Improvement of force health protection through preventive medicine oversight of contractor support.INTRODUCTION
The federal government, including the Department of Defense (DoD), is increasingly reliant on contractors to carry out support functions in contingency operations. (1) The estimated number of private contractors working in Iraq may now top 100,000 and could exceed the actual number of troops in theater. (2) In addition to US contractors and third country nationals brought into Iraq to work for contracting firms, Coalition forces are also contracting services from local nationals at hundreds of smaller Coalition outposts and joint security sites.
Contracting offers numerous advantages to the DoD. It is an effective way to furnish the massive manpower necessary to construct and sustain base camps, thus freeing Soldiers from these onerous duties and enabling them to focus their energies on winning the counterinsurgency fight. Contracting provides technicians and other highly-skilled professionals such as Arabic interpreters, law enforcement trainers, intelligence analysts, fire fighters, and unmanned aircraft operators that are either critically short or unavailable among the DoD civilian and service member workforce. Contracting also aids in stimulating host nation economies by pumping American dollars to local businesses and employing large numbers of local nationals. On the flip side, the phenomenal growth in contracting has taxed DoD's oversight and accountability systems. This, in turn, has made thwarting malfeasance, fraud, abuse, and second rate performance more difficult.
THE FORCE HEALTH PROTECTION CHALLENGES OF CONTRACTING
Most of the basic life support services delivered by contractors have direct impacts on Soldier health. These services include pest management, waterworks (ie, potable water production, storage, transport, and distribution), trash disposal, and dining facility operations. (3) Heightened disease and nonbattle injury rates in the form of waterborne, foodborne, or vectorborne disease outbreaks could result if these vital services are delivered in a substandard manner.
The contractors themselves can pose a health threat to Soldiers. Most third country national workers originate from less developed countries, where medical care is poor or nonexistent, and communicable diseases such as tuberculosis and hepatitis are highly endemic. The same conditions hold true for their local national counterparts. Without proper precautions, third country nationals and local nationals can transmit diseases to Soldiers. Most contracts require workers to pass a health exam or screening as a condition for employment. There are generally no contract provisions stipulating where these screenings occur. As a result, the majority of screenings are conducted abroad or in the host nation at nonaccredited, insufficiently equipped, and meagerly staffed clinics. These clinic shortcomings, coupled with rampant corruption and several tuberculosis outbreaks among prescreened third country national contractor populations, makes most screening results dubious at best.
Contracts utilizing third country nationals and US workers usually obligate the contractor to furnish medical care to their employees. Cases of noncompliance are quite common with significant numbers of laborers arriving in theater without the support, equipment, and pharmaceuticals necessary to medically sustain them. When this occurs, the burden of care falls on the DoD medical facilities. Presently, there is no standardized mechanism for the DoD to charge the contractor for delivered medical services, thus allowing the contractor to often escape paying compensation and penalties for this contractual violation.
Bases employing third country national and local national laborers are more vulnerable to attacks on critical infrastructure and intentional contamination of food and water supplies should the contractors harbor hostility towards Coalition forces. As residents and frequent visitors to the bases, these laborers can poison wells, bottled water stocks, and stored rations. They could also destroy critical infrastructure such as reverse osmosis water purification units and radar systems by sabotage or relate invaluable targeting intelligence to insurgent groups. Even without hostile intent, the workers could steal unsecured rations or bring unapproved and contaminated food supplies onto the base to sell or serve to Soldiers
As the principal proponent for force health protection (FHP), preventive medicine (PM) units must play a decisive role in the contracting process. Their ability to recognize health threats, assess camp sanitation conditions, discern food and water system vulnerabilities, and devise disease prevention stratagems are crucial towards resolving these daunting FHP challenges.
TYPES OF SUPPORT CONTRACTS
The two main types of basic life support service contracts utilized within the Iraq theater of operations are Logistics Civil Augmentation Program (LOGCAP) and contingency contracts in the form of purchase request and commitments (PR&Cs). Each contract type has its own unique quality assurance and quality control processes. For effective oversight to occur, PM must understand these processes and the differences between contract types.
LOGCAP is a worldwide contingency service contract that reinforces military assets with civilian contract support primarily focused on the provision of basic life support services to Coalition forces. The sole LOGCAP provider in Iraq for the Army is KBR, Inc (Houston, Texas) which embeds its personnel within the logistic divisions on the contingency operating bases. LOGCAP services are not contractually authorized for outlying locations with less than 150 Soldiers, with the exception of repairs essential to the protection of life, health, and safety. (4) Under LOGCAP, contract administration, property administration, and quality assurance are performed by the Defense Contract Management Agency (DCMA). (5)
The more numerous and austere contingency operating locations, such as joint security sites and Coalition outposts, are unsupported by LOGCAP. At these sites, PR&Cs are enacted that employ local national contractors for services that cannot be provided by organic combat support/combat service support assets due to competing missions or lack of skill sets. (4) PR&Cs are usually initiated at the battalion command level and must include detailed statements of work (SOWs) and 3 bids/estimates from different contractors. Under unique time/safety/mission circumstances, a sole-source contractor may be used. (4) The SOWs and other supporting documents are compiled into a packet staffed through brigade, division, and corps headquarters before receiving ultimate approval or rejection from the Joint Contracting Command-Iraq. The entire vetting process can take several weeks, especially if the packet is incomplete and the SOW is too vague or poorly written.
FORCE HEALTH PROTECTION SHORTFALLS IN THE LOGCAP OVERSIGHT PROCESS
The DCMA quality assurance representatives are tasked with monitoring the quality of LOGCAP contractor work and assessing their performance. They execute this mission by auditing contractor processes, projects, and internal management controls and receiving monthly assessments conducted by contracting officer representatives (CORs) on specific basic life support services. (6) In theory, personnel designated as CORs are professionally trained and subject matter experts who possess the technical wherewithal to evaluate their basic life support area. In reality, unqualified individuals are frequently assigned COR responsibilities for expediency sake. This has been especially problematic in the selection of waterworks and pest management CORs, services which PM personnel are uniquely qualified to assess.
Both quality assurance representatives and CORs use checklists to perform their assessments. These checklists typically mirror checklists found in existing DoD policy documents. For example, the dining facility operations checklist closely resembles Army Form 5162-R, Routine Food Establishment Inspection Report, which is found in Army Technical Bulletin MED 530. (7) Each requirement listed on the checklist is furnished with the name and paragraph number of its corresponding reference document. If there is no relevant DoD reference document , the requirement is referenced against its corresponding LOGCAP contract task order and section number. Responses to inquiries made to DCMA by this author suggest that PM reviews of checklists and task orders relevant to force health protection occur sporadically, but are not institutionalized document development requirements.
FORCE HEALTH PROTECTION SHORTFALLS IN THE PR&C OVERSIGHT PROCESS
Many of the battalion contracting officers tasked with development, submission, and management of PR&Cs receive no formal training on their duties before they are named to the positions. Since the position is considered an additional duty, the appointing authorities often make opportune appointments and not necessarily assign the person best-suited for the position. In general, these contracting officers are unfamiliar with PM and fail to recognize the FHP implications of the contracts. When coupled with no PM oversight, this unfamiliarity is a recipe for disaster and has led to shoddy contract work and increased health risks. Examples of this include the interior coating of potable water storage tanks with paints mixed/thinned with hazardous solvents, an attempt to purchase and install a $108,000 commercial reverse osmosis water purification system incapable of treating the exceptionally salty water from a joint security site groundwater source, and efforts to utilize local national personnel who have not received food service sanitation training or medical screening in food preparation positions.
Level II PM (ie, brigade combat team PM sections and division surgeon section PM officers) can prevent PR&C shortfalls by carefully reviewing and inserting FHP stipulations into statements of work. This will provide the contracting officer with a defense against poor performance since the contract can be terminated if the local national contractor fails to execute the service in a manner protective of health and safety. A tightly-written statement of work also offers the additional advantage of educating local national contractors on "acceptable" Coalition performance standards, which, in numerous instances, differ from their own. Examples of FHP stipulations that are often missing in common types of PR&Cs statements of work are shown in the Figure.
STEPS TO ENHANCE CONTRACT OVERSIGHT BY PREVENTIVE MEDICINE
The following changes in PM doctrine, training, leadership, and education practices will strengthen PM's role in contract oversight processes:
* Clearly define contract oversight responsibilities in PM policy documents. Current doctrine is woefully insufficient on this subject. For example, there is no discussion of contract oversight in Army Field Manual 4.02-17, (8) the Army's premiere guidance document on the organization, mission, function, capabilities, and employment of deployed PM elements.
* Establish a rapport between Headquarters, DCMA, and the service medical authorities to ensure FHP is integrated into LOGCAP and PM input is incorporated into contracting officer representative checklists. A joint working group comprised of Army, Navy, and Air Force PM experts could be created to collectively address FHP-related contracting issues, should excessive confusion arise from each of the individual service's respective PM proponents interactions with DCMA. The Armed Forces Pest Management Board, a jointly staffed organization, is pursuing this approach to address vector control services. The joint working group could also include health care administrators to discuss the compensation mechanisms associated with contract labor use of DoD medical assets.
* Appoint PM officers and noncommissioned officers (NCOs) as the waterworks and pest management contracting officer representatives at LOGCAP sites. Since these Soldiers receive extensive training on water production and storage site inspections, water system vulnerability assessments, and integrated pest management practices, and deploy with the equipment needed to monitor water quality and conduct pest surveillance, they are ideally suited to assume contracting officer representative responsibilities. At forward operating bases, where both level II and level III PM (ie, PM detachments) are present, level III PM should; by default, be designated as the lead evaluators. This is in deference to their greater professional experience and higher rank command structure.
* Task PM detachment entomologists (area of concentration 72B) to provide technical support to all pest management contracting officer representatives (CORs) within their respective geographical mission support areas. With a minimum of a master's degree in entomology and graduation from the DoD certified pesticide applicator course, they are the best-trained, uniformed, pest management professionals in theater. Their expertise should be put to good use training CORs in the evaluation of performance oversight roles and performance standards.
* Introduce contract oversight and PR&C statement of work reviews as part of the 6A-F5: Principles of Preventive Medicine Course, and the 6A-F6: Preventive Medicine Program Management Course, both of which are taught at the Army Medical Department Center and School. Incorporate contract oversight and statement of work review into Combat Training Center scenarios and US Army Center for Health Promotion and Preventive Medicine (USACHPPM) technical assistance visits.
* Recommend that all officers and senior NCOs assigned to level II and level III PM units enroll and complete the Defense Acquisition University's online COR course. * The course provides an excellent overview of COR ethics, duties, and responsibilities. Course completion is a prerequisite for COR position assumption. Completion prior to deployment is preferable due to the connectivity challenges and online time constraints commonly encountered in theater.
* Furnish CORs of other basic life support services with copies of relevant inspections and alert them to force health protection related deficiencies which are detected during PM assessments and inspections. For example, the food service and Morale, Welfare, and Recreation CORs should be notified when contractor-operated dining facilities and fitness facilities fail their routine sanitation inspections. This will aid those CORs to more accurately assess performance and exert their considerable influence in rectifying deficiencies.
* Archive completed waterworks and pest management COR checklists in the USACHPPM occupational and environmental health surveillance data archive. ([dagger]) Competent and diligent performance of these services is vital for the creation of salubrious environmental health conditions at base camps. The health consequences of substandard performance can be severe and may not become evident until long after the deployment. By archiving the checklists, epidemiologists could better understand site health conditions and diagnose the causes of post deployment medical problems were they to arise.
* Assist contracting officers in preparing the initial PR&C statements of work. This step would foster teamwork between PM and battalion contracting officers, strengthen the FHP provisions within the statements of work, reduce approval delays, and better educate the contracting community about the importance of PM and how to write contracts protective of health.
* Formalize the PR&C packet staff approval process to mandate level II PM review of all statements of work bearing FHP implications, with the initial and final PM reviews performed by brigade combat team and division surgeon section PM officers; respectively. Such a process would ensure that FHP concerns are addressed at the lowest levels, expediting packet approval and contract letting. This was done with much success by the Multinational Division-Baghdad (MND-B) staff through an automated process that permitted each section to examine scanned statements of work in digitized packets on the secure internet protocol router email and either approve, approve with comments, or reject the contract.
Whether it is LOGCAP-provided cooks feeding headcounts into the thousands at a large forward operating base dining facility, or an Iraqi entrepreneur pumping out chemical latrines at a joint security site or Coalition outpost, contractors are now the main providers of basic life support services at forward operating bases. Contractor performance directly impacts the health and welfare of our Soldiers, but the current oversight mechanisms necessary to champion force health protection are insufficient. The solutions to this problem will require a concerted effort by commanders, logisticians, and the PM community, and implementation of numerous enhancements to contract oversight processes.
I wish to extend special thanks to LTC Peyton Potts, MNDB G4 LOGCAP Officer, and MAJ Robert Huber, MND-B Contracting Officer, for their review and input on the contracting processes. Also, LTC David Ristedt, MND-B Division Surgeon, Troy Ross, the MND-B Preventive Medicine Officer, and MAJ James Waddick, MND-B Deputy Division Surgeon, provided invaluable input to this article.
(1.) Office of the Comptroller General of the United States. Defense Management: DoD Needs to Reexamine Its Extensive Reliance on Contractors and Continue to Improve Management and Oversight. Washington, DC: US Government Accountability Office; March 11, 2008. Available at: http://www.gao.gov/new.items/d08572t.pdf.
(2.) Gregory L. Increasing reliance on private contractors in Iraq raises questions. Chattanooga Times Free Press. May 2, 2008; Local News. Available at: http://timesfreepress.com/news/2008/may/02.
(3.) Llama W. Contingency contracting and LOGCAP support in MND-B, Iraq. Army Logistician. 2007;37 (5):28-29. Available at: http://www.almc.army.mil/alog/issues/SepOct07/browse.html.
(4.) Potts P. Presentation to the Victory Base Complex Preventive Medicine Forum. January 2008; Camp Liberty, Iraq.
(5.) Spencer GT. DCMA Supporting Multi-National Forces in Iraq. [News release, Defense Contract Management Agency Web site]. September 13, 2005. Available at: http://www.dcma.mil/communicator/news_release/2004/NR_091304.htm.
(6.) Office of the Assistant Secretary of the Army for Acquisition, Logistics, and Technology. Memorandum for Record. Subject: Contract Administration and Surveillance for Service Contracts. Washington, DC: US Dept of the Army; February 9, 2007.
(7.) Technical Bulletin MED 530: Occupational and Environmental Health Food Sanitation. Washington, DC: US Dept of the Army; October 30, 2002.
(8.) Field Manual 4-02.17: Preventive Medicine Services. Washington, DC: US Dept of the Army; August 28, 2000.
MAJ Scott A. Mower, MS, USA
* Information available at https://acc.dau.mil
([dagger]) Information available at firstname.lastname@example.org
MAJ Mower was the Multinational Division-Baghdad Environmental Science Officer during Operation Iraqi Freedom 07-09.
Examples of force health protection stipulations that should be included in purchase request and commitment statements of work. Contracted Necessary Force Health Protection Service Stipulations Chemical latrines Mount and maintain hand sanitizer dispensers (portable toilets) Use 62% ethanol-based hand sanitizers Refill with a blue water solution after emptying Trash removal Pressure wash/clean dumpsters on a monthly basis Require functioning dumpster lids and replacement when broken Request metal dumpsters rather than plastic (metal dumpsters are preferable since trash can be burned inside them when overfilled or the contractor fails to empty them on schedule) Bulk water deliveries Delivered water must have a minimum 2 PPM and maximum 5 PPM residual chlorine Truck must be cleaned and inspected by field sanitation team member before acceptance of delivery Water must meet acceptable aesthetic qualities (color, odor, and clarity) as determined by PM Local national Restrict laborers from direct food handling, janitorial support preparation, and serving Prohibit sick individuals from working Building renovation Ban use of paints with added diesel fuel, and construction benzene, and other thinners projects Instruct contractor to use practices that minimize aerosolization of paint chips, insulation, and other debris to reduce exposure risks to Coalition forces