Protecting Those Who Serve Strategies to Protect the Health of Deployed U.S. Forces (2000) / Chapter Skim
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The Strategy
The Strategy
Pages 13-38
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From page 13... ...
· Strategy 5. Implement strategies to address medically unexplained symptoms in populations that have deployed.
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From page 14... ...
Forces project, Lorenz Rhomberg carried out a study charged with developing an analytical framework for assessing the risks to the health of deployed forces, particularly from disease and non-battle-related injuries or from chemical or biological warfare agents. The National Research Council report Strategies to Protect the Health of Deployed U.S.
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Such an exposure minimization orientation is one in which, in the absence of complete information about the health risks posed by particular compounds, efforts are made to use them with caution and limit exposure to them. Uncertainty is an inevitable component of health risk assessment.
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Furthermore, the risk management concepts derived from these efforts should be included in scenarios used for military exercises and war games, with the lessons learned used to further refine the assessment and planning process. Contemporary models of health risk management and assessment suggest that effective responses to risk situations require a broad understanding of the values of importance to the affected populations (Fisher, 1991, International Life Sciences Institute, 1993, Kasperson and Kasperson, 1996, Kuehn, 1996, Kunreuther and Slovic, 1996, NRC, 1996~.
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From page 17... ...
, as well as other discussions in the public sector regarding community exposures, represent a rich source of information for pending health risk assessments. The organization appointed to carry on the work of the DoD Office of the Special Assistant for Gulf War Illnesses should provide another source of information from lessons that have already been learned.
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Currently, however, medical intelligence information is not available to most deployed preventive medicine professionals because of their lack of access to classified databases and communications, particularly in deployed and remote locations. Medical intelligence must make its way to the commanders as well as to the medical community.
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1.4 DoD should ensure that medical intelligence is incorporated into the intelligence annex to the operations plan and is considered in shaping the operational plan. 1.5 DoD should devise mechanisms to ensure that state-of-the-art medical knowledge is brought to bear in developing medical annexes to the operational plans and preventive medicine requirements, drawing on expertise both inside and outside DoD.
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As discussed for Strategy 1, health risk assessment before deployment can help to identify risks most likely to be associated with the activities of a deployment. On the basis of that health risk assessment, decisions must be made about what environmental data and biological samples might be most useful to collect in the field.
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From page 21... ...
The commander will need information in advance about the spectrum of disease and non-battlerelated risks facing the troops in a deployment setting so that, together with staff (who will provide integrated engineering, safety, preventive medicine, nuclear, biological, and chemical information) , he or she can plan protective and control measures and determine the potential impact of risks and countermeasures on accomplishment of the mission.
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For substances for which such a biomarker has been developed and validated and when a putative exposure has occurred, analysis of biological samples collected from deployed forces may help to assess past exposures. Environmental monitoring is important to allow avoidance or minimization of an exposure before it has occurred.
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It is vital that the locations of units and individuals during deployments be documented, together with activity information. This information is important not only for real-time command decision making on the battlefield but also for enabling the reconstruction of deployment exposures for epidemiological studies and the provision of appropriate medical care after the deployment.9 However, despite painful lessons learned from both the Vietnam War and Operations Desert Shield and Desert Storm, adequate systems for recording and archiving the locations of deployed forces are still not in place.
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Strategy 2 Recommendations 2.1 DoD should assign single responsibility for collecting, managing, and integrating information on non-battle-related hazards. 2.2 DoD should integrate expertise in the nuclear, biological, chemical, and environmental sciences for efficient environmental monitoring of chemical warfare agents and toxic industrial chemicals for both short- and long-term risks.
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2.5 DoD should ensure that adequate preventive medicine assets including laboratory capability are available to analyze deployment exposure data in near real time and respond appropriately. 2.6 DoD should ensure that the deployed medical contingent from command surgeons to unit medics has mission-essential information on the likely non-battle-related hazards of the deployments and access to timely updates.
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All levels, but particularly commanders and medical personnel, need training in how health risk assessments are generated and how risk is communicated and managed, taking into account evolving societal concerns. The current guidance provided to commanders and military medical personnel is inadequate because it can result in incomplete and inaccurate descriptions of risk, and thus mismanagement of the risk and insufficient communication about the risk of concern.
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Commanders will need to be trained in discussing and hearing the concerns of the individuals in their units about potential health risks. They will also need to turn to their medical staffs and unit medics for additional information about the concerns of their units.
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It should develop an overall plan for risk communication generally that involves stakeholders (the service members and their families) and outside experts and that includes a response plan for new risks to or health concerns of deployed forces (IOM, 1999~.
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DoD must be candid with and trusted by service members, their families, and the American people. Strategy 3 Recommendations 3.1 DoD should provide training in the contemporary principles of health risk assessment and health risk management to leaders at all levels to convey understanding of the capabilities and uncertainties in these processes.
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Here, the committee highlights some of the most urgent needs: health history and health status information on recruits, periodic updates of health status information that continue to be obtained after deployments, improved laboratory-based surveillance, and clarified leadership for preventive medicine and health surveillance. Baseline health information on service members that begins upon their entrance in the military and that is periodically updated is crucial.
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From page 31... ...
DoD should ensure that adequate preventive medicine personnel and resources are available early on deployments. 4.2 DoD should collect health status and risk factor data on recruits as they enter the military, as planned through the Recruit Assessment Program, now in the pilot stage.
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From page 32... ...
The medically unexplained symptoms reported by veterans of the Gulf War have been the driving force behind many expert studies as well as several new programs and initiatives in DoD and VA. The committee believes that, in addition to the improvements in health surveillance and preventive measures described earlier, DoD's approach to medically unexplained symptoms is another means to address an issue of importance to service members, their families, and the public.
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From page 33... ...
Thus, a program of continuing education about medically unexplained symptoms should be undertaken for military primary care providers, as should a program that educates those starting their military medical service in the military graduate medical education programs and the service schools. Care providers must learn to establish working relationships with patients with medically unexplained symptoms so that they understand the current limits of medical knowledge and do not feel dismissed or stigmatized by the lack of an identified medical etiology.
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5.3 DoD should establish a treatment outcomes and health services research program within DoD to further provide an empirical basis for improvement of treatment programs to address medically unexplained symptoms. This program should be carried out in collaboration and cooperation with the U.S.
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There is still no consistent means for documenting in individual medical records ambulatory care that service members receive during deployments (Office of the Special Assistant for Gulf War Illnesses, 1999, COL Mark Rubertone, Director, Army Medical Surveillance Activity, personal communication, March 10, 2000~. Progress has been unacceptably slow toward development of the computer-based patient record (CPR)
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From page 36... ...
Since they receive their medical care from civilian systems, the military has no accessible health status or medical data on these individuals before deployments, beyond the predeployment questionnaire.~5 As a result, individuals among reservist units may needlessly be receiving an additional immunization when reserve units are sometimes immunized en masse (LaBoa, 2000, Lynch, 2000~. At a minimum, records of the immunizations provided to service members including members of the reserves need to be stored in individual medical records.
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From page 37... ...
6.4 DoD should establish an external advisory board that reports to the Secretary of Defense to provide ongoing review and advice regarding the military health information system's strategy and implementation. 6.5 DoD should include immunization data, ambulatory care data, and data from deployment exposures with immediate medical implications in the individual medical records and should develop a mechanism for linking individual records to other databases with information about deployment exposures.
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