U.S. Army Medical Command: Disasters, Pandemics, and Surprises

Military Medicine, Jul 2006 by Casscells, Samuel Ward

"What possessed you to join the Army? Was your practice boring, or frustrating?"

We were at a meeting of alumni of Harvard and Yale, schools without ROTC programs, and - as only 1 in 200 Americans is in the service today -I was the only soldier they knew.

They asked the quality of military medicine. Many had doubts about the war in Iraq. Others asked whether military medical personnel should have a greater role in disasters, or none at all. A few seemed interested in volunteering. For these reasons I offer this personal account.

This time last year, on what would have been my father's 89th birthday, I joined the Army Reserve. His birthday had caused me to take an extra look at the fraying uniform in my closet, and to recall the career of an orphan who worked his way through college and medical school, enlisted, served in Ration's 8th Evacuation Hospital in north Africa and Italy, and went on to crusade against unnecessary surgery, for which reason he developed arthroscopy.

I broached the idea with my wife, who gave a bemused look that said, "I would bet anything this impulse passes". My younger son, age 9, was more encouraging, "Dad, why aren't you a Marine? Not tough enough?"

I had to get a waiver for age (53) and a prior cancer, but eventually found myself sworn in. A few weeks later I got a phone call from Army Surgeon General Kevin Kiley: "Dr. Casscells, welcome aboard. I want you to be ready in case of a flu pandemic. We may even have some fun. Stand by for orders."

There was some fun, and more: a gripping, inspiring, and humbling experience, filled with surprises.

Surprises

One surprise was the roster of medical giants whose medical contributions began while in uniform: Benjamin Rush, Hunter McGuire, William Beaumont, Walter Reed, Hans Zinsser, William Gorgas, George Sternberg, John Shaw Billings, Charles Mayo, William Welch, Michael DeBakey, Maurice Hilleman, George Crile, Denton A. Cooley, Norman Shumway, O. Howard Frazier, and M. Judah Folkman, among others.

Another surprise was seeing statistics on military mortality: despite the risks posed by crowding, stress, travel, explosives, and dangerous exercises, in most years mortality of service personnel is no higher than that of age-matched civilians. Likely explanations include a disciplined emphasis on hygiene, safety, health education, vaccinations, ready availability of health care, unannounced (and observed) drug inspections, physical fitness standards, active disease surveillance programs, and electronic medical records. These areas of emphasis should prove advantageous as military medicine prepares for a potential pandemic of avian influenza.

Still other surprises relate to the Army culture, as described below.

Pandemic Readiness

The military is well aware that soldiers in 1918 spread the "Spanish flu", which led Maurice Hilleman, of Walter Reed Army Institute of Research (and Merck), to develop the world's first influenza vaccine, plus vaccines for seven other diseases. Today's military remains at risk because we are deployed in dozens of countries, in close quarters with each other and with local personnel.

We also travel frequently, and so are potential vectors. Consequently, the military has placed great emphasis on hygiene (including plans for isolation and quarantine, drills and inspections). The military also has active surveillance programs (using real-time PCR and culture) in Thailand, Kenya, Indonesia, Cairo, and other regions at risk of an outbreak of H5N1 influenza. These are linked by advanced informatics. Under development are new sensors and systems of artificial intelligence to permit syndromic surveillance and situational awareness.

In short, the military has unique vulnerabilities, capabilities, and responsibilities as regards emerging infectious diseases. But like the rest of the world, we depend on the US Department of Health and Human Services, World Health Organization, and the global pharmaceutical industry to develop new vaccines and antivirals.

Disaster Response

An additional role now being debated is earlier involvement in natural disasters. After last December's tsunami, I was one of the first American doctors to arrive in Phuket, Thailand. We were not there in time for the initial rescue and resuscitation, but US Navy helicopters played a critical role in Indonesia, to international acclaim. Likewise, after Hurricane Katrina broke the levees and New Orleans began to flood, we were "leaning forward", ready for an order to assist the National Guard and Coast Guard. The regular Army got orders three days later, and helped to restore order, deliver supplies, evacuate survivors, and treat the injured.

After-action analyses, including mine, addressed: 1) the need to clarify lines of authority in advance, and 2) the need for better and more redundant communication technologies.

Local commanders are empowered to assist in civilian emergencies for up to 72 hours without special authorization, but are prohibited by the Posse Comitatus Act from serving in a domestic police role unless the President invokes the Insurrection Act.