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David A. Rubenstein

It is with great personal pleasure that I present the first issue of the AMEDD Journal published during my tour as Commanding General, US Army Medical Department Center and School (AMEDDC&S). This publication exists for the specific purpose of enhancing and advancing the science of military medicine, the primary mission of which is maintaining the health and combat effectiveness of our military force. However, the vast majority of topics addressed in these pages also have direct corollaries in the practice of civilian healthcare. Indeed, the history of military medicine is replete with examples of the synergistic effect of efforts by both military and civilian resources producing results beneficial to both general populations and military mission accomplishment.

The AMEDD Journal is an invaluable forum for the presentation of and dialogue about the most current healthcare issues and combat experiences related to military medicine and doctrine development for the medical battlefield. The Journal receives manuscripts from across the spectrum of medical professionals, including highly-experienced medical and dental practitioners, accomplished research scientists, preventive medicine and public health specialists, veterinarians, healthcare support and service specialists, and non-medical professionals who contribute to healthcare delivery in various ways. The diversity of subject matter reflects the depth and breadth of functions in military medicine.

Likewise, the AMEDD Journal has a broad reach in readership. It is distributed throughout the Army, Navy, Air Force, and DoD, as well as to many civilian medical schools and libraries. It is also distributed to a number of foreign military medical schools and commands. The quality of the content and presentation of the AMEDD Journal was recognized by the National Library of Medicine, which, in November 2009, selected it to be included and indexed in MEDLINE, the nation's premier bibliographic database of life sciences and biomedical information from publications worldwide. The Journal is a superb presentation of who we are and what we do as healthcare professionals, both on the battlefield and in garrison. The topic of this edition also supports AMEDD Balanced Scorecard objective 3.0, "Improved Healthy and Protected Warriors."

For the fifth consecutive year, COL Mustapha Debboun, the senior medical and veterinary entomologist at the AMEDDC&S and Chairman of the AMEDD Journal Editorial Review Board, has organized and compiled an outstanding collection of articles addressing preventive medicine and public health in the context of force health protection. History has shown time and again that preventive medicine is the foundation for sustainable, effective combat capability.


The US Army has long recognized the inestimable value of a Soldier's healthy mind and body to the combat readiness of the unit. The Army has continually sought improvements in effectiveness and efficiency in the methods and tools to ensure our Warriors remain healthy and fit, whether at home or in the theater of combat operations. The research, planning, application, and resources that are necessary to achieve this desired result are considerable. The recent establishment of the Army Public Health Command (APHC) is a significant step in the commitment to focus and optimize efforts among the various disciplines working towards that common goal. The leadoff article in this issue of the Journal is an account of the detailed planning and execution necessary to transition force health protection functions and responsibilities into the newly created APHC. The authors, Rosemarie Ugalde and John Resta, are key players in this ongoing process, and their article provides a detailed overview of the procedures involved, the schedule, and the ultimate organization of the APHC.

Unconventional warfare presents an almost indefinable array of challenges to those charged with anticipating and countering the threats. Usually, thoughts of guerilla-style attacks or use of chemical or biological agents come immediately to mind. However, in a timely, important article, CPT Derek Monthei and his coauthors discuss a potential threat that usually does not enter most discussions--the use of insects as attack weapons, for destruction of food sources, or as disease vectors. Use of stinging or toxic insects in warfare has been chronicled throughout history, and the article explains how such a threat is not improbable today. However, the threats posed to food sources (agroterrorism) and as vectors of disease are of much greater concern. The article clearly and succinctly describes the threats represented, and the measures that have been, or should be, implemented to first detect and then control the outbreaks.

As long as humans have congregated in living and working areas, accumulation of trash and solid waste has been an inevitable byproduct of our activities. The health threat of such accumulation has long been recognized, and has been a serious concern for US military operations for well over a century. In her excellent article, Dr Colleen Weese presents a historical perspective of the problem, and then describes the situation as it exists today in the Iraq theater. Not only are modern societies, including military forces, faced with the expected hygiene and sanitation problems of accumulating waste, but we are also dealing with new categories of toxic (or potentially toxic) substances which pose additional problems in safe handling and disposal. Dr Weese focuses on the particularly troubling disposal method of burn pits, which is often the only method a commander may have to address the immediate situation. The article is a well-researched, detailed discussion of the environmental and health hazards posed by open burning of accumulated waste, and the measures taken by the US military to mitigate those problems. It provides an in-depth look into how the hazards associated with waste disposal should be addressed. This article is a must-read for those charged with planning and implementing waste disposal procedures for deployed forces.

Brian Zeichner and Sheila Adams have contributed an article describing a technological tool to assist preventive medicine and public health specialists in the collection and analysis of environmental data related to entomological threats in a given area. They demonstrate how readily-available geographic information system instruments can be used to define source areas of mosquito infestations, and then enable precise planning to attack those areas. They also illustrate identification of tick infestations, as well as agriculturally important beetle infestations. This is an interesting, easily understood article which presents sound, statistical evidence of the effectiveness of the techniques employed. The article should provide a stimulus for others to adopt the techniques for local, immediate applications addressing similar entomological threats. We have all become accustomed to the use of radiation in diagnosis and treatment of various health conditions. Although we are aware of the hazards represented by the radiation, we trust that the professionals employing it are experts in their craft, and the threat is essentially nonexistent. Indeed, this is the case. It is so because of the continuous training, practice, and attention to every detail of the clinical use of radiation that is demanded of these professionals. The next 2 articles discuss various aspects of that attention to training and monitoring of their potentially hazardous tools. First, COL Mark Melanson and his coauthors discuss a workshop for Army Nuclear Medical Science Officers to expand their skills in working as a group in communicating information about a potentially hazardous situation which could be present following a radiation incident, with special emphasis given to dealing with potential victims, and then the media. The workshop presented training in the personal skills and techniques necessary for such situations, and then participants worked through a real-world case study to understand how it can either get quickly out of control, or handled correctly and sensitively for all concerned. In the second article, MAJ Christopher Pitcher and COL Melanson describe the concerns presented by the expanding use of fluoroscopy in interventional pain management (IPM), an increasingly important specialty which uses nerve blocks and other techniques for pain management. The Health Physics Office at Walter Reed Army Medical Center performed a measurement study and implemented a peer-based training program to reduce as much as possible the radiation doses experienced by staff, patients, and the public as a result of the operation of the IPM clinic. This is a well-developed, thoroughly researched article which demonstrates the correct way to evaluate and address potentially hazardous situations which may exist in our medical facilities.

The emotional and psychological toll on medical providers who treat casualties of war has been recognized for years, but was not directly addressed as a potentially serious condition until relatively recently. Over the last few years, the AMEDD Journal has published several articles discussing the evolving understanding of this condition, and the ongoing research and developing approaches to deal with it. LTC Sheila Adams and her coauthors present the latest article on this subject, describing the formal training course, Professional Provider Resiliency Program, introduced by the AMEDD Center and School in May 2009. The article is a detailed discussion of the basis on which the training was developed, the training itself, and includes the results of a survey of the participants in a recent class who evaluated the training received. This is a valuable depiction of another of the increasingly more sophisticated approaches that the AMEDD is taking to answer the proverbial question, "who heals the healer?"

The military has dedicated considerable resources to research, training, and the development of equipment to mitigate environmental health threats, both endemic to the location and resulting from military operations. Unfortunately, the best of preventive measures and equipment are valueless if not diligently, continuously applied throughout all levels and locations of military units and facilities. CPT Elizabeth Wanja has contributed an important, revealing article that details her deployment experiences investigating and addressing a number of problems resulting from noncompliance with preventive medicine regulations and training, as well as the inconsistent distribution and availability of equipment. Such problems should be expected in the chaos and unpredictability of extensive, ongoing combat operations, but cannot be tolerated in a mature theater of fixed installations and reduced combat activity. Sadly, this is not a new situation. Commanders and other leaders must constantly balance priorities and resources--but the health and safety of their Soldiers must always be the first of those priorities. This article is must-reading for all who are charged with that responsibility, whether as leaders or providing preventive medicine support to units and facilities.

The Army Hearing Program was instituted in 2007 and has been implemented throughout Army installations in the United States. However, application of the Program elements in the deployed theaters has been problematic, in that available audiologists were necessarily focused on diagnostic care of injured Soldiers. The article by CPTs Kara Cave and Edward Price describe how the Program elements were implemented in Iraq as soon as the circumstances permitted. As the clinical role diminished, CPT Cave began training technicians, including classes in noise hazard evaluation in collaboration with CPT Price of the preventive medicine medical detachment. The arrangement expanded to proactive evaluations of noise hazards, and resulted in a fully developed model and process of identifying and mitigating noise hazards throughout the Iraq theater. This article is another excellent example of how the initiative and competence of our military medical professionals benefit the Warfighters who serve every day, everywhere in the world.

In their article, Todd Hoover and COL Kyle Campbell address a health problem that is completely preventable among healthy individuals, namely, excess body fat. They describe the collaboration between what is now the APHC (Provisional)--Europe and the Army Medical Department Activity, Heidelberg, to develop a weight reduction program designed around each individual's metabolic rate and other physiological factors. Using students over a year of training cycles at the Warrior Leader Course as the target population, the program achieved a 99% success in the body fat standards, and 6-month follow-on checks indicate that over 86% remain within the established standards. This approach could be applicable in similar environments throughout the Army.

Dr Wayne Austerman closes this issue with an excellent historical perspective on another completely preventable condition that not only damages the individual's health, but also, without question, severely degrades combat effectiveness. The abuse of alcohol has always been a part of human history, which includes a significant presence in military history. The article examines the role it played during the Texas War for Independence, highlighting the legendary battle of the Alamo where alcohol was a constant debilitating element, among both the men and some of their leadership. As Dr Austerman relates in fascinating detail, as the Mexican Army approached San Antonio, the majority of the Alamo garrison had been engaged in 2 days of revelry and drinking in town, rendering them virtually unable to mount a serious defense to any attack. Fortunately for Texas, bad weather and timid leadership delayed any action from the Mexicans. The article then postulates on how history may have changed had the Mexicans rolled up the defenders in the streets of town. Today's military leaders must still be alert to the appeal of alcohol, whether chronic or opportunistic, and ensure immediate, positive action always addresses its abuse. No individual's self-inflicted impairment can ever be allowed to jeopardize either the mission or his or her fellow Warriors.
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Author:Rubenstein, David A.
Publication:U.S. Army Medical Department Journal
Article Type:Editorial
Date:Apr 1, 2010
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