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One health and force health protection during foreign humanitarian assistance operations: 2010 Pakistan flood relief.

Army Regulation 40-1 (1) defines the duties of the various Army Medical Department (AMEDD) Corps. Traditionally, there has been a clear distinction between the duties of one Corps and those of the others with little overlap, although exceptions do exist, such as food inspections performed by both veterinary and preventive medicine personnel. This is largely a result of the specialized training that AMEDD personnel receive. Officers often require 4 to 8 years or more of formal education prior to entry into military service, which is followed by additional Corps specific training within the military, and oftentimes annual professional continuing education. This training is necessary to ensure officers possess the knowledge, skills, and proficiency to carry out the demanding requirements of their respective professions. These individuals are subsequently assigned to specific medical units which have clearly defined capabilities that are distinct from the medical units of the other AMEDD Corps. (2) Deployment of these units during military operations is generally related to the size of the supported force (for example, one medical detachment, veterinary services per 70,000 Army personnel in a combat zone). This basis of allocation is intended to ensure that adequate numbers of trained individuals are present in the theater to carry out the broad range of medical missions necessary to protect and promote the health of the fighting force.

Unfortunately, during foreign humanitarian assistance (FHA) operations such as disaster relief, it may not be possible to deploy these medical units in their entirety. The number of deployed servicemembers in the area of operations may not warrant an entire unit, or a complete unit may not be readily available for a rapid response to an unexpected disaster. In other situations, the existing status of forces agreement, or lack of one, may have restrictions which limit the number of US servicemembers that may be present in the country or disaster area. Although the US forces supporting FHA operations may have some reduced medical requirements, (for example, no combat realted trauma care), they are not completely eliminated. In some instances, as in the case of preventive medicine, the requirements and workload may actually be increased compared to other military operations. (3) In such situations, AMEDD personnel should prepare themselves to perform additional duties beyond those normally associated with their military specialty.

A CASE EXAMPLE: FORCE HEALTH PROTECTION DURING THE 2010 PAKISTAN FLOOD

Sustained, torrential rains beginning in July 2010 resulted in widespread flooding of over 795,000 sq km, one-fifth of Pakistan's total land area, and directly affected over 20 million residents (Figure 1). (4) Similar to the 2005 earthquake response, beginning in August 2010, the US Department of Defense (DoD) deployed troops to Pakistan as part of a coordinated US foreign humanitarian assistance response. However, unlike the 2005 response, the DoD's 2010 response did not provide direct medical care to the local population and instead was primarily directed at supporting the movement of people and supplies to and from flood affected areas.

Restrictions on the number of US servicemembers in Pakistan limited the in-country FHA force to approximately 600 total personnel. (5) US military helicopters were deployed to Ghazi Aviation Base in the north and Pano Aqil Army Airfield in the south, with a small central hub at Chaklala Airbase outside Islamabad for coordination of transient fixed-wing airplanes. Limited medical assets consisting of 2 physicians, a physician assistant, a veterinarian, and several medics/corpsmen were deployed to help protect and sustain the health of the deployed force. Although the risk of combat related injuries was low for US personnel in Pakistan (in comparison to neighboring Afghanistan), disease and nonbattle injuries remained a significant threat which required the continued attention of the medical staff, particularly with regards to implementation of preventive medicine measures. (6) In many deployments, these measures are implemented by traditional preventive medicine units, but due to the troop limitations in Pakistan, they were instead implemented by nontraditional medical personnel.

[FIGURE 1 OMITTED]

One of the initial preventive medicine issues which required attention was an Occupational and Environmental Health Site Assessment (OEHSA) for each of the 3 US military base camps to identify health threats and develop recommendations to minimize their potential impact on US servicemembers. An OEHSA is normally conducted by trained preventive medicine personnel with specialized equipment which is used to detect and measure potential health threats such as exposure to contaminated air, soil, and water, excessive noise, non-ionizing radiation, and arthropod borne diseases. It was not possible to complete an OEHSA in its entirety due to a lack of certain equipment, such as a noise dosimeter, and properly trained personnel. However, a thorough OEHSA was still performed at each base camp thanks to previous cross-training and subsequent refresher training of personnel prior to deployment. The cross-training was conducted several years prior by members of the 30th Medical Brigade to improve awareness and coordination of efforts between veterinary and preventive medicine personnel and units in the US European Command area of responsibility. This training provided participants with a basic understanding of the roles, responsibilities, and methods of their medical counterparts in promoting force health protection through food, water, and environmental health safety. The subsequent predeployment training by US Army Public Health Command (USAPHC) personnel was able to rapidly build off this basic training so that non-preventive medicine personnel were able to competently perform OEHSAs for all 3 sites, identify significant health threats, and develop mitigative measures which were instrumental in reducing incidence of disease and nonbattle injuries, and protecting the servicemembers' health.

A significant health threat identified during the OEHSA was the lack of DoD-approved sources for food and water within Pakistan. While shipment of operational rations and bottled water via military airlift was available, it was only possible with a like reduction in the transportation of humanitarian goods. Fortunately, trained veterinary personnel were available to conduct Food and Water Risk Assessments (FWRAs) of local caterers which provided the base camp commanders with an alternative to operational rations (see related article on page 63). Like the OEHSA, a key principle behind the FWRA is the identification of food and water associated health threats and development of mitigative measures to reduce the overall risk to acceptable limits. A common finding among all 3 FWRAs was general noncompliance with US requirements for cooking/holding times and temperatures, and cleaning and sanitation of food and food contact items and surfaces. Noncompliance was largely due to the contractor's unfamiliarity with US requirements which was partially corrected during the FWRA inspection and outbrief, as well as subsequent training of food service personnel by the contractor. Compliance was further improved by deploying US military food service personnel to provide oversight of the kitchens and dining facilities at the 2 larger US base camps. The deployment of these individuals in the face of the restrictions on the number of US servicemembers allowed in Pakistan is a testament to the importance that the base camp commanders placed on food safety. Neither of the 2 camps where US food service personnel were deployed experienced any significant food borne incidents during the deployment. Unfortunately, the third camp which did not have a US cook supervising operations experienced a food-borne outbreak which affected approximately 50% of the US personnel. As a final step towards improving safety, medical staff at each of the 3 base camps received instruction on basic food sanitation and guidance on critical items to look for during food service operations. Those personnel then performed local food safety inspections in the absence of formally trained veterinary or preventive medicine food inspectors.

Another major challenge facing the medical personnel in Pakistan was surveillance and control of arthropod vectors, particularly mosquitoes. Application of most DoD approved insecticides, and all ultra-low volume (ULV) insecticide applications, requires special training and certification due to their potential health risks. In some instances, insecticides may not be applied unless warranted by vector surveillance conditions such as confirmed presence of malaria positive mosquitoes. Although the force restrictions in Pakistan prevented the deployment of traditional DoD vector surveillance and control teams, vector surveillance and control was still performed by the deployed medical force through coordination with organizations. Part of the rapid predeployment training conducted by the USAPHC included refresher instruction on the use of Centers for Disease Control and Prevention light traps for mosquito and sand fly surveillance. Those items were shipped to the deployed medical personnel in Pakistan, along with shipping material and containers, so that local arthropods could be trapped and sent to the laboratory at USAPHC Region Europe for identification and testing. Although Anopheles sp mosquitoes (Figure 2) were identified from the samples, none of the specimens tested positive for malaria. However, malaria was eventually diagnosed in one US servicemember at Pano Aqil, at which point the deployed personnel consulted with the Armed Forces Pest Management Board (AFPMB) to determine an acceptable insecticide. That insecticide was subsequently applied by Pakistani military personnel via ULV application. Additionally, all personnel were reminded of the importance of proper wear of permethrin treated uniform, daily compliance with doxycycline malaria chemoprophylaxis, and the proper use of bed-nets. No additional cases of malaria among US servicemembers were detected following these actions.

[FIGURE 2 OMITTED]

Other medical challenges encountered during the Pakistan flood relief operations included outbreak investigations and laboratory analysis of food and water samples, patient movement within and out of country, and obtaining advanced diagnostics and care. In some of these instances, DoD medical personnel were able to make arrangements with Department of State medical personnel at the US Embassy in Islamabad. In other cases, coordination with DoD assets at sea and in Afghanistan, Germany, and the United States facilitated accomplishment of the mission.

LESSONS LEARNED

Although it's unlikely that any future FHA operation will be exactly the same as the 2010 Pakistan Flood Relief, similarities are bound to occur, especially with regards to the numbers and types of personnel deployed. Whether or not the affected country places restrictions on the number of US servicemembers which may enter the country or disaster area, other factors such as the limited availability of qualified personnel during the initial rapid disaster response deployment may exist which limit the number of deployed medical personnel. In these instances, medical personnel may have to cover gaps and mission responsibilities traditionally performed by other personnel, including tasks which may fall outside of their normal military occupational specialty.

Fortunately, while Pakistani restrictions limited the number of deployed servicemembers in country, the gradual onset of the flood disaster, as opposed to an earthquake or tsunami, facilitated a more measured deployment of troops compared to some previous FHA operations. The additional time allowed limited refresher training for the deploying medical personnel which aided them in their ability to perform additional force health protection duties. However, this refresher training would likely have been much less effective, and potentially impossible, if it were not for the previous cross-training that had been conducted by the 30th Medical Brigade veterinary and preventive medicine units several years earlier. This prior training was instrumental in raising awareness, not only regarding other military medical missions and responsibilities, but also on the availability of medical resources such as the AFPMB and its disease vector ecology profiles, (7) the Walter Reed Biosystematics Unit vector identification services and tools, (8) and the USAPHC's environmental sampling program.

THE WAY AHEAD

The One Health * mission statement asserts:
   Recognizing that human health (including mental health
   via the human-animal bond phenomenon), animal health,
   and ecosystem health are inextricably linked, One Health
   seeks to promote, improve, and defend the health and
   well-being of all species by enhancing cooperation and
   collaboration between physicians, veterinarians, other
   scientific health and environmental professionals and by
   promoting strengths in leadership and management to
   achieve these goals. (10)


The One Health initiative is recognized by over 4 dozen health-related organizations, including the American Medical Association, the American Nurses Association, the American Veterinary Medical Association, and the National Environmental Health Association. The US Army is uniquely positioned to implement the One Health concept as health personnel from all 3 disciplines (animal, environment, and human) work to protect and promote health. Unfortunately, the current lack of awareness of the One Health concept and the current structural relationships of professionals across the 3 healthcare disciplines have resulted in virtual stovepipe organizations ([dagger]) of efforts and a failure to share information across the health systems. In normal operations, such a construct jeopardizes our ability to rapidly detect emerging health threats. In operations where limited personnel are deployed such as the 2010 Pakistan Flood Relief, this lack of awareness and "stovepiping" may result in mission failure if deployed medical personnel lack the training needed to accomplish missions which are nontraditional for their career field. Even worse, the deployed personnel may not even be aware of the other mission requirements and gaps in responsibilities.

While the recent creation of the USAPHC has brought together members from the 3 health professions into a single organization, additional efforts are still needed to increase awareness of the One Health concept at all levels of the military. Cross-training programs such as the one conducted by 30th Medical Brigade units should be encouraged, particularly between veterinary and preventive medicine units. Although complete cross-training between specialties may not be possible, particularly for functions which require special training and certification such as pasteurized milk audits and pest control application, these joint training programs are nonetheless valuable. At a minimum, these training programs will increase awareness of the roles, responsibilities, methods, and equipment of each health profession. This basic understanding can then be rapidly refreshed and expanded as part of predeployment training for FHA and other military operations. Perhaps of greatest importance, these cross-training exercises can facilitate the identification of existing gaps and serve as a platform for developing future collaborations in force health protection.

The AMEDD Basic Officers Leaders Course (BOLC) is another potential opportunity to promote the One Health concept. Students from all 3 health professions receive combined training as part of the "All-Corps" portion of BOLC. However, while the 3 professions train together, little discussion is provided as to how the actions of one health profession impact the other two. Formal introduction of the One Health concept during the All-Corps portion of BOLC would not only increase awareness, but also increase information sharing and coordination of efforts during the officers' future assignments. It would also improve their knowledge of the numerous resources in other health fields, both human and electronic, which can be readily consulted during military deployments.

CONCLUSION

Many of the functions performed by AMEDD personnel require highly specialized training. However, this specialization, while necessary, may lead to stovepiping of efforts in which many AMEDD personnel may not be aware of the other efforts that exist, let alone how they are accomplished, particularly if these efforts are in different health professions. This may result in ignorance of mission gaps and an inability to deal with them during FHA operations where limited medical personnel are deployed. Promotion of the One Health concept through instruction and training will help to increase awareness of these efforts, facilitate the identification of critical gaps during deployments, and provide personnel with the knowledge and skills needed to address them.

REFERENCES

(1.) Army Regulation 40-1: Composition, Mission, and Functions of the Army Medical Department. Washington, DC: US Dept of the Army; July 1, 1983. Available at: http://www.apd.army.mil/pdffiles/r40 _1.pdf. Accessed October 2, 2012.

(2.) Field Manual 8-55: Planning for Health Service Support. Washington, DC: US Dept of the Army; September 9, 1994.

(3.) Joint Publication 4-02: Health Service Support. Washington, DC: Joint Staff, US Dept of Defense; October 31, 2006. Available at: http://www.dtic. mil/doctrine/new_pubs/jp4_02.pdf. Accessed October 2, 2012.

(4.) Goodwin L. One-fifth of Pakistan under water as flooding disaster continues. Yahoo News. Available at: http://news.yahoo.com/blogs/upshot/one-fifthpakistan-under-water.html. Accessed July 8, 2012.

(5.) Military reaches Pakistan flood relief milestone. Armed Forces Press Service. US Dept of Defense Web site. http://www.defense.gov/news/newsarticle. aspx?id=61461. Accessed October 2, 2012.

(6.) Infectious disease risk assessment for non-indigenous relief personnel [Pakistan]. ReliefWeb Website. August 23, 2010. Available at: http://relief web.int/sites/reliefweb.int/files/resources/ A79F599D2567314385257788006B32B3-Full_Re port.pdf. Accessed July 8, 2012.

(7.) Disease vector ecology profiles. Armed Forces Pest Management Board Website. Available at: http:// www.afpmb.org/content/disease-vector-ecologyprofiles. Accessed August 3, 2012.

(8.) Vector identification resources. Walter Reed Biosystematics Unit Website. Available at: http://www. wrbu.org/. Accessed August 3, 2012.

(9.) King LJ, Anderson LR, Blackmore CG, et al. Executive summary of the AVMA One Health Initiative Task Force report. J Am Vet Med Assoc. 2008;233(2):259-261.

(10.) One Health mission statement. Available at: http:// onehealthinitiative.com/mission.php. Accessed August 3, 2012.

(11.) Khosrow-Pour M, ed. Dictionary of Information Science and Technology. Hershey, Pennsylvania: Idea Group Inc; 2007.

MAJ Ronald L. Burke, VC, USA

MAJ Burke is the Assistant Director, Division of GEIS Operations, Armed Forces Health Surveillance Center, Silver Spring, Maryland.

* The One Health Concept, first articulated by early scientists such as Rudolph Virchow, recognizes the intimate relationship between human health, animal health and the environment, and calls for an integrative, collaborative approach to health by encouraging collaboration between experts of diverse fields of study. (9)

([dagger]) A stovepipe organization is defined as a structural model in which the management and workers have narrowly and rigidly defined responsibilities. Projects involving such organizations are characterized by lack of integration and interoperability, and duplication of efforts. (11)
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Author:Burke, Ronald L.
Publication:U.S. Army Medical Department Journal
Geographic Code:1USA
Date:Jan 1, 2013
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