July 21, 2024
The U.S. military has long realized the importance of preventive medicine to proactively reduce disease and non-battle injury as part of the larger health force protection effort. Greg Gharst, Sascha Jung, Benjamin Torsrud, and Artemio Tulio argue that there is still room for improvement. They recommend restructuring Army preventative medicine organization and employment in collaboration with joint and coalition health protection partners to meet the challenges of an ever-changing battlefield.

The current doctrinal format by which PM missions are conducted is inadequate for the ever changing and fluid composition of the modern-day asymmetric warfare battlefield.

Since World War II, the military has known that there is a necessity in having personnel keep track of disease and non-battle injury (DNBI) and provide recommendations to mitigate the associated risks. In fact, DNBI is attributed to have caused 80% of all battlefield casualties according to the May 2015 Field Hygiene and Sanitation Training Circular. Although recent operations have shown that these numbers have decreased, the importance of risk mitigation must not be lost.

Force Health Protection is the Army Medical Department’s mission in the protection of the warfighting function and all measures taken by commanders, supervisors, and individual service members to promote, protect, improve, conserve, and restore the mental and physical well-being of service members across the full range of military activities and operations. Preventive medicine (PM), a vital component of force health protection, seeks to continue quality of life improvement by looking at all variables that affect the health of a service member. It is defined as the anticipation, prediction, identification, prevention, and control of communicable diseases, illnesses (including vector, food, and waterborne diseases), injuries, and diseases due to exposure to Occupational and Environmental Health threats, including nonbattle injury threats. From communicable and vector-borne diseases; hearing and vision injuries; venomous or toxic flora and fauna; musculoskeletal injuries from training and recreation; occupational illness and injury; and environmental injury (for example, heat, cold, and humidity) to environmental sampling.

PM personnel compile large quantities of data that facilitate recommendations for short-term solutions to correct immediate deficiencies and long-term solutions that protect service members well after the completion of their service. Therefore, PM requires support from the highest levels of command. It is increasingly important that, along with surveillance provided by PM personnel, commanders, at all levels, enforce the standards of sanitation and hygiene as stated in the regulations, as well as the recommendations provided by PM.

In its current doctrinal configuration, a PM Detachment of 12 personnel provides coverage for 17,000 personnel, to include any contractors and coalition forces attached in support. This small group is expected to provide subject matter expertise regarding endemic, epidemic and pandemic diseases, occupational and environmental health hazards, such as toxic industrial materials, accidental or deliberate dispersion of radiological and biological material, toxic poisonous plants and bacteria, poisonous reptiles, amphibians, arthropods and animals, medical effects of weapons, such as conventional, improvised (to include improvised explosive devices), chemical, biological, radiological, and nuclear warfare agents. This population can be spread across multiple countries within a given theater of operation. The multiple locations present unique hurdles for PM to service their customers, such as travel inside conflict areas with ongoing kinetic activity demonstrating to be the primary barrier regarding PM support for the war fighters. Of importance to note, these highly specialized support taskings are not provided by operational units that only appoint an organic company-level team with a main emphasis placed on those measures necessary to maintain basic sanitation and hygiene.

This presents the need for a better and more realistic allocation strategy for PM assets. Rather than allocating them based solely on numbers of military personnel covered in theater, senior medical leaders should pursue a more strategic approach that allocates according to the total demand signal — that of U.S. military and civilians, contractors, and coalition forces. This will provide greater agility to respond to changes in the environment and reduce the risk of overwhelming medical assets.    

Typically, there are two PM detachments within the Army Central (ARCENT) area of operations (AO). The PM detachment conducting operations in the ARCENT AO is a PM Detachment enhanced composed of 20-23 assigned personnel compared to the doctrine of 12. The additional personnel allow the detachment enhanced to provide more capabilities to project greater PM medical power across the ARCENT AO. Of note, the detachment enhanced is responsible for providing PM services to all ARCENT except, during this case study time period, Afghanistan (AFG). Conversely, the PM detachment in AFG is a detachment reduced, as they have only 8 personnel compared to the doctrinal 12.

The current doctrinal format by which PM missions are conducted is inadequate for the ever changing and fluid composition of the modern-day asymmetric warfare battlefield. Thus, to project efficient and effective PM medical power, the common operating picture must evolve into one of total PM collaboration.

The main idea regarding evolution of how PM medical power is projected focuses on adjusting the scope of PM on the modern-day asymmetric warfare battlefield. For PM to be efficient and effective, the notion of a certain population amount being necessary to determine how many PM personnel are assigned needs to be addressed. For example, instead of adhering to the doctrine that one PM detachment (12 personnel) cover 17,000 personnel (Department of Defense personnel, contractors, and coalition forces), the logical decision should be made to ensure that PM coverage is provided regardless of how many people are on site and in-line with mission requirements. A way to accomplish this would be to encourage a total PM collaboration among all force health protection assets available such as infectious disease, public health, preventive medicine, veterinary medicine, laboratory, etc. As an illustration, if Navy or Air Force PM assets are nearby then they should be tasked to provide PM coverage regardless of the customer requiring assistance. Furthermore, enabling our coalition and contractor partners that have PM or public health assets to provide aid and coverage, where applicable, provides an enhancing of highly necessary geopolitical partnerships. We need to depart from the current planning factor of one detachment per 17,000 personnel because that assumes forces are relatively centralized and is not sufficient for a population widely distributed across an entire theater.

The suggested first short-term solution to providing adequate PM assets where needed  would be to ensure that enhanced PM detachments have adequate personnel to conduct its mission at echelons above brigade and for any additional rotation purposes. This means, for example, that the enhanced detachment should have a four-person element ready to conduct asymmetric battlefield mission circulation for no longer than 90 days within the current operational environment that currently has minimal organic PM resources. This would provide a short-term result, as the team would provide continuous PM support for the operational period specified without having to allocate an entire PM detachment to a particular region or country.

The proposed second short-term solution would be to station an entire PM detachment in a specific region or country and then split off three (3) two-person teams to provide mission coverage. The team locations would be dependent on the medical mission prioritization, i.e., key locations that support a certain number of outlying locations and meet the medical mission requirements. The headquarters element, with an additional two-person team for backup, would be stationed at a location that would allow for centralization of the mission command.

A third short-term solution proposal is to station a PM Detachment reduced in Iraq. In essence, this is like the second short-term solution except that there would not be a two-person team as backup. The entire detachment would be stationed centrally and available for mission movement to all locations in the country to provide PM mission coverage.

The proposed fourth short-term solution would be to rely solely on the two-person brigade combat team PM asset. This asset would circulate to all locations within the operating area to provide PM mission support.

The following long-term solutions are proposed and discussed to align PM with current medical practices on the modern-day battlefield. The first long-term solution proposal is to put a non-commissioned officer and enlisted soldier in each battalion with technical supervision provided at the brigade level. Rather than the previous format, a two person PM asset from the brigade provide services for their brigade’s entire area of responsibility, placing two-person PM asset at the battalion level will provide an effective approach within the area of operation. These smaller element PM assets would competently act as preventive medicine’s quick reaction forces and can move within the battlefield at a moment’s notice to various locations.

The second long-term solution is the placement of multiple PM detachments reduced, defined as a PM detachment comprised of eight personnel, within regional divisions instead of relying on a PM Detachment plus to cover multiple countries/regions. Having multiple iterations of these detachments allows for increased preventive medicine care and ease of dissemination regarding PM support for the war fighter. Moreover, the two-person command element may remain stationary, and (3) two person teams may be placed at strategic locations within their assigned region/country to provide greater circulation of PM capabilities.

The third long-term solution is the creation of preventive medicine units company-sized elements comprising all force health protection assets. This would fully supplant the PM detachment and necessitate new allocation rules. These units would include a company HQ and staff element with teams similar in size to current PM detachments of 10-12 personnel responsible for each area of force health protection.

The fourth long-term solution proposal is the creation of a Joint Force Health Protection Command which would incorporate force health protection assets and proponency from all services and whose missions would include support to our coalition partners. By aligning all force health protection assets under one umbrella, the sharing of ideas to improve quality of life among the forces is communicated better, which allows for the implementation of solutions on a faster timeline.

In conclusion, are our PM resources spread too thin, too far away from the locations they are needed and largely unable to collaborate with other assets outside of their immediate command? The analysis of continuous improvements, short- and long-term solutions, allows us to adapt to the fluid battlefield. Just like the unification of the military medical assets from all the U.S. medical services (Army, Navy and Air Force) into the Defense Health Agency, the PM field must also evolve and grow into a multiservice force health protection command as identified in the fourth long-term solution proposal. This will allow for United States and allied force health protection assets to interact and collaborate more closely and without delays. It also enables the United States to utilize its limited resources more directly and efficiently across larger areas, removing unnecessary duplications and redundancies, and quickly deploying available assets into needed areas. Within the force health protection command umbrella, solutions and trends can be easily communicated between different commands and across the U.S. military forces. One standard can be taught in training and one joint standard document that is updated rapidly and more frequently while also being utilized across all services can be created and maintained.

“To improve is to change, to be perfect is to change often.”

-Winston Churchill

In the end, the fact remains that change is inevitable and to succeed and remain relevant, PM must change and evolve with the rest of the military world.

Greg Gharst is a Lieutenant Colonel and a Medical Services Officer in the U.S. Army. He earned his PhD from North Carolina State University and currently serves as a Research Fellow in the Center for Strategic Learning at the U.S. Army War College. 

Sascha Jung is a retired Captain and served as a Medical Services Officer in the U.S. Army.

Benjamin Torsrud is a Staff Sergeant and former Preventive Medicine NCO in the U.S. Army Reserve. He earned his BS in Public Health from American Military University and is currently working towards his Masters in Healthcare Administration. He current serves as the Army Reserve Administrator for a Preventive Medicine Detachment and is the supply sergeant for a Drill Sergeant company

Artemio Tulio, Jr. is a past Laboratory Manager for a multinational food conglomerate and a former Visiting Scientist-Chemist at the U.S. Food and Drug Administration, with over seventeen years of experience working in the manufacturing, academia, and regulatory industries. He graduated from the University of the Philippines with a bachelor’s degree in Food Technology and holds both masters and doctorate degrees from the Osaka Prefecture University in Japan. He did his postdoctoral studies at the Ohio State University and University of Florida. 

The views expressed in this article are those of the author and do not necessarily reflect those of the U.S. Army War College, the U.S. Army, or the Department of Defense.

Photo Description: U.S. Army Spc. Samantha Griffin, combat medic who serves as a preventive medicine technician with Company C, 526th Brigade Support Battalion, 2nd Brigade Combat Team, 101st Airborne Division (Air Assault), conducts a health assessment at Forward Operating Base Gamberi, Afghanistan, May 17, 2014. 

Photo Credit: U.S. Army photo by Sgt. David Cox, 2nd Brigade Combat Team Public Affairs

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