|
Items in cart [0] |
Questions? Call 888-624-8373 |
| Copyright © 2009. National Academy of Sciences. All rights reserved. Terms of Use and Privacy Statement |
Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter.
Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.
OCR for page 15
Introduction
Nine years after Operations Desert Shield and Desert Storm (the Gulf War)
ended in June 1991, uncertainty and questions remain about illnesses reported in
a substantial percentage of the 697,000 service members who were deployed.
Even though it was a short conflict with very few battle casualties, the events
that occurred during the Gulf War and the experiences of the ensuing years have
made clear many potentially instructive aspects of the deployment and its haz-
ards. Since the Gulf War, several other large deployments have also occurred,
including deployments to Haiti and Somalia. Major deployments to Bosnia,
Southwest Asia, and, most recently, Kosovo, are ongoing as this report is writ-
ten. This report draws on lessons learned from some of these deployments to
consider strategies for improved preventive measures to protect the health of
troops in future deployments.
By the spring of 1996, at least six different expert panels had reviewed or
were in the process of reviewing various aspects of the illnesses reported by
Gulf War veterans or programs developed in response to the illnesses (National
Institutes of Health Technology Assessment Workshop Panel, 1994; U.S. De-
partment of Defense, 1994b; Institute of Medicine, 1996a; Institute of Medicine,
1996c; Presidential Advisory Committee on Gulf War Veterans' Illnesses,
1996b; U.S. Department of Veterans Affairs, 1996~. Deputy Secretary of De-
fense John White met with leadership of the National Research Council and the
Institute of Medicine to explore the idea of an independent, proactive effort to
learn from lessons of the Gulf War and to develop a strategy to better protect the
health of troops in future deployments.
The study presented in this report developed from those discussions. The
U.S. Department of Defense (DoD) (acronyms used in this report are found in
front of the Table of Contents) sought an independent, external, and unbiased
evaluation of its efforts regarding the protection of U.S. forces in four areas: (1)
15
OCR for page 16
16 STRATEGIESTOPROTECTTHEHEALTHOFDEPLOYED U.S. FORCES
assessment of health risks during deployments in hostile environments, (2) tech-
nologies and methods for detection and tracking of exposures to a subset of
harmful agents, (3) physical protection and decontamination, and (4) medical
protection, health consequences and treatment, and medical record keeping.
Studies that have addressed topics 1, 2, and 3 have been carried out concurrently
by the Commission on Life Sciences and the Commission on Engineering and
Technical Systems of the National Research Council, and have resulted in three
companion reports (National Research Council, 1 999a,b,c).
The study presented here, carried out with staff support from the Medical
Follow-up Agency of the Institute of Medicine, addresses the topics of medical
protection, health consequences and treatment, and medical record keeping. The
charge to the study team was included in the contract between the Department of
Defense and the National Academies and became central to the Statement of Task:
The [overall] project will advise DOD on a long-term strategy for protecting the
health of our nation's military personnel when deployed to unfamiliar environ-
ments. Drawing on the lessons of previous conflicts, it will advise the DOD with re-
gard to a strategy for managing the health and exposure issues faced during de-
ployments; these include infectious agents, vaccines, drug interactions, and stress. It
also will include adverse reactions to chemical or biological warfare agents and
other substances. The project will address the problem of limited and variable data
in the past, and in the development of a prospective strategy for improved handling
of health and exposure issues in future deployments.
This study concerns medical protection, health consequences and treatment,
and medical record keeping. Specific issues to be addressed include:
Prevention of adverse health outcomes that could result from exposures to
threats and risks including chemical warfare and biological warfare, infectious
disease, psychological stress, heat and cold injuries, unintentional injuries;
Requirements for compliance with active duty retention standards;
Pre-deployment screening, physical evaluation, risk education for troops and
medical personnel;
Vaccine and other prophylactic agents;
improvements in risk communication with military personnel in order to mini-
mize stress casualties among exposed, or potentially exposed personnel;
Improvements in the reintegration of all troops to the home environment;
Treatment of the health consequences of prevention failures, including battle
injuries, disease and non-battle injury (DNBI), acute management, and long-
term follow-up;
Surveillance for short- and long-term outcomes, to include adverse reproduc-
tive outcomes; and
Improvement in keeping medical records, perhaps using entirely new technol-
ogy, in documenting exposures, treatment, tracking of individuals through the
OCR for page 17
INTRODUCTION
medical evacuation system, and health/administrative outcomes. (Statement of
Task, Appendix B)
EMPHASIS AND IMPLICIT ASSUMPTIONS
17
The charge to the study team is very broad. Its different specific compo-
nents roughly include all of military preventive medicine. With this broad scope,
the study team members chose to emphasize areas in which they saw the great-
est needs or needs of a systemic nature and to treat other areas with a necessarily
broader brush. A brief review of many of the risks to the health of deployed
forces is found in Chapter 2. Since an important motivating force for the study
was the health concerns of veterans following the Gulf War, the study team
chose to focus on the major challenges for prevention and data needs pointed out
by the health problems widely reported by deployed forces after the Gulf War
and the efforts to better understand them.
What were the lessons of the Gulf War? Briefly, one of the lessons was that
even in the absence of widespread acute casualties from battle, war takes its toll
on human health and well-being long after the shooting or bombing stops. A1-
though military preventive medicine programs have developed reasonably ef-
fective countermeasures against many of the discrete disease and non-battle in-
jury hazards of deployment, they have not yet systematically addressed the
medically unexplained symptoms seen not only after the Gulf War but also after
major wars dating back at least to the Civil War. Medically unexplained symp-
toms are described and discussed in Chapter 3.
The health problems reported by veterans after the Gulf War also brought
out two other major and interrelated needs for improvements in preventive care
for deployed forces. One is for a health surveillance system with documentation
so that health events in the field are noted and responded to. This is discussed in
Chapter 4. Closely allied is the need for an automated medical record that can
provide information about a service member's health events over his or her
service career and into civilian life after military service. Chapter 5 discusses
DoD plans for electronic medical record keeping.
Although the study team considered the service member's life cycle of re-
cruitment, predeployment, deployment, and postdeployment to include separa-
tion from the service, the postdeployment period appeared to be a time when, in
particular, additional effort could be crucial in attending to the health of the de-
ployed forces. The report discusses needs and opportunities for improved sur-
veillance, special focused health care, and assistance with reintegration into the
home environment during this time.
Two other major issues emerged as the study group went about its work.
One serious challenge to the protection of deployed U.S. forces, discussed in
Chapter 8, is that of providing the National Guard and Reserve components with
the preparation for deployment and health surveillance afforded the active duty
component. As active-duty forces have been reduced, the reserves play an in-
creasingly important role in military deployments. Yet, their lack of access to
OCR for page 18
18 STRATEGIESTOPROTECTTHEHEALTHOFDEPLOYED U.S. FORCES
the military health care system while they are inactive places serious limitations
on the routine health care that they receive and the ability to monitor their health
status over both the short and long term after a deployment. This problem for the
reserves highlights a challenge for many active-duty service members after they
separate from military service. To the extent that they receive their health care in
the civilian sector and not through the U.S. Department of Veterans Affairs
(VA), the capture of any data on their health care is problematic, as is the con-
cept of a true lifetime medical record promised by the President in 1997 (White
House, Office ofthe Press Secretary, 1997~.
A second issue that the study team came to recognize as a serious concern was
that although there have been encouraging changes in DoD policy with new empha-
sis on what is termed Force Health Protection, these changes have not yet been re-
flected in the structural and cultural changes that will be needed within the services
(the Army, Navy, and Air Force; the Marines are a part of the Navy, and the Coast
Guard is part of the Navy only in wartime) and DoD so that they may carry out the
laudable new policies. Effective application of an improved health surveillance sys-
tem (Chapter 4) and integrated computer-based patient record (Chapter 5) will re-
quire concerted leadership and coordination to prevent the inexorable tendency to-
ward "stovepiping" that is, the development or continuation of an array of
independent tasks or service-specific systems that cannot meet the current needs for
information exchange and follow-up.
High-level leadership and coordination are also needed to effect changes in
the way in which medically unexplained symptoms are addressed in military
populations. Although the problem is not unique to the military, it is regularly
seen in populations who have participated in major deployments and will likely
be observed after future deployments. Efforts to intervene to try to prevent or
ameliorate medically unexplained symptoms are needed, as are careful evalua-
tions of these efforts and a related research program. The needs in this area are
further described in Chapter 6.
Need for additional high-level leadership and coordination for military pub-
lic health and preventive medicine run counter to the current momentum within
DoD. The medical structure of DoD is focused on the delivery of health care and
the operation of the Tri-Care program (the military health maintenance organi-
zation). The costs of the health care delivery system are enormous, and man-
agement of the health care delivery system has come to dominate DoD's medi-
cal leadership. High-quality health care is crucial to recruitment and retention of
good service members, but in the current environment, the practice of military
preventive medicine and military medicine appears to compete very poorly for
personnel, funding, and leadership resources.
RELATED EFFORTS
As the study took place, several relevant efforts were under way at DoD and
VA. In response to recommendations from the Presidential Advisory Committee
OCR for page 19
INTRODUCTION
19
on Gulf War Veterans' Illnesses, an interagency task force with representatives
from DoD, VA, and the U.S. Department of Health and Human Services prepared
a plan to protect the health of service members and their families. Released in No-
vember 1998, the plan, entitled A National Obligation: Planning for Health Pre-
paredness for and Readjustment of the Military, Veterans, and Their Families
after Future Deployments, articulated many goals that the study team found laud-
able (National Science and Technology Council, 1998~. The document is referred
to several times throughout the report, frequently with the hope that the strategies
described to meet the goals stated in the plan are actually implemented.
As the present study was under way, the U.S. Congress passed legislation
that required the VA to contract with the National Academies to carry out a
critical review of their proposed plan for a National Center for War-Related Ill-
nesses. Presumably, such a center would coordinate research related to several
of the areas of focus in this report. DoD has also recently named several of its
research institutions as centers for clinical and epidemiologic studies of war-
related illnesses. Finally, a recent DoD Broad Agency Announcement invited
proposals for research related to war-related illnesses (Commerce Business
Daily, 1999~.
STUDY PROCESS AND INFORMATION SOURCES
The study presented in this report was led by two principal investigators: an
infectious disease specialist and a psychiatrist. To provide additional breadth of
expertise to match the breadth of the charge to the study, a panel of expert advi-
sors was convened. Members of the panel had expertise in the fields of medical
record keeping, epidemiology, reproductive health, toxicology, infectious dis-
eases and vaccines, psychology, psychiatry, chemical warfare agents, risk com-
munication, biomedical ethics, and neurobiology.
The principal investigators and advisors (the study team) gathered informa-
tion through several means. Four public workshops and a discussion meeting
were held to collect relevant information. At the workshops, members of the
military services, DOD, and representatives of other relevant agencies such as
VA provided briefings and participated in discussions about ongoing and
planned programs related to protecting the health of deployed forces. Outside
(non-military) experts were also invited to provide relevant information from the
civilian sector. The information provided in workshop presentations and discus-
sions formed an important basis of this report. The dates and agendas from these
workshops, including names and affiliations of speakers, are provided in Ap-
pendixes D and E, respectively.
The study team sought additional inputs from experts through commis-
sioned papers. Focused questions related to various study topics were directed to
11 distinguished people who wrote background papers for the study team. The
papers served as useful bases for the workshop discussions and study team con-
siderations. These papers and their authors and affiliations are listed in Appen
OCR for page 20
20 STRATEGIESTOPROTECTTHEHEALTHOFDEPLOYED U.S. FORCES
dix F. One paper in particular was integral to the evolution of the report. Chapter
3 draws much of its information from that paper, which is included as a signed
contribution in Appendix A. Institute of Medicine staff gathered journal articles,
DoD documents, and material from the World Wide Web and other sources to
supplement information from the workshops and commissioned papers. Finally,
Institute of Medicine staff gathered information and carried out a literature re-
view to augment the information available to the study team on the topic of re-
integration into the home environment.
THE FUTURE MILITARY
Joint Vision 2010 is a document prepared by the Joint Chiefs of Staff in 1996
to describe the nature of warfare envisioned in the near future (U.S. Department of
Defense, 1996b). Revised operational concepts of dominant maneuver, precision
engagement, focused logistics, and full-dimensional protection provide a frame-
work for planning in the future. At the foundation of the vision are quality forces
who are better trained and more highly skilled than they were in the past. Active
and passive protection measures are anticipated to provide better protection
against opponents at all echelons. At the same time, service members will use
higher-technology equipment to carry out their missions. Forces will be increas-
ingly dispersed and mobile, with less continuous support from a smaller logistics
"footprint" (the size of the deployed presence). The document notes a first priority
of recruiting and retaining dedicated high-quality people. For reserve components,
less startup time between employment and deployment is anticipated, with the
need for rapid integration into joint operations.
The implications of this vision for strategies to protect the health of de-
ployed forces are several. The deployment of smaller, more mobile units means
that each service member is more crucial to the success of the mission, but fewer
medical resources are available to him or her. Preventive tools will be crucial for
the prevention of disease and injury.
Accordingly, this report focuses on prevention measures for future deploy-
ments. Lessons learned from the past and from public health suggest that sur-
veillance coupled with record keeping will be crucial. Medical surveillance
permits the identification of problems and opportunities for intervention, and the
associated record keeping permits additional benefit from retrospective analysis.
Coupled with these, research and intervention efforts directed towards medically
unexplained symptoms will provide important tools for the future military.
Representative terms from entire chapter:
gulf war
