Establishing a base camp assessment program for a forward operating base.
Historically, 80% of all hospital admissions have been from disease and nonbattle injuries. (1) Preventive medicine measures are simple, common sense actions that any service member can perform and to which every leader can subscribe. In the preventive medicine world, there have always been difficulties ensuring the safety of geographically separated Soldiers. During Operation Joint Endeavour in 1995, base camp assessment teams were established to evaluate quality of life at forward operating sites in Bosnia. Currently, we have Soldiers located in many parts of the world, eastern Europe, the middle east, southwest Asia, and in the Balkans. The names change, but the basic concept of a base camp assessment team remains the same--and is always applicable.
It is easy when an entire brigade combat team is on a single forward operating base, but what do you do when there are many forward operating bases? For example, while deployed to Afghanistan in 2006 for Operation Enduring Freedom, my brigade was dispersed over 12 geographically separated forward operating bases. Since you cannot be everywhere at one time, how do you prevent mission failure due to environmental health issues? There must be a program to organize a systematic, holistic approach to plan, develop, implement, and maintain environmental health surveillance at these forward base camps. That program is the base camp assessment program. Implementation of a base camp assessment program begins prior to arrival in-theater.
BASE CAMP ASSESSMENT PROGRAM
The 2 main references that form the basis of an environmental health surveillance program are Department of Defense Instruction 6490.03, (2) and Joint Chiefs of Staff Memorandum MCM 0028-07. (3) These documents define environmental health surveillance as the regular or repeated collection, analysis, archiving, interpretation, and dissemination of data related to deployment occupational and environmental health.
The base camp assessment program uses environmental health surveillance data for health monitoring, the determination of potential health hazard impact on a population or individual personnel, and for the timely intervention to prevent, treat, or control the occurrence of disease or injury when determined necessary. (2,3) This is the starting point.
Department of the Army Pamphlet 40-11 (DA PAM 40-11) (4) defines the programs and services within the medical functional area of preventive medicine. All preventive medicine Soldiers should read this pamphlet to identify US Army publications that delineate functions and contain the detailed instructions, guidance, and procedures necessary for implementing the policies and responsibilities outlined in Army Regulation 40-5. (5)
At this point many will say, "those are garrison programs, I am in the field." While it is true that these are predominately garrison-based programs, they should not be excluded. Where better to find out what you can and should be doing than by mirroring an established garrison-based program. Train as you fight. DA PAM 40-11 (4) outlines all of the environmental health programs included in a base camp assessment program. It is more than just checking trash cans and sniffing latrines.
The base camp assessment is the key in an active preventive medicine program; however, there needs to be a clear understanding of the purpose of the base camp assessment program. The program is the assessment of the overall health status of Soldiers. The program should be flexible enough to meet the continually evolving needs of the Soldier and to accommodate the operation and changes in patterns of disease and injury. The goal of the program is to develop a comprehensive preventive medicine program to reduce disease and nonbattle injury through proactive measures.
Figure 1. Typical components of a base camp assessment (list not exhaustive). * Water Supply * Food Service Sanitation * Troop Billeting/Sleeping Area * Waste Disposal * Pest Management * Noise Hazard Identification & Control * Field Sanitation Teams * Barbershop Sanitation * Heat Injury Prevention
COMPONENTS OF THE PROGRAM
Using DA PAM 40-11 (4) as a guide, a base camp assessment program can comprise many components. The individual components will vary depending on the forward operating base and the maturity of the theater. Typically, a base camp assessment program will consist of water surveillance, food service inspections, living area inspections, waste disposal, pest management, climatic injury prevention, and basic camp sanitation inspections. But it need not be limited to these (Figure 1). As the camp and theater mature, some programs will become routine, while others will emerge as greater risks. This may sound like a daunting task and one that is beyond the scope of a small preventive medicine cell within a brigade combat team. However, it is what you already do. The base camp assessment just brings it all together.
COMPREHENSIVE ASSESSMENTS: A HOLISTIC APPROACH
Development of a base camp assessment program for a forward base camp should follow a holistic approach. Focusing on a few individual components will not be sufficient in establishing a successful base camp assessment program. It needs to address the full spectrum of preventive medicine programs. A key to a successful base camp assessment program involves linking together what you already do, as illustrated in Figure 2. The problem is that we typically do not look at these programs on a continuum. Instead, we approach them as individual stovepipes and miss or overlook the warning signs. Typically, it is only after an outbreak or an increased incidence of disease that we start looking at the different environmental health programs holistically.
Sickness can come faster than you can anticipate. Being proactive with your preventive medicine duties is essential in stopping a possible mission failure. Something as simple as Soldiers not washing their hands could have a catastrophic effect on a platoon. Highlighting this simple failure as the starting point for an example of the spread of infection/disease/ illness: a Soldier acquires gastrointestinal disease, he/she could easily spread that illness to all his/her fellow Soldiers by playing cards. If the platoon is ineffective because of sickness, the mission will suffer. This could have a domino effect that could impact the battalion. The break in the preventive medicine measures chain can put other missions on hold. It is our job not only to get the word out to the Soldier, but also to ensure the Soldier is practicing his/her preventive medicine measures.
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A proper base camp assessment program attempts to tie the different preventive medicine and environmental health programs into a single assessment. The aim is to be proactive. To do this, we need to look at the second and third order effects of the individual findings. Then ask ourselves if any of them are related. Do the less than satisfactory sanitation practices in the dining facility, no chlorine residual, and a slight increase in sick call numbers have anything in common? Is it a sign of a bigger problem? These are some of the questions we should ask ourselves when we look at this holistically.
COMPOSITE RISK MANAGEMENT
The actual assessment portion of a base camp assessment requires the use of the information collected from your findings to identify hazards, assess the potential risks, determine appropriate risk control measures, and communicate the risks to the forces using composite risk management (CRM), graphically portrayed in Figure 3. Hazard severity is a measure of the impact of the interaction of the health hazards on Soldiers. Hazard probability is determined by estimating the percentage of the population that could be exposed to that hazard. Finally, the overall health risk estimate is determined by using the CRM matrix in Table 3-3 of the US Army Center for Health Promotion and Preventive Medi cine (USACHPPM) Technical Guide 230 6 and Army Field Manual 5-19.7 Using CRM doctrine will enable you to convey your message in a clear and universally understandable language: green, amber, red, and black. After determining the health risk, set in place a risk communication plan to deliver key messages of the health risk and the recommendations to lower the risk.
[FIGURE 3 OMITTED]
Communication consists of 3 key components: document (eg, report), inform, and archive (Figure 4).
Documentation of everything is not only critical for presenting accurate results to your chain of command, it is essential for future missions. Having great documentation can effectively help the next preventive medicine team that follows you, and retains complete, accurate records of your findings and recommendations. Document the negative and the positive findings, and, keep your findings straightforward so that higher leadership will understand. The report does not need to be complex or a lengthy dissertation: keep it simple. Use an executive summary for the senior commanders and staff. Ideally, it should be a one-page snapshot of your work. Graphics are good. The report should be detailed enough to paint a picture of the health status of your forward operating base. If you have the capability, include all of your inspection forms as enclosures. Document negative findings; if you looked at something and found nothing, state it. It is important to note when everything was okay. We in preventive medicine do not do a good job in this area. We are very good about documenting when we see deficiencies, but fail to properly record and report when everything was satisfactory.
Keep your command informed. Routine reporting of your base camp assessment to your command keeps them apprised of the preventive medicine "health" of their command and they will come to expect to see your report. It is not whom you include, it is whom you leave out. Inform critical personnel, key staff, and commanders on a regular basis. Document and keep records of whom you inform.
Archiving the base camp assessment reports is important. All of your inspection forms and reports should be archived by submitting directly to the Defense Occupational and Environmental Health Readiness System data portal. * Use historical data for that specific site to develop an environmental health surveillance program for a specific forward base camp. Contact USACHPPM ([dagger]) to receive information on that site/location, using the Global Threat Assessment Program.
SOME TACTICS, TECHNIQUES, AND PROCEDURES
Putting prevention into practice is not always easy. Inspect, monitor, and record all documents for dining facilities, barbershops, gymnasiums, detention cells, food establishments, and water storage containers to ensure the safety of the Soldiers. There are a number of ways to accomplish this mission, here are a few tips:
1. Know doctrine and the regulations backwards and forwards. If you know doctrine, you will know when to follow it and when to modify it according to your situation. Remember, doctrine is a starting point. Likewise, regulations can assist you in knowing what you need to do.
2. Establish field standard operating procedures and smart-book checklists before you deploy. Test your program in garrison, what better way to run a battle drill and get your command familiar with your reports and preventive medicine. Use historical data for that specific site to develop your base camp assessment program for a specific forward base camp. Contact USACHPPM ([dagger]) to obtain information on that site/location, using the Global Threat Assessment Program.
3. Do not settle for the status quo. Once you have established the basic programs and they are running smoothly, expand those programs. Increase the level of expectation as facilities and support services increase their ability to provide safer, better quality services. If contracted services are used, be sure you coordinate actions through the contracting office.
4. Be an evangelistic preventive medicine Soldier. You should be getting out and reaching out to all. Everyone should know you. During meetings, have a "tip of the week" for your commander. Get out and go to every meeting. Be around at all times. No matter what types of questions they ask, they still know who you are. These managers want to do what is right. Helping them succeed means you have a better chance to succeed in your preventive medicine mission. In addition, develop personal working relationships with the mayor's cell, base camp commander, and the contracting office on the forward operating base.
Figure 4. The elements of a risk communication plan. COMMUNICATION Document Report Document negative findings Executive summary (keep it simple) Inform Keep base camp & task force commanders informed Set routine schedule/timeline for report Get involved Archive Data and Reports Submit directly to DOEHRS data portal https://doehrswww.apgea.army.mil/front.htm Submit via email Unsecuredfirstname.lastname@example.org Securedemail@example.com Submit via regular mail USACHPPM Attn: MCHB-TS-RDD Bldg E-1675 5158 Blackhawk Road Aberdeen Proving Ground, MD 21010-5403
The base camp assessment is not another rock in your rucksack; it is a holistic approach to preventive medicine that enables you to interconnect the inspections you routinely do in order to gauge the overall health and sanitation of your forward operating base. It is what you already do: just a different approach to packaging the findings. Use this collection of data to lower the possibility of mission failure and maximize the fighting strength. Have an established base camp assessment program for forward base camps to monitor all aspects of preventive medicine. The program is dynamic and must readily change and adapt as Soldiers and missions change. The overall result of a successful base camp assessment program for forward base camps is lower numbers of casualties due to disease and nonbattle injury.
(1.) Field Manual 21-10: Field Hygiene and Sanitation. Washington, DC: US Dept of the Army; June 21, 2000.
(2.) Department of Defense Instruction 6490.03: Deployment Health. Washington, DC: US Dept of Defense; August 11, 2006.
(3.) Office of the Chairman, Joint Chiefs of Staff. Memorandum MCM 0028-07, Procedures for Deployment Health Surveillance. Washington DC: US Dept of Defense; November 2, 2007. Available at: http://amsa.army.mil/Documents/JCS_PDFs/ MCM-0028-07.pdf.
(4.) Department of the Army Pamphlet 40-11: Medical Services: Preventive Medicine. Washington, DC: US Dept of the Army; October 20, 2008.
(5.) Army Regulation 40-5: Preventive Medicine. Washington, DC: US Dept of the Army; May 25, 2007.
(6.) Technical Guide 230: Chemical Exposure Guidelines for Deployed Military Personnel. Version 1.3. Aberdeen Proving Ground, MD: US Army Center for Health Promotion and Preventive Medicine. May 2003. Available at: http://chppm-www.apgea.army .mil/documents/tg/techguid/tg230.pdf.
(7.) Field Manual 5-19: Composite Risk Management. Washington, DC: US Dept of the Army; August 21, 2006.
LTC Timothy Bosetti, MS, USA
([dagger]) email address: firstname.lastname@example.org
CPT Davin Bridges, MS, USA
CPT Bridges is an Environmental Science Officer and the Program Manager of the US Army Center for Health Promotion and Preventive Medicine--Europe Deployment Environmental Surveillance Program.
LTC Bosetti is Chief of the Department of Environmental Sciences at the US Army Center for Health Promotion and Preventive Medicine--Europe.