. Spicer, MS, USA

* Throughout this article, brigade-sized maneuver elements are referred to as BCTs. They include infantry brigade combat team, heavy brigade combat team, stryker brigade combat team, armored cavalry regiment, and stryker cavalry regiment. The Author

* Defines the structure and equipment for a military organization or unit.

MAJ Spicer is the Division Environmental Science and Engineering Officer for Headquarters, First Armored Division, Wiesbaden, Germany.